BACKGROUND:The prison population in England and Wales exceeds 88,000, with a high turnover - 47% of sentenced admissions in 2023 served less than 12 months. Transitions from prison to the community are recognised as high-risk periods for medication-related harm, driven by complex health needs, short custodial stays, and fragmented healthcare systems. While national and international guidance exists to support safe medication management, implementation during prison-community transitions remains inconsistent, and evidence on both the drivers of unsafe medication practices and potential solutions is limited. AIM:This study explored the human, organisational, and environmental factors influencing medication safety during transitions from prison to the community, as well as potential solutions for improvement, from the perspective of staff involved in these transitions. METHODS:Qualitative semi-structured interviews were conducted with 12 staff members working in roles relevant to transitions from prison to the community, including general practitioners, pharmacists, and prison officers. Participants were recruited through professional networks and snowball sampling. Data were thematically analysed using the Systems Engineering Initiative for Patient Safety (SEIPS) framework. RESULTS:Five main factors impacting medication safety during transitions were identified: release practices, care coordination and communication issues, staffing shortages, IT system limitations, and patient-related factors. Key findings highlighted risks associated with immediate releases, discontinuity in medication regimens, insufficient staffing for discharge planning, and poor information transfer between prison and community healthcare providers. These challenges were further compounded by patient-level issues such as low health literacy, substance use, and housing instability. Staff proposed several improvements to enhance medication safety during prison-to-community transitions, including electronic prescribing for timely access to medication, improved information transfer, dedicated discharge teams to ensure medication follow-up, early discharge planning to address medication needs, and multi-disciplinary meetings to coordinate complex care. CONCLUSION:Medication safety during transitions from prison to community healthcare requires coordinated efforts to address organisational challenges, including short-notice releases and inadequate information transfer, as well as human factors such as communication barriers and staffing constraints. Improvements that clarify roles, enhance processes and technology, and foster cross-system collaboration are essential to ensuring continuity of care and medication safety. PATIENT OR PUBLIC CONTRIBUTION:Two people, one with lived experience of care transitions and one carer, contributed to study design, recruitment strategies, participant materials, and the analysis plan through quarterly input. Findings were shared with a wider group of lived experience representatives, carers, professionals, and policy makers, who informed interpretation and dissemination. While PPI members did not directly participate in coding or analysing the data, their input ensured that the study design and interpretation were informed by real-world perspectives.

Background Rates of self-harm and suicide in prisoners in England and Wales are high, exceeding rates observed in the general population, of similar age and gender. Assessment, Care in Custody and Teamwork (ACCT) is the prison service’s self-harm monitoring process. Closure of this process is a high-risk time where people may be at risk of self-harm. Mechanisms to manage risk, particularly following closure of the ACCT management process, mean that many people subsequently self-harm while not being monitored. This creates an opportunity to evaluate the examination of a new tool that could be used to assess ongoing risk after an incident of self-harm and closure of ACCT, and bridge ongoing support. Objective To assess the acceptability of a new risk tool to clinicians, prison officers and people in custody, and subsequently, develop an operational implementation pathway to embed the risk tool in practice. Design A qualitative study using action learning groups. Results A total of five action learning groups were conducted in four male and one female prison sites. These included participation from six staff and eight people in custody. Four themes emerged from the thematic analysis, including establishing an effective implementation process, consistent administration and scoring, purposeful follow-up procedure, and meaningful engagement with people in custody. Two exemplar operational pathways were presented to identify how the risk tool could be incorporated into routine practice. Limitations Although this qualitative study used transparent and systematic methods, our sample size was small and may not be representative. Conclusion Suicidal thoughts, behaviours and attempts in people in prison continue to be common, and there is a need for a structured approach to reduce repetition. Action learning methods identified barriers, potential solutions and how a new tool could work alongside existing risk management. Future research should focus on the development of the exemplar pathways. In the first instance, a stakeholder working group could review the tool to make initial refinements, followed by a wider implementation study to develop the processes of how the tool could work in practice. Funding This article presents independent research funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme as award number 16/159/09.

