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13: Mental healthcare (2019)

Standard 13:

People with serious mental health issues are diverted from the prison system and receive appropriate treatment and supports in a timely manner.

Rationale:

It is well established that the prison environment exacerbates mental health issues. Mental illness in the context of prison must be viewed as a health issue requiring an effective and prompt health intervention, including diversion to appropriate treatment services outside prison.

Current context:

In Ireland, a 2005 research study showed that for all mental illnesses combined, rates ranged from 16% of male committals to 27% of sentenced men, while the rate for female committals was 41% and 60% for sentenced women.[287]

The prison chaplaincy service has been highly critical of the practice of accommodating people with severe mental illness in Irish prisons.[288] The Wheatfield prison chaplaincy service said mentally-ill prisoners were being ‘doubly punished’ and that officers were at risk of injury as a result.[289]

In April 2019, it was reported that the IPS, the HSE, the Department of Health and the Department of Justice and Equality are in discussions to establish a national personality disorder unit.[290]

The Central Mental Hospital (CMH) is currently operating at 100% of its capacity, with admissions to the CMH “systematically triaged according to the level of therapeutic security required and the urgency of clinical need”.[291] The average waiting time for transfer from prison to the CMH is 120.86 days (with a range from seven to 504 days)[292]. A new forensic mental health facility in Portrane is due to replace the CMH in 2020.[293] It will have a maximum capacity for 170 patients (comprising 130 secure spaces; 30 step-down spaces; and 10 CAMHS beds)[294]; however this will not meet demand based on the current and persistent number of prisoners awaiting transfer.

The second report of an inter-departmental group established to examine issues relating to people with mental illness who come into contact with the criminal justice system is due to be published shortly. This report will examine matters relating to mental health services for prisoners and post-release mental health services for prisoners.[295]

IPRT welcomes a recent study on self-harm in prisons.[296] The study showed that there were 223 incidents of self-harm in Irish prisons between 1 January and 31 December 2017. An episode of self-harm was recorded for 4% of the prison population. While four-fifths (80%) of these prisoners were male (with a mean age of 32), the rate of self-harm was 4.4 times higher among female prisoners than male prisoners. The rate of self-harm was higher among prisoners on remand compared to sentenced prisoners.

In 2019, the IPS was urged to keep its nursing committal forms under review following an inquest in 2019 which returned a verdict of suicide by a man who died four hours after he had been committed to Cork Prison.[297] Evidence demonstrated that, contrary to standard operating procedures, 15-minute checks were not being carried out. Following the inquest, the IPS introduced a new policy whereby ordinary observations are every three hours, allowing the IPS to direct resources to those on special observations or those deemed ‘at risk’, with an officer dedicated to perform the checks.[298]

Indicators for Standard:

Indicators for Standard 13

Indicator S13.1: The number of prisoners awaiting transfer to the CMH.

At the week ending 29 April 2019, there were 29 prisoners awaiting transfer to the CMH.[299] Of these, 26 were male and 3 were female.[300]

Between June 2018 and May 2019, the lowest number of prisoners awaiting transfer to the CMH was 18, for three weeks in September 2018, while the highest number was 34, in the week of 14 January 2019.[301]

Indicator S13.2: The length of time individual prisoners are being held in safety observation cells.

This information has been requested but was not provided at the time of publication.[302]

Indicator S13.3: The number of high support units across prisons nationwide.

There are currently two operational high support units in Cloverhill and Mountjoy prisons. Cork Prison also has a ‘vulnerable prisoners unit’ for individuals categorised as particularly vulnerable for medical or safety reasons.[303] It was previously recommended that all prisons should have a high support unit.[304]

Indicator S13.4: Ratio of one psychologist to 150 prisoners.

Outlined below is the ratio of psychologists-to-closed-prison-capacity.[305] (Note, however, that a number of prisons are operating above capacity, in which cases the ratio will actually be even lower.)

Psychologist-capacity ratio by prison in 2019[306]

Prison Bed space Psychologist-capacity ratio
Arbour Hill 138 1:115
Cloverhill 431 1:287
Wheatfield 550 1:166
Mountjoy 755 1:215
Dóchas (female) 105 0.5:105
Midlands 835 (excluding National Violence Reduction Unit) 1:384
Portlaoise 263 0.2:263
Limerick 238 0.8:238
Cork 296 1:227
Castlerea 340 0.5:340
National Violence Redcution Unit 10 0.3:10
Target 1:150
Total 3,925 1:251

Psychologist–prisoner ratios are poor for much of the prison population, with the lowest found in Castlerea and Cloverhill prisons. Cloverhill is the main remand facility; as already noted, there is a high prevalence of mental health issues among the remand population, with previous domestic research having shown rates of psychosis to be among the highest for the remand population, at 7.6%.[307]

In addition to the number of psychologists outlined above, the IPS employs 10 assistant psychologists on one-year contracts working in the area of primary mental health care and with young adults. The IPS Psychology Service also provides a consultancy service to Loughan House one day per month, as well as a psychology ‘drop-in’ clinic to Shelton Abbey one day per month.[308] This limited access to psychology services in open prisons is of concern, given the transitional adjustments a prisoner who has served a long sentence in a closed prison environment will make.

