A report by the United Kingdom’s Inspectorate of Prisons has found a litany of failures in the prison health services in the Cayman Islands’ two correctional facilities.
Among the inspectors’ concerns was the legality of prison staff giving psychiatric injections under force to inmates with mental health issues.
According to the report, based on findings by inspectors who toured the prisons in June 2012, almost all aspects of provision of healthcare were “poor, falling well short of acceptable basic clinical standards or … any broad equivalence with provision in the community”.
Although no prisoner was being held during the period of the inspection under the Cayman Island Mental Health Law, which allows for the prison to be used as a place of safety, some prisoners were given psychiatric medication under force, the inspectors found.
“The medication was sometimes prescribed without the psychiatrist seeing the patient. We questioned the legality of such practices and did not receive a satisfactory response,” the inspectors said in their report.
British inspectors immediately called for the prison service and the Health Services Authority, which is responsible for healthcare at both the men’s prison at Northward and the women’s facility at Fairbanks, to check whether or not the practice is legal.
Inspectors also found the sole nurse working at both prisons was “overwhelmed by his unacceptably high workload and prisoners’ access to him was problematic”.
The sole nurse at the prisons, who is general and mental health trained, works from 8am to 4.30pm, Monday through Friday, mostly at Northward but also going occasionally to Fairbanks or Cayman Islands Hospital in George Town.
“In effect, he was the physical and mental health nurse, pharmacist, practice manager, administration clerk and porter. He had little support from senior managers in the HSA and no clinical supervision, although he was able to undertake some mandatory training days,” the inspectors reported.
Meanwhile, the prison inspectors described the clinic at Northward as “cramped, shambolic and not fit for purpose”. While they found medical facilities at the women’s prison Fairbanks were better than those at Northward, neither clinic was secure, nor met infection control standards.
The Health Practice Commission certified the clinics as meeting national standards and the health facilities inspector inspected the clinic at Northward just a few weeks before the prison inspectors.
The prison inspectorate described the clinic at Northward, saying: “The layout of the room was poor. There was a ‘working trolley’ that was untidy, and it was unclear what it was used for, and the tap was broken on the inadequate hand-wash sink. There were unlocked cupboards containing a range of items, including syringes, needles and intravenous fluids. The medicines cupboard was untidy and was unlocked when patients were in the room. The storage of clinical records was poor.
“The clinical room at Fairbanks was larger but in a similar state. In both rooms, infection control measures were inadequate, with both having dirty, unsterile cloth privacy screens.” The inspectors also visited the Bodden Town health clinic to compare prison health facilities with those available to the general public and found the community clinic to be “clean, clinical, light and airy, with relevant health promotion materials available to patients and secure storage of medicines and clinical records”.
However, Dr. Steve Tomlinson, chairman of the Health Practice Commission queried that comparison, saying that at the time the prison inspectors visited the Bodden Town clinic, that facility had not been signed off by the health facilities inspector, Barrie Quappe, and was subsequently closed down and renovated because it could not meet national standards in its unrenovated state.
Ms Quappe said she inspected the prison clinics on 5 July and found some “issues of non-compliance” about which she notified the Health Services Authority. She said: “The issues were remedied following which the prison clinics were certified as compliant”.
“Inspections are not done randomly and conceivably this does give clinics the opportunity to do some housecleaning before inspection,” Ms Quappe said of her inspection visits. “Comparatively, we were told by one of the UK inspectors, the UK team was given unfettered access during their stay and their visits were unannounced.”
“Assuming that the UK prison inspector’s report is accurate, I am left to conclude that the standards at the prison were not maintained after certification, thereby resulting in the ‘shambolic, not fit for use’ state in which they found the clinic,” she added.
The inspectors also reported that chronic conditions were not followed up and GP clinics were regularly cancelled and not rescheduled.
The one policy that covered all aspects of prison health services was “poorly written and it was not clear whether it had been ratified by all affected parties”. That policy was not known to the prison officers and was not followed, the report stated.
The inspectors also found that there were numerous breaches of confidentiality, with prison officers being aware of the details of a prisoner’s medical history and conditions.
The prisons inspectors also found that clinical records were “deficient”. Although a paper record existed for each prisoner of the care they received in prison, it was “not contemporaneous because any care provided by the hospital, including test results, was recorded onto the HSA’s electronic clinical record system and not in the paper record”.
The nurse could access the electronic system to obtain test results but not for anything else, the inspectors said. But they added that there were plans to extend the nurse’s access to electronic records.
The inspectors described the medicines management at the prisons as “appalling”, with stock medicines in Northward being kept in a metal filing cabinet that was unlocked when prisoners were present. They also found pharmacy reference materials were out of date and the drugs refrigerator’s temperature was not checked to ensure the medicines were stored correctly. They described mental healthcare provision at the prisons as “minimal”, with a consultant psychiatrist with a caseload of 10 men and one woman at the time of the inspection, visiting the prison monthly.
“During the inspection, the consultant saw seven men in 1.5 hours at Northward, including a new referral from the prison psychologist who had expressed suicidal thoughts and had been moved to ‘basic’ on A wing as a consequence,” report read.
Among the other recommendations called for by the prisons inspectorate were physical and mental health screening for prisoners on the day of arrival; all prisoners should be offered hepatitis B vaccinations; applications to see health services staff should be confidential and not rely on the discretion of prison officers; GP clinics should not be cancelled, and if they are, they should be rescheduled within a week; up-to-date lists of all patients with lifelong conditions should be kept and these patients should receive care and reviews in line with evidence-based best practice; installing an electronic clinical record system for use by health services staff at both establishments.