A comparative study of people transferred from prison to hospital under the Mental Health Act 1983: their pathways and outcomes.

Student thesis: Phd


Background: Little is known about the treatment pathways, transition and discharge of prisoner-patients detained in secure psychiatric services and how best to support and manage remittal back to prison. Remittals to prison now constitute just over 20% of discharges from medium secure services annually. Currently, there is no formal mental health care-pathway or national targeted post-discharge service for prison remittals in the United Kingdom, and there is need for formal guidance on follow-up and after care provision which may be appropriate for this group. This collection of studies aimed to produce essential data which would characterise prison remittals, their pathways through medium secure services and aftercare received post-remittal. Method: A mixed methodological design was adopted which utilised both quantitative and qualitative data collection methods. A national prospective cohort study with a one year follow-up was conducted to identify factors associated with remittal to prison. All prisoner-patients discharged over a 6 month baseline period were included subject to Section 251 of the NHS Act (2006). Collection of demographic, clinical and criminological characteristics alongside ratings on 4 standardised clinical measures was informed by data extracted from medical case notes and telephone interviews with collateral informants. These data were compared across discharge destination for individuals discharged into the community and those remitted to prison. A concurrent qualitative investigation was conducted to further explore the identified key areas of interest. This involved a focus group interview and series of semi-structured interviews. Prison remittals were followed-up in the prison estate at 12 months post-discharge. Data were extracted from individual patient medical case notes to complete a proforma covering access to prison mental health services, treatment / care received post-remittal and incidents of self-harm / attempted suicide, readmission, and release into the community. Results: There were 153 eligible prisoner-patients identified across 33 medium secure services. Comparative analysis revealed that prison remittals were 4 times more likely to have a primary diagnosis of personality disorder than community discharges and had a significantly shorter length of stay; patients with a length of stay of 6 months or less were 2 times more likely to be remitted to prison. Prison remittal scored lower for the presence of protective factors with the largest difference observed for presence of motivation for and attitudes towards treatment. Prison remittals were also rated as significantly higher risk of future violence and offending, with the largest difference observed for risk of future serious offending. Interview and focus group data allowed for exploration of how clinicians account for these observed differences and exposed the internal and external processes that guide prisoner-patient pathways through medium secure services. Overall, it appeared that different factors are taken into account depending on a prisoner-patients discharge destination, and many clinicians expressed their concern for the outlook of some patients post remittal. Eighty-nine prison remittals across 56 prisons were followed-up. It was identified that post-remittal aftercare is limited and that many patients present as vulnerable upon discharge, particularly those with a primary diagnosis of personality disorder. Discussion: Evidence on the needs of prisoners requiring inpatient psychiatric care is improving and, through the data presented in this thesis, arguments for how best to respond to these needs can be further developed. It is hoped that this research will act as a platform for further development and consideration as to how best to manage prisoners who require secondary mental health care and the extent to which the medium secure estate can provide a proactive role in the care and rehabilitation of these individuals.
Date of Award1 Aug 2019
Original languageEnglish
Awarding Institution
  • The University of Manchester
SupervisorJennifer Shaw (Supervisor), Roger Webb (Supervisor), Michael Doyle (Supervisor) & Caroline Sanders (Supervisor)


  • prison transfer
  • mental health act
  • prisoner pathways
  • medium secure services
  • secure services
  • prison
  • forensic mental health
  • forensic services
  • offender health
  • mental health

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