ABSTRACTThe mental health needs of older people in prison (OPiP) are considerable but remain overlooked. This review aimed to develop an Initial Programme Theory (IPT) to understand how the mental health needs of OPiP can be addressed and how mental health care for older people in the community could be adapted for the prison environment. A review and realist synthesis pertaining to the mental health needs of OPiP was conducted across three stages, including: (1) a systematic review of empirical work; (2) a scoping review of prison guidance documents; and (3) a scoping review of community mental health guidance documents. Synthesis of eligible literature and development of the IPT followed realist principles and was supplemented by a stakeholder workshop of experts by personal and occupational experience. Overall, 122 sources were included. The IPT suggested that prisons can address the mental health needs of OPiP via micro‐level mechanisms (i.e., screening, assessment, care planning, intervention, continuity of care/release), meso‐level mechanisms (i.e., accommodation, environment, activities, religion/spirituality, peer support, family support) and macro‐level mechanisms (i.e., staff training/education, governance). Each mechanism is underpinned by trauma‐informed, integrated and patient‐centered care principles and their implementation should be guided by a local assessment of prison‐specific needs. Our IPT provides a framework for how prisons can address the mental health needs of OPiP, informed by community care provision, via several mechanisms across different levels. Future research should build on this work to inform a full evaluation of its impact on meaningful outcomes to promote equivalency of care for OPiP and non‐discriminatory access to mental health support for those at risk of marginalization.

As a result of the ageing prison population, it is anticipated that there will be a steady increase in individuals living in prison requiring access to End of Life (EoL) care in coming years. Research in this area is limited, despite it being concern of policy makers for several years. This paper aims to explore current EoL care provision in prison via nominal group methodology, to identify what forms of care have been implemented, what provision needs to be developed, and how might this be achieved. Ten professionals were recruited to a nominal group discussion and four themes were identified: 1) 'Consistent Family Input'; 2) 'Staffing'; 3) 'Ensuring Best Practice'; and 4) 'Person-Centred Assessment'. There was consensus that care pathways are currently in place for older prisoners diagnosed with a life limiting disease; however, the consistency of services is variable. Policy makers should consider the development of a national prison EoL strategy which embeds current good areas of practice whilst promoting equitable care delivery using multi-agency networks across the prison estate.

Prisons represent a significant public health concern. The challenging living and working conditions within prisons are widely acknowledged to contribute to elevated rates of ill health among both prisoners and prison officers. Officers hold a vital role in supporting individuals in custody. However, the intense pressures associated with the role, compounded by toxic workplace cultures, are frequently reported to negatively impact their wellbeing. This deterioration not only affects officers personally but can also compromise the effective functioning of the prison service. While structured support systems exist to meet the rehabilitation and care needs of prisoners, equivalent care and professional support for prison officers remains inadequate and insufficiently prioritised. A total of 27 in-depth qualitative interviews were conducted with both former and current prison officers to explore their subjective experiences and to collaboratively identify the support, supervision, and wellbeing training needs arising from their roles. A process of reflexive thematic analysis was adopted. Six main themes were constructed from the data analysis: (1) responsible recruitment, training, and development; (2) dual duty of care; (3) acknowledgement of psychological hardship; (4) superficial support systems; (5) collaborative cultural change; and (6) components of a good model of practice. This study highlights the urgent need for reform in how prison officers are supported and serves as a framework for the development of more effective support structures. It also contributes to the growing body of literature by deepening our understanding of the emotional labour inherent in the role and the associated psychological impact. Furthermore, it acknowledges the wider societal implications of these findings, emphasising that supporting prison officers is a matter of institutional responsibility and a critical public health concern.

Background:Palliative care, including advance care planning (ACP), ensures a patient's medical care aligns with their values, goals, and priorities throughout serious illness or injury. The Alaska Native and American Indian (AN/AI) population is greatly increasing and less likely to have documentation on ACP conversations. AN/AI peoples are more likely to engage in ACP when it is culturally-tailored to their specific needs. Jumpstart AN/AI is a culturally-tailored tool to assist providers and customer-owners with starting ACP conversations. We conducted a qualitative study to gather feedback from customer-owners and employees to inform implementation of Jumpstart AN/AI within primary care at Southcentral Foundation (SCF), a Tribal health system. Methods:We conducted a qualitative, descriptive study using a community-based participatory research approach. Semi-structured interviews and focus groups were conducted with customer-owners (n=14) and SCF employees (n=16). We used template analysis, a rapid qualitative data reduction technique, to analyze results from the qualitative interviews and focus groups. Results were then presented to the research team and SCF leadership to finalize implementation plans for Jumpstart AN/AI within SCF. Results:All participant groups were in favor of implementing Jumpstart AN/AI and expressed the importance of ACP conversations for AN/AI peoples. SCF employees stated Jumpstart AN/AI delivery would need to be flexible and meet the needs of customer-owners as well as providers and staff. Customer-owners reported they trust their care teams to deliver Jumpstart AN/AI and would also value patient-facing materials so they could ask their provider about Jumpstart AN/AI. Conclusions:Qualitative data collected from SCF employees and customer-owners, rapid template analysis, and collaboration with Tribal health system leaders resulted in successfully and quickly developing a flexible implementation plan to integrate Jumpstart AN/AI into the Tribal health system. Implementation of Jumpstart AN/AI will contribute to the limited evidence base for AN/AI-tailored ACP interventions and inform implementation research and practice.For clinical trials, the trial registry name and URL, and registration number must be included at the end of the abstract.

