This is the latest in a series of posts on the report of the Committee for the Prevention of Torture on its visit to Ireland in 2010.
Health Care Services
The CPT noted that the health care service in prisons has continued to evolve since its previous visit in 2006 with the further development of Healthcare Standards, the introduction of nurse managers and nurse-led initiatives, in-reach mental health services and the provision of a professional pharmaceutical service in each prison. However, the CPT was critical of a number of aspects of medical care, finding that the central management of prison health care services and the provision of health care in some of the prisons remain weak.
One point which may be lost in other analyses of the CPT’s report is critically important. The CPT noted that “the lack of any epidemiological information on the prison population hampers the ability to evaluate prisoners’ real health needs as regards medical and nursing care. The CPT continues to consider that in order to better identify the health-care needs within the prison system, the compiling of an annual report on the state of the medical services in the Irish Prison Service would be beneficial” (page 34).
There is a much more general point to be made here about the collection and publication of data about Irish prisoners. The type of data which is collected once a prisoner is committed is not publicly known. Nor is the information about literacy levels, medical history, previous convictions and previous residence made available publicly. It is not known if this information is collected across the entire prison estate. The publication of figures for the prison population of this nature would provide an enormously revealing picture of Irish prisoners. It would also provide a very rich source for researchers wishing to analyse the nature of that population and its particular characteristics. Such researchers are likely to include criminologists and penologists, but experts in education, social policy and perhaps especially public health would be able to provide us with much-needed analysis of prisons.
A number of studies have given us an insight into a population that is characterised by poor educational achievements, socio-economic disadvantage, homelessness, high incidences of mental illness and physical diseases, especially blood-borne viruses. However, in every case, the researchers had to seek out specific datasets and examine sectors of the overall population, or in the case of the O’Donnell et al study, obtain access to a large dataset of released prisoners. Gathering this information requires seeking access and consent every time and we cannot make direct links between each study because the data are not ‘cross-matched’, so, for example, we cannot say that the released prisoners in the O’Donnell et al study, for example, also have particular medical needs, or levels of educational attainment. It is not possible to create this very full, layered and in-depth picture of our prison population because these data are collected separately, or perhaps not collected at all, which necessitates each set of researchers having to start with a new population, gather new material and reinvent the wheel each time they carry out a study. The importance of data collection, which should be placed in the power of the Central Statistics Office, cannot be overstated. In its response, the Government pointed to the chapter on Healthcare in the Annual Report of the Irish Prison Service, but this chapter does not contain the kind of information the CPT is referring to.
On the specific health services within each prison, the verdict of the Committee was, overall, not favourable. It found that Mountjoy Prison had two general practitioners who attended the prison typically for a couple of hours during weekday mornings, but were contracted for 27.5 hours per week, which itself would not be enough for an adequate medical presence in Mountjoy. However, the nursing practices were found to be much better. Praise was also given to the in-reach team for mental health from the Central Mental Hospital and the prison’s medical centre. There was also a need to increase the attendance of medical practitioners at St. Patrick’s Institution and in Cork. In the latter, the only doctor attended from 7am until 9am, which was considered inadequate, especially when the doctor could only see inmates from 8am for one hour. At the Midlands Prison the doctors were in attendance for far less than their contracted hours.
“Regrettably, the delegation came across many cases of prisoners not receiving proper health care, particularly at Cork, Midlands and Mountoy Prisons” (page 36) said the Committee, considering this a consequence of the low levels of attendance by doctors. The interviews as admissions were inadequate and the recommendations made in hospital letters were not adequately followed up, there was also a lack of follow-up for those with chronic diseases and at Cork prison medication was often not given to prisoners at the required times. In one case in Mountjoy, a prisoner had been bitten and stabbed by another prisoner who was known to be hepatitis C positive, but no discussion or risk assessment was undertaken for that prisoner to discover whether he had required treatment to prevent other blood-borne viruses.
The Committee also heard several complaints regarding medical confidentiality, where prisoners attended external consultations in the presence of custodial staff as a mater of policy. At Portlaoise General Hospital, there was a secure room, but prisoners were attached on a permanent basis to a prison officer via a chain no more than a metre long including when the prisoner had to go to the toilet or take a bath, which the CPT considered “unacceptable” (page 37).
The CPT also found that the quality of medical record keeping was inadequate in too many instances, with the doctors’ notes scant but nurses’ notes more comprehensive. In addition, consultations in Cork, Midlands and Mountjoy often took place without the benefit of proper medical records and the electronic medical records system often contained limited information.
Moreover, the Committee noted that some prisoners were not being examined when admitted by a nurse or a doctor on the day of their admission and sometimes not at all. The committal interviews were often “extremely cursory” and notes on committal were of “poor quality” (page 39), in a number of cases appropriate steps were not taken to verify the past medical history of new prisoners. The CPT recognised that updated 2009 Irish Prison Health Care Standards recognise the importance of a thorough medical screening upon entry into the prisons system and advocated these need to be rigorously applied, especially given that there is a high prevalence of drug users. It also argued that injuries upon arrival in prison were often not correctly recorded or even recorded at all. This is particularly serious. As the CPT reiterates, prison health-care services can make a major contribution to the prevention of ill-treatment of detained persons through proper and systematic recording of injuries and recommended that the practice in our prisons live up to the written standards which state that the record drawn up following a medical examination of a newly admitted prisoner should contain an account of statements made by the person concerned relevant to the medical examination, an account of objective medical findings based on a thorough examination and the doctor’s conclusions.
The response of the Government indicates that independent reviews of primary care at Midlands, Cork and Mountjoy Prisons are underway and that IPS is engaged with the Irish Medical Organisation on compliance with the contracted hours of doctors and the matter is now before the Labour Court.
On confidentiality, the Government indicated that the reception area of Mountjoy has been altered to ensure confidentiality and where such facilities are not available in other prisons, “arrangements have been made” to carry out assessments on committal in the consultation room in the surgery. Regarding external consultations, the Irish Prison Service stated that its paramount responsibility is to ensure the secure custody of prisoners and where it is considered the person is a potential risk to staff or a flight risk, “those risks are managed in line with standard operating procedures” (page 46) though no further detail is given.
On medical records, the Government advised that a new system had replaced that criticised by the CPT, called the “Prisoner Healthcare Management System”. It allows for the documentation of injuries, self-harm and accidents. It also stated a system of scanning external consultation notes was being piloted and that doctors had been reminded by the Director General of the Irish Prison Service of the importance of timely and comprehensive committal assessments.