The incidence of avoidable healthcare-associated harm in prisons in England: a retrospective case note review

Abstract

Objective: To estimate the incidence of avoidable healthcare-associated harm for prisoners in England. Design: A retrospective cross-sectional case note review of prisoner healthcare records. Setting: 18 prisons in England were purposively sampled for maximum variation of characteristics based on prison category (open, local, training, high security and female), type (publicly and privately run) and population size. Population: After screening 15 027 prisoner records, two cohorts were selected: a sample of 6294 ‘enhanced risk’ prisoners and a random sample of 853 prisoners not included in the enhanced risk sample (n=7147). Main outcome measures: The primary outcome was the incidence of patient harm per 100 000 patient-years, judged at least probably avoidable. The secondary outcome was the incidence of patient harm judged at least possibly avoidable. Cases of avoidable harm were characterised in terms of patient impact, known as patient outcome(s), and the severity of harm experienced. Results: Within 18 prisons, 247 cases of avoidable harm were experienced by 244 prisoners and were identified from 7147 patient records. The incidence of avoidable harm was 2241.4 (95% CI 1970.5 to 2539.0) per 100 000 patient-years, and this rate could be as high as 3412.0 (95% CI 3075.8 to 3774.9) based on the records screened during this study. Most patient outcomes involved prisoners experiencing discomfort and pain (99/247, 40.1%) and delays receiving appropriate healthcare management or assessment (91/247, 36.8%). The identified cases of avoidable healthcare-associated harm for prisoners resulted mainly in moderate harm severity (157/247 cases, 63.6%), followed by severe harm (27, 10.9%) and death (27, 10.9%). Conclusions: Compared with community settings, people in prison experience a 41–67 times greater risk of avoidable significant healthcare-associated harm. This stark disparity underscores the urgent need for government and policy action. Delivering safe, equitable healthcare in secure environments remains a major challenge that demands focused attention.