- Inquest heard of waits of 10 to 12 months in London
- One woman self-harmed more than once a day for six months but was not transferred
- NHS England reviewing transfer guidelines
Prisoners are waiting for as long as a year to access secure beds in psychiatric hospitals, despite guidance stating they should be transferred within 14 days.
The long waiting times were exposed after a woman at a privately-run prison in Surrey self-harmed more than once a day for six months, but was not transferred to a hospital bed. Kirsty Walker, 26, later died in a local acute hospital after she was found unresponsive with a ligature round her neck at HMP Bronzefield in Surrey in 2015.
Anna Crawford, assistant coroner for Surrey, issued a prevention of future deaths report after hearing the average time for transfer to a secure hospital was two to three months at Bronzefield, which she said was comparable to other prisons. However, the inquest also heard that, in London, this wait was 10 to 12 months on average.
A 2009 review by Lord Bradley into the experience of people with mental health problems or learning disabilities in the criminal justice system recommended prisoners be transferred to a hospital within 14 days if they are assessed as being detainable under the Mental Health Act 1982. The government reiterated this 14-day timeline in good practice guidance in 2011.
Ms Crawford asked both health and social care secretary Matt Hancock and NHS England chief executive Simon Stevens to explain what actions they were going to take and set out a timescale for them. She expressed concerns the average transfer times were “well in excess” of the 14 days recommended and warned this presented a risk of future deaths.
NHS England medical director Stephen Powis responded, saying NHSE was reviewing the guidelines around transfer to provide more “clinically informed timescales”. Local systems are also becoming more responsive with budget management being devolved to low and medium security services, he said.
An NHS England spokesman said: “A number of pieces of work are being undertaken, including improved performance management and increased collection and analysis of data – alongside a demand and capacity review in relation to adult high, medium and low secure services.
“Those initiatives, when complete, should lead to improved access to adult secure beds and reductions in length of stay.”
In its response, the Department of Health and Social Care referenced the work NHS England was carrying out.
Ms Walker was serving a nine-month prison sentence for breaching an anti-social behaviour order at HMP Bronzefield, which is run by Sodexo Justice Services. She had previously been diagnosed with borderline personality disorder and had a history of self-harming. On 25 March 2015, the day after she entered prison, Ms Walker was managed under the prison’s suicide and self-harm prevention procedures.
Between 25 March and 25 September 2015, Ms Walker self-harmed 235 times, with 215 of these incidences involving ligatures. On 25 September, she was found unresponsive in her cell and died two days later at nearby St Peter’s Hospital. An inquest jury concluded her death was accidental.
The prison contracted secondary mental health services to Central and North West London Foundation Trust. The trust, which was not criticised in the report, declined to comment.
Around 1,000 English and Welsh prisoners are transferred to hospitals each year because they are experiencing severe mental health problems. Figures released by the Ministry of Justice in April 2019 showed in the 12 months to March 2019, 87 of the 317 deaths in prison were self-inflicted.