The number of people aged 50 and over entering the criminal justice system (CJS) in England and Wales is growing. This raises questions as to the suitability of the CJS to equitably accommodate individuals with complex illness or impairment, who might experience difficulties in cognitive function, frailty, and/or impaired mobility. Findings from the government, the third sector, and academic literature have highlighted the difficulties experienced by older adults in the CJS and those tasked with supporting them. To inform the development of the Ministry of Justice's national strategy for older people in prison, we conducted a series of nominal focus groups with policy makers, practitioners, prison staff, representatives from the third sector, and academics, each focusing on a specific topic area that impacts older adults in prison. These were: 1) older adult trajectories; 2) long term conditions; 3) dementia; 4) mental health; 5) social care; 6) end of life care; 7) women; 8) ethnicity; and 9) COVID-19. An additional nominal group was also held with older adults currently in prison to discuss what they thought should be included in the national strategy more broadly. This paper presents the methodology of the nominal groups and subsequent analysis, as well as providing a rationale for the research. It serves as a precursor to a series of papers reporting and discussing the findings of the topic-specific nominal groups.

Firearms are the most common means of suicide in the United States and a leading cause of death among all persons aged 10-64 years. Most persons who die by suicide see a clinician in the year preceding their death; thus, health care encounters are important opportunities for suicide prevention. Persons who die by firearm suicide differ demographically and clinically from those who die by other suicide means, suggesting that opportunities for prevention might also differ between these groups. This report examined patterns of health care use in the year preceding suicide death to identify potential opportunities for prevention among persons who died by firearm suicide and those who died by other means of suicide. State cause-of-death records for 2020-2022 were linked to electronic health records from health systems in Alaska (Southcentral Foundation) and Colorado and Washington (both Kaiser Permanente). Quarterly past-year health care use preceding death was examined across service settings, including primary care, outpatient mental health specialty care, emergency care, and inpatient care. During 2020-2022, across the three health systems, 683 persons died by suicide. The majority of these deaths (54.6%) occurred by firearm. Patterns of past-year health care use preceding suicide were similar for persons who died by firearm and other suicide means, with the exception of mental health care, which was significantly lower in specialty and primary care settings. These findings suggest that many persons who die by firearm suicide do not access mental health care before their death. Suicide prevention practices in health care, designed to help identify and engage persons at risk in supportive care, need to reach beyond mental health encounters, particularly for firearm suicide prevention.

BACKGROUND:The number of older adults entering the criminal justice system is growing. Approximately 8% of older prisoners in England and Wales have suspected dementia or mild cognitive impairment (MCI) and experience difficulties in everyday functioning, and disruption to their daily life. At present, no specific dementia/MCI care pathway has been implemented that is applicable and appropriate for use across different prisons in England and Wales. The aim of this paper is to explore the experiences of older adults with dementia/MCI in prison, and a range of key stakeholders, around the day-to-day issues faced by people with dementia/MCI and prison, healthcare, and third sector staff regarding the delivery of support for individuals with dementia/MCI. METHODS:Thirty-two semi structured interviews were conducted with prison, local authority, and healthcare staff; peer supporters; third sector care providers; and individuals with dementia/MCI themselves, across five establishments, to provide multidimensional perspectives of dementia/MCI in criminal justice settings. The data obtained during interviews were thematically analysed. RESULTS:From the data, six key themes emerged: (I) ethical concerns around trial, sentencing and detainment for people with dementia/MCI; (II) An unforgiving prison system, providing physical and social environments incompatible with supporting individuals with dementia/MCI; (III) An unprepared workforce requiring training in dementia/MCI. (IV) A lack of collaboration leading to sub-optimum management of the support needs of people with dementia/MCI in prison; (V) Peer support 'plugging the gap'; and (VI) staff 'hands tied behind back'. CONCLUSIONS:Results point towards a pressing need to develop more appropriate support systems for individuals with dementia/MCI throughout the criminal justice system. Ethical concerns around the judicial process for individuals with diminished cognitive capacity must be considered. Prison governors should examine ways to make the living environment more appropriate for these individuals, and a joined-up collaborative approach to health and social care should be adopted. Staff must be appropriately trained to support and identify individuals with dementia/MCI. Peer support schemes require formal evaluation, and training/oversight of these schemes should be comprehensive.