There are currently 614 prisoners on a waiting list for an intervention from psychology services, as outlined in the table below.[309]

Waiting lists for psychology services by prison, 2019[310]

Prison Waiting list (awaiting triage or intervention)
Arbour Hill 36
Castlerea 41
Cloverhill Remand 22
Cork 27
Limerick 27
Midlands 185
Mountjoy (f) Dóchas 5
Mountjoy Male 138
Portlaoise 69
Wheatfield 64
Total 614

Analysis

Mental healthcare was a spotlight issue in the PIPS 2018 report and is being raised again due to the lack of progress in this area. It is disappointing that there appears to have been no new measures introduced to divert people with mental illness out of the prison system and into an appropriate environment.

The dearth of information on this issue needs to be addressed. For example, it is important to know the lengths of time prisoners are on the waiting list for transfer to the CMH, as well as the type of accommodation and regime available to this cohort while they await transfer.

A comparative review of the diversion of mentally ill prisoners in Ireland and England and Wales found that both jurisdictions showed significant geographic variability in diversion services.[311] However, it also found that England and Wales had a broader diversion options, whereas in Ireland, diversion services were primarily linked to imprisonment, with little or no special psychiatric expertise available to An Garda Síochána. The Health Service Executive (Ireland) has previously recommended that there should be a senior Garda within each Garda division trained to act as a resource and liaison mental health officer.[312]

The review also highlighted a lack of intensive regional care units in Ireland compared to England and Wales, with limited scope in Ireland to divert to hospital at sentencing stage due to the absence of a ‘hospital order’ provision in Irish legislation.

The authors of the review concluded by recommending three key areas for the development of diversion services in Ireland:

  • enhance provision of advice and assistance to Gardaí at arrest, custody and initial court hearing stages;
  • legislative reform to remove barriers to diverting remand prisoners and facilitating hospital disposal on sentencing; and
  • develop intensive care regional units to facilitate provision of appropriate care by local mental health services (which they deemed urgent).

More generally, while the overall ratio of psychologist-to-prisoners appears to have narrowed, this may be attributed to the increased psychologist–prisoner ratio following the opening of the National Violence Reduction Unit (see Standard 28). Overall, the psychologist–prisoner ratio is nowhere near the recommended rate of 1:150.[313]

There continues to be a substantial number of prisoners awaiting a psychological intervention, significantly in Ireland’s two largest prisons, Midlands and Mountjoy. Lack of access to these services may result in delays in relation to prisoners’ progress through the system; for example, prisoners serving life or long-term sentences may be unable to fulfil their Parole Board recommendations.

Status of Standard 13: No change

Progressive Practice:

The STAIR model

Research has highlighted the importance of the STAIR (Screening, Triage, Assessment, Intervention and Re-integration) model, which highlights the essential conditions of mental health service provision in prison settings, encompassing the following.[314]

  • Screening: This should take place as soon as possible following committal. Trained mental health staff should administer validated screening tools. Initial screening aims to identify mental health issues requiring immediate intervention, for example, acute psychosis or substance withdrawal.
  • Triage: A second stage of evaluation should be carried out by mental health staff for all prisoners. This should provide a more detailed assessment of the individual’s mental health needs. This should be followed by triage to the appropriate service, following discussion in a multi-disciplinary meeting.
  • Assessment: This may include an in-depth psychiatric review and the development of an individualised treatment plan for those in need of a specialist mental health service based on their level of need.
  • Intervention: To respond effectively to the differential levels of illness presented, a comprehensive range of mental health services is required.
  • Re-integration: Planning for prisoner release should begin in advance of the release date. This must ensure the continued delivery of healthcare services including referral to community mental health services and support services for housing, employment and finances.

Actions required:

Action 13.1:

A high level Task Force on Prisons and Mental Health should be established comprising the Department of Health, Department of Justice and Equality, Irish Prison Service, the HSE, the National Forensic Mental Health Service and An Garda Síochána, with a focus on short, medium and long term solutions.
Action 13.2: The IPS should publish data, on an annual basis, on the number of people awaiting transfer to the CMH and lengths of time waiting. It should also publish information on the type of accommodation and regime available to this cohort while in prison.
Action 13.3: Prison psychology services should be adequately resourced in order to meet the psychology needs of the prison population. A ratio of 1 psychologist to every 220 prisoners should be a target in 2020, towards meeting the overall goal of 1:150.

References:

Irish Penal Reform Trust

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