Title: Understanding the scale and nature of avoidable harm in prison healthcare
Funder: Department of Health and Social Care

Abstract: Research question What is the frequency and nature of avoidable harm in prison healthcare in England? Background Concerns about the quality and safety of healthcare in English prisons are longstanding. We have just completed the largest ever meta-analysis of avoidable harm across community healthcare settings involving 144 empirical studies. We found that one in 20 patients experience avoidable harm across healthcare but in prisons, evidence is lacking. There is therefore an important need to understand the scale and nature of avoidable harm in prison healthcare in England. Aims and objectives Estimate the incidence of avoidable harm in prison healthcare; Quantify, describe and classify the nature and severity of avoidable harm; Explore key stakeholder perspectives on the nature of avoidable harm in prison healthcare; Advise on interventions and implementation strategies to reduce the incidence of avoidable harm in prisons. Methods We will undertake a large retrospective cross-sectional study involving case note review of patient records in 12 prisons in England (months 10-26): we will identify the total population of prison records on a specific census date in the participating prisons (estimated 15,000); trained nurses will screen all records to identify an enhanced sample of patients at increased risk of avoidable harm (estimated 2,225); experienced and trained prison doctors will independently examine in depth the enhanced sample to identify incidents of avoidable harm and evaluate their nature over a 12 month period. To support and complement this central study, we will pursue: an initial phase of operationalising avoidable harm, training data collectors and piloting research procedures (months 1-9); parallel qualitative interviews with service user/stakeholders to capture their unique and rich perspectives regarding the nature of avoidable harm in prison healthcare (months 10-26); two conferences with service users/stakeholders to assess and translate our findings into research/policy priorities and dissemination materials (months 27-30). Research team We are a multi-disciplinary team of world-leading experts in patient safety and prison healthcare. Shaw has led relevant major projects in prison including a national study of self-inflicted deaths in custody. Several members are leads of the NIHR Greater Manchester Patient Safety Translational Research Centre. We are currently leading the avoidable harm study in primary care, we developed classification systems for the severity of avoidable harm which informs the current proposal, and we have well-established PPI collaborators. Anticipated impact and dissemination Our findings will have an important impact on NHS policy in England. For the first time, the NHS will have robust evidence of the nature and frequency of avoidable harm in prison healthcare and will be able to develop policies and strategic implementation plans to improve patient safety in prison. The research will help practitioners in prison to improve their working practices and minimise the risk of avoidable harm. The findings will help patient groups to advocate for improvements in safety in prison healthcare. We will disseminate via our strong links with the 3rd sector organisations, DHSC, NHS Improvement, NIHR CCF, NHS England, Ministry of Justice and Arms-Length-Bodies.

Lay abstract: Everyone has a right to high quality care for physical and mental health problems. Being in prison makes this difficult, as people have less opportunity to self-care or be in control of treatment, due to the prison regime and security. This is a particular problem because people in prison have more physical and mental health problems than those outside and more people now grow old in prison. Healthcare available to prisoners should not disadvantage them further, and services must make sure that people are not exposed to extra risks. Harm from healthcare refers to services not performing as they should &ndash; for example missing symptoms, or when treatment is late or is unsuitable for a person s diagnosis and their health getting worse as a result. There is research on healthcare services outside prison about the causes/prevention of avoidable harm, but we do not have the same level of knowledge about the services delivered in prisons. In this study, we will address this knowledge gap and identify avoidable harms, both physical and mental health, which happen specifically in prison healthcare services. Research in prisons is difficult. Prisoners are often vulnerable people with multiple life, health and care problems and they have high levels of need for care services. Prisoners may receive care from various organisations within and outside prisons. Information on their health or healthcare can be missing or incomplete and the turnover of people within prisons is often rapid. Our experienced research team has a long history of working together and has recently completed a study on avoidable harm in general practice. We have skills and knowledge about healthcare in and out of prison, thus the expertise to complete this important work well. Our research will find out how often and why avoidable harm occurs in prison healthcare in England. We will: (1) define what we mean by avoidable harm relevant to prison healthcare; (2) look at prisoner healthcare records and talk with prisoners, prison officers and healthcare staff to find out what harms take place and why; and (3) use our findings to recommend how healthcare in prisons can be made safer. We will create support groups of professionals and service users to guide us. We will involve healthcare and prison staff, prisoners and their family/friends and key people at the Department of Health and Social Care, NHS England and Ministry of Justice. This will make sure our research tackles the most important problems for everyone who is most affected by those problems. As we have done some similar work before, we can use existing resources from our universities so that the project costs are limited and provide value for money to tackle this very important topic.

Research activity codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES;7.3 MANAGEMENT AND DECISION MAKING
Health categories: GENERIC HEALTH RELEVANCE;MENTAL HEALTH