March 2010

Not a Marginal IssueMental Health and the criminal

justice system in Northern Ireland

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Not a Marginal IssueMental Health and the criminaljustice system in Northern Ireland

March 2010

Presented to the Houses of Parliament by the Secretaryof State for Northern Ireland under Section 49 (2) ofthe Justice (Northern Ireland) Act 2002.

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Contents

List of abbreviations vi

Chief Inspector’s Foreword vii

Executive Summary viii

Recommendations x

Section 1 Inspection Report

Chapter 1: The issues to be addressed 3

Mental illness and personality disorder 3Addiction and mental disability 5Children and young people 6Human rights 6The Bamford Review 7Early intervention 9Aims of this inspection 10

Chapter 2: Arrest and detention 11

Police involvement 11Policy on mental health 12Public protection 12A place of safety 13Diversion out of the criminal justice system 14Police cells 15Role of the police vis à vis the Health Service 15Information systems 16The Appropriate Adult scheme 16Forensic Medical Officers 17The Mentally Disordered Offender scheme 17

Chapter 3: The options available to the Court 19

The Judges’ perspective 19A Mental Health Court 21The Public Prosecution Service for Northern Ireland 22Victims and Witnesses 24The legal framework for disposals 25The Pre-Sentence Report 25What are the alternative disposals? 27High secure hospitals 27The Shannon Clinic 27Other medium and low secure facilities 28Hostel accommodation 29Community Mental Health Orders 29

Chapter 4: Prison and parole 31

Northern Ireland’s prisons 31The transfer of responsibility for healthcare in prison 32Reception into prison 34Continuity of healthcare 34Psychiatric services 35The REACH project 37Suicide and self-harm 37Addiction services 40Prison officers 40Listener schemes 41Women prisoners 41Psychologists 42Preparation for discharge 44Prison inreach in the Republic of Ireland 45

Chapter 5: Children and young people 47

Mental disorder in young people 47The Youth Justice Agency 48Mental health strategy 48Community Services 49Youth Conferencing 50The Juvenile Justice Centre (Woodlands) 50Professional staff 51General practitioners 52Relationship with community healthcare 52Relationship with education 52Statistics 53

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Chapter 6: Work in progress 55

Mental health in the prisons 55The Personality Disorder Strategy 56

Chapter 7: Conclusions 59

Tensions in the system 59The governance of prison healthcare 60The future of the prison system 61Management arrangements for delivery across the system 62The need for a realism 63

Section 2 Appendices

Appendix 1: Republic of Ireland: Prison Inreach and Court Liaison Service 66

Appendix 2: List of agencies and organisations consulted 68

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List of abbreviations

ACE Assessment, Case Management and Evaluation used by the PBNIACPO Association of Chief Police OfficersASD Anti-social personality disorderASIST Applied Suicide Intervention Skills TrainingCAMHS Child and adolescent mental health servicesCBT Cognitive behavioural therapyCJI Criminal Justice Inspection Northern IrelandCJS Criminal Justice SystemCPN Community psychiatric nurseDHSSPS Department of Health and Social Services & Public SafetyFMO Forensic Medical OfficerGB Great BritainGP General PractitionerHMIP Her Majesty’s Inspectorate of PrisonsIQ Intelligence quotientJJC Juvenile Justice CentreMDO Mentally Disordered OffenderMHLOs Mental Health Liaison OfficersNACRO National Association for the Care and Resettlement of OffendersNIACRO Northern Ireland Association for the Care and Resettlement of OffendersNI Northern IrelandNiCHE RMS Records Management System provide by Niche Technology (in PSNI)NICtS Northern Ireland Court ServiceNIPS Northern Ireland Prison ServicePBNI Probation Board for Northern IrelandPD Personality disorderPDP Potentially Dangerous PersonPPANI Public Protection Arrangements for Northern IrelandPPS Public Prosecution Service for Northern IrelandPSNI Police Service of Northern IrelandPSR Pre-Sentence Report (by the Probation Board)REACH Reaching out to prisoners through Engagement,Assessment,

Collaborative working and Holistic approachRMN Registered mental health nurseSpR Specialist RegistrarYCS Youth Conference ServiceYJA Youth Justice AgencyYOC Young Offenders Centre

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Evidence suggests that around 16% of those individuals who are placed into custody meet oneor more of the assessment criteria for mental disorder. In addition, it is estimated that 78%of male prisoners on remand and approximately 50% of female prisoners are personalitydisordered – a figure seven times that of the general population. Personality disorder is oftencombined with and aggravated by the abuse of alcohol and drugs. Mental health within thecriminal justice system is not a marginal issue.

This report follows the treatment of people with mental health problems through the criminaljustice system starting with the police, moving through prosecution and the courts and endingup with prisons and probation. During this thematic inspection Inspectors saw some excellentpractice across the system as professional staff try to deal with some very vulnerable, difficultand in some cases, dangerous people. Our report highlights a range of deficiencies in provisionacross the system. Agencies struggle with the demands of dealing with people with mentalhealth issues and find it difficult to access the expert services they need.

The amount the justice system spends on mentally disordered persons who are repeatoffenders is substantial; to the detriment of the rest of the criminal justice system. There arealso important questions of how society can be sure that justice is being done, the rights ofindividuals are being respected and, the safety of staff assured when dealing with vulnerableand sometimes very dangerous people. The consequences of the release from prison of peoplewith mental health problems without having received adequate treatment, are seen in some ofthe most appalling offences ever to hit the news headlines.

The treatment of people with mental disorders presents enormous challenges to the criminaljustice system. Earlier screening and assessment is critical. The strategic objective should thenbe to divert, whenever appropriate, more offenders away from custodial care. Prisons are nottherapeutic environments and generally make mental health matters worse. For those whoare imprisoned, the quality of care within the system needs to be improved. In addition, moreeffort should be made to successfully re-integrate people into the community when theyemerge from the justice system. Greater collaboration between justice agencies is required toprovide a more connected service that deals with the needs of individuals at each critical stageof their interaction with the criminal justice system. We also recognise that this cannot be thesole responsibility of the justice system. A stronger relationship between justice and health isan important foundation for moving forward.

The inspection was carried out by John Shanks, Brendan McGuigan and Danielle Reaney. Iwould like to express my thanks to them and to all those who participated in the inspection.

Dr Michael MaguireChief Inspector of Criminal Justice in Northern IrelandMarch 2010

Chief Inspector’s Foreword

Northern Ireland’s prisons hold a number of people with mental health problems whoarguably should not be there. Imprisoning them is not always the best response to theiroffending; it frequently does them no good and risks further harming their mental health,making them more likely to re-offend. Mentally disordered offenders are adding to the prisonpopulation and will increasingly do so with the introduction of extended and indeterminatesentences for offences of ‘dangerousness’. The cost implications are worrying. Moreover, theprisons are not staffed to deal with these people. There has been a deficit of professionalpsychological and psychiatric input not just for the Northern Ireland Prison Service (NIPS) butfor the Criminal Justice System as a whole.

The Police Service of Northern Ireland (PSNI) likewise is struggling to deal with mentallydisordered persons, with often inadequate support from the Health Service. On occasion itfinds hospitals unco-operative and having to return people into the community with everyexpectation that they will be back into the criminal justice system within a short time.

In Northern Ireland there has been a historic lack of resourcing for mental health services.There is an estimated 25% higher level of need than in England and Wales, and in this context,a wide-ranging review of mental health services (The Bamford Review) was undertaken.This review, among other things, looked specifically at mental health in relation to the justicesystem. There are some commendable initiatives being taken in response to Bamford, but itsrecommendations were ambitious and there is understandable difficulty in implementing manyof them in the face of current resource constraints.

Mental health provision is deficient across Northern Ireland and we cannot expect a topclass service for offenders. Nevertheless, there is a particular concentration of mental healthproblems in the offending population and it is in the wider public interest - for financialreasons no less than for reasons of public protection - that they should receive specialattention. This may well mean a criminal justice ‘premium’ in terms of budget for theprovision of mental health provision. There needs to be greater clarity about who isresponsible for what in relation to mentally disordered offenders, and a real commitmenton the part of the Health Service to accord the necessary priority and resources to theirtreatment.

Even if more mentally disordered offenders are diverted into the Health Service, it may bethat, at the end of the day, society is forced to conclude that there is no alternative toimprisonment for an increasing number of people. But if so, that has radical implications forthe future character of the NIPS. It will need to be seen as a secure care service, no less thanas a penal service. In addition it will need to be resourced with the right mix of professionalsto provide mental healthcare as a core function. It will also be required to plan its estate anddesign its next generation of buildings with mental health, not just security, in mind. Above all,it will need to run ‘healthy prisons’ as defined in previous inspection reports by CriminalJustice Inspection Northern Ireland (CJI) and Her Majesty’s Inspectorate of Prisons (HMIP).

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Executive Summary

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There are messages in this report for all the agencies of the criminal justice system.They all struggle with the issues of mental health, and find it difficult to access the expertservices they need. The Inspectorate has been cautious in its recommendations, recognisingthat these are difficult times and additional resources are unlikely to be forthcoming.Nevertheless, we believe that a clearer understanding of the issues can lead to betterco-operation between the justice agencies and health and social care services, resulting inbetter outcomes, both in terms of fairness and appropriate clinical treatment for theindividual, and of safety and cost for the citizen and taxpayer.

Developing effective partnership arrangements between the criminal justice system and theHealth Service is the right way forward in the next few years. This cannot be taken forgranted, and it is necessary to ensure that appropriate services are being delivered thatprovide a meaningful impact on the care regime for prisoners. We accept that the HealthService should have responsibility for the delivery of healthcare in prisons. This is in linewith practice in England and Wales. We recommend, however, that the quality of servicedelivery should be subject to formal review to ensure that appropriate developments aretaking place.

This report identifies the following as the six main areas in which changes need to be made:• Establish clear rules about where mentally disordered people are to be taken when they

are arrested or detained by the police. The rules should distinguish between differentsorts of cases and should be specific about the relevant place of safety for each categoryin each police district.

• Make sure that mentally disordered people are properly assessed when they arrive atthe place of safety. In police stations, this means extending the Mentally DisorderedOffender (MDO) scheme to cover all the custody suites in Northern Ireland.

• Make sure that the assessment (and any other available information) is properlyrecorded on the PSNI’s information system (NiCHE) and is passed on as part ofany file which goes to the Public Prosecution Service for Northern Ireland (PPS).

• Make sure that the PPS brings any mental health issues to the attention of the Court atthe earliest opportunity, so that the judge can consider it (and call for further expertadvice, if necessary) before the case is heard.

• Make sure the care of prisoners is based around the ‘healthy prison’ agenda whichprovides real and significant outcomes for prisoners. There is a need for on-going reviewof the quality of care provided by the Health Service and corrective action taken wherenecessary. In addition, there is a need for a local high secure hospital to which the mostdangerous mentally disordered prisoners can be transferred for treatment.

• Focus on the need for suitable accommodation to help mentally disordered offenders tomake the transition back into the community with adequate supervision and aftercare.

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• The PSNI should introduce a training module on mental health based on an e-learningpackage currently being developed by The National Centre for Applied LearningTechnologies, the National Police Improvement Agency and Association of Chief PoliceOfficers (ACPO) (paragraph 2.4).

• The PSNI should finalise a protocol with the Health Service making clear the preciserespective responsibilities of the two services, so that there is clarity abouthow mentally disordered persons are to be handled (paragraph 2.12).

• The PSNI should ensure that Custody Officers complete a mental disorder warning onNiCHE RMS for those detainees presenting with a mental health condition (paragraph2.23).

• The Mentally Disordered Offender (MDO) scheme should be extended to all custodysuites in Northern Ireland (paragraph 2.32).

• The Northern Ireland Court Service (NICtS) should arrange for judges to have accessto expert advice in interpreting psychiatric reports and handling cases which involvemental health issues (paragraph 3.3).

• Where material issues of mental health are raised by the Public Prosecution Service forNorthern Ireland (PPS) or other advisers, judges should hold preliminary hearings toestablish the mental state of the defendant (paragraph 3.4).

• The Public Prosecution Service Code for Prosecutors should devote more space toquestions of fitness to plead and possible non-responsibility by virtue of mentalincapacity or mental disorder (paragraph 3.15).

• The PSNI should bring mental health issues that might affect the conduct of a case tothe attention of the PPS at the earliest opportunity (paragraph 3.17).

• The PPS should be pro-active in flagging up for the Courts, mental health issues thatmight affect the conduct of a case (paragraph 3.17).

• The Probation Board for Northern Ireland (PBNI) should be granted more time toprepare Pre-Sentence Reports (PSRs) in cases which involve difficult mental health issues(paragraph 3.29).

• Assess the need for a local high secure hospital to which the most dangerous mentallydisordered remand prisoners can be transferred for medical treatment (paragraph 3.36).

Recommendations

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• The needs of mentally disordered offenders should be factored into the strategic reviewof hostel (Approved Premises) accommodation (paragraph 3.44).

• A specialist child and adolescent psychiatrist should be appointed, based in NorthernIreland, to advise the criminal justice agencies (paragraph 5.23).

• All the criminal justice agencies in Northern Ireland should collect statistics on theincidence of mental health issues in the cases they handle and these should be sharedwith the Health Service (paragraph 5.32).

• The Health Service should be held accountable for the delivery of the programme ofimprovements to mental healthcare in prisons which is planned (paragraph 6.2).

• The Northern Ireland Personality Disorder Strategy should be pursued as quickly aspossible, and to the degree that, resources allow (paragraph 6.7).

• A formal review of the service provided by the Health Service to the NIPS should beundertaken in 2014. The review would consider the impact on prisoner outcomesof the services provided by the South Eastern Health and Social Care Trust againstNIPS requirements and Her Majesty’s Inspectorate of Prisons’ ‘healthy prison’ test(paragraph 7.9).

• A joint Health and Criminal Justice Programme Board should be created to bringtogether all relevant organisations to develop a clear approach to the needs of mentallydisordered offenders (paragraph 7.15).

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Inspection Report

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Section

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1.1 The treatment of people with mentaldisorders presents enormouschallenges to the criminal justicesystem. Mentally disordered persons1

are not merely troublesome to dealwith, but are also costly to thesystem. There are importantquestions to ask about how one canmake sure that justice is being doneto them, that their rights are beingrespected, and that the safety of staffand of the public is being assured.

Mental illness and personality disorder

1.2 The subject is complicated by theproblem of definitions and by thefrequent difficulty of diagnosis. Theterm ‘mental disorder’ embracesboth mental illnesses such asparanoia and schizophrenia andpersonality disorders such asborderline personality disorderand anti-social personality disorder.We are talking primarily aboutpeople whose behaviour is seriouslydisturbed and perhaps aggressive andunpredictable, such that they pose adanger to others or to themselves.Lord Bradley, in his review of peoplewith mental health problems andlearning difficulties within the criminaljustice system,2 provides what seems

an acceptable option: “Those whocome into contact with the criminaljustice system because they havecommitted or are suspected ofcommitting, a criminal offence, andwho may be acutely or chronically ill.It also includes those in whom a degreeof disturbance is recognised even thoughit may not be severe enough to bringit within the criteria laid down by theMental Health Order NorthernIreland 1986.”

1.3 It is estimated that 78% of maleprisoners on remand and 64% ofsentenced prisoners are personalitydisordered. For females the figure issaid to be 50%. Anti-social disorder(ASD) is the most common in allcategories, particularly among men.Paranoid personality disorder (PD)is the second most common amongmen, while borderline PD is secondamong women. The Probation Boardfor Northern Ireland (PBNI) told usthey believed there was a great dealof confusion and mis-diagnosis, andthat many people were on medicationfor mental illness who were actuallypersonality disordered. Inspectorsunderstand that medication isindicated and commonly prescribed,in the management of co-morbid

The issues to be addressed

CHAPTER 1:

1 The NI Human Rights Commission prefers the term ‘people with mental health problems’. The reasons for that are acknowledged,but ‘mentally disordered persons’ is more convenient and is in standard use in discussions of this subject.

2 Review of people with mental health problems or learning disabilities in the criminal justice system; The Rt. Hon Lord Bradley, 30 April 2009;www.dh.gov.uk/en/Publications and statistics/Publications/PublicationsPolicyandGuidance/DH_098694

symptoms in people with apersonality disorder.

1.4 These high figures for the incidenceof personality disorder, however,cover a wide range of degrees ofdisorder and have to be treated withcaution. The incidence of PD in theoffender population is significantlyhigher than in the population at large,but the majority of them have to beseen as offenders who have a degreeof PD, rather than as innocentsufferers from PD. There is atendency sometimes to interpret thehigh figures for PD in the prisonerpopulation as a sign that the justicesystem is flawed. Inspectors do notshare that view. The boundarybetween responsibility and incapacityis necessarily fuzzy, and it may not beset exactly right – we look at theissues of fitness to plead and or thecapacity to form a criminal intent(doli capax) in Chapter 3 – but thereare no grounds for thinking that thegreat majority of those convictedshould not have been tried for theiroffences.