BACKGROUND:Incorporating American Indian and Alaska Native (AI/AN) traditional practices and knowledge into healthcare can support AI/AN health. Drug overdose deaths disproportionately impact AI/AN communities due to colonization, genocide, historical trauma, discriminatory policies, and under-resourced healthcare. Medications for opioid use disorder (MOUD; e.g., buprenorphine, methadone, naltrexone) are considered the most effective treatment for reducing mortality. Integrating AI/AN cultural practices with MOUD may increase acceptability and uptake of MOUD within AI/AN communities. METHODS:National Institute on Drug Abuse (NIDA) Clinical Trials Network (CTN) Protocol #0096 (Tribal MOUD) is a two-phase community-based participatory research (CBPR) trial to develop and evaluate an implementation intervention to culturally center MOUD delivery in AI/AN communities (N = 4 sites). A Collaborative Board (CB) guided intervention development (Phase I completed). A stepped wedge design (two sites/step) allows intervention implementation at all sites and improvements across sites (Phase II ongoing). The primary implementation outcome is the number of consumers with OUD who initiate MOUD in the six months pre-intervention vs. implementation periods; secondary outcomes are MOUD screening and retention (de-identified electronic medical record data). Additional data include organizational predictors (staff surveys) and moderators (consumer assessments) of implementation outcomes; and MOUD intervention acceptability (staff/consumer qualitative interviews). CONCLUSIONS:This is the first study to develop and evaluate an implementation intervention to culturally center MOUD delivery in AI/AN communities. Implementation science and CBPR are complimentary for co-developing strategies with AI/AN communities to integrate Indigenous and Western best practices, which may ultimately reduce opioid-related mortality among AI/AN peoples and enhance Indigenous community wellness. Clinical Trials NCT Registration Number:NCT04958798.

Prisoners are at increased risk of multiple health conditions relative to the general population. The effective management of long-term conditions amongst prisoners is vital to reducing health inequalities. A nominal group was conducted exploring facilitators and barriers to the identification, diagnosis, and treatment of chronic physical illness amongst older adult prisoners in England and Wales, as well as innovations and suggestions for improvement in this area. The nominal group included 12 prison staff from a range of professions and specialist roles, including nurses, general practitioners, consultants, junior doctors, researchers, and managers. Eight key themes were identified from group discussions, including: 1) primary and secondary care interfaces; 2) quality and outcomes framework (QOF); 3) healthcare during transitions; 4) prison environments and lifestyles; 5) expert patients; 6) service design and healthcare roles; 7) telemedicine; and 8) data availability. The importance of collaboration between prison staff, primary and secondary healthcare professionals, and patients themselves to effectively manage long-term conditions infiltrated several themes. Further research is needed to determine the most effective interventions for managing chronic illness and multimorbidity amongst older prisoners. This research is urgently required given the ageing prisoner population and could help to standardise healthcare across the prison estate.

The American Indian Enculturation Scale (AIES) was developed for American Indian populations to measure connection to traditional culture, but it has not been evaluated in Alaska Native people. While American Indian and Alaska Native individuals are grouped together, significant differences exist between groups. As a part of a randomized controlled trial for contingency management to reduce alcohol use, 160 Alaska Native adults completed the AIES. The confirmatory factor analysis indicated that a one-factor, 15-item version of the AIES, removing items 1 and 2 and correlating items 8 and 10, was a reliable (15 items; α = 0.896) and valid measure in this sample (χ2 [89] = 155.788, p<.001; CFI = 0.903; TLI = 0.886; RMSEA = 0.068 [90% confidence interval {CI} 0.050-0.086]; p<.001; SRMR = 0.060). The study provides limited evidence of enculturation's structural validity, as measured by the AIES, for Alaska Native adults. Future confirmatory work and potential adaptation is needed to evaluate the empirical utility of the AIES for Alaska Native individuals seeking help to reduce alcohol use.

