Prisons ill-prepared to deal with ageing population
Dementia is the subject of the latest (July 2016) Learning Lessons bulletin from the Prisons and Probation Ombudsman. The bulletin contains case studies which show how poorly equipped most prisons are to deal with an ageing population.
This is hardly surprising since prisons were designed to meet the needs of younger people and not those with chronic age-related conditions. However, meeting the needs of older prisoners is becoming increasingly important since 6% of inmates are now aged 60 years or older.
Those aged over 60 are the fastest-growing segment of the prison population, increasing 125% between 2004 and 2014. Those aged over 50 are the second-fastest-growing segment, increasing by 104% in the same timeframe, while the overall prison population increased by just 15%.
The MoJ projects the population in prison aged over 60 to increase from 4,100 in 2015 to 5,500 in 2020. Two of the main drivers for this demographic shift are longer sentences, and more late in life prosecutions for historic sex offences.
The ageing of the prison population shows no signs of abating, leading to an increase in deaths from natural causes in prisons and increasing social care needs of elderly and infirm prisoners. This has been recognised in the Care Act 2014, parts of which came into force in April 2015. The Act makes local authorities responsible for assessing and meeting the eligible social care needs of adult prisoners, although prisons will need to make referrals first. The aim is to bring the delivery of social care in prisons in line with the care of those in the community.
Just how important it is for prisons to start to respond to the needs of older prisoners is illustrated by three very sad and shocking case studies included in the learning bulletin, two of which are reproduced in full below.
Confusion about resuscitation
Mr A was admitted to prison in 2009, at the age of 79. He was already suffering from diabetes, heart disease and dementia. His health deteriorated over time and, in 2013, he was admitted to a specialist unit in the prison for older prisoners with long term medical conditions. On admission, a care plan should have been completed involving an assessment of Mr A’s mental capacity to see if he was capable of discussing his future care arrangements.
No plan was completed and healthcare staff did not discuss with Mr A his preferences about his care and treatment, including whether he wanted to be resuscitated if his heart or breathing stopped. An undated note in Mr A’s medical records stated that he did not have the mental capacity to make an informed decision and should be referred to independent mental capacity advocates. Such advocates are used for people who lack the capacity to make important decisions, when there is no one else able to represent the person who is independent of the service. This referral was not made.
When Mr A died, there was confusion about whether to try to resuscitate him, because no clear decision about his mental capacity or whether he should be resuscitated had been made. Resuscitation was attempted but was unsuccessful.
The Ombudsman concluded that a properly considered, comprehensive and recorded care plan would have better guided staff and addressed Mr A’s needs and recommended that such a plan should be the standard expectation in similar cases in future.
Dying but still in handcuffs
Mr B was 63 years old when he was sent to prison. He had several health problems, but in particular he had been diagnosed with vascular dementia, caused by a lack of blood to his brain, thought to have been caused by high blood pressure and previous strokes. A number of professionals assessed him to identify his care needs. He had a disability care plan, received appropriate medication and healthcare staff monitored him frequently.
However, no one took overall responsibility to ensure that all his needs were met. Healthcare staff decided that the cause of his dementia was largely physical, and the mental health team did not assess him for almost a year. Mr B did not always remember to take his medication as prescribed and his personal hygiene deteriorated. He was seen by a doctor when he complained of painful feet, and the doctor noted that this was due to poor hygiene. The doctor made a referral to a podiatrist, but there is no record of this ever happening.
A healthcare manager at the prison told the PPO investigator that Mr B would have had to make a written application to see a podiatrist himself, if he wanted to be treated. The Ombudsman found this to be neglectful for a man with his poor mental capacity.
At the end of life, prison managers decided that Mr B should be restrained by an escort chain in hospital, without a proper risk assessment that took into account his health and mobility. He was restrained for three days in hospital before the restraints were removed, two days before he died.
The Ombudsman uses this learning bulletin to repeat his plea that the Prison Service badly needs a properly resourced national strategy for its rapidly growing population of older prisoners, to guide its staff in their management of age-related conditions such as dementia.