Patient safety in prisons: a multi-method analysis of reported incidents in England

Isobel J McFadzean, Kate Davies, Thomas Purchase, Adrian Edwards, Stuart Hellard, Darren M Ashcroft, Anthony J Avery, Sandra Flynn, Tom Hewson, Melanie Jordan, Richard Keers, Maria Panagioti, Verity Wainwright, Florian Walter, Jenny Shaw, Andrew Carson-Stevens

Research output: Contribution to journalArticlepeer-review


OBJECTIVES: Prisoners use healthcare services three times more frequently than the general population with poorer health outcomes. Their distinct healthcare needs often pose challenges to safe healthcare provision. This study aimed to characterise patient safety incidents reported in prisons to guide practice improvement and identify health policy priorities. Design: We carried out an exploratory multi-method analysis of anonymised safety incidents from prisons.

SETTING: Safety incidents had been reported to the National Reporting and Learning System by prisons in England between April 2018 and March 2019.

PARTICIPANTS: Reports were reviewed to identify any unintended or unexpected incident(s) which could have, or did, lead to harm for prisoners receiving healthcare.

MAIN OUTCOME MEASURES: Free-text descriptions were examined to identify the type and nature of safety incidents, their outcomes and harm severity. Analysis was contextualised with subject experts through structured workshops to explain relationships between the most common incidents and contributory factors.

RESULTS: Of 4112 reports, the most frequently observed incidents were medication-related (n = 1167, 33%), specifically whilst administering medications (n = 626, 54%). Next, were access-related (n = 559,15%), inclusive of delays in patients accessing healthcare professionals (n = 236, 42%) and managing medical appointments (n =  171, 31%). The workshops contextualised incidents involving contributing factors (n = 1529, 28%) into three key themes, namely healthcare access, continuity of care and the balance between prison and healthcare priorities.

CONCLUSIONS: This study highlights the importance of improving medication safety and access to healthcare services for prisoners. We recommend staffing level reviews to ensure healthcare appointments are attended, and to review procedures for handling missed appointments, communication during patient transfers and medication prescribing.

Original languageEnglish
Article number1410768231166138
JournalRoyal Society of Medicine. Journal
Early online date17 May 2023
Publication statusE-pub ahead of print - 17 May 2023


  • Drugs and medicines
  • healthcare-associated harm
  • medical management
  • patient safety
  • primary care
  • prison medicine


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