1.5 There is a separate question of howmentally disordered offenders shouldbe sentenced once they have beenconvicted. To what extent shouldmental disorder count as a mitigatingfactor? Even if mental disorder is notdirectly causative of offences, it is atleast stochastically causative3, with theincidence of PD in the prisonerpopulation three or four times that inthe general population. The reality is,

however, that for a wide range ofoffences of ‘dangerousness,’ currentsentencing policy means that mentallydisordered offenders are liable to besentenced more severely than others4

for similar offences. There is anacknowledged policy dilemma there.5

Personality disorder‘Psychopathic disorder’ is the term usedin the Mental Health Act (England andWales), referring to people who have:“a persistent disorder or disability of mind... which results in abnormally aggressive orseriously irresponsible conduct.”The Act distinguishes between‘psychopathic disorder’ and ‘mentalillness,’ but puts both under anumbrella term of ‘mental disorder’.Anti-social disorder is the diagnosismost commonly, though not exclusively,associated with psychopathy.People all have a mixture of personalitytraits, and where a tendency to one orother trait shades into personalitydisorder is necessarily a matter ofjudgment. Someone with a personalitydisorder will engage in a certainbehaviour pattern that causes moreproblems than it solves - if not forthem, then for the people around them.This behaviour tends to be the result ofa deeply held belief related to the waythey view the world. Their belief in thisworld view is so strong that anyevidence to the contrary is discounted.They may be aware of the problemsexperienced by the people aroundthem, but are unable to make aconnection between these problemsand their behaviour. When they are

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3 In the way that smoking can be said to cause cancer: it does not happen in every case, and plenty of personality disordered personsmanage their lives successfully, but there is a strong positive correlation between PD and offending.

4 Under the Criminal Justice Order (NI) 2008 extended and indeterminate sentences have been introduced for a range of offencesindicative of ‘dangerousness’.

5 There are currently proposals in England and Wales for sentencing guidelines which would reduce the ability of judges to exercisediscretion in cases of diminished responsibility. Inspectors believe that, if anything, more not less room for judicial discretion isrequired, and would be concerned if such guidelines were to be introduced in Northern Ireland.

affected by negative consequences theywill often try to find ways of copingthat, because they are based on thesame world view, only create morenegative outcomes.Given the uncertainty about diagnosingpersonality disorder, it is not surprisingthat there are disagreements aboutwhich patterns of belief and behaviourmake up antisocial personality disorder.Four features recur, though, all of whichare linked to offending behaviour.They are:• failure to make intimate

relationships;• impulsiveness;• lack of guilt; and• not learning from adverse

experience.

Addiction and mental disability

1.6 Mental disorder is often combinedwith, aggravated by and sometimesmasked by the abuse of alcohol andother drugs. The combination isknown as a ‘dual diagnosis’. Separatingout the effects of the mental disordercan often be problematic. But we donot include people with a drugaddiction alone in the category of thementally disordered. If we did so theproportion of offenders and suspectscovered by the definition would beimpossibly large.

1.7 Another ‘dual diagnosis’ is thecombination of mental disorderand learning difficulty (or learningdisability). People with learningdisability amount to about seven per1,000 of the population, or about10,000 people in Northern Ireland.The figure is imprecise, especially at

the more moderate end of learningdisability. Of those, roughly halfwould have severe or profoundlearning disability, which in a quarterto a third of cases is accompaniedby very challenging behaviour,not dissimilar to the behaviourencountered in some personalitydisordered patients. A large numberof people coming into custodywould have a low IQ, but those withserious learning disability are usuallyidentified by the police and divertedinto care without ever coming beforethe courts. It is particularly difficultto treat personality disorderedpatients with learning disabilitiesbecause many of the therapies(such as Cognitive BehaviouralTherapy - CBT) rely on a degreeof verbal ability.

1.8 Even without the addicted and thelearning disabled, the proportion ofpeople coming into the criminaljustice system who suffer fromsome significant mental disorder issubstantial. The PSNI Musgrave Streetscheme for mentally disorderedoffenders (‘the MDO Scheme’) foundthat 16% of custody records metone or more assessment criteria formental disorder. Studies in Englandand Wales found a range from 7 –15%. Central Belfast is not typical ofNorthern Ireland as a whole, but ona conservative estimate, at least oneperson in eight coming into contactwith the criminal justice system inNorthern Ireland is likely to besuffering from some mental disorder.

1.9 Mental health is therefore not amarginal issue for the criminaljustice agencies, especially since manyof those with mental disorders are

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liable to be persistent offenders. TheSocial Exclusion Unit of the CabinetOffice calculated in 2002 that thecost to the system of each recidivistwas around £65,000. Good qualitymental healthcare is not cheap, as weshall see, and not all conditions aretreatable, but if even a proportion ofmentally disordered offenders couldbe restored to a stable mentalcondition, there would be significantfinancial savings.6

Children and young people

1.10 Within the category of mentallydisordered offenders, specialattention needs to be given tochildren and young people, for whomseparate arrangements are in place inNorthern Ireland under the aegis ofthe Youth Justice Agency. We devotea separate chapter (Chapter 5) tothat subject.

Human rights

1.11 The concept of responsibility iscentral to consideration of the humanrights of people with mental healthproblems. It is a general principleof law that a person liable to bepunished should, at the time ofhis/her offence have had the capacityto understand what was requiredby the law and to control his/herconduct accordingly. Normally,functioning adults are generallyassumed to have these capacities, andtherefore to be responsible for their

actions. In principle, if someone isnot responsible for their actions theyshould not be punished but should bediverted to the appropriate health orsocial care services.

1.12 The courts, however, also have totake into account the safety of thepublic, the public demand forretribution for the offence, thegeneral deterrent effect of thesentence on the offender and onothers, and the long-term interestsof the offender. In theory, there is apresumption against prosecutingsomeone who was mentallydisordered at the time of the offenceunless that is overridden by thepublic interest, as in the more seriouscases. In practice, in the greatmajority of cases there is a bias infavour of prosecution.

1.13 The Association of Chief PoliceOfficers (ACPO) guidance7 reflectsa restrictive stance on diversionaway from criminal proceedings.It says: “The mental health of anindividual should only be taken intoaccount in deciding not to charge or totake other action through the criminaljustice system if all of the followingcriteria apply:• The offence is not serious andrelates to a minor infringementof the law;

• the offence is not part of a seriesof offences or a pattern of offendingbehaviour;

• the mental health issue has affected

6 If, very roughly, an eighth of those arrested each year are mentally disordered there are at least 3,000 regularly active mentallydisordered offenders in Northern Ireland (almost certainly more). If a quarter of them could be caused to desist as a result ofimproved treatment that would produce savings of about £5 million a year to the justice system. £5 million a year could also besaved if the prison population could be reduced by 60, or if 80 of those currently in prison could be moved out to supervised hostelaccommodation.

7 Guidance/Practice Advice on Police Responses to People with Mental Health Issues, issued on behalf of the Association of Chief PoliceOfficers by the National Police Improvement Agency, 2008.

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the individual’s criminal responsibilityfor their actions;

• the decision has been made inconsultation with the CPS [PPS inNorthern Ireland] through pre-chargeadvice and health and social careprofessionals who agree that it is inthe public interest, and the interestsof the offender, that a criminaljustice system (CJS) response shouldnot be pursued; and

• the individual’s needs will beaddressed by an appropriate healthand/or social care response.”

1.14 There is often a tension between therights of the mentally disorderedoffender and the rights of others; andthe fact that the overwhelmingmajority of mentally disorderedoffenders are prosecuted, rather thandiverted out of the justice systemprior to prosecution (as we shall seein Chapter 3), is not necessarilywrong in terms of human rights. Itmay be in the interests of somementally disordered offenders to beprosecuted for their offences as a wayof helping them to measure theirown perceptions of their behaviouragainst those of society at large.Sometimes encouraging aggressivepatients to accept responsibility fortheir behaviour in this way can beclinically beneficial.

The Bamford Review

1.15 The background to this thematicinspection is the review of ForensicServices conducted as part of theBamford Review of Mental Healthand Learning Disability in NorthernIreland, published in October 2006.That review was extremely thorough,and a great many of those with

expertise in the field contributed toit. There can be no question of thisinspection attempting to improveupon the analysis contained in it.

1.16 The review produced 169recommendations, all of which havemuch to be said for them. But it isoften the problem when a reportmakes so many recommendationsthat it is seen as something of acounsel of perfection and the systemfails to respond to it. The NorthernIreland Assembly Executive publisheda draft response for consultation inJune 2008, but it was sketchy inrelation to Forensic Services.Admittedly some of Bamford’srecommendations would havebeen expensive, and in the currenteconomic climate we have to berealistic about what can be achieved,but there is clearly more to bedone. Bamford can be regardedas an agenda for the next 20 years.

1.17 Bamford’s perspective was essentiallya therapeutic one: the perspective ofmental health practitioners ratherthan that of the justice system.In looking at the subject from thecriminal justice perspective, as we doin this report, it is important not tolose that focus. Mentally disorderedoffenders are in the first placepatients, without prejudice to theextent of their criminal liability.The principles of the Code attachedto the Mental Health (NI) Order1986 must be regarded:

“People with mental health problems should:• be treated or cared for in such a wayas to maintain their dignity;

• receive respect for, and considerationof, their individual qualities and

background: social, cultural andreligious;

• have their needs taken fully intoaccount notwithstanding the fact thatwithin available resources, it may notbe possible to meet them;

• receive any necessary treatment orcare with the least degree of controland segregation consistent with theirsafety and the safety of others;

• be discharged from any form ofconstraint or control to which they aresubject under the Order immediatelythis is no longer necessary; and

• be treated or cared for in such a wayas to promote their self-determinationand encourage personal responsibilityto the greatest possible degreeconsistent with their needs, wishes andabilities.”

1.18 Apart from Bamford, a great deal hasbeen written about this subject byother authorities in recent years. In1996 HM Inspectorate of Prisonspublished a report entitled Patient orprisoner?, which drew attention to thedeficiencies in mental health provisionin the Prison Service and led, some10 years later in England and Walesand 12 years later in NorthernIreland, to the transfer of primaryresponsibility for prisoner health tothe Health Service. They produced afurther report in October 2007,which made two main findings: “Thefirst is that there are still too many gapsin provision and too much unmet andsometimes unrecognised need in prisons.The second is that the need will alwaysremain greater than the capacity, unlessmental health and community servicesoutside prison are improved and peopleare appropriately directed to them

before, instead of after, custody.”

Those findings would be equallyrelevant to this report.

1.19 Some of the specific needs theyidentified were:• the need for the organisation and

provision of specialised primarymental healthcare;

• the need for joint working betweenmental health and substance misuseteams;

• the need for care and support forthose with mental and emotionalneeds not to be seen as theexclusive province of mental healthprofessionals;

• the needs of learning disabilityprisoners to be properly identifiedand adequately met; and

• the special needs of women, whohad the highest levels of emotionaland psychological distress, oftenrelated to past abuse andexacerbated by distance fromhome and children.

1.20 In 2002 the NI Human RightsCommission published a report onMental Health and Human Rights, fromwhich we have already quoted. TheNational Association for the Care andResettlement of Offenders (NACRO)published an important report in2005 on mental health liaisonschemes for mentally disorderedoffenders in England and Wales,together with proposed standards forthe treatment of mentally disorderedoffenders; and in 2009 a report hasbeen issued by Policy Exchange8

bringing together a valuablecollection of national and

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8 Inside Out: the case for improving mental healthcare across the criminal justice system, by Professor Charlie Brooker and Ben Ullman, PolicyExchange, 2009.

international evidence bearing on theissues. Lord Bradley’s admirablereport on people with mental healthand learning difficulties in the justicesystem in Great Britain (GB) hasprovided further clarity on the issue.Inspectors acknowledge a debt to allthese publications.

Early intervention

1.21 This report follows the usual orderfor thematic inspections of thecriminal justice system, startingwith the police, moving throughprosecution and the courts andending up with prisons and probation.

1.22 But there is an alternative way oflooking at the subject. In a way itwould be logical to start with theYouth Justice Agency, because of theimportance of early interventions indetermining the life chances of amentally disordered offender.Experts hesitate to make diagnosesof personality disorder duringchildhood, because the personalitymay not yet be fully developed, andwhat is normal behaviour for adults isnot necessarily normal for children.But teachers - as we note in Chapter5 - as well as others who work withchildren, such as social workers, canoften pick up signs of mental disorderat an early age, and it is importantthat they should do so and that suchdetection should be followed up withprofessional intervention.

1.23 Early interventions can be extremelyvaluable. As a mental health nurse atthe Woodlands Juvenile Justice

Centre (JJC) told us: “Betterintervention at a younger age reducesthe risk to the young person and to thecommunity and keeps the young personout of the criminal justice system.” Ifpeople do not receive treatment theycan end up as habitual offenders andprison residents, their mental healthbeing so poor that they feel safeonly in prison and will re-offendimmediately in order to be re-admitted. The cost of this, quite apartfrom the human tragedy, is immense.Not all interventions are going to besuccessful: sometimes there is agenetic element and sometimes thereis early childhood trauma which isvery hard to treat, but concentratingon early interventions in childhood islikely to yield disproportionatebenefits.

1.24 NACRO9 has made the case for‘early intervention’ in another sense,meaning ‘before the case goes tocourt’. NACRO believes that thefocus of efforts to improve healthcarefor offenders with mental healthneeds should be on the criminaljustice process before sentencing.This shift in focus, it argues, wouldensure that resources are not pre-empted by prison healthcare whenthey could more advantageously bedirected towards treating offendersat an earlier stage of the process.Better systems need to be put inplace to ensure that offenders withmental health problems are properlyidentified and treated as early on aspossible.

1.25 Dr Shadd Maruna, Reader in

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9 NACRO Mental Health and Crime Policy Briefing, 2007. See also Liaison and diversion schemes for mentally disordered offenders,NACRO, 2006.

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Criminology at Queen’s University,Belfast endorsed that view to us,arguing that the focus should be onimproving community mental healthprovision, since mental health needsbecome compounded once someoneis in prison. He argued forcefully formore diversion away from prison atthe court stage. We shall look at thescope for that in Northern Ireland inChapter 3.

Aims of this inspection

1.26 On the face of it, there are few votesto be won by championing bettermental healthcare for offenders. Butthe amount the justice system spendson mentally disordered persons whoare repeat offenders is substantial, tothe detriment of the rest of thecriminal justice system; and theconsequences when mentallydisordered people are released backinto the community without havingreceived adequate treatment are seenin some of the most appallingoffences ever to hit the headlines.This is therefore a subject whichmerits the closest political attention.

1.27 It could be argued that, especiallynow that responsibility for prisonhealthcare has transferred to theHealth Service, mental health is nolonger an issue for the criminaljustice system (or for CJI), and thatthis inspection should limit itself tothe specific issues of:• the management of dangerous

offenders, particularly thosementally disordered offenders whopose the greatest threat to publicsafety; and

• the question of whether justice isbeing done equitably to those who

are mentally disordered.

1.28 Those are indeed the priorities, butthey do not narrow the scope ofthe inspection much. Every part ofthe criminal justice system (CJS) isconcerned with the handling ofpersons with mental disorders andwith the management of the threatthey pose to themselves and others;while ensuring that they are treatedfairly is a responsibility of all thosewho work in the justice system.In prisons, care of the mentallydisordered is a matter for prisonstaff, not just for the healthprofessionals. The case of Colin Bell(see Chapter 4) was not at the highend of the range of PD, but his deathin custody was a matter of theutmost concern to the NIPS.

1.29 Better management of mental healthissues in the justice system couldresult in:• more just outcomes and fairer

treatment generally for mentallydisordered offenders;

• improvements in the safety of staffworking with such offenders andsuspects;

• more effective treatment ofmentally disordered offenders,leading to wider societal benefits,including improved public safety,and

• a reduction in the cost to thecriminal justice system resultingfrom the ‘revolving door’ ofmentally disordered offendersrepeatedly presenting at policestations.

These are what we shall be looking for inthe following chapters.

Police involvement

2.1 The police come into contact withmentally disordered persons in twomain ways. Mentally disorderedpersons may be arrested on suspicionof having committed an offence, orthey may be detained under theMental Health Order (MHO) becausetheir conduct has given cause forconcern. Under the MHO, someonein a public place who is deemed tobe ‘in immediate need of care orcontrol’ can be taken to a designatedplace of safety, where he may bedetained for up to 72 hours.

2.2 The police may remove someonefrom private premises only with awarrant from a court. This is seen bysome we spoke to as an unnecessaryconstraint, and many in the policetold us they would like to see thelaw amended to obviate the need fora warrant. However, there are clearhuman rights implications and it is apolicy matter on which CJI does nottake a view10.

2.3 There is a lack of clarity among thepolice about their powers under theMHO, which reflects the fact that, for

most officers, their training in mentalhealth matters is very limited. Inbasic training at the PSNI PoliceCollege at Garnerville, PSNI officersreceive only a few notes on thesubject, and in subsequent trainingthe main emphasis is on recognisingsituations of risk (such as exciteddelirium and positional asphyxia)and the physical actions to be takenin terms of restraint and control.Suicide prevention also features. APSNI Procedure (Operational Procedureand Guidance for dealing with personswith a mental disorder) had recentlybeen completed and circulatedacross the PSNI and the police haveappointed a Mental Health LiaisonOfficer (MHLO) who is attached toOperational Support Department atPolice HQ. This officer is currentlyattending the North West (England)Regional Forum where best practiceis shared. In addition, the ACCOperational Support Department isthe PSNI ACPO lead on mentalhealth issues and represents thePSNI at a national level.

2.4 Inspectors would not want to imposeextensive new training obligations onofficers, which would be unrealistic,

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Arrest and detention

CHAPTER 2:

10 Some police officers admitted that they occasionally circumvented the Order by arresting someone for breach of the peace inthe first instance and then switching to the Order once in the police car, but that should not be necessary and can clearly notbe condoned.

but there is a need for a little moreattention to mental health issues.We were told that there was amanageable training package currentlybeing developed which would bebeneficial, and we recommend thatthe PSNI should consider adopting it.We recommend the PSNI shouldintroduce a training module onmental health based on ane-learning package currentlybeing developed byThe NationalCentre for Applied LearningTechnologies, the NationalPolice Improvement Agencyand the Association of ChiefPolice Officers (ACPO).

