Behind bars: The hidden health crisis in England's prisons

A new government report reveals alarming trends in prisoner health and what it means for healthcare providers and the justice system.

When the Department of Health and Social Care recently published its comprehensive review into The health of people in prison, on probation and in the secure NHS estate in England (the Report), it laid bare a troubling reality. Our prisons are facing a health crisis that affects not only those in prison, but also the staff who care for them.

Commissioned jointly by the Lord Chancellor and Secretary of State for Justice and the Secretary of State for Health and Social Care from the Chief Medical Officer, Professor Chris Whitty, the Report draws on extensive engagement with frontline health and justice professionals working across prison, probation and secure NHS hospitals.

A perfect storm of poor health

The statistics paint a stark picture. Prisoners and people on probation experience significantly worse physical and mental health than the general population and the prison environment itself often exacerbates these issues. Add to this an ageing prison population bringing increased age-related health problems, and the challenge becomes clear.

Whilst improvements in health provision have been made, significant barriers persist: gaps in services, poor data sharing, and risks during the critical transitions into and out of custody. Pregnant women, those with chronic or preventable infections, people with mental health needs, and those requiring palliative care remain particularly vulnerable and in need of improved care. Although some regions are making progress, wider implementation and prioritisation of vulnerable groups is needed, requiring genuine collaboration between healthcare and justice sectors. 

Drawing on our extensive experience in prison-related inquests and healthcare litigation, we examine the Report's key findings through both a legal and practical lens.

The self-harm epidemic: Numbers that demand action

Chapter ten of the Report focuses on trends in self-harm and suicide in prison and the figures are deeply concerning.

Self-harm rates in English and Welsh prisons have surged over the past decade. In the 12 months to March 2025 alone, there were 77,898 incidents of self-harm constituting a 6% increase from the previous year. The gender disparity is particularly striking: female prisoners experience rates more than eight times higher than males (5,906 versus 684 incidents per 1,000 prisoners).

Self-inflicted deaths have averaged around 88 per year over the last decade in England and Wales. When viewed across an 18-year European comparison, our prison suicide rates exceed the European average – a sobering benchmark that demands urgent attention.

The human cost: Impact on staff

Behind every statistic lies a human story – and not only for those in custody. Frequent exposure to traumatic events, including suicide and self-harm, takes a significant toll on both healthcare and prison staff. Research from 2019 found that approximately half of mental health nurses and prison officers surveyed reported medium or high levels of burnout, with around one in three experiencing medium levels of compassion fatigue.  Lived experience accounts raised concerns about trauma-informed care and how nurses respond to cases of self-harm.

In response, HM Prison and Probation Service (HMPPS) and healthcare teams have implemented various support mechanisms: Wellbeing and Support leads who focus on staff welfare following workplace incidents, Trauma Risk Management training (a peer-led support scheme for frontline staff who have experienced traumatic events) and proactive support from care teams following self-inflicted deaths.

In representing healthcare organisations and staff in prison-related inquests, we have witnessed first-hand how staff burnout and compassion fatigue can compromise clinical decision-making, documentation quality, and the delivery of trauma-informed care. These human factors frequently emerge during coronial investigations, underscoring that robust staff support mechanisms matter not only for workforce wellbeing but also for patient safety. Organisations that prioritise staff mental health and implement comprehensive support programmes are consistently better positioned to deliver high-quality care in these challenging environments.

Clinical factors: The key to reducing self-harm

The Report identifies multiple factors that increase self-harm risk in prisons, but clinical factors carry the strongest impact. Major depression, psychotic disorders (including schizophrenia and bipolar disorder), substance misuse and anxiety disorders emerge as key risk factors. This places primary care and mental health services at the heart of any strategy to lower self-harm rates, through early identification and treatment of clinical depression, psychotic disorders, personality disorders and other mental health conditions.

Significantly, the Report highlights that both National Institute for Health and Care Excellence (NICE) (2022) and NHS England (2025) guidelines state that risk assessment tools and scales should not be used to predict future suicide or repetition of self-harm, and that risk should not be stratified into simplistic low, medium or high risk categories to determine treatment or discharge. Newer risk assessment tools employing innovative methods and probability scores aim to enhance accuracy and enable more personalised decision-making, supporting greater consistency in clinical practice.

