Emergency care of prisoners in Australia.

Abstract

There can be nothing quite so anxiety provoking than the acute care of an unwell prisoner by health practitioners in both custodial and emergency environments. A lack of usual process due to security mandates like locked environments and handcuffs, the uncertain potential of behaviour challenges due to the potential presence of severe mental illness and personality disorders, a lack of full health information and the poor health literacy for someone who may have been traumatised in a number of ways, all contribute to unease. The subset of deliberate self-harm in people with severe personality disorder is of particular concern. Emergency physicians need to be specifically attuned to this group of patients as a recent study confirmed frequent ED use is independently associated with incarceration. This is not surprising as the social determinants of health and incarceration are similar.1 The article by Wu et al. in this journal2 is a timely reminder of the need for good care for this population and comes on the background of a number of deaths in custody. Systemic improvements will not be possible without first addressing the need for improved access to patients in non-health settings, effective systems, a level of tailored and respectful care, and a professionalised workforce. Navigating an environment not designed for health but where security is the highest priority is the key challenge, which results in a lack of proper access and non-health staff being the first point of contact. The approach to addressing this must be one of both formal and informal arrangements. Health services need to work with the custodial services to ensure policies and procedures exist, which maximise access in acute care in custodial settings and transfer to EDs in a timely manner. In the clinic or hospital setting, it is also important to acknowledge the senior correctional officer and their responsibility for security. EDs are a particularly high-risk environment for a correctional officer where a patient may try to escape or try to secure drugs. Acknowledging and working collaboratively with correctional staff assist to access the best care in a safe way. Systems need to be continually improved and specific clinical pathways need to be honed. An emphasis in resourcing for and training in reception screening will assist in identifying high-risk patients. Specific pathways for some diseases can be of use and have been developed. Improvements in clinical care require improvements in clinical governance. The Royal Australian College of General Practitioners will be soon releasing a second edition of Standards for health services in Australian prisons. This provides a fit for purpose standard for healthcare in prisons, which aligns with community equivalents. Systems to ensure handover of clinical information by all parties are important in this cohort with low health literacy. The people who enter custody are a traumatised and vulnerable group with high prevalence of mental illness, substance use disorders and physical conditions. There are high rates of homelessness and out of home care, sexual and physical abuse and trauma of various kinds. There is also a disproportionate number of Aboriginal people in custody around the country.3 A consultation will only be successful if it is approached in a trauma-informed and culturally sensitive manner. It is important to understand the person and especially any mental health matters before enquiring into physical ailments. These patients require good whole person care, and there are specific skill sets that benefit by bespoke education, which includes skills in providing physical care to people with mental illness (and personality disorders). There are formal postgraduate qualifications in custodial health in Australia for nurses currently and courses being developed for medical professionals. Stigmatisation is a particular problem for people in prison. This can and does occur in a number of ways by correctional officers, custodial health staff and hospital staff. Empathy and understanding will result in safer and more efficient care. Respect should be shown for the patients who are drawn from the most vulnerable groups, but also the correctional officers and the health staff who care for them. Promotion of prisoners as a subset of society and a cohort in their own right with specific needs will assist with care. Professionalising and empowering the workforce is necessary. The discipline needs support across specialities, educational opportunities at undergraduate, graduate and postgraduate levels, governance support and research undertaken to provide an evidence base of best care models in this environment. By addressing these elements of a complex challenge, we will see improved outcomes in health and recidivism for the incarcerated. SH works for the Justice Health and Forensic Mental Health Network which provides health services to people in prisons in New South Wales.