Policy on mental health

2.5 More generally, there is a need formental health to be given a greatersalience in police management.It is something of a poor relation atpresent. We were told it was “notviewed as an issue to be championed”.In policy terms it comes underVictims and Witnesses, and isregarded as a subset of policy ondisability. Its handling is patchy in thedifferent police Districts, and it is notmanaged consistently by OperationalSupport. This does not match theimportance of the subject in terms ofthe number of offenders and otherdetainees who present with mentalhealth problems. It is almost asthough (as with the ACPO guidancementioned at paragraph 1.14) thesystem plays down the significance ofthe mental health dimension, lest itshould get in the way of the primaryfunction of preventing crime andprotecting the public.

2.6 Recently MHLOs have beenappointed in each police District.But they range in rank, and none ofthem has that as their full-timeresponsibility. In one case, Inspectorswere told it had simply been addedon to existing full-time duties in aPublic Protection Unit. No policeofficers on the ground that we spoketo had heard about their introductionor knew who they were. Inspectorsare sure that MHLOs can perform auseful function, but the role needs tobe taken seriously by management.

2.7 The MHLOs we spoke to showedenthusiasm for the role and weredoing good work building contactswith local hospitals and socialservices, but they need to be giventhe time to do the job and they coulddo with a central mental health unitat headquarters to guide and co-ordinate their work. Some had toliaise with a number of health trusts.They told us that it would be helpfulif their training could be localised, sothat in the course of it they hadopportunities to meet with theiractual counterparts in health andsocial services.

Public protection

2.8 Public Protection Units have animportant role in relation to mentalhealth. They act as a central pointfor mental health issues in the policeDistricts. A range of mental healthrelated issues come within theirambit. Potentially Dangerous Persons(PDPs) are now covered by thePublic Protection Arrangementsfor Northern Ireland (PPANI)arrangements for offender

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management. The great majority ofPDPs would be personalitydisordered. Domestic violence alsooften involves perpetrators withmental disorder. Similarly most sexoffenders are personality disorderedin one way or another, though thereis a wider variety of diagnoses and, aswith all these offences, other thanexceptions, PD is not to be regardedas an excuse.

2.9 There has been a markedimprovement in the arrangements forthe management of PDPs in recentyears, but the end result has beenthat the majority of the most seriousPDPs are now in prison. Offender Aprovides an example of how difficultit can be for the system to deal withsuch people:

Offender AOffender A, who suffered frompersonality disorder, completed a sevenyear sentence for very serious sexualviolence but was still deemed by theauthorities to be highly dangerous whenthe time came for his release. He wasthree times re-arrested at the prisongates and re-committed for breachingthe terms of his licence in that he hadno suitable accommodation to go to.Judicial Review found against theSecretary of State for a breach ofhuman rights. The new extended andindeterminate sentences will simplifythe procedure for holding PDPs incustody, but there may still be humanrights appeals if the prisoner can showthat he has not been given a fairopportunity to demonstrate that he isnow safe to be released.

2.10 It is also worth flagging up the extentto which the new arrangements willincrease the PBNI’s workload.Overall, Category Three (high risk)clients amount to about nine percentof those subject to PPANI. Thismeans that the Category Threecaseload should be approximately37 cases. This figure will increase byapproximately 15% annually, and willbe further increased by the additionof domestic violence cases and hatecrimes. Estimates would thereforesuggest that by October 2011, thenumber of PBNI clients subject toPPANI will increase from 359 toapproximately 640, with a possible58 in Category Three.

A place of safety

2.11 The ‘place of safety’ will usually be ahospital or a police station. Inpractice hospitals are reluctant toadmit mentally disordered persons,especially when they are stillintoxicated, and police cells aremore often used. Inspectors acceptthat people require to be managedaccording to clincial indications and itmay not be appropriate or beneficialto admit them to hospital. ButCustody Sergeants are likewisereluctant to accommodate mentallydisordered persons unless they haveto. Inspectors heard that policeofficers are often frustrated at havingnowhere suitable to place suchpeople: they feel a sense ofresponsibility for them, and findthemselves sometimes having torelease them back into thecommunity against their betterjudgement.

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2.12 There is an alternative view of thisin the Health Service, however as aconsultant told us that in his view thepolice could be more effective aboutthis, and accused some of them ofdisplaying ‘learned helplessness’.The Mater Hospital felt that it wasunfairly used as a dumping ground bypolice from all over Belfast –particularly for off-loading people atthe weekend. The police themselveswere sensitive to a degree of anti-police feeling from the HealthService. There is clearly a need forbuilding better understandingbetween the two services; even ifsome tension is unavoidable becauseof the competing pressures they areboth under. We recommend thePSNI should finalise a protocolwith the Health Service makingclear the precise respectiveresponsibilities of the twoservices, so that there is clarityabout how mentally disorderedpersons are to be handled.

2.13 Hospitals do not see A&EDepartments as a suitable place ofsafety. Police officers complained ofhaving to stay with patients inhospital waiting rooms for longperiods, especially if they needed tosee a psychiatrist, who might workonly normal office hours. Inspectorsacknowledge that psychiatric sessionsare available out of hours and provide24/7 cover. The ideal solution, it wasput to us, would be to create a 24-hour central mental health unit inhospital grounds, with a psychiatricward close by; but that idea wouldneed close examination and cost-benefit analysis before any suchrecommendation could be made.

Diversion out of the criminal justicesystem

2.14 Judges told us that they believe thereshould be a stronger diversionarypolicy in place to reduce the numberof mentally disordered personsappearing before the courts. They feltthe police should be diverting themto community health teams and givingthem an informed warning. But thePSNI told us that they found it hardto divert such people effectively.

2.15 There is a widespread feeling amongthe police officers we spoke to thatthe level of care available in thecommunity is inadequate, and thisresults in the same people comingback to the attention of the policerepeatedly without having receivedany effective treatment. Policesometimes find themselves having toprovide aftercare as long as 48 hoursafter an incident, which they say, isnot a good use of their time. Theyfelt they should be able to handover responsibility for the care of amentally disordered person to healthand social services as soon as theperson has been discharged from thepolice station.

2.16 Diversion into the health servicedoes not necessarily mean that theperson is lost sight of by the criminaljustice system. On the contrary, inserious cases the police will watchclosely the progress of the individualand will be ready to take appropriateaction whenever they are ready to bereleased from healthcare.

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Police cells

2.17 Police cells are not well suited tothe purpose of a place of safety.The Joint Committee of the Lordsand Commons on Human Rights in a2005 report on Deaths in Custody said:“People requiring detention under theMental Health Act should not be held inpolice cells. Police custody suites,however well resourced and staffed theymay be, will not be suitable or safe forthis purpose. In our view, there shouldbe statutory obligation on healthcaretrusts to provide places of safety”.

2.18 There is evidence to suggest that thepolice station environment can havea negative effect on the conditionof a mentally disordered person.It has been noted that a significantproportion of deaths in custody andof serious complaints against thepolice in England and Wales haverelated to detention under theMental Health Act.

2.19 Although Custody Sergeantsrecognised that custody should notbe used as a place of safety formental health detainees, in reality,most admitted that it was being usedas such in the absence of alternatives.They saw a lack of formalisedstrategic partnership arrangementswith healthcare providers, and officersspoke of their frustration at the waymanagement did not seem to be ableto resolve these difficulties.

2.20 There are therefore suggestions for adifferent sort of facility to be set upspecifically for this purpose under theauspices of the Health Service: manyof those we interviewed (including

the psychiatric nurses working inpolice custody facilities) argued for acentral detox facility, which wouldprovide for offenders and non-offenders alike, with the necessarysecure facilities for the former.Once patients were detoxified theycould be assessed and directed asappropriate into healthcare or intocustody. Inspectors can see thedesirability of this but, are not certainthat it is a first priority in currentcircumstances. We believe it wouldbe more cost-effective on the onehand to strengthen the healthcaresupport given to police stations andon the other hand to support theexisting detox facilities for non-offenders provided by charities suchas Extern.

Role of the police vis à vis the HealthService

2.21 At the root of many of the problemsInspectors encountered is a lack ofclarity about who is responsible fordealing with mentally disorderedpersons who come in to the criminaljustice system. The police and theHealth Service are both underpressure to meet potentially limitlessdemands from the public. They aretherefore almost bound to want topass responsibility on to someoneelse if they can. The present situationof uncertainty leads to friction andbad feeling between the services.There needs to be an agreedprotocol for the handling of mentalhealth cases – which is indeed beingworked upon. If that could besupplemented by some joint trainingof police and health servicepersonnel, that would help to

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improve mutual understanding andpromote good working relations.

2.22 One solution which was suggestedwas that the Health Service shouldtake full responsibility for healthassessment and treatment in policestations, as it has (or is doing) in theprisons. In England and Wales thereare discussions currently about thatpossibility. But the police told us thatthey would not find that acceptable,because they see their own forensicagenda as being in conflict, to someextent, with the clinical agenda. Theyregard offenders as first and foremost,criminals who need to be subject tosanctions, and they are distrustful ofhealth professionals who, by regardingthem as patients, might help them toescape justice (as the police wouldsee it). It is not unknown foroffenders to attempt to manipulatethe system by feigning illness, and thepolice have reason to be sceptical.Inspectors agree with the police thatthey should retain control of healthprovision in police stations subject tothe duty of health professionals toprovide essential care.

Information systems

2.23 It would be helpful if the PSNI’sNiCHE IT system could flag up if anoffender has mental health problems.At present NiCHE records whethersomeone is vulnerable or intimidatedand it records if they are violenttowards others, but it does notrecord mental health issues as such.It would also be helpful if statisticscould be kept of the numbers ofmentally disordered person beingprocessed through police stations.The nurses at Musgrave Street

recorded 450 cases last year, but thatis only a small proportion of thetotal. Inspectors recommend thePSNI should ensure thatCustody Officers complete amental disorder warning onNiCHE RMS for those detaineespresenting with a mental healthcondition.

The Appropriate Adult scheme

2.24 If a Custody Sergeant suspects that aperson might be mentally disorderedor otherwise mentally vulnerable heis obliged under PACE to seek theservices of an ‘appropriate adult’ torepresent the person’s best interests(as with juveniles). Their role is tosupport, advise and assist thedetainee, and in particular to ensurethat the individual understands theprocesses and their rights duringdetention in police custody. TheAppropriate Adult scheme inNorthern Ireland has been inoperation since 1 June 2009. Thescheme is funded by the NIO andMindWise an independent mentalhealth charity whose staff membersare trained in mental health issues,and whose work is well regarded bythose we spoke to. In the case ofjuveniles, the appropriate adult isnormally a parent or guardian, butMindWise will provide a pool ofspecially trained adults able to standin if required. MindWise staff have anadvantage in terms of their familiaritywith police procedures and they havedemonstrated good response times.

2.25 The service is only available in policecustody, but it has been suggestedthat it would be useful to roll it outacross the criminal justice system.

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Judges told us that they are doubtfulabout it. They wonder whether thescheme should rely on a charity inthe first place. They think it may bejust about adequate for low levelcases, but believe it would strugglewith more serious cases. Therewould be a danger, indeed, thatmishandling of such a case might leadto its coming off the rails. Inspectorscan see that an extension of thescheme might be desirable, but thestage at which quick assistance ismost necessary and no other help isavailable is the point of initialdetention by the police. Inspectorstherefore make no recommendationfor extension.

Forensic Medical Officers

2.26 In police custody, healthcare isconducted under the supervision ofForensic Medical Officers (FMOs)who are responsible for decidingwhether a detainee is fit forquestioning by the police. Where anFMO thinks admission to hospitalmay be appropriate he or she mayadvise the Custody Sergeant toarrange a MHO assessment, whichcan lead to compulsory admissionunder the Order or to voluntaryadmission. When an FMO decides aperson is not ill enough to justifyadmission but is at the same timenot fit for custody he will bereleased, and a file will be completedand passed to social services tofollow-up.

2.27 In its recent report on Police Custody(published in June 2009) CJIcommented on the work of thehealthcare staff in Northern Ireland’spolice stations. There were positive

comments from detainees, andcustody staff confirmed that theFMOs worked in a caring andsensitive manner. There were,however, deficiencies in the way inwhich the FMOs were managed,which the PSNI is already addressing.The Youth Justice Agency (YJA)expressed some doubts aboutwhether many FMOs were adequatelytrained to deal with children withmental health issues: they said somehad admitted to them that it was nottheir area of expertise. This wouldnot be surprising, as FMOs areessentially General Practitioners(GPs) and would not be specialistsin mental health.

2.28 In most custody suites there was noformal liaison or diversion scheme toenable detainees with mental healthissues to be diverted into appropriatemental health services. Localarrangements existed betweencustody suites and local healthcareproviders but these were ad hoc andnot always sufficient. For example,one Custody Sergeant whose suitewas close to a mental health hospital,commented that it was much harderthan expected to divert detaineesdespite the proximity of the hospital,due to the reluctance of healthcarestaff to admit them – particularlythose who had a personality disorder,had consumed drugs or wereconsidered violent. Healthcare staffare reluctant to admit people in thiscondition when there is an absenceof any clinical indication.

The Mentally Disordered Offender(MDO) scheme

2.29 There are two psychiatric nurses

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based in Musgrave Street who coverthe four Belfast custody suites,undertake risk-based mental healthassessments and when appropriate,make onward referral to mentalhealth specialists. The scheme, whichwas introduced in 1998, is highlyregarded by many within the PSNIand by observers abroad. The nursesare effective in placing people inhealthcare, partly because of theirpersonal contacts with their oppositenumbers in the Belfast hospitals.Inspectors were told that when theyaccompanied a person to hospitalthey were never refused admission.They also had good links with thehealthcare team at Hydebank Wood,and could advise them when youngpeople with mental health issueswere about to be remanded. Theirrecommendations as to how casesshould be disposed were given greatweight by District Judges.

2.30 The nurses said that it was oftendifficult to get a bed for someone ofno fixed abode. They wouldsometimes liaise with the DistrictCourts (formerly the magistrates’court) and agree that the person wasbest not released into the community,and the result was then that theperson might end up in MaghaberryPrison for lack of an alternative.They said that they sometimesfollowed up people they knew to beat risk of suicide or self-harm afterthey returned to the community.

2.31 There were some criticisms of theMDO scheme, mainly on the groundsthat the service was limited todaylight hours and alternateweekends, and there was a suggestionthat there was occasionally frictionbetween the nurses and the FMOs.But overall the assessment Inspectorsreceived, which was confirmed by anindependent academic review of thescheme11, was highly positive: “Ourfindings illustrate unambiguously thatmental illness among many detaineeswas not detected by Custody Sergeantsor by FMOs, but was identifiedaccurately by the mental health nurses,who also achieved considerable successin linking MDOs to health and socialservices.”

2.32 The service is confined to Belfast,and there is no counterpart in otherpolice Districts. Inspectors weresurprised to discover that there issome uncertainty about the futureof the scheme, and it is possible thatit may be absorbed into communitypsychiatric nursing. They believe itrepresents good practice, andrecommend that the MDO schemeshould be preserved and rolled outacross Northern Ireland. Werecommend the MentallyDisordered Offender (MDO)scheme should be extended toall custody suites in NorthernIreland.

11 Mental illness in the Criminal Justice System:A police liaison scheme for Mentally Disordered Offenders in Belfast, by Dr Sinead McGillowayand Michael Donnelly, published in the Journal of Mental Health, 2009.

3.1 Significant numbers of mentallydisordered offenders are ending up inprison when they ought, it is argued,to be diverted into the HealthService. There is a particularproblem in Northern Ireland atpresent due to the failure torecognise personality disorder on apar with mental illness. Inspectorsunderstand that there are differencesbetween mental illness andpersonality disorder, that are relevantto diverting offenders, and while bothgroups are particularly challenging tothe criminal justice system, theyrequire different solutions not leastbecause of current mental healthlegislation. As a result the prisonssee themselves having to cope withtoo many personality disorderedoffenders who pose a risk tothemselves, to staff and to otherprisoners. The Director of theNorthern Ireland Prison Service(NIPS) told Inspectors he had madeseveral approaches to the judiciaryto attempt to persuade them toconsider alternative disposals inmore cases.

3.2 There are two questions that need tobe addressed. Firstly, are the courtsreceiving the best possible advice asto the mental condition of thosebrought before them? And secondly,do they have a suitable range of

options open to them whenconsidering what disposal to order?

The Judges’ perspective

3.3 Judges told us that from their pointof view there were three mainproblems:

• The large number of ‘poor copers’who were offending repeatedly,generally receiving short sentencesfor petty offences, and not stayingin prison long enough to receiveany useful treatment. Theydescribed it as a ‘revolving door’;

• The difficulty they had in obtainingadvice about mental health issuesearly enough. In the great majorityof cases mental health issues werenot addressed until afterconviction, on the basis of thePBNI’s pre-sentence report (PSR).Or the first the judge would knowabout the issues was when theywere raised by the defence: it wasmost often the defence thatrecommended some form ofexamination, having picked up onthe issues through its dealings withthe client. Judges said they wouldoften find it helpful if mentalhealth issues could be identifiedearlier and could, if possible beestablished non-adversarially by

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The options available to the Court

CHAPTER 3:

some form of pre-trial conference;

• Their isolation from sources ofexpert mental health advice. ThePBNI told us that they thoughtjudges sometimes needed help ininterpreting psychiatric reports,and the judges we spoke to agreed.A particular problem was when, assometimes happened, someonewith a mental health issuedismissed his counsel half waythrough a trial. If they had mentalhealth professionals close at hand,they felt they would be betterplaced to co-ordinate a moresatisfactory solution. They alsotold us they did not know how tocontact the psychiatrists whoassisted the NIPS, and they wouldsometimes find it valuable to beable to talk to the mental healthnurses who assisted the PSNI.They said that the most difficultcases were those involvingpersonality disorder, which werecurrently outside the scope of theMental Health Order.