The provision of social care for people in prison in England has historically been lacking. Seeking to address this, the 2014 Care Act clarified that local authorities are responsible for identifying, assessing and meeting prisoners' social care needs. Against this background, in 2020 we undertook a survey to explore the emerging services for this group. Eighty-six (57%) local authorities responded. A mixed methods approach was taken. Numerical data were analysed through descriptive statistics with comparisons made to the previous survey. An inductive approach to thematic analysis was used to analyse the free text responses. The findings revealed some improvements since the 2015/16 surveys, including the wider introduction of self-referral systems, the success of peer supporters in identifying people in need of social care and greater multi-disciplinary working. However, other issues remained stubbornly persistent, including a dearth of systematic processes to identify those needing social care on release from prison, a lack of timely information sharing and disputes over the sending and receiving authorities' responsibilities. There were also particular concerns about the shortage of appropriate accommodation for people leaving prison. Perhaps the most striking finding, however, was how little most authorities knew about this population. Building on discussions in previous papers, we explore three ways in which arrangements could be strengthened for this group: the collection of better data, the wider use of release on temporary licence and the greater employment of technology in planning people's release.

BackgroundSubstance use treatment programs are ideal places for suicide prevention interventions. People who misuse substances are at elevated risk for suicide compared to the general population. However, most treatment programs do not incorporate suicide prevention, and none have been adapted for American Indian and Alaska Native (AI/AN) people. Preventing Addiction Related Suicide (PARS) is a suicide prevention module developed for use with people in treatment for substance misuse. A previous study demonstrated increased suicide help-seeking among this population.ObjectiveCulturally adapt PARS for use with AI/AN communities.MethodsWe conducted focus groups and interviews with stakeholders in three Tribal health systems. We elicited feedback on PARS content, structure, and implementation. Data were analyzed using constant comparison. Results were used to adapt PARS and member checking was used to refine it.ResultsParticipants unanimously endorsed using PARS in their health systems. Suggested adaptations included shortening the module, using community-specific information, removing jargon and stigmatizing language, and emphasizing cultural connectedness.DiscussionThis community-based, qualitative study adapted the PARS module for use with AI/AN communities. Research is needed to evaluate the clinical effectiveness of the adapted module. If found effective, this would represent the first evidence-based suicide prevention intervention among AI/AN individuals in treatment for substance misuse.

The structured professional judgement (SPJ) approach was initially developed to support risk assessment and management decisions. The approach is now being adapted and applied to admission assessments for adult secure services. This systematic review aims to summarise the evidence for the effectiveness and acceptability of the SPJ approach in admission assessments of this kind. A comprehensive electronic search strategy was used to identify studies indexed in PubMed, PsycInfo, Medline and Cochrane Library (January 2007 -January 2024). Two search strategies included terms (and synonyms) for psychiatric patients (quantitative) or clinicians and clinicians' experiences (qualitative), structured professional judgement, admission, and secure services. Twelve quantitative articles (published 2007-2020) were identified. SPJ-informed guidance included were the DUNDRUM-1, DUNDRUM-2, DUNDRUM-3, DUNDRUM-4, and the HCR-20. While findings were variable, the overall pattern indicated that ratings suggestive of more problems were associated with increased likelihood of admission or movement to higher security levels. There is emerging evidence for the use of SPJ guidance to support admission decision-making. Specifically, it should be used as an adjunct to existing decision-making processes rather than as a replacement for those processes. Further research, both quantitative and qualitative, across a wider range of settings and populations is recommended.

Enhancing social support and connectedness can reduce suicide risk, yet few studies have examined this effect in American Indian and Alaska Native (AI/AN) adults. We assessed suicidal ideation and behavior, thwarted belongingness, social support, enculturation, historical trauma, and traumatic life events in 709 AI/AN adults at high risk of suicide from five AI/AN communities. Suicidal ideation was associated with thwarted belongingness and protected against by social support and engaging in AI/AN ceremonies. Among those who made lifetime suicide attempts, traumatic life events, symptoms of depression/anxiety due to historical trauma, and thwarted belongingness were linked to more attempts. More engagement in cultural practices was associated with fewer suicide