Substantive changes are needed to improve patient safety in prisons, according to a new study published by the Journal of the Royal Society of Medicine. Practical changes such as timely access to health care services and better processes to mitigate medication-related harm should be prioritized, according to the researchers.

In the first nationwide analysis of patient safety incidents in prisons in England, researchers found that security, staffing constraints and the high turnover of prisoners are among the main barriers to the safe delivery of health care in prisons. They made several recommendations for how prison and health care leaders can work together in the interests of better coordinated and safer care.

The authors, from Cardiff University, the University of Manchester and the University of Nottingham, reviewed more than 4,000 reports across a whole year from prisons where a patient could have or did come to harm.

A third of cases were related to medication—for example, patients missing doses of prescribed medication or given the wrong treatment. Staff mistakes, such as mixing up similar patient names, were the most common reasons cited, and over 20% of medication-related reports were discovered and mitigated by staff, preventing any harm to patients.

In three out of 20 reports, prisoners were delayed in accessing or unable to access health care, including appointments at external hospitals. Security barriers, such as when prison wings are on lockdown, and lack of staff were the biggest causes identified by researchers, with changes to escalation policies required to prevent this and more support needed for prisons to maintain safe staffing levels.

They noted that prisoners use health care services three times more frequently than the general population, with poorer health outcomes. “Health care priorities are often overshadowed by a prison’s main objective of securing detained individuals,” the authors wrote. The risk of this is that the health care and criminal justice systems are out of sync to “adequately consider prisoner needs and responsibility of care.”

The researchers suggested that reviewing staff rotations, improving training and rethinking prison layouts could help improve access to in-house care. For external hospital appointments, they recommended revised escalation policies and plans to ensure staff escorts are put in place, and increased use of remote appointments and “in-reach” clinics. Standard handover practices, policies to ensure the safe transfer of medication and prescription information, and appropriate discharge planning could help to ensure continuity of care when people transfer in or out of a prison.