Inspectors recommend theNorthern Ireland Court Service(NICtS) should arrange forjudges to have access to expertadvice in interpreting psychiatricreports and handling cases whichinvolve mental health issues.

3.4 As regards the second point above, ajudge’s options are more limited oncea trial has commenced, and betteroutcomes might be possible if rathermore cases could be disposedwithout ever coming to trial. The test

of ‘fitness to plead’ is not always asufficient protection, because it doesnot address the question of mentalcapacity at the time of the offence.Someone like the psychotic OffenderC (referred to in Chapter 7) may befit to plead once he has taken hismedication (because he would thenbe able to understand theproceedings in court), even if he wasout of his mind at the time of theoffence.12. What is needed, as learnedjudges suggested, is a hearing in whichquestions of non-responsibility byvirtue of mental incapacity or mentaldisorder, can be examined outside thecontext of a criminal trial. Inspectorsrecommend that there should besuch hearings, which could withadvantage be held by a judgespecialising in mental health issues.Inspectors accept that in manyinstances the defendant’s mental stateor condition may only be within theknowledge of the defendant and hislegal advisors. However, it should bea duty of the Public ProsecutionService for Northern Ireland (PPS) toidentify such cases from the policefiles and to bring them to theattention of the court as soon aspossible. We recommend that wherematerial issues of mental healthare raised by the PPS or otheradvisers, judges should holdpreliminary hearings to establishthe mental state of thedefendant.

3.5 The PPS told us that it was, inprinciple, open to the defence tomake representations to them pre-trial that the defendant was not

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12 Conversely, in the Bulger case the problem with Thompson and Venables was not that they were doli incapaces but that they wereevidently unfit to plead. If the test of fitness to plead were applied more liberally it might reduce the pressure for raising theminimum age of criminal responsibility.

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capable of having formed the intent tocommit the crime, but it rarelyhappened. The defence usually leftsuch issues to the trial. If they wereto raise it, there was then thequestion of whether the defendantwould consent to being examined bythe PPS’s expert or, whether the PPSwould be restricted to the evidencesupplied by the defence’s psychiatrist.Unless the defendant consented, itwas difficult for the PPS to judge whatweight to give to the representations.

Fitness to pleadAt the police station, a FMO examinesthe offender to assure their health andto check that they are fit forquestioning. If the FMO suspects thats/he may be mentally disordered, s/hemay ask a psychiatrist to examinehim/her, and it is that psychiatrist’sreport which determines fitness toplead. If the psychiatrist decides thats/he is not fit to plead, the offender isdiverted to the Health Service and thatis the end of the matter so far as theCriminal Justice System (CJS) isconcerned. The CJS cannot appeal thedecision.

Conversely, if the psychiatrist finds thatthe offender is fit to plead, there is littlefurther opportunity to stop the trialgoing ahead. The judges told us theyhad effectively no role in the matter atthat stage. In principle, if a defendantappeared before them about whosemental capacity they had doubts, theycould ask for a psychiatrist’s report, butthey would not usually know unless thedefence raised the question, which thedefence would be unlikely to do, untilsentence had been passed for fear that

it might be prejudicial.

The criteria for unfitness to plead areextremely restrictive. Essentially theyrelate to whether the defendant has themental capacity to understand the courtproceedings. Even if the defendant wasout of his/her mind at the time of theoffence, s/he may still be deemed to beable to understand what is going ononce s/he has been detoxified and/orgiven appropriate medication. The PPSconfirmed that as things stood, very fewcases were excluded on the grounds ofunfitness to plead.

There is some concern in the legalprofession13 that the test of fitness toplead in the criminal courts is out ofline with the tests in the 2007 MentalCapacity Act, and that the Lords may atsome time be asked to rule on whetherthat disparity might constitute a breachof the Human Rights Act. In themeantime, it is possible that somementally disordered offenders are goingthrough the criminal process and endingup in prison who should have beendiverted at an earlier stage.

A Mental Health Court

3.6 It has been suggested that thereshould be a separate court inNorthern Ireland to take casesinvolving mental health issues. Thereare examples of this quoted in theliterature, notably one in Brooklyn,NY, which serves to divert mentallydisordered offenders into community-based sentences and treatmentprogrammes.

13 See, for example, Lucy Scott-Moncrieff and Guy Vassall-Adams in Counsel for October 2006.

Brooklyn Mental Health CourtBrooklyn Mental Health Court is aspecialised court for mentallydisordered offenders. It aims to addressboth the treatment needs of defendantsand the public safety concerns of thecommunity, by diverting mentallydisordered offenders away from custodyand into long-term treatment inhospital or in the community.

To achieve its goals it has adopted thefollowing operating principles:

- detailed screening and assessmentto create individualised treatmentplans;

- frequent judicial monitoring tokeep the judge engaged with thedefendant and emphasise to thedefendant the seriousness of theprocess;

- accountability of the defendant forhis or her actions; and

- co-ordination of services with abroad network of government andvoluntary providers to address theproblems of substance abuse,homelessness, unemployment andphysical and mental health.

3.7 Though there were some supporters,the judiciary in Northern Irelandwere by and large sceptical of thisproposal. They saw difficulty indefining the cases that would come tothe court, pointing out that perhaps60% of the cases coming before theDistrict Court would involve somemental health issue, broadly defined.Who was to conduct the necessaryassessment, and who was to decide?They feared that introducing such acourt would lead to delay, and theywere doubtful about the benefit: onthe contrary, there was the possibility

that inequities could result.Moreover, in a small jurisdiction likeNorthern Ireland, users of a mentalhealth court could be unfairlystigmatised if they were known.The answer was rather to ensure thatevery court had the capacity to dealwith mental health issues when theyarose.

3.8 Inspectors are not convinced that adedicated Mental Health Court iswhat is needed in Northern Ireland.As we stated in the introduction tothis report, mentally disorderedoffenders are not a marginal issue: ahigh proportion of those comingbefore any court are likely to sufferfrom some degree of mental disorder,and all courts therefore need to bemental health courts. However, pre-trial hearings of the kind mentionedin paragraph 3.4 could usefully beheld by a judge specialising in the fieldof mental health, and in that sense amental health court could be a usefuldevelopment.

The Public Prosecution Service forNorthern Ireland

3.9 The Public Prosecution Service forNorthern Ireland (PPS) is involvedboth in the decision to prosecute, onwhat charge or charges a prosecutionis taken forward, and in the treatmentof victims and witnesses.

3.10 As regards the decision to prosecute,the PPS relies largely on theinformation presented by the policein the investigation file. If there aremental health issues in relation to theoffender, the PPS told us they wouldexpect to find them flagged up in thefile in the form of a mental health

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assessment. They may also pick upthe fact from the presence of anAppropriate Adult in the policestation. They would not, however,commonly see medical reports. Theprosecutors we spoke to were notaware of the assessment formsprepared by the psychiatric nursesworking out of PSNI Musgrave Street,but thought it would be extremelyhelpful to receive them.

3.11 Basically prosecutors take theirdecisions to prosecute on the basis ofthe twin tests in The Public ProsecutionService Code for Public Prosecutors (TheCode):The Test for Prosecution is metif (i) ‘the evidence which can be adducedin court is sufficient to provide areasonable prospect of conviction’; and(ii) ‘prosecution is required in the publicinterest’. Among the considerationsweighing against prosecution onpublic interest grounds is: ‘where thedefendant was at the time of the offenceor trial suffering from significant mentalor physical ill-health.’

3.12 If a defendant was found to besuffering from significant mental orphysical ill-health either at the timeof the offence or at trial, the PPShaving weighed the public interestconsideration, could divert theoffender to a police caution, but therewould be no prescription regardingtreatment for the mental disorder.It was not within the power of thePPS to divert an offender to a mentalhealth hospital. Young offenderscould be diverted into youthconferencing.

3.13 Fitness to plead is a separate issue tothe decision to prosecute. If theTest for Prosecution is met, the PPS

will prosecute. It is for the court todetermine whether or not thedefendant is fit to plead and in doingso, will have regard to evidence whichmay be called by either party, and thesubmissions made by both theprosecution and defence. If the courtrules that the defendant is fit, thenthe case will proceed to trial. If thecourt rules that the defendant is notfit, the trial will not proceed to trial.

3.14 For those cases that do proceed totrial and the accused is found to havecommitted the act with which s/he ischarged, the court does have at itsdisposal a variety of orders. Thesecan range from an order that theaccused be admitted to hospital to anabsolute discharge, depending on thecircumstances of the individual case.

3.15 The Code for Prosecutors whilementioning that ‘significant mental illhealth is a public interest factor againstprosecution’, there is not a fulltreatment of the issue ofresponsibility for one’s actions, oranything about the alternativedisposals (or diversions) that mightbe possible. Inspectors suggest that itwould be worth giving the subjectslightly fuller treatment in the Code.We therefore recommend thePublic Prosecution ServiceCode for Prosecutors shoulddevote more space to questionsof fitness to plead and possiblenon-responsibility by virtue ofmental incapacity or mentaldisorder.

3.16 As noted above, judges said that theywould welcome it if the PPS weremore pro-active and would flag upto them, at the earliest opportunity,

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that there was a question about thedefendant’s mental state at the timeof the offence. Evidence bearing onthat might affect the course of thetrial or even obviate the need for atrial at all.

3.17 Inspectors believe that the role of thePPS in relation to diversion ongrounds of mental health could befurther developed, and recommendthat they should be more pro-activein advising the Court on mentalhealth issues. For that to happen, thePPS needs to receive better and moreprompt information from the police.They told us they were only receivingrelevant information from the PSNIwhen it was needed for Court, ratherthan as soon as it was available. Thisput them under pressure and meantthat the best use was not alwaysmade of the information. Providingthat necessary professional/patientrelationships and confidentiality issuesare addressed, the assessment formscompleted by the psychiatric nursesat Musgrave Street should beincluded in the file submitted by thePSNI to the PPS, and there is scopefor more training within the PPS toalert prosecutors to watch out formental health issues. Inspectorsrecommend the PSNI should bringmental health issues that mightaffect the conduct of a case tothe attention of the PPS at theearliest opportunity. They alsorecommend that the PPS shouldbe pro-active in flagging up forthe Courts, mental health issuesthat might affect the conduct ofa case.

Victims and witnesses

3.18 The PPS must consider what evidencecan be presented at court and if theevidence is credible. Where issues ofmental health arise in respect of aprosecution witness, great care mustbe taken to ensure that suchevidence is properly assessed andall appropriate steps are taken toprotect the vulnerable witnessincluding ‘Special Measures’. Theyneed to make sure that the witness isreliable and then to ensure that thequality of the witness’s evidence ismaximised.

3.19 The PPS told us that they wouldgenerally assume that a witnesswould be satisfactory unless thepolice told them that there was aquestion about it. The police reportmight contain an assessment of thewitness which would advise themif there was a potential problem.The prosecution will ask a witnessto consent to examination by apsychiatrist if the circumstancesso require. The outcome of suchexamination could be extremelyimportant, if, for example, there wasevidence that the witness was ahabitual fantasist.

3.20 When a witness with mental healthproblems came to court14 they couldreceive the treatment accorded toother categories of vulnerablewitnesses, such as:• the possibility of giving evidence

by pre-recorded video;• the use of screens to protect them

from the view of the defendant;

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14 There is an underlying problem, according to MENCAP, of a large proportion of victims with mental health and learning disabilitiesfailing to report crime.

• the removal of wigs and gowns;and

• arranging their court appearancein short periods.

3.21 The usual caveats however applied tothe giving of evidence by video. It is ageneral rule that evidence should begiven orally at court. However, aseach case and witness is different, thedecision to give video evidence is stillsubject to the Court being satisfiedthat the witness was available andcould be called live, if necessary, forthe purpose of cross-examination.

3.22 Inspectors were told that staff in thePPS Northern Region had joined aVulnerable Adults forum, where theycould train with social workers onthe treatment of clients with mentalhealth issues. This had led to usefulcontacts being made with colleaguesin the Health Service,Women’s Aidand social services.

3.23 Prosecutors said that it was acommon problem that witnessesclaimed they could not attend courtbecause of depression or othermental ailments (actual or alleged)and suggested that GPs too readilysigned them off as unfit. When thishad happened more than once, judgeswould often dismiss the case. It isimportant that GPs should exercisecareful judgement and bear in mindthe potential importance of thewitness’s evidence.

The legal framework for disposals

3.24 In Northern Ireland the MentalHealth (NI) Order 1986 provides arange of powers for the courts toseek information about a person’s

mental health and, if appropriate,divert or transfer them from prisonto hospital. The most frequently(though still very sparingly) usedpower is a Hospital Order underArticle 44 which enables the Courtto detain a person who has beenconvicted of an offence in hospital or(rarely) place them underguardianship rather than sending themto prison. The number of HospitalOrders has been in single figures inmost recent years, while total courtdisposals have been running at thelevel of around 25,000 a year.

3.25 The specific powers available to theCourt are to:• remand to hospital for a report on

the accused’s mental condition(Art. 42);

• remand to hospital for treatment(Art. 43);

• order hospital admission orguardianship for people whohave been convicted (Art. 44);

• impose an interim Hospital Order(Art. 45); or

• restrict discharge from hospital(Art. 47).

3.26 People may also be treated bycommunity mental health services asa condition of probation.

The Pre-Sentence Report (PSR)

3.27 The main source of advice to theCourts is the Probation Board forNorthern Ireland (PBNI), by means ofthe pre-sentence report (PSR). ThePSR will contain a risk assessment,which will highlight any mental healthissues. The ACE (Assessment, CaseManagement and Evaluation) riskassessment form gives the Probation

25

Officer a good insight into the mentalcondition of the offender. It asksabout any medication s/he is receivingand about any physical or mentaldifficulties s/he is experiencing. ThePBNI’s Standards specify that: “Wherethe main proposal envisages a ProbationOrder which includes a requirement fortreatment of a psychiatric condition ordrug/alcohol dependency, the reportshould reflect prior consultation with arelevant practitioner.”

The PBNI is currently strengtheningits complement of forensicpsychologists to help with thepreparation of risk assessments.

3.28 Nevertheless, Probation Officers toldus that they experienced difficulty inobtaining all the information theyrequired in order to advise the Courtadequately. The judges themselvesfelt that the PBNI was not alwaysable to identify the issues as well as itmight. Other agencies did not shareinformation readily, and the PBNI hadto take the initiative in seeking it out.Community Psychiatric Nurses(CPNs) did not disclose information,and psychiatric reports were oftennot attached to depositions whenthey should be. There were caseswhere the Probation Officersuspected mental health issues, butwhere no report had ever beencommissioned. The defencesometimes recommendedprogrammes of treatment to theCourt without consulting the PBNI,and the recommendations wereoften inappropriate in the ProbationOfficer’s view but, there was noway of challenging them.

3.29 The PBNI said that the timescalefor writing PSRs was extremelyconstraining and did not varyaccording to the nature andseriousness of the offence. If theoffender had mental health problems,and PBNI required reports fromhealth professionals, that could easilytake longer than the time allowed.Inspectors have recommended thatthe Probation Board forNorthern Ireland (PBNI) shouldbe granted more time toprepare Pre-Sentice Reports(PSRs) in cases which involvedifficult mental health issues.

3.30 The PBNI’s Standards said that theduty of the Probation Officer was tosupport and divert offenders withmental health issues into appropriateservices, but that was not always easy.Probation Officers experienceddifficulties in obtaining appropriatecommunity mental health supportand a perceived reluctance ofpsychiatrists to commit resourcesto offenders.

3.31 Probation Officers emphasised theextent to which homelessness wasrelated to addiction and mentalhealth issues and said that it wouldbe beneficial if in mental health casesthere could be a multi-agency, pre-sentence conference which couldinclude the Northern Ireland HousingExecutive (NIHE). They drewattention particularly to the difficultyof finding suitable places for mentallydisordered women in view of the lackof suitable hostel (ApprovedPremises) accommodation.

3.32 On the positive side, ProbationOfficers said that the regime for sexoffenders was working well. Their

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mental health needs were generallyidentified and Article 26 was used togood effect.

What are the alternative disposals?

3.33 If an offender suffering from a mentaldisorder (within the meaning of the1986 Mental Health Order) is madesubject to a Hospital Order withrestrictions, the Secretary of State isresponsible for:• referring the case to the Mental

Health Review Tribunal;• reviewing Restriction Orders;• exercising powers of discharge

or variation;• granting leave of absence; and• exercising powers of recall.

3.34 A Hospital Order can be regardedas a criminal sanction15, even though itis carried out within the healthservice. However, once someoneis a mental patient within the HealthService they can be released by theMental Health Tribunal. Inspectorswere told that the NIO representthe Secretary of State’s interest andsubmit reports and representations atthe hearings, however the focus ofsuch hearings tends to be on themedical officer’s advice.

Offender BOffender B was committed to the StateHospital at Carstairs in Scotland undera Hospital Order and later transferredto the Shannon Clinic at Knockbrackenoutside Belfast. His psychiatricdiagnosis was changed, and the MentalHealth Tribunal then ordered hisrelease. The criminal justice system hadno way of challenging that decision,which was a purely clinical one.

3.35 At the time of writing there were52 restricted patients in NorthernIreland, 48 of whom were men andfour women. Of those, 42 wereheld in hospital and 10 had beenconditionally discharged. A total of18 were held in the Shannon Clinic atKnockbracken, eight in the StateHospital at Carstairs, Scotland, and16 were in other Northern Irelandhospitals. Of the 38 patients subjectto a Hospital Order, six were on lifesentences, one is sentenced and sevenwere on remand.