In complex prison-related inquests, inadequate or poorly implemented risk assessments frequently emerge as a critical issue. Whilst the development of innovative risk assessment tools is welcome, the effectiveness of any tool depends heavily on proper training, consistent application, and meaningful clinical oversight. Inquests often reveal that risk assessments were either not completed, not updated following significant events, or not adequately communicated between teams. The focus must therefore extend beyond developing better tools to ensuring robust systems for their implementation and review.

Making suicide more difficult: Environment and collaboration

The Report notes a reduction in deaths by hanging or strangulation in secure hospital estates since 2015, largely attributable to regular ligature reviews. New prisons have been predominantly fitted with ligature-resistant cells, where ligature points have been removed through cell design and careful installation of fittings and furniture. The aim is for every site to maintain a small number of such cells available for prisoners at the highest risk of ligaturing. However, the Report highlights that a few cells per prison falls short of what's needed. 

The Report also examines the Assessment, Care in Custody and Teamwork (ACCT) process, which is initiated when someone self-harms or is identified as being at risk, and can be opened by either custodial or healthcare staff. Notably, the ACCT's effectiveness in reducing self-harm or suicide has not been independently evaluated. The Report suggests that improving care for people who self-harm may require closer liaison between custodial and mental health staff. Whilst joint working can potentially create a shared focus in addressing risks, tensions can sometimes arise when healthcare service priorities misalign with prison service objectives. In prison settings, multidisciplinary risk assessment and management is required, incorporating wider systemic and environmental interventions.

Our experience representing healthcare organisations in prison-related inquests demonstrates that effective collaboration between healthcare and prison services is critical. Breakdowns in inter-agency communication and coordination frequently feature as contributing factors in coronial proceedings. When organisations fail to share information effectively or operate in silos, the consequences for vulnerable individuals can be severe. Recurring issues highlighted in Prevention of Future Deaths (PFD) reports following prison inquests include: failures to initiate ACCTs when risk indicators were present, poor quality and management of ACCT reviews, insufficient multidisciplinary involvement, premature closure without adequate safeguards, and incomplete documentation. These concerns underscore the need for enhanced training, robust quality assurance, and genuine multidisciplinary ownership of the ACCT process.

The missing link: Integrated prison and health records

The Report highlights that whilst clinical research within prisons could provide a robust evidence base to inform practice, undertaking such research is complicated by practical obstacles: organisational complexity, difficulties with randomisation, recruiting sufficiently large sample sizes, and following people up over time. A potential solution lies in using routinely collected linked datasets, which can reliably examine health service use following self-harm, stratify risk, and track repeat self-harm. However, prison service and health records are not currently linked. This is something the Report identifies as a critical gap that should be central to initiatives improving prison health.

The absence of linked prison service and health records creates difficulties not only for research but also at inquests and for organisational learning. In post-death and coronial investigations, the lack of integrated data systems can significantly impede the reconstruction of events and the identification of missed opportunities for intervention and learning (and this challenge extends beyond offender healthcare). Integrated information systems should be prioritised as a fundamental requirement for effective healthcare delivery, oversight and improvement.

How we can help

The findings of this Report underscore the critical importance of integrated healthcare delivery in custodial settings. As the legal landscape continues to evolve, with increasing scrutiny from coroners and regulatory bodies, healthcare organisations must prioritise the implementation of robust systems, effective inter-agency collaboration, and comprehensive staff support mechanisms. Our firm remains committed to supporting healthcare organisations in navigating these complex challenges and implementing sustainable improvements that enhance both patient safety and organisational resilience.

Our offender health team offers comprehensive legal services for healthcare organisations providing care in custodial settings, drawing on expertise in health, public sector, regulatory, and coronial law. Browne Jacobson is highly respected in offender health work, with significant experience in complex physical and mental healthcare inquests for prisoners.

Our inquest team provides holistic advice on cases involving transfers between community and secure settings, supports trusts and staff through challenging inquests, and offers practical guidance to witnesses. Our inquest barristers cover pre-inquest reviews and complex jury inquests nationwide, ensuring excellent service and support for public sector clients across the UK.

Our mental health and offender health clinical claims team assists healthcare organisations in the investigation, management and resolution of clinical claims arising in prison and mental health settings, many of which are high-profile and extremely sensitive.