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National Confidential Enquiry into Patient Outcome and Death
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Home/Studies/Prison Healthcare Study
Prison Healthcare Study

This study has been commissioned by the Health Foundation HQIP
For information on how we use data click here

Data collection for study: Spring 2022  
Publication date:      Spring 2023 (TBC)   

Aim:To identify remediable factors in the clinical and organisation of healthcare for people who died from a ‘natural’ or other ‘non-natural’ death whilst detained in prison or were transferred to an acute NHS hospital or hospice, whilst detained.
To produce focused, evidence-based recommendations to improve the commissioning, monitoring, provision and quality of healthcare in prisons, with the aim of preventing avoidable and premature deaths in the future.

  • Objectives:

  • Organisational To review:
    • The healthcare provision available
    • Networks of care/healthcare pathways
    • Access to acute NHS hospitals
    • Processes/ standards/ systems and impact of transfers between prisons
    • Multidisciplinary team working
    • The commissioning of services
    • Adherence to national clinical guidelines/quality standards relevant to the organisation of services for the medical conditions being treated (e.g. NICE guidelines and quality standards)
    • The use of local policies and protocols
    • Training for healthcare related matters
    • Healthcare commissioning arrangements
    • Interface between healthcare and operational staff
    • Professional structures, networks and support for prison doctors
    • Examples of good practice
    Clinical To review:
    • The cause of death
    • Whether death was thought to be avoidable or premature
    • The quality, nature and timeliness of healthcare provision and delivery, including ‘out of hours’ care
    • Recognition and treatment of acute medical emergencies and deteriorating clinical conditions
    • The quality of multidisciplinary healthcare delivered
    • Evidence of healthcare reviews for individuals
    • Prescribing and medicines reconciliation by pharmacists
    • Adherence to national clinical guidelines/quality standards relevant to the medical conditions being treated (e.g. NICE guidelines and quality standards)
    • The quality of drug and alcohol detoxification, including an assessment of dependence
    • The content and quality of the NHS commissioned independent clinical review
    • PPOs judgment of whether healthcare received was commensurate with that expected in the community.
  • Participation:
  • All prisons and hospitals in England and Wales where an adult prisoner (aged 18 or over) has died of a ‘natural’ or ‘other non-natural’ death whist in custody of HMPPS.
    This page will be regularly updated, so please check for updates. Any queries relating to this study should be also addressed to prisonhealth@ncepod.org.uk.
    Resources:
    Her Majesty’s Prison & Probation Service
    Prisons and Probation Ombudsman
    House of Commons Health and Social Care Committee report ‘Prison Health’ 2018
    Nuffield Trust Research on healthcare in prisons

    Download links
    • General study poster
    • Study information poster
    • Audio
    • Study information poster - easy read
    • Study information leaflet
    • Audio
    • Study information leaflet - easy read
    • Prison healthcare scoping survey
    • Use of personal data survey
    • Case Reviewer Advert
    If you would like this information in any other language or format, please contact us

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