High secure hospitals

3.36 The most dangerous mentallydisordered offenders can be sent tothe State Hospital at Carstairs, oroccasionally to English hospitalssuch as Ashworth, Broadmoor andRampton. Since there are no suitablesecure facilities in Northern Ireland,it is often the case that some verydangerous mentally disorderedoffenders therefore sometimesremain in Maghaberry Prison forthe whole of their sentences.Inspectors recommend anassessment of the need for alocal high secure hospital towhich the most dangerousmentally disordered remandprisoners can be transferredfor medical treatment.

The Shannon Clinic

3.37 The local Shannon Clinic is mediumsecure. It has 34 beds, not all ofwhich are available for offenders.They are allocated on the basis of

15 It is the one aspect of the health service in Northern Irelandwhich formally comes within the remit of Criminal JusticeInspection Northern Ireland.

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clinical need, but that does notnecessarily work to the disadvantageof offenders, who often have highneeds. However, the rules foradmission are restrictive, and thereferral process is lengthy. The cliniccaters only for mentally ill people,and it will accept mentally disorderedoffenders as a step-down from statehospitals like Carstairs.

3.38 The clinic is owned by the BelfastTrust. Inspectors were told thatthere were good relations betweenthe clinic and the mental healthcareprofessionals in the NIPS, and thework of the clinic was highlyregarded. There can, however, be atension between the health agendaand the requirements of the criminaljustice system for public protection –between clinical and forensicpriorities – as we discuss inChapter 7.

Other medium and low secure facilities

3.39 Adult and adolescent offenders maybe sent to privately run facilities inEngland, such as Cheswold ParkHospital (Doncaster) and St AndrewsHospital (Northampton). The NIPStold us that it had in the past senttwo severely personality disorderedoffenders to Cheswold Park.Inspectors have visited thesehospitals, and can confirm that thefacilities they offer are of a highstandard, and there is availability.But they are not cheap, costingaround £250,000 a year for eachresident and typically taking peoplefor 18 months to two years.

3.40 The question has been raisedwhether we should not invite one ofthese private providers to build a newfacility in Northern Ireland, whichwould have the benefit of easieraccess for officials and for visitors.There is a strong case to be madethat local provision would bebeneficial to the patients and improvetheir chances of recovery. The YouthJustice Agency (see Chapter 5) wassceptical of the benefit of sendingyoung people outside NorthernIreland in this way, and emphasisedthe value of keeping young peopleclose to their families and supportnetworks. Inspectors understand thatthe providers would be willing toinvest here if they were guaranteed asufficient caseload. But the economicunit seems to be around 70 beds, andit is unlikely that Northern Irelandcould justify a facility of its own –unless, just conceivably, in partnershipwith the Republic of Ireland.

3.41 Inspectors conclude that it is best forthe Health Trusts (selectively, andwhen the need arises) to pay to usethe high-quality facilities which areavailable in England for adults, despitethe disadvantages of their distancefrom home; but in the case ofchildren the balance of advantage islikely to favour treatment withinNorthern Ireland if at all possible.

3.42 Muckamore Abbey Hospital nearAntrim is a treatment facility forpeople with learning disabilities,and includes a forensic treatmentward. Individuals can be placed inMuckamore by direct order of theCourts through a Hospital Order.

Knockbracken Mental Health Services(Belfast Trust) is a psychiatric facilitycomprising 12 wards providing shortand long term care for people withmental illness. Some wards offerlimited security and the establishmentis a major resource for placing peopledetained under the Mental HealthOrder. Each of the five Health andSocial Care Trusts have at least onelocal psychiatric facility whichprovides care and treatment forpeople with a mental illness,including those who require theircare to be delivered in a low secureenvironment. Each Trust also has afacility where people detained underthe Mental Health Order can beassessed and treated.

Hostel accommodation

3.43 There is a case for building a new,semi-secure hostel accommodation asa step-down from custody for thosewho do not pose a significant threatbut, who find it extremely difficult tosurvive in the outside world. Aconsultant psychiatrist called for‘clusters of housing and hostels’ withprogrammes for continuing treatmentand resettlement. Without support,too many people who find it difficultto cope resort to excessive use ofalcohol or other drugs, which makestheir physical and mental conditionworse and inevitably brings them backinto the criminal justice system.Probation Officers drew attention tothe close links between homelessnessand problems of addiction and mentalhealth, and emphasised the need forsuitable accommodation for mentallydisordered women. Judges told us

that it was a problem that hostels(Approved Premises) were notavailable to be used as a bail addressfor mentally disordered offenders.

3.44 Approved Premises are unpopularwith local residents wherever theyare sited, but if they are properlystaffed to provide the necessary levelof supervision and support they arenot expensive (perhaps £20-30,000per place per year). Nevertheless, CJIis very supportive of the work of theexisting Approved Premises, andadditional well-run hostels couldrepresent good value in relation tothe alternatives.We recommendthat the needs of mentallydisordered offenders should befactored into the ongoingstrategic review of hostel(Approved Premises)accommodation.

Community Mental Health Orders

3.45 Probation Officers told us that therewas a need for more CommunityOrders with mental healthrequirements and for offendingbehaviour programmes to be tailoredfor individuals with personalitydisorders. Judges said that they foundcommunity-based sentences difficult,as it was hard to design the rightpackage for an individual. They saidthat sometimes a defendant wouldrequest, on his own initiative, to belinked to CPN services with which hewas familiar, and that often led to agood outcome. They thought therewas a need for continuing mentalhealth supervision for many mentallydisordered offenders, and that it was

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frequently unsatisfactory to impose asix-month hospital order without anassurance that there would becontinuing supervision for as long asnecessary thereafter. Offenders maybehave acceptably while takingmedication in a secure environment,but there can often be a questionabout how to manage the risk oncethey return to the community.

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Northern Ireland’s prisons

4.3 Northern Ireland has three prisonestablishments, one of whichcomprises a young offenders’ centre(YOC) and a women’s prison:

Establishment Security ComplementLevel

Maghaberry Prison High 850

Magilligan Prison Medium 500

Hydebank Wood YOC Low 200

Ash House - HydebankWood Women’s Prison Low 60

4.4 Maghaberry Prison houses a widerange of prisoners, from lifers toshort-term and remand prisoners, inconditions of high security. MagilliganPrison takes the less dangerousprisoners and those coming towardsthe end of their sentence, including ahigh proportion of sex offenders.Hydebank Wood YOC houses youngmen between 18 and 23, as well as asmall number of under-18s who forone reason or another cannot betaken into the Juvenile Justice Centre(Woodlands).

Prison and parole

CHAPTER 4:

“Care in the community has nowbecome care in custody”

– quoted by a number of interviewees

4.1 Northern Ireland’s prisons contain alarge number of prisoners withmental health problems, and thatproportion would appear to beincreasing. A total of 700 out of 850prisoners in Maghaberry Prison areon medication, mainly tranquillisers,and about seven per cent of thewhole prison population – around100 prisoners – are thought to beseriously mentally ill. WhileInspectors have to be concerned forthe welfare of all prisoners, it is thatsmaller number that is the primefocus of this inspection.

4.2 By and large prison does not maketheir condition better, and oftenmakes it worse. The transition fromprison back into the community isparticularly problematic. In Englandand Wales, some 200 persons a yearcommit suicide within a few weeks ofleaving prison. In addition, there areconcentrations of addiction and oflearning disability in the prisonpopulation.

4.5 The prison population has beengrowing steadily in recent years,though it still represents one of thelowest imprisonment ratios in theseislands:

Additional capacity has recently beencreated at Magilligan Prison, andthere are further plans to developthe prison estate to cater for theincrease in prisoner numberswhich will be consequent on theintroduction of extended andindeterminate sentences under theCriminal Justice Order 2008.

4.6 The increase in prisoner numbers asa result of the Order will not bespread evenly across all types ofprisoners. The prisoners whowill find themselves stacking up inprison on grounds of assesseddangerousness will tend to be thosewith severe personality disorders.The population of prisoners whohave special needs and who areparticularly hard to manage couldtherefore double even if the overallprison population rises by only 10%.

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* These numbers are not representative of the yearly average asper the previous years, as the population usually peaks in thesummer.

Chart showing average prison populationin Northern Ireland broken down by

establishment from 2003 - 30 Sept 2009

4.7 It could be argued that if someone isto be given a disproportionate termof imprisonment on account ofmental problems which are not theirfault, society owes it to them to offerthem a better environment than thatof Maghaberry Prison in which tospend their days. The problem isthough, that whatever facility they areheld in needs to be high secure.Transfer to a state hospital is notalways appropriate, because theirmental disorders are oftenintractable and would represent apoor use of scarce medicalresources. The only conclusion isthat these personality disorderedoffenders will have to remain inprison, and the best we can do forthem is to promote a high standardof ‘healthy prison’ regime for themand for all prisoners, with excellentcare and plenty of purposeful activity.

4.8 This accords with what a formerGovernor said to us. In his view, theimprovement of mental health inprisons should not be seen inisolation. The best way to improvemental health was through a totalHealthy Prisons agenda: safety, respect,purposeful activity and effectivepreparation for resettlement.Inspectors would endorse that view.

The transfer of responsibility forhealthcare in prison

4.9 In 1996 HM Inspectorate of Prisonspublished an important report on theinadequacy of care for the mentallydisordered in prisons, entitled Patientor Prisoner? The report said: “Prisonersare entitled to the same level ofhealthcare as that provided in society atlarge. Those who are sick, addicted,

30 Sept 2009

mentally ill or disabled should betreated to the same standardsdemanded in the National HealthService.”

This led in due course to thetransfer of responsibility for thecommissioning of healthcare inNorthern Ireland prisons from thePrison Service to the Health Servicewith effect from 1 April 2008. It washoped that that transfer, which wasaccompanied by a re-allocation offinancial resources, would lead to asignificant improvement in healthcare.

4.10 The NIPS management toldInspectors that it was developinggood collaboration with theHealth Service but most of thoseinterviewed who were involved withprovision on the ground said thatthere had been little sign of changeas yet. A consultant psychiatrist toldus that the policies and proceduresof the NHS needed to be brought into the prisons: they did not have aproper psychiatric unit operating toHealth Service standards, althoughInspectors acknowledge therestrictions both environmental andlegal that impact on this situation.

4.11 Another doctor said that he did notbelieve the Health Service coulddrive change in the prisons withoutoperational control of staff.Healthcare in Northern Irelandprisons is still mainly delivered byNIPS staff, and it is sometimes arguedthat there is a problem in havingstaff within a prison who are notunder the control of the Governor.However, Inspectors believe thatit is essential that there should beclarity as to which agency has lead

responsibility for the delivery ofhealthcare in the prisons.

4.12 That is not to deny the importanceof working in partnership. TheNIPS/Health Service task force whichplanned the transfer in England andWales emphasised the importanceof the two services working togetherclosely to identify the health needsof prisoners and plan servicesaccordingly. Inspectors are notconvinced that a positive andconstructive partnership on theselines yet exists on the ground inNorthern Ireland’s prisons, thoughthe parties are working towards it.Indeed, they are uncertain whether inthe long term partnership is thecorrect relationship: this is furtherdiscussed in Chapter 7.

4.13 The transfer of responsibility forhealthcare in prisons to HealthPersonal Social Services (HPSS)commenced in April 2008 with leadresponsibility taken by the SouthEastern Health & Social Care Trust(SEHSCT). The transfer is nowcomplete with core servicestransferring in April 2008 andaddiction services on 1 October 2008.The Trust has signalled its intent toprovide an equivalent service to thosein prisons to that afforded to those inthe community. It has now deliveredinvestment in mental health in theprisons in relation to:• the appointment of a single

provider of substance misuseservices to the prisons;

• mental health dischargeco-ordinator nurses based inMaghaberry Prison and covering allthree establishments; and

• addiction nurses.

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Further investment is required including:• additional sessions from psychiatrists

at consultant and staff grade;• strengthening CBT services; and• recruitment of a range of care

and support staff to assist in theadministration of medicines,observation of patients and thedelivery of basic nursing care.This will allow better use ofnurses’ time for the provision ofassessment, care planning and theimplementation and evaluation ofprogrammes of care.

Reception into prison

4.14 On committal every prisonerreceives a health assessment,including mental health screeningand onward referral, if required, to amental health nurse. S/He canthen make a further referral, after amore comprehensive mental healthassessment, to another specialist suchas a consultant psychiatrist, cognitivebehavioural therapist or voluntaryagency for drugs and alcohol abuse.

4.15 A review of the committal processrecently took place and currently atwo-stage committal process isunderway as a pilot at HydebankWood YOC and at MaghaberryPrison, which involves a first nightscreening for key risks followed by amore in-depth screening 72-hoursafter committal. This second stagescreening is a welcome development.Inspectors were told by expertsthat the initial assessment form was‘unsophisticated’ and the process wasnot wholly reliable, so that problemsoften emerged afterwards. The newsystem should pick up more of theseissues.

Continuity of healthcare

4.16 There is a problem over theexchange of information between theHealth Service and the NIPS. Medicalconfidentiality is a constraint. It isoften difficult for Governors andeven for the medical staff in prisonto obtain patient records from GPs,though Inspectors were told theposition was getting better. Thetransfer of responsibility for prisonerhealth to the Health Service shouldhelp with this. Within the prisonthere can also be restrictions on thetransmission of essential information.Probation Officers, too, complainedabout the difficulty of communicatingeither with GPs or with thepsychiatrists attached to the NIPS.Judges told us that they consideredit imperative that prisons shouldsystematically receive all medicalrecords requested at court.The Health Service is now focussingits attention on the sharing ofinformation between GPs and theNIPS and it is confident that thedifficulties experienced in the pastcan be resolved.

4.17 It is critical that the screening ofprisoners in reception is NOTthe first time when problems areidentified. The HSCB supportsthe appropriate flow of medicalinformation between the communityGP and the prison GP and vice versaas happens with any patient inthe Health Service. A confidentialconversation between the GP andthe prison GP about any prisonershould be facilitated at any stageshould either party request it.However, medical records should notbe accessed by anyone other than

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healthcare staff. The Health andSocial Care Board (HSCB) arecurrently preparing a template whichcan be used to share informationbetween the community GP and theprison GP and vice versa.

4.18 Prisoners may remain on remand inNorthern Ireland prisons for a yearor more, but there are limitations onthe treatment mentally disorderedprisoners can receive during thattime unless they agree to do so.They may be advised by theirsolicitor not to assent, in case itmight in some way prejudice theirtrial. There is a particular problemof remand prisoners with personalitydisorders, and the current system isnot working adequately to get themtransferred in to the appropriateprogrammes in the prisons.

4.19 There is a particular problem at thepoint where remand prisoners go tocourt, are acquitted and therefore donot return. Mental healthcare stafftold us that they are usually notnotified when a patient has returnedto the community, so there is noscope for them to liaise withcommunity mental health services.The point of return into thecommunity is a critical one, and formentally disordered prisoners whohave been ‘inside’ for a year or moreit is no less critical because they havebeen acquitted. They should not bereleased into the community withoutany support arrangements in place.Inspectors were told of some graphicexamples of personality disorderedprisoners who had gone on tocommit extremely serious crimesvery shortly after release.

Psychiatric services

4.20 There are two consultantpsychiatrists who assist the NIPSpart-time. Both are highly valued,but the time they can devote to theprisons is not equal to the demandsupon them. It is recognised by allconcerned that there is a need formore sessions in the prisons. Oneof them pointed out, however, thatthis simply mirrors the position inthe outside world. Even with thepressures on them in the prisons, aprisoner with acute problems is stilllikely to see a psychiatrist soonerthan a similar patient in thecommunity.

4.21 The same would be true in relationto the availability of mental healthnurses. There was a need for moremental health nurses in the prisons,but there were currently vacancies inmental health nursing training inNorthern Ireland. It was pointed outthat nursing in prison used tocommand a pay premium overnursing in the community, but thatwas no longer the case. Recruitmentinto the NIPS was slow, with securitychecks taking a long time. It wasemphasised that work in prisonrequired experienced and clinicallyconfident staff.

4.22 Each of the consultant psychiatristsdivide their time between the prisonsand the community. One providesfive sessions per week in MaghaberryPrison; the other looks after remandprisoners and the REACH landing atMaghaberry, visits Hydebank WoodYOC for two sessions a week andprovides one session a fortnight atMagilligan Prison. The total

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psychiatric input is shown in the tablebelow.

4.23 At Hydebank Wood YOC there is ahealthcare manager, two mentalhealth nurses and the visitingconsultant psychiatrist. Six mentalhealth beds are available. The mentalhealth nurses often have to help outwith general nursing. There is noroutine provision for the treatmentof mental illness among the juveniles(as opposed to the young men) atHydebank Wood, but the consultantwould see them in an emergency.Judges told us that they felt that theYOC was less well equipped to dealwith mental health issues than themain prisons. There is a programmeof CBT at Hydebank Wood YOCprovided by visiting therapists, which

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Psychiatry input per week

Prison Consultant Staff grade Psychiatricpsychiatry psychiatry Specialist Registrarsessions sessions (SpR) sessions

Maghaberry 5 10 2

Magilligan 0 0.5 0

Hydebank Wood 2 1 0

is popular and well regarded, but itdoes not seem to be linked to anyother mental health services.

4.24 Magilligan Prison has a largepopulation of sex offenders, whooften have personality disorders, andyet mental health provision is verylimited. There is no in-patient unit atMagilligan Prison, and any patientwith acute mental health needs istransferred to Maghaberry Prison.Magilligan Prison has 14 nurses, ofwhom two are Registered MentalHealth Nurses (RMNs), but they areoften diverted to generic nursingduties.

Nursing staff in NI Prisonscomplement (staff in post)

Prison Healthcare Senior Nurse Healthcare TotalManager Officer Officer Officer

Maghaberry 1(1) 4(4) 39(32) 3(3) 47(40)

Magilligan 1(1) 1(1) 10(10) 4(4) 16(16)

Hydebank Wood 1(1) 1(1) 8(7) 4(4) 14(13)

Total 3(3) 6(6) 57(49) 11(11) 77(69)

**The compliment of staff changes over time. Indeed we were told by the Prison Service that there werevacancies of over 42% in Maghaberry Prison in November 2009.

4.25 Inspectors were told that there was aneed for more hospital beds withinMaghaberry Prison as a safe haven forthose with mental health problems asa short term measure, since life onthe landings was noisy and chaotic.An alternative facility is, however,provided by the REACH project.

The REACH project

4.26 The REACH project, based in LaganHouse, assists prisoners withcomplex needs under the guidanceof a Prison Service Safer CustodySteering Group. It is essentiallydesigned for those exhibitingpersonality disorder, poor copingskills, self-harming or otherwisedisturbed behaviours, and providesmulti-disciplinary support whereneeded, in a slightly more shelteredenvironment. It is staffed by prisonofficers who have received specialtraining and aims to improve theprisoners’ social functioning andcreate better prisoner/staffrelationships through a pattern ofstructured participative activities.There are 20 places for remand orsentenced prisoners.

4.27 A senior manager told us that theREACH project had done good work,but it had not quite reached itspotential and seemed to have‘plateau-ed’ since the departure ofthe governor who had instituted it.It perhaps also lacked sufficientcorporate ownership by the NIPS.This was confirmed by our inspectionon the treatment of vulnerableprisoners, published in December2009. Despite the REACH landinghaving a high priority within theprison, it still had to fight for

resources on an on-going basis. Itshould, he thought, have been moreoccupational and therapeutic, but itdid not have enough psychiatricsupport. A consultant agreed thatthe REACH landing should increaseits capacity and the scope of its work,with additional support from theSEHSCT.

Suicide and self-harm

4.28 There have been four suicides inprison in Northern Ireland in recentyears, two of them being women.It should be noted that the suiciderate for Northern Ireland prisons isno higher, however, than the rest ofthe United Kingdom. Attention hasrecently centred on the suicide ofColin Bell in Maghaberry in August2008, which has been the subject of areport by the Prisoner Ombudsmanfor Northern Ireland and a clinicalreview by Professor Roy McClelland.

Colin BellColin Bell, aged 34, was known tobe in a poor mental condition. He wasreported to be restless and anxious, andto show signs of paranoia. Herepeatedly self-harmed and attemptedsuicide during the later stages of histime in prison. He had receivedattention from the mental health staff atMaghaberry Prison on several occasions,but it was not a lack of mental healthcare that resulted in his death (thoughthere could have been improvements inthat care, as the Prisoner Ombudsmannoted). The main problem was thepoor handling by the NIPS of a prisonerin his condition, and what would appearto have been negligence by prison staffon the night of his death.

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The Prisoner Ombudsman noted in herreport that she had discussed ProfessorMcClelland’s clinical report with theHealth and Social Care Trust and hadraised with them in particular:

- Gaps in the specialist psychologicalinput into the deliberations of themulti-disciplinary team, particularly asMr Bell’s situation became moredifficult, that might have producedalternative strategies for managing hissituation;

- Lack of medical input into multi-disciplinary case conferences and intothe decisions to extend the use of aSafer/Observation cell and anti-ligatureclothing; and

- The fundamental problem of theabsence of a secure hospital facility forprisoners with mental health problemsin Northern Ireland and the acutedifficulties this presents for the NIPS.

The Trust agreed that in six months[from January 2009], when a review ofthe implementation of therecommendations of the Ombudsman’sreport was carried out, it would make astatement about progress and plans onthe health management issues theOmbudsman identified.

4.29 Joint inspections of NorthernIreland’s prisons by CJI and HerMajesty’s Inspectorate of Prisons(HMIP) have criticised several aspectsof their provision for vulnerableprisoners. Most recently, in January2009 Inspectors found that safercustody in Maghaberry Prison hadlargely been a neglected area. Withan average of 29 prisoners being

designated as vulnerable each monthin Maghaberry, the numbers involvedwere significant. A more recentinspection on the treatment ofvulnerable prisoners noted thatthe NIPS clearly understands thechallenges of managing vulnerableprisoners and had developedappropriate policies and procedures.The difficulty lay in giving effect tothese positive intentions atestablishment level and particularlyin Maghaberry Prison.

4.30 At establishment level, particularly inMaghaberry Prison, Inspectors haveexpressed concerns about theemotional and physical care of theseprisoners. Some communal areas ofthe prison, such as association rooms,were not directly supervised byofficers. Vulnerable men were oftenheld in strip clothing in observationrooms which were cold, unsuitable,and were the antithesis of atherapeutic environment. Theinspection on the treatment ofvulnerable prisoners highlightedthe on-going problems for theseprisoners.

4.31 Despite the positive policy intent safercustody had largely been a neglectedarea at operational level and therehad been no consistent leadership inrecent years. Policies and procedureswere often poor, both in content andin application. There had been noreview of the anti-bullying policy forover seven years, case reviews (whichprisoners were not routinely invitedto attend) were not multi-disciplinary,the quality of care plans was poor,their content was non-specific, andchairing was frequently delegated tolower level managers who received

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no training for this important role.

4.32 Inspectors were told that Death inCustody Action Plans and outcomesfrom Coroner’s inquests werediscussed at the bi-monthly service-wide self-harm and suicide preventionforum that involved all threeNorthern Ireland establishments.Yet, the inspections of MaghaberryPrison in January 2009 (published inJuly 2009) and the Colin Bell ActionPlan in September 2009 have shownthat there is still considerable roomfor improvement in implementingprevious recommendations. As withprevious NIPS Action Plans, managersconfuse actions with outcomes andfail to recognise that manyrecommendations require continuousmanagerial attention and cannot besigned-off by a specific date.

4.33 Maghaberry Prison had taken somepositive steps by establishing theREACH landing to support thoseidentified as poor copers or withchallenging behaviours; and by settingup a listener scheme. Our recentinspection on the treatment ofvulnerable prisoners has consideredthis issue in some detail and we donot propose to repeat the argumentsagain here. Suffice to say at this pointis that the potential of the REACHlanding has yet to be achieved. Boththe NIPS and the SEHSCT have aclear idea as to what needs tohappen and these requirements havebeen published in a joint memo inApril 2009. Future inspections willdetermine the success of theseefforts in changing the outcomes forvulnerable prisoners. Our overallconclusion is that there remains asignificant job of work to be done in

delivering a therapeutic approach forvulnerable prisoners in MaghaberryPrison, and this needs to besupported by appropriate governancearrangements.

4.34 Some improvements have been madein the management of the risk ofsuicide and self-harm. A range of staffgroups now attend Applied SuicideIntervention Skills Training (ASIST)training to ensure that they have abetter awareness of prisoners withmental health needs, and there is aclear suicide prevention policy forthe NIPS as a whole. A PrincipalOfficer in each establishment nowhas suicide and self-harm as his orher primary responsibility. Howeveran inspection by HMIP and CJI inJanuary 2009 found that its earlierrecommendation that: “A local suicideprevention policy should be introducedthat describes how the Northern IrelandPrison Service policy is implemented atMaghaberry Prison and sets out localprocedures and responsibilities forintroducing a more supportive andtherapeutic response to those at risk ofsuicide and self-harm” had not beenachieved. There was no local policyto describe how the service-widesuicide prevention policy applied tothe particular context of MaghaberryPrison. Our recent review of thetreatment of vulnerable prisonersshowed a number of importantactivities had taken place since thedeath of Colin Bell. In general, thesetended to focus on the immediatesystem and negligence issues arisingfrom his death. There remains moreto do as the work of the SaferCustody Group and the MinisterialForum on Safer Custody impacts onthe delivery of services for prisoners.

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Addiction services

4.35 Many offenders with mental healthproblems also suffer from drug andalcohol problems. Within thecaseloads of the mental health teamsin the prisons, a relatively smallnumber of patients have severemental illness, as defined, but agreater number have personalitydisorders exacerbated by drugs andalcohol.

4.36 Within the NIPS a range of teams areresponsible for the assessment,treatment and care of individualswith substance misuse problems.They include prison healthcare, withspecialist input from the consultantpsychiatrist, but also substancemisuse services provided by prison-based voluntary agencies. In 2000three voluntary sector agencies wereappointed to provide services to thethree establishments:

Establishment Addiction service

Maghaberry Prison Dunlewey SubstanceAdvice Centre

Magilligan Prison Northlands Centre

Hydebank Wood YOC Opportunity Youth

4.37 They offer counselling and supportiveinterventions to all prisoners andoften work in tandem withresettlement staff to provide drugand alcohol related programmes.The services of these agencies arewell regarded, but Inspectors heardcomments that there wereinconsistencies in their approaches,and that they did not liaise sufficientlywith one another. Information wasnot always being passed on to followthe movement of a prisoner.

4.38 At Magilligan Prison Inspectors weretold it was not always easy to getpatients on to drug treatmentprogrammes. It required referral bythe GP. This is something thatperhaps needs to be looked at.NIPS management confirmed thatclinical interventions had beenslower to develop as investment inspecialist services had beenconstrained. The new sentencingframework of the Criminal JusticeOrder 2008 and the increasingcomplexity of substance misuseproblems had influenced the needto review how alcohol and drugservices were delivered. They toldInspectors:• an Addiction Services Manager

had been appointed and hadbeen in post since June 2007;

• the transfer of the budget forAddiction Services was expectedto transfer to the Health Trustvery shortly;

• a service specification for re-tendering for specialist addictionsservices would be drawn up;

• two Addiction Nurses and anadditional half-time ConsultantPsychiatrist would be recruited;and

• lead responsibility for addictionservices transferred to theSEHSCT at 1 October 2008.

Prison officers

4.39 Prison officers have the most contactwith prisoners from day to day and assuch can act as their primary carers.A HQ official told Inspectors that theNIPS should look for ways ofenhancing the skills of prison officersto enable them to perform that rolemore effectively, observing prisoners

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thoughtfully and recording theiraberrant behaviour. However, inNorthern Ireland the prison culturedoes not lend itself to that approach.For historical reasons, prison officerstend to maintain a psychologicaldistance from their prisoners and notto engage too closely. Inspectorswere told that prison officers wouldcall healthcare as soon as there wasa mental health issue with a prisoner,and simply hand over the problem.There is no ‘personal officer’ schemein Northern Ireland’s prisons. CJIunderstands, however, that modulesfor prison officers in pro-socialmodelling, and improved reportwriting have been introduced intothe training regime.

4.40 There is certainly potential for prisonofficers to make a more positivecontribution to the mental welfare ofprisoners, and there are an increasingnumber of officers who are preparedto rise to the challenge, but there isstill a need for a radical change in theculture within the prisons. Forinstance, we were told that theprovision of healthcare is ofteninterrupted and curtailed by thefrequent lockdowns which are afeature of the way the prisons arerun.

Listener schemes

4.41 Schemes have been tried out in theNorthern Ireland prisons underwhich selected prisoners have beentrained to act as ‘Listeners’ to otherprisoners with mental health issues,particularly those at risk of self-harming. Sometimes such prisonerswould be ‘doubled up’ with theirListeners. The schemes have had

some success in the adult maleestablishments, and were commendedby HMIP and CJI in a recent report,though there is a problem with theturn-over of suitable prisoners. AtHydebank Wood YOC, there havebeen problems with both the womenand, for different reasons, the youngoffenders. Listener schemes can beuseful, but they need to be managedwith care and in the view ofInspectors they should not be askedto bear more weight than theyreasonably can.

Women prisoners

4.42 Women are held in Ash House withinthe Hydebank Wood site. There isaccommodation for about 60 women,and in the year prior to the 2007inspection it had been running closeto capacity.

4.43 Women prisoners have specialmental health needs, as discussed inBaroness Corston’s widely respected2007 report. Corston commentedthat “many women in prison have beenfailed by the NHS long before theyarrive at the prison gates, and many aresimply too ill for prison to be anappropriate location for them”.

4.44 Fewer women than male prisonersare mentally ill, but they have morecomplex psychological needs and inparticular, feel the separationinvolved in imprisonment morekeenly than men do. Many womenprisoners have a history of abuse, andthey are at high risk of self-harming.They tend to be very demanding ofmental health staff (and of healthcarestaff in general).

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4.45 There is a strong view, whichInspectors endorse, that women withpersonality disorders should not bein prison if it can possibly be avoided:even more than is the case with men,imprisonment has a negative impacton them. CJI has recommendedelsewhere that there should,whenever it can be afforded, be anew type of facility to accommodatewomen in custody, which shouldhave less emphasis on security and agreater emphasis on providing atherapeutic environment for womenwho are often very damaged andvery vulnerable.

4.46 In the 2007 inspection report on AshHouse, HMIP and CJI drew attentionto the shortcomings of the mentalhealth provision for the women.The report said: “Until the week ofthe inspection, there had been only onemental health nurse for the wholeestablishment (i.e. HydebankWood,including theYOC) for some time andwomen complained about the quality ofthe service. The mental health in-reachteams provided only cognitivebehavioural therapy, and there was onlyone session of a consultant psychiatristto provide secondary care for women,which was insufficient.”

4.47 The NIPS with the PBNI isdeveloping a holistic strategyaddressing the delivery of servicesto women offenders both within thecommunity and in custody. Thestrategy for women prisonerspublished in the spring of 2009includes the following as ‘keypriorities’:• the scope for increased diversion

of women from court;• strengthening community

sentences;• creating appropriate

community-based facilities tosupport women offenders; and

• the implementation of a gender-specific approach to policy andprocedures in custody.

4.48 A conference was held in April 2008and consultation events in summer2009 to take this forward. Work isalso progressing with the HealthService looking at options fordealing with mental health issuesamong women in prison, including:• improvement of the committal

screening process;• development of a model of

care to meet the mental healthneeds of women prisoners;

• exploration of other therapeuticinterventions, including those thatmight address post-traumaticstress disorder;

• development of policies andprocedures to inform clinicaldecisions; and

• development of health promotionamong women in prison.

NIPS have recently published genderspecific standards and a guide forstaff working with women prisoners.Inspectors welcome thesedevelopments.

Psychologists

4.49 Psychologists play an important partin two aspects of the work of theNIPS. They help to plan and delivercourses of treatment for prisoners,such as cognitive skills, angermanagement and sexual offendertreatment programmes; and theyassess potentially dangerous

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prisoners as they come to the pointof release. However, they are inshort supply, not only in the NIPS butin other parts of the justice systemtoo. The NIPS has not succeeded inrecruiting the posts it requires16, andwill in all probability continue tostruggle to do so.

4.50 When life sentence prisoners andthose with extended orindeterminate sentences cometoward the end of their tariff, areport has to be prepared for theconsideration of the ParoleCommissioners for Northern Ireland,and although there are other inputsto that process, the Commissionersare known to attach considerableweight to the judgment of theforensic psychologists. It is thereforecrucially important that there shouldbe a sufficient number of qualifiedand experienced psychologistsperforming this role. If the ParoleCommissioners were not to haveconfidence in the assessments theywere receiving, there would be adanger that prisoners would begin tostack up in the prisons, contrary tojustice, and at great expense17.

4.51 The psychologists in the NIPS areforensic rather than clinical oroccupational psychologists, and theyare detached from the mental healthservices, the psychiatrists, mentalhealth nurses and CBT therapists.It would be useful for the NIPS tohave a clinical psychologist. At onetime it used to have two; and the

recent internal review of psychologyservices suggested that there wasscope for taking a wider range ofnon-specialist psychologists andinducting them into forensic work.

4.52 Inspectors agree that there is scopefor, and there would be benefits from,a wider range of psychological inputand from closer liaison between theforensic and therapeutic professionalservices. As the review stated,psychology services need to bebetter managed and it is importantthat they are used in the roles onlythey can fulfil. Prison officers needto be developed to do the work thatdoes not require a full professionalinput. CJI’s 2007 inspection of theNorthern Ireland Prisoner ResettlementStrategy had also drawn attention todeficiencies in the management ofpsychology services in the prisons.The psychology service has been thesubject of Review by the PrisonService (Daniell Review) and thisprovides a useful basis to make thenecessary changes required toimprove overall service delivery.Once again there needs to bemeaningful changes to the currentstructures and model of servicedelivery to have an impact on theregime for prisoners. Inspectorswelcome the fact that NIPS haverecently issued an Invitation toTender (ITT) for psychology servicesin an effort to meet the currentshortfall in forensic psychologyservices.

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16 In 2008 the Director of the Prison Service invited Mr J A Daniell to conduct a stocktaking of the NI Prison Service’s psychologyresources in the light of the new demands arising from the Criminal Justice Order and PPANI.

17 CJI’s 2007 inspection of the NI Prisoner Resettlement Strategy reported that the Life Sentence review Commissioners “were recentlyshocked to discover that there was no quality assurance process in relation to lifer assessments, and there had been some recent cases wherethe assessments provided to them had been defective”.

Preparation for discharge

4.53 No agency currently takesresponsibility for mentally disorderedex-prisoners at the point of theirrelease into the community. Oneprison governor accused the HealthService of ‘dipping out of theproblem’. But it is not always thefault of the health and social servicesas support services in the communityare often not made aware of peoplebeing released from prison.

4.54 There is concern in the HealthService about the new PublicProtection Arrangements forNorthern Ireland (PPANI), which it isfelt will place greater pressure onservices which are already in shortsupply. It acknowledged that it wouldbe unacceptable to say that someonecould not be released simply becausethe services were not available, butsaid that that was the reality.

4.55 A repeated message was that mentalhealthcare in Northern Ireland wasdisjointed. There needed to be waysof following cases through. Thereshould be better pathways andcommunication between agencies inand out of prison – which ought tobe possible in Northern Ireland sinceit is such as small place. A consultanttold us that 70% of his patientswould benefit from a linked-upsystem with continuing programmesand longitudinal care. A formerGovernor said that he felt that therehad been a greater focus onresettlement and addressing offendingbehaviour in recent years, but thoseefforts were in vain if the mentalhealth needs of the prisoners werenot tackled first.

