Analysis

Making reasonable adjustments in prisons: the role of the learning disability nurse

With one third of prisoners having autism, a learning disability or difficulty, specialist nurses are a necessity
Learning disability nurses in prisons

With one third of prisoners having autism, a learning disability or difficulty, specialist nurses are a necessity

  • There is a high proportion of people with learning disabilities or autism in prison and they often struggle to cope with life inside
  • Prison services have recently begun to recognise the need to employ learning disability nurses, and new specifications about meeting the healthcare needs of people with learning disabilities in prisons have been published this year
  • Learning disability nurses working in prisons talk about their work creating care pathways to support prisoners as well as training other prison staff to help them understand the extra challenges this cohort faces

Its a chilling scenario: a young man with autism is in prison. He is approached by another inmate and asked to keep some drugs for him. The other inmate tells

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With one third of prisoners having autism, a learning disability or difficulty, specialist nurses are a necessity

  • There is a high proportion of people with learning disabilities or autism in prison and they often struggle to cope with life inside
  • Prison services have recently begun to recognise the need to employ learning disability nurses, and new specifications about meeting the healthcare needs of people with learning disabilities in prisons have been published this year
  • Learning disability nurses working in prisons talk about their work creating care pathways to support prisoners as well as training other prison staff to help them understand the extra challenges this cohort faces
Picture shows prison officer addressing prisoners in hallway outside their cells. Learning disability nurses have a role in making reasonable adjustments in prisons
Picture: Alamy

It’s a chilling scenario: a young man with autism is in prison. He is approached by another inmate and asked to keep some drugs for him. The other inmate tells him that the prison officers are happy for him to take drugs, but that he prefers someone else to look after them. The young man with autism takes this request at face value – he’s happy to help, but then the drugs are found in his cell…

This, says Antony Hawkins, happens ‘every single day’ in prisons across the country – with unfortunate consequences for the individual.

1/3

of people assessed in prison in 2017-18 reported they had a learning disability or difficulty

4/5

of people with learning disabilities or difficulties report having problems reading prison information

Source: Prison Reform Trust 2019

Prison is difficult to navigate – particularly when you have learning difficulties or autism

Antony Hawkins, service manager for the Greenwich Prisons Learning Disability Service
Antony Hawkins

‘Prison is very black and white: the attitude is that if you’ve got the drugs, it’s your problem and you are the one that's going to get punished. If you are the one found holding the drugs, you will go to segregation, you will get put on report, you’ll get your TV taken away, and that just exacerbates the problem – imagine that for someone with autism.’

Mr Hawkins is service manager for the Greenwich Prisons Learning Disability Service, which covers Belmarsh, Isis and Thameside prisons. He is one of a growing number of learning disability nurses working in prisons across the UK as more institutions begin to develop specific services and pathway for this cohort.

‘Some say as many as 80% of prisoners will have some form of learning difficulty or learning disability, whether it be ADHD, dyslexia, autism, reduced IQ or some form of mild learning disability,’ says Mr Hawkins, although he cautions that the prison service has a wider definition than that generally used in healthcare. ‘It’s usually towards the mild end of the disability spectrum but the numbers are large, and the difficulties that presents in prison are complex and scary, and difficult to manage.’

Prison services have begun to recognise the need for learning disability nurses 

RCN professional lead for criminal justice and learning disability Ann Norman
Ann Norman

RCN professional lead for criminal justice and learning disability Ann Norman says prisons have only recently begun to understand the importance of learning disability nurses' input. ‘We’ve been campaigning to say that when you employ a learning disability nurse, you’re getting someone with enhanced communication skills; they’re skilful in de-escalation; if you think about the work they’ve done with people with challenging behaviour in other settings – and a prison setting is a challenging environment – they’ve got special skills that they can use.’

There are examples of good practice, says Ms Norman, but one of the issues is a lack of information. ‘It’s difficult to quantify the actual numbers of learning disability nurses in prisons – maybe 150–200 as a crude guess. A lot of the learning disabilities nurses who have been working in prisons for some time have just been getting on with it, developing and adapting tools, providing support and training to officers who don’t really know what they’re dealing with, so they are adding value there as well.’

New guidance on meeting healthcare needs of people with learning disabilities in prison

5x

Prisoners with learning disabilities or difficulties are five times more likely to have been subject to control or restraint. They are also more likely than others to have broken a prison rule

3x

and about three times more likely to report having spent time in segregation

Source: Prison Reform Trust 2019

In March, NHS England and NHS Improvement published an updated prison primary care services specification which, along with the integrated mental health service for prisons specification, outlines specific outcomes for meeting the healthcare needs of people with learning disabilities or autism (or both) or other vulnerabilities. It is anticipated that best practice guidance will be published to accompany this soon.

The primary care specification says that ‘appropriate support must be provided to people in secure or detained environments with an identified or suspected learning disability or difficulty to enable them to cope better within the secure environment and ensure that their healthcare needs are met’.

Some prisons are already doing this – Greenwich Prisons, where Mr Hawkins works, for example, has a detailed pathway to support inmates. If someone is found to have a learning disability the team will work with them and prison staff.

‘We’re looking at reasonable adjustments, working with the prison to understand what this person’s strengths are, and what support they will need in any areas of deficit, such as communication.’

This could include getting special permission to have digitised methods of communication, such as clocks – until this year, prisoners were not allowed digital clocks or watches – or timetables so that they know where they need to be at particular times. ‘We’ll work with the prison key worker to develop a care plan that works for the individual, but also for the prison regime. We’ll make sure that they have more appointment times, and that they get the right GP support. We make sure they understand how to complain and we’ll support them through any complaints.’

Identifying strengths and working to enhance them

They also identify and work with individuals’ strengths. ‘I used to see a guy regularly in and out of prison and what was important to him was having a worthwhile role. With prison, there’s an expectation that you do education first, so I had to support him to get him fast-tracked out of education into employment. It was about making sure he had an appropriate work role in prison that suited him – and that was cleaning.’

A national network for prison learning disability nurses

Mr Hawkins is enthusiastic about the role of learning disability nurses in prisons but says it can be isolating. That’s why he is involved in a national network for practitioners working with people with learning disabilities and autism in the criminal justice system.

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More than half of the prisons inspected in 2016-17 were actively supporting and identifying prisoners with learning disabilities – a significant improvement on previous years

Source: Prison Reform Trust 2019

‘We hold events where we all get together and share practice, have a chat and support each other. We’ve got an internet forum as well where we can ask questions and get a bit of support. It would be great to widen that so prison learning disability nurses are acknowledged and our voices are heard. That goes for prison nursing as a whole as well. It’s the fastest growing area of nursing – prisoners are becoming older and becoming more unwell. Prison healthcare is a high-pressure job that needs a lot of different skills.’

Nevertheless, he says more learning disability nurses are needed in prisons. ‘I love nursing and I love seeing the positive impact it has in prisons, but it’s hard to go into other prisons that do not have a specialist service. I know there are prisons where there are guys with a learning disability sitting in cells and we’re not doing anything about it. That needs to change.’

HMP Liverpool: ‘It’s been a massive benefit having a learning disability service in the prison’

Abigail Cardwell, learning disability nurse at HMP LiverpoolAbigail Cardwell, pictured, had always been interested in forensics, so when the opportunity came up to work as a learning disability nurse at HMP Liverpool, she jumped at it. More than 18 months on, she clearly loves it.

‘It’s a rewarding job,’ she says. ‘I enjoy working with people and the team around them. I like the consistently good feedback that we get from staff, individuals and internal and external agencies. If we weren’t there, there would be a lot of unmet need and a lot of inequalities.’

Until recently, HMP Liverpool, a remand prison, did not have a specific learning disability pathway. This was no different to many prisons around the country, says Mersey Care NHS Foundation Trust learning disability forensic nurse Lynsey Brown, who was asked to develop the pathway back in 2018.

‘My interest is in addressing the inequalities that people with learning disabilities face when they go into prison – the difficulty they face in being able to serve their sentences safely and fairly’

‘My interest is in addressing the inequalities that people with learning disabilities face when they go into prison – the difficulty they face in being able to serve their sentences safely and fairly. That includes being able to access health services, having reading and writing difficulties recognised – the things that can often create a real barrier for people trying to access services.

Pathways for release help people prepare for life beyond prison

‘We also create pathways for release, because people were leaving prison without any support and this would often lead to reoffending. A lack of support can lead to social isolation and difficulty finding work and so on.’

At HMP Liverpool, all new prisoners are screened at reception, usually by a mental health or primary care nurse trained in learning disability awareness, and referred to the service if they require support. If they agree, Ms Cardwell will work with them – in some cases even facilitating a diagnosis. ‘Some do come in with a diagnosis but a lot come in with a learning difficulties marker, and then we work with them to find out what their difficulties are, what are their support needs, what are their strengths and how we can support them while they are in custody to reduce any inequalities while they’re in our care.’

She also provides training to healthcare and discipline staff about learning disability awareness and what inequalities a person with a learning disability might face while being in custody – and how they can work together to support the individual.

‘A lot of the challenges that we face involve a breakdown in communication,’ she says. ‘Someone may present at a point of stress and they’re therefore not compliant with the regime. That, in turn, has an impact on their mental health and on the staff working to support them. We would identify how best to communicate with that individual and embed it in a support plan for them, and share it with staff if the individual has given consent.’

Specialist expertise has helped to reduce the need for restrictive practices

Having input from a learning disability nurse is hugely helpful, says Jonathon Drew, clinical specialist manager in the Secure and Specialist Learning Disability Division at Mersey Care NHS Foundation Trust. ‘It’s been a massive benefit having a learning disability service in the prison – our secure division is linked to learning disability and mental health so it’s great to have that input and expertise. One of the things that sticks out for me was that officers working with patients who have a learning disability wouldn’t have an understanding of why they hadn’t answered when they’d asked them a question, or why they didn't act straight away when given a direction.

‘There’s been lots of work in education and explaining the reason why, and the need to give the patient that bit of extra time so that they can cognitively process what they are being asked to do. We’ve seen some good work in, for example, reducing restrictive practice. So where in the past a patient might have been restrained, we’ve found a way of preventing that from happening.’

 


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