4.56 The importance of the role of thePBNI was mentioned by severalinterviewees. For those onProbation Orders, probation officerscoordinated the management oftransfer to community probation.Resettlement, Inspectors were told,unquestionably worked better whenprobation were involved than whenthey were not. Probation Officerscomplained, however, about theslowness of action on assessing needswhen prisoners were coming to theend of their sentences.

4.57 It is also important that, so far aspossible, prisoners should be cleanof drugs at the point of discharge, togive them the best possible chanceof surviving in the outside worldwithout returning to drug-taking andcrime. It was specifically suggestedthat there should be a detox unit inMaghaberry Prison to get prisonersready for release.

4.58 When prisoners are discharged aletter is sent to their GP, butsometimes the GP has by thenremoved the patient from their list,so the contact with communityhealth services fails. Steps are nowbeing taken to check so far aspossible, whether a prisoner has aGP before s/he is released. A staffmember from the Southern Healthand Social Care Trust now comes into the Maghaberry Prison health suiteone morning a month to help withthe discharges. A positive note is thatthe NIPS has appointed twodischarge co-ordinators.

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Prison in-reach in the Republic ofIreland

4.59 Inspectors visited the Prison Inreachand Court Liaison Service in theRepublic of Ireland, which offers aninteresting model for diversion outof the prison system. Brief notes onthis are attached as an appendix tothis report.

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Mental disorder in young people

5.1 As with adult offenders, there is ahigh incidence of mental health needsin the young offender population.A survey in 2006 using a screeningsystem developed by the Youth JusticeBoard in England and Wales indicatedthat 59% of the sample of youngpeople who were clients of the YouthJustice Agency for Northern Ireland(YJA) showed signs of mental healthissues of one sort or another.

5.2 Inspectors were impressed by whatthey were told (paragraph 1.22)about the importance of earlyintervention with children and thedesirability, if possible, of picking upmental health needs at the primaryschool stage. Teachers told Inspectorsthat they could often identify childrenwith PD at an early age, but theyfaced difficulty in getting attentionfor them. There was a shortage ofeducational psychologists, and thefact that children were ‘statemented’did not secure treatment.

5.3 A teacher who specialised inproviding support for pupils withbehavioural difficulties commentedthat personality disorder on its ownwas not usually an insuperableproblem. If children were reasonably

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Children and young people

CHAPTER 5:

bright and had supportive parents,they could often overcome PD andbecome successful pupils. It was thecombination of PD with below-average intelligence and a disturbedhome background that created thegreatest problems. This accords withwhat can be observed in the prisonerpopulation, where the combination ofPD and below-average intelligenceresults in un-socialised lifestyles andpredisposes an individual towardsoffending behaviour.

5.4 The Youth Justice Agency (YJA)agreed with this, and told Inspectorsthat when a young person whooffends is found to have mentalhealth needs that:• the needs are typically diverse

and complex;• they are almost always linked to

other critical issues affecting theyoung person, such as housing,education, substance misuse,training and employment; and

• family relationships and socialcare are also of centralimportance.

5.5 The diagnosis of personality disorderin children and adolescents isproblematic, and a definite diagnosis isnot usually made before the age of18. Psychiatrists are often able to

detect if a child is developing apersonality disorder, and Inspectorswere told that with the righttreatment and help, such childrencould be given a second chance to gothrough adolescence successfully.YJA staff told Inspectors that therewas a need for more therapies thatcould address these problems.

5.6 As happens with adults in NorthernIreland, young people are occasionallysent to hospitals in England fortreatment, but this is rare. The YJAbelieves that whenever possible,children should be kept in NorthernIreland and treated close to theirfamilies and social support networks.It emphasises the importance ofliaising and working with parents toaddress underlying developmentaland family relationship issues.

5.7 The YJA commented that the needsof young people can fluctuatemarkedly, and that special attentionneeds to be given to periods ofheightened risk. These would includeremand to custody, the period leadingup to and during criminal trials, andthe period before and immediatelyafter release from custody. Evidencesuggests that depressed mood orsubstance misuse will substantiallyincrease the risk of suicide or self-harm in such periods.

The Youth Justice Agency

5.8 The YJA is involved with youngoffenders with mental health issues ineach of the three arms of its work.They are:• Community Services,• Youth Conferencing, and

• Woodlands Juvenile JusticeCentre.

5.9 There are also around 18 juvenilemales at any time accommodatedin a separate wing of HydebankWood Young Offenders Centre.Young people are predominatelyin Hydebank Wood due to thelegislation restrictions on theplacement of 17-year-olds inWoodlands, a small number,however, are there because theyare too difficult to handle. CJI hascommented elsewhere18 on the verypoor regime offered to juveniles atHydebank Wood YOC, and has urgedthat the courts should not commitchildren there unless the reasons arecompelling.

Mental health strategy

5.10 The YJA has produced a mentalhealth strategy, the key elementsof which are:• needs assessment;• awareness raising and

de-stigmatising of mental illness;• promotion and prevention;• specialist services; and• evaluation.

5.11 As part of the strategy, an audit wasconducted of the mental health skillsof the YJA staff, which showed a greatdegree of experience of working withyoung people with mental healthdifficulties, particularly in the areasof suicide, self-harm, learning andconduct disorders, trauma, addiction,adolescent depression, and in thedelivery of intervention plans. ManyYJA staff are trained in family therapy

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18 Report of an Announced Inspection of HydebankWoodYOC,CJI and HM Inspectorate of Prisons, November 2007.

techniques. However, half of allstaff surveyed identified a need forimproved access to psychological andpsychiatric services, to be providedin-house if possible.

5.12 The YJA is piloting the drugs andalcohol Regional Initial AssessmentTool (RIAT), in which all CommunityServices staff are now trained. Anumber of staff members are alsotrained in the AIM2 assessment forinappropriate sexual behaviour. TheYJA is aiming to train some staff inMental Health First Aid developed bythe Health Promotion Agency.

Community Services

5.13 In the community, mental healthcarefor children is provided by Child andAdolescent Mental Health Services(CAMHS). The YJA’s CommunityServices liaise closely with CAMHS,and would be pro-active in identifyingyoung people with mental healthneeds. The principle is that the coreCAMHS in any area should offerassessment and treatment of childmental health disorders and onwardreferral to specialists. SpecialistCAMHS may provide for more thanone district or region, and should beable to offer a range of services.

5.14 Where possible the YJA attempts toaccess mainstream child andadolescent services through localCAMHS services. At times, accesscan be difficult and there can be longwaiting lists for less serious cases.Ideally the YJA would like to seeCAMHS outreach workers going in toeach of its projects once a month forthree hours, but not all of theCAMHS teams would be able to

meet such a commitment.

5.15 The YJA has been participating invarious initiatives designed to improvethe commissioning and developmentof CAMHS services. They areworking on a protocol or ServiceLevel Agreement (SLA) coveringCommunity Services and YouthConferencing. This would standardisethe procedures (which at presentvary from team to team) and result inbetter access and fewer inappropriatereferrals. At present, according tothe YJA, CAHMS feel that the YJA isover-referring to CAMHS becausestaff are not confident and want to beon the safe side. This is especially aproblem in North Belfast, because ofthe concern about the number ofsuicides among young people therehave been recently.

5.16 The YJA said that there was aproblem with CAMHS cutting offinvolvement with a young person ator around their 18th birthday. Itwould be helpful if there could besome service for the 18 to 21-year-olds, who were not yet fully ‘adult’but fell outside the ‘child’ category.

5.17 We understand that the regionalCAMHS teams will by summer 2010have access to a total of 33 bedsat a child and adolescent unit atthe Forster Green site. They toldInspectors their priorities were:• developing speedy in-house

assessment arrangements, to avoidthe current practice of referringyoung people to A&E in anemergency. They would like toput an alternative in place, butthey may be limited in thecoverage they can offer;

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• helping the staff who are used tohandling adult patients to learnhow to deal with children andadolescents who come in to theircare;

• creating integrated teams drawingon the resources of the JuvenileJustice Centre (JJC) and Looked-after Children to provide betterhandling of the significant numberof children who are known toboth services. (The JJC staffsupport the idea of a fullyintegrated model); and

• providing more support forteachers and residential staff.

Youth Conferencing

5.18 The criminal justice system inNorthern Ireland aims to divert asmany children as possible away fromthe courts and into restorativeconferencing, organised by the YouthConferencing Service (YCS) of theYJA. Young offenders with identifiedmental health needs would almostalways be diverted to conferencing19

if they were not diverted earlier bythe police to the Health Servicefollowing a caution or informedwarning. The YCS provides theopportunity for a more holisticperspective to be taken whichaddresses the needs of victims,offenders and community safety andpublic protection concerns. Creativeplans can be put in place whichsatisfy the public interest and, at thesame time, address complex needs.

5.19 When the YCS becomes aware ofmental health needs which may relateto an offence which is going throughthe conferencing process, part of aYouth Conference Order mayrequire a young person to agree topsychiatric evaluation and to co-operate with any treatment advised.In most cases these young people arereferred to their local CAMHS, butoccasionally they may require morespecialist forensic referral.

The Juvenile Justice Centre (Woodlands)

5.20 Woodlands JJC providesaccommodation for up to 48 childrenin modern, well-designed premises.The new facility was designed toimprove supervision and reduce therisk of self-harm. Managementrecognises that the young peopleare very vulnerable and takes theconcerns of potential suicide and self-harm very seriously. CJI’s inspectionof Woodlands Juvenile Justice Centrein May 2008 found that many childrenin the JJC had poor mental healthand other negative indicators.Of the 30 children in residence on30 November 2007:• 20 had a diagnosed mental health

disorder;• 17 had a history of self-harm;• 8 had at least one suicide attempt

on record;• 8 were on the child protection

register; and• 14 had a statement of educational

needs.

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19 Referrals to the YCS may come from the PPS as a diversion from prosecution or from the courts as a court-ordered conferencefollowing a finding of guilt. Both require the consent of the offender to participate in a conference. Following conference a plan isagreed which may be affirmed by the PPS or the court. Once affirmed, it becomes a statutory order which may be enforced. CJIreported on Youth Conferencing in February 2008.

5.21 Young people are screened andassessed as soon as possible afteradmission, and a risk managementplan is put into effect where thereare concerns. The assessmentincludes:• basic health;• medications;• mental health issues;• any contact with CAMHS;• any contact with Social Services;

and• family history.

5.22 Where risk is believed to be high,referral is made to the psychologistin the Centre and onwards tospecialist services such as psychiatrywhen appropriate. The assessmentwill identify any issues with drugabuse and any mental health issues.Almost all the children going throughit are found to have some such issues.There is very little evidence ofaddiction to drugs and when this isthe case, a detox programme isoffered. Staff said that it oftentook a few days before any underlyingmental health issues could beidentified.

Professional staff

5.23 Within the JJC there are four full-time Registered Mental HealthNurses (RMNs) and there is accessto a forensic psychologist and aconsultant psychiatrist who willsometimes conduct an assessment.The JJC therefore has a reasonablygood coverage of experts in mentalhealth, and the RMNs said that theyregarded the ratio of staff to childrenas good. The YJA have a visitingforensic consultant psychiatrist based

in Manchester (who they say isexcellent) because there is nospecialist in this area available inNorthern Ireland. We recommendthat the SEHSCT should continue totry to recruit a locally-based forensicadolescent psychiatrist to serve theneeds of Northern Ireland.Inspectors recommend that aspecialist child and adolescentpsychiatrist should be appointed,based in Northern Ireland, toadvise the criminal justiceagencies.

5.24 The YJA has been exploring ways ofimproving the commissioning ofmental health services, perhapsfollowing the model that is beingdeveloped in the NIPS. They havebeen negotiating with two healthtrusts about the possibility ofpurchasing a full range of CAMHSservices on a sessional basis. Thetrusts have expressed interest inproviding the services, but there maystill be a further need for additionalforensic mental health services in thelight of the new legislation relating todangerous and sexual offenders.

5.25 The RMNs said that they worked aspart of a multi-skilled team, and theywould not want more peopleinvolved, as it made it more difficultfor the children if they had torelate to too many people. Theyemphasised that young people werealways involved in discussions abouttheir mental health needs. They saidthat the house staff in Woodlands JJCwere also very good at working withchildren who had mental healthissues.

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General practitioners

5.26 As with the NIPS, the JJC finds that itis often difficult to get the necessaryinformation from GPs. Some GPsprovide excellent information, andsome were reported to go out of theirway to visit their young patients inWoodlands. But by and largeobtaining medical information is aproblem. Medical records are notusually transferred to the JJC, becausethe children are not likely to bethere long enough, and the JJC’sGP is reluctant to prescribe somemedications without sight of them.The RMNs emphasised the need forspeedy information, and said that itcould be very frustrating to have tomanage without it.

Relationship with community healthcare

5.27 Many of the children are there forvery short periods, which militatesagainst effective treatment while insideand points to the need for a seamlesstransition between mental healthcarein the JJC and outside. While thedischarge planning system aimed toensure continuity of healthcare afterrelease, staff identified a number ofgaps. Many children were motivatedto get help while in custody but thiswas not sustained when they returnedto the community, due to lack ofresponse from external professionalsand/or poor compliance by children inkeeping community appointments.

5.28 Inspectors were told that it was notthe practice for CAMHS to come intothe JJC to develop a relationship witha young person before they werereleased into the community. It wouldbe very desirable if that could happen:

if no relationship had been forgedbefore a young person leaves, therewas a high probability that theywould not attend meetings withCAMHS subsequently. It wascrucially important that the justicesystem should bring the youngperson to engage with CAMHS uponrelease. There was a feeling in theYJA that CAMHS regarded Looked-after Children as their first priority,and that young offenders camesecond.

5.29 As with prison, some young peoplecommit repeat offences in order tobe re-admitted to the JJC becausethey feel safe there. Many vulnerableyoung people find it difficult to returnto life in the outside world, which isoften chaotic and abusive, or evendangerous, and it would be valuable ifthere were some step-down facilityto help them to re-adjust to life onthe outside. It is analogous to theproblem of ‘poor copers’ in the adultprison population, but more acuteamong children because of theirgreater vulnerability.

Relationship with education

5.30 Research suggests that those at riskof becoming tomorrow’s criminalscan be identified in some cases by theage of five years because of theenvironment in which they are livingwith high risk factors being poorparenting, poverty and criminality inthe family. At the same time, researchwith school principals on theestablishment of the Education andSkills Authority in Northern Irelandhas demonstrated that schoolsrequire a robust child and familysupport system to help address issues

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around truancy and disruptivebehaviour in schools. Support toenable school principals to deal withchildren who present with significantproblems that impact upon theireducation.

5.31 The creation of the Education andSkills Authority in Northern Irelandprovides an opportunity to re-consider the approaches to family andchildren support. Early interventionis a critical factor in diverting youngpeople away from criminal behaviour.It is equally important in bringing tothe attention of the care systemthose children who present withmental health difficulties that mayultimately contribute to thebeginnings of a criminal career.We will return to this issue in aforthcoming joint inspection with theEducation and Training Inspectorate inNorthern Ireland. In the meantime,it reinforces the importance of ajoined-up justice system withdevolved Departments whenconsidering policy development inthis sphere.

Statistics

5.32 The YJA does not keep statisticsrelating to the mental health of thechildren and young people who areits clients, and we recommend that it- and all the agencies of the criminaljustice system - should do so.Inspectors recommend that allthe criminal justice agenciesshould collect statistics on theincidence of mental health issuesin the cases they handle andthese should be shared with theHealth Service.

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6.1 We have commented at severalpoints in this report on work that isin progress to improve the handlingof mentally disordered persons in thecriminal justice system. However,there are two initiatives in particularthat deserve to be described in moredetail.

Mental health in the prisons

6.2 When the budget for prison healthwas transferred to the DHSSPS, aspecific allocation was made inrespect of mental health servicedevelopment. The sum of £225,000was transferred from the NIPS forthis purpose and £225,000 wasallocated by the DHSSPS. TheSEHSCT has developed plans forthe reform and modernisation of theservices, which include the following,drawing on the additional £450,000 ayear which has been allocated:

1. Additional psychiatric sessions

Additional sessions at consultant andstaff grade level will enable theassessment and treatment of thosemost seriously ill, those withtreatable personality disorders andthose with alcohol and drugproblems. At the time of theinspection, an extra half-time

consultant forensic psychiatrist wasbeing added to increase the provisionto a full-time consultant with effectfrom April 2009, and it was intendedthat a further full-time staff gradepsychiatrist should be recruitedsubsequently.

2. Two discharge co-ordinators

These nursing staff will beresponsible for ensuring that noprisoner with mental health needsleaves prison without the relevantcommunity services having beenbrought in to the planning of thedischarge. Their appointments havenow been made.

3. Two addiction nurses

These staff will be responsible forthe development of treatmentprogrammes to alleviate withdrawal,provide counselling and motivationalwork to promote recovery and tolink in with community services, toensure continuity of care whenreleased into the community. Theywill be responsible for co-ordinatingindividual and group programmesthat provide education to the widerprison population and take a leadrole in health development. Theirappointments have now been made.

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Work in progress

CHAPTER 6:

4. Cognitive behaviouralservices

The provision of additional sessionsprovided either by psychologists,counselling services or qualifiedCBT nurses will help treat anxiety,depression and other mentaldisorders. Discussions wereunderway with Belfast Health andSocial Care Trust regarding a furtherfull-time post for this purpose.

5. Nursing assistants

These support staff will assist thenursing staff, freeing up their time tocarry out their professional duties.Their appointments have now beenmade.

Inspectors recommend theHealth Service should be heldaccountable for the deliveryof the programme ofimprovements to mentalhealthcare in prisons which isplanned.

The Personality Disorder Strategy

6.3 The criminal justice agencies inNorthern Ireland have recognised theshortcomings of the treatment ofpersonality disordered offenders inthe present system, and a strategy isbeing developed to improve matters.At present it is acknowledged that:• the legislative framework is

inadequate;• there is a lack of co-ordination in

the services provided;• there is uncertainty about the

responsibilities of agencies andwhich should take the lead; and

• health priorities are elsewhere,and clinical needs are not beingbalanced properly against theneeds of public protection.

6.4 A number of factors have broughtabout the pressure for change,including certain high-profile seriouscase reviews and the new publicprotection arrangements (PPANI)for violent and sexual offenders.

6.5 The Northern Ireland PersonalityDisorder Strategy recommends thedevelopment of a dedicatedcommunity-based unit for theassessment and management ofpersonality disordered offenders,together with a strengthenedpartnership with health and otherstatutory and voluntary agencies,and a programme of joint training,research and evaluation. The aim isto produce a pathway for offenderslinking prison, a dedicated residentialunit and other placements in thecommunity.

6.6 The strategic vision involves thefollowing elements:• pre-sentence screening and

assessment by the PBNI;• referral for specialist assessment;• formulation of timely and

sequenced interventions;• treatment in the right place, and

at the right time, through effectivemovement between and withinservices; and

• review and lifelong management.

6.7 Inspectors endorse this approach inprinciple. As the authors of thestrategy recognise, however,progressing the idea of a dedicatedresidential unit is dependent on the

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availability of resources fromelsewhere in the criminal justicesystem, and the prospects do notseem good in the near future. Werecommend the Northern IrelandPersonality Disorder Strategyshould be pursued as quicklyas possible, and to the degreethat resources allow.

6.8 The ultimate test for success inrelation to the delivery of initiativesis not activity but the successfuldelivery of changed outcomes.Unless we can divert prisonersaway from the justice system asappropriate, provide meaningfultreatment and care while in custody,and plan for their resettlement backinto the community, then conditionswill not improve.

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Tensions in the system

7.1 Mental health and the criminal justicesystem is one of those subjects whichthe Cabinet Office calls ‘wicked’.The wicked subjects - the onesthat are the most difficult for thegovernment to handle - are thosethat spread across different arms ofthe government that have differentagendas and do not naturally talk toone another. In this case, the arms ofthe government in question are thecriminal justice system and the HealthService, each of which is very largeand comprises a number of separate,semi-autonomous agencies. There isthe added complication in NorthernIreland that at the time of thisinspection, health and social serviceswere devolved to the NorthernIreland Assembly and Executive, whileresponsibility for policing and criminaljustice remained with the WestminsterGovernment.

7.2 Although its profile has certainly beenraised in the Health Service followingthe Bamford Review, mental health isnot (and perhaps will never be) at thetop of health or policing priorities. Inany case each of the services is highlydevolved in practice, with front-linestaff having to exercise their individualdiscretion in dealing with a constant

stream of day-to-day events. Althoughthe PSNI is a disciplined service, onecannot change the behaviour (i.e. thepractical priorities) of over 7,000officers by issuing a new directivefrom HQ, nor can one change thebehaviour of however many cliniciansin the health service. It is importantto be realistic about the practicality ofmaking changes.

7.3 There is another difficulty about thissubject on the criminal justice side.It makes the agencies of the criminaljustice system uncomfortable becauseit goes to the heart of the questionof criminal responsibility. Is it‘either/or’? Are people mentally ill orcriminal, mad or bad? In the theoryof jurisprudence there has to be mensrea (a criminal intention or knowledgethat an act is wrong) for mostoffences (there are a few absoluteoffences), but in practice the law is, aswe have seen, very restrictive aboutexempting people from criminalresponsibility. One can have a verylow IQ (well below 70), one can beintoxicated, and one can be seriouslymentally disordered, and still beconvicted of a crime. How theoffence is disposed is another matter,but criminal prosecutions andconvictions proceed in the greatmajority of cases.

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Conclusions

CHAPTER 7:

Offender CA recent case provides an illustrationof this. Offender C was a paranoidschizophrenic who, while not taking hismedication, killed a police officer for noapparent reason in broad daylight in themiddle of an English city. He entered aplea of guilty to manslaughter ongrounds of diminished responsibility, butwas convicted of murder and sentencedto prison for a minimum of 25 years.Inspectors do not question that theverdict and sentence were inaccordance with law: it is the very factthat this was not an abnormal decisionthat gives force to the example.

7.4 This probably reflects the wishes ofthe public. It is a pragmaticapproach, and it does not necessarilyresult in bad outcomes, despite thedanger of not always being entirelyfair to the mentally disordered, andthose of low mental capacity. Butproceeding in this way introduces atension between the forensic and theclinical ways of viewing mentallydisordered offenders. The judgmentswhich different sets of professionalsmake may not infrequently be inconflict. The two services, health andjustice, need to work in partnershipon issues of mental health - as wehave observed at many points in thisreport - but that is not always aneasy thing to ask of either service.

The governance of prison healthcare

7.5 Indeed, although the newarrangements for healthcare in theprisons are being launched with agreat deal of good intent, andalthough they are likely to bring

about improvements, Inspectors areuncertain whether they will offerthe best solution in the long run.A partnership only works if thepartners share common objectives,and in this context there is, as wehave seen, a tension between clinicaland forensic need. Moreover, bringinghealthcare standards in prison up tothe level prevailing in the communitymay not be good enough if there areendemic shortages of resources inmental health.

7.6 Parity between prison and thecommunity may not be enough: theremay need to be a criminal justicepremium. The justice system has adouble claim on mental healthservices, because the public safetybenefit, flowing from appropriatetreatment, needs to be added to theclinical benefit to the individual.That can only adequately be reflectedby giving the NIPS (and possiblyother parts of the justice system) anenhanced budget for the purchase ofmental health services, and allowingthem to purchase those servicesfrom the best available source.

7.7 There is the further point that CJIbelieves in principle, that it is best ifone person or agency is clearly inoverall charge of a function and canbe held accountable for it. Inspectorswould always be doubtful about ashared responsibility.

7.8 Inspectors therefore favour a robustcommissioner – provider relationshiprather than a partnership. It is rightthat full responsibility for the healthcare of prisoners rests with theHealth Service, as this is the case inother parts of the United Kingdom.

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This means that all aspects of thecurrent service delivery architecturemust deliver. The NIPS must bespecific in relation to its needs,and this should feed into thecommissioning arrangements of theHealth and Social Care Board.They must hold to account theSEHSCT for delivery and manageperformance against agreedstandards.

7.9 Having said this, the risk is that thetreatment of mental health offenderswithin the Health Service gets anunsympathetic ear and indeed suffersnegative consequences when difficultdecisions on resources within thehealth service have to be made.Ultimately, the achievement ofsuccess means the delivery ofmeaningful outcomes for prisonersagainst the internationally recognised‘healthy prison’ tests. If the currentarrangements are not working overtime then they should be changed toreflect the needs of the prisonpopulation. The success or otherwiseof the current arrangements shouldbe the subject of a formal reviewwhen the current arrangements havehad the opportunity to bed downand when management and servicedelivery arrangements become morestable. Inspectors would not suggestthat the present arrangements shouldbe disturbed for the next five years.They should be given another fiveyears to run in and prove theirpotential, and should then bereviewed in 2014 to see whetherthere is a case for change. The healthneeds of prisoners needs to beowned by the Health Service andbuilt into on-going servicedevelopments. Inspectors

recommend that a formal reviewof the service provided by theHealth Service to the NorthernIreland Prison Service should beundertaken in 2014. The reviewwould consider the impact onprisoner outcomes of theservices provided by the SouthEastern Health and Social CareTrust against NIPS requirementsand Her Majesty’s Inspectorateof Prisons’ ‘healthy prison’ test.

The future of the prison system

7.10 Perhaps the most importantconclusion to come out of thisreport is that even if adjustmentsand improvements are made to thesystem, mentally disordered personsare going to continue to end up inprison, and in increasing numbers,because those who are deemed to bedangerous are likely to remain therefor considerably longer. If mentalhealth is not a marginal issue for thejustice system as a whole, for theNIPS it is going to become anabsolute pre-occupation. Makingsure that there are adequate mentalhealth services, adequate treatmentprogrammes and a ‘healthy prison’environment which will notexacerbate the mental problems ofprisoners, needs to be a top priority.NIPS management recognises this andare responding to the challenge,but it will need committed supportfrom the Health Service and fromMinisters. Prisons and the regimeswithin them will need to be designednot just to be penal establishments,but to provide secure care for anincreasing part of the populationsuffering from serious mentaldisorders.

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7.11 There also needs to be closeattention to the problem of bringingmentally disordered offenders backinto the community, making surethat there is continuity of care andthat there is appropriate continuedsupervision where it is needed.Inspectors believe that there is aneed for more sheltered or hostelaccommodation, which will be criticalif the Parole Commissioners forNorthern Ireland are going to havethe confidence to allow prisoners tobe discharged.

Management arrangements for deliveryacross the system

7.12 Lord Bradley in his recent report onpeople with mental health problemsor learning difficulties in the justicesystem in Great Britain highlightedthat one of the main problems withpolicy development has been thepiecemeal basis upon which it hasbeen undertaken. As he notes:“Thereis no one organisation that can be heldresponsible for making changes for thispopulation…If we are not to repeat themistakes of the past, as exemplified bythe rather uncoordinated approach tothe implementation of liaison anddiversion services, it will be vital toensure that there is a clear, visiblenational focus on this agenda thattranscends all the traditionalgovernmental and organisationalboundaries”. Bradley goes on torecommend national accountabilityfor the service improvement agendavia a new Programme Board. Hisintention is to bring together all therelevant government departmentscovering health, social care and

criminal justice to develop andoversee the delivery of services tooffenders with mental health andlearning disability issues. This isto be supported by a NationalAdvisory Group and a small crossdepartmental implementation team.He goes on to note “ultimately thedelivery of this agenda will be viapartners at a regional and local level,building on existing structures andrelationships”.

7.13 In response to the Bradley Reviewthe Government published inNovember 2009 ‘Improving HealthSupporting Justice’20. The responsehighlighted a number of areasincluding the importance of crossDepartmental working to implementchanges at a time of finite resources,the need for innovation in servicedelivery and the contribution ofimproved commissioning based onidentified needs. The message fromthe response is strong; “our overarching aim at each stage of theoffender journey is to develop themechanisms that enable the provisionof mental healthcare in the mostappropriate environment, whether in thecriminal justice system or in a healthsetting” and the need to look forimprovements in the system by“appropriately diverting offenders withmental health problems away fromshort sentences in prison towardseffective treatment in the community”.The Government also intends to setup a Health and Criminal JusticeProgramme Board reporting to theInter-Ministerial Group and theNational Criminal Justice Board.

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20 ‘Improving Health, Supporting Justice – The National Delivery Plan of the Health and Criminal Justice Board’ HM GovernmentNovember 2009

7.14 Inspectors see merit in thedevelopment of such an approach forNorthern Ireland. There are clearissues around fragmentation ofservice delivery across the justiceorganisations and between justice andhealth. It is our understanding thatthe Department of Health aims tocreate a Forensic Sub Group to theBamford Taskforce. This is early daysand certainly there was limitedunderstanding of its role or potentialwithin the justice system. This may,however, provide an operational basisfor improved co-operation andcollaboration in the delivery of localservices at all stages of the patientpathway. Indeed the implementationof the ‘Offender Mental Health CarePathway’ provides a basis for supportand intervention for the end-to-endmanagement of offender mentalhealth needs.

7.15 At a more strategic level we seemerit in the creation of a joint Healthand Criminal Justice ProgrammeBoard to help provide greatercollaboration and partnership inthe design and the delivery ofservices to offenders with mentalhealth problems. Inspectorsrecommend a joint Health andCriminal Justice ProgrammeBoard should be created tobring together all relevantorganisations to develop aclear approach to the needs ofmentally disordered offenders.

The need for realism

7.16 The Bamford Review produced anadmirable report, and it would behard to disagree with any of its 169recommendations relating to criminal

justice services. However it isscarcely surprising that the Executivefound it hard to commit to many ofthem: they are just too wide-rangingand too ambitious for immediateimplementation.

7.17 We have identified six key areas thatthe criminal justice agencies, withhelp from the Health Service couldfocus on, which we believe wouldmake the most difference. They are:• Establish clear rules about where

mentally disordered people are tobe taken when they are arrested ordetained by the police. The rulesshould distinguish between differentsorts of cases and should bespecific about the relevant place ofsafety for each category in eachpolice district.

• Make sure that mentally disorderedpeople are properly assessed whenthey arrive at the place of safety.In police stations, this meansextending the Mentally DisorderedOffender (MDO) scheme to coverall the custody suites in NorthernIreland.

• Make sure that the assessment (andany other available information) isproperly recorded on NiCHE RMSIT system and is passed on as partof any file which goes to the PPS.

• Make sure that the PPS brings anymental health issues to theattention of the Court at theearliest opportunity, so that thejudge can consider it (and call forfurther expert advice, if necessary)before the case is heard.

• Make sure the care of prisoners isbased around the ‘healthy prison’agenda which provides real andsignificant outcomes for prisoners.There is a need for on-going review

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of the quality of care provided bythe Health Service and correctiveaction taken where necessary.In addition there is a need for alocal high secure hospital towhich the most dangerous mentallydisordered prisoners can betransferred for treatment.

• Focus on the need for suitableaccommodation to help mentallydisordered offenders to make thetransition back into the communitywith adequate supervision andaftercare.

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Appendices

2

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Section

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Appendix 1

The Republic of Ireland: Prison Inreach and Court Liaison Service

The PICLS is based at the Central Mental Hospital, Dundrum, (CMH) and CloverhillRemand Prison.The CMH is a Health Service Executive facility which has 95 patients, ofwhom 87 are male. It averages 100 admissions a year. Most patients have psychoses that canbe treated.The Inreach Team does not deal with Personality Disorders.A total of 20% ofpatients arrive under the 2001 Mental Health Act as non-adjudicated offenders.They arereviewed by Mental Health Tribunals. A total of 80% arrive following criminal proceedingsunder the Criminal Law (Insanity) Act 2006. Decisions about their release are taken by theMental Health Review Board, which makes recommendations to the Department of Justice,Equality and Law Reform. Diversion does not necessarily equate with discontinuation ofprosecution.

The CMH risk assesses and offers a progressive regime for men, but is currently unable todo so for the small numbers of women.The progressive regime ranges from high securitywith high staff/patient ratios, through to on-site and off-site hostels which afford greaterdegrees of independence. Oversight is exercised by the Mental Health Commission whovisit twice a year, once announced and once unannounced.The Royal College ofPsychiatrists also undertakes peer assessment across the islands through its Quality Auditnetwork; and the European Commission for the Prevention of Torture (ECPT) also visits.

The multi-disciplinary Inreach Team has been operational for 20-30 years, but it wasformalised and strengthened in 2006, and fully staffed since 2007. It is based in CloverhillPrison with CMH staff: a psychiatrist, Community Psychiatric Nurses (CPNs) and socialWorkers. It took a deliberate decision to work with the remand prison rather than viaGarda stations or the courts as numbers outside could be too great and it would be toodifficult to monitor patients’ progress. It is recognised that this may mean opportunities forearlier diversion are lost.There are different local diversion arrangements for other prisons,for both sentenced and remanded prisoners, outside Dublin.

The Inreach Teams’ main functions are psychiatric screening of new remands; provision ofcourt reports; triage according to the level of treatment need (this includes a gatekeepingrole in respect of the CMH); psychiatric care for existing prisoners; and arrangement fordiversion to community psychiatric facilities. It aims to screen out minor offenders whohave major mental illnesses. The service is provided free to the Irish Prison Service, as aredrugs and STI (sexually transmitted infection) services.Although it is an informalrelationship and the Inreach Team is not accountable to the Cloverhill governor, it is said towork well because those involved are committed and communicate well.

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Some key achievements and data are as follows:

• 680 new assessments in 2008 – many were minor offenders, but were remanded incustody due to their psychiatric conditions;

• 80% seen within seven days of committal;

• 113 had an active psychosis; 189 had a lifetime psychosis;

• 91 diverted to general psychiatric hospitals or community psychiatric facilities, within anaverage of 14 days;

• 19 admissions to the CMH from Cloverhill in 2008;

• Four CMH admissions were subsequently diverted;

• Significant reduction of people with major mental illness/minor offences entering theCMH, from 74% of assessments in 2005 to only 10% of assessments in 2007;

• Time spent in custody for those deemed suitable for local psychiatric treatment reducedfrom average 57 days in 2005 to 21 days in 2007; and

• While 77% of all patients transferred from Cloverhill to the CMH in 2005 were notactually deemed to need high security, this had reduced to 28% by 2007.

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Appendix 2

List of agencies and organisations consulted

1. Aware Defeat Depression

2. Department of Health, Social Services and Public Safety (DHSSPS)

3. Representatives from a variety of Health and Social Care Trusts (HSC)

4. Judiciary

5. Northern Ireland Court Service (NICtS)

6. Northern Ireland Office (NIO)

7. Northern Ireland Prison Service (NIPS)

8. Police Service of Northern Ireland (PSNI)

9. Probation Board for Northern Ireland (PBNI)

10. Public Prosecution Service (PPS)

11. Rethink

12. University of Lincoln Mental Health and Criminal Justice Department

13. Youth Justice Agency (YJA)

14. Inspectors also undertook site visits to secure hospital premises in England.

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First published in Northern Ireland in March 2010 byCRIMINAL JUSTICE INSPECTION NORTHERN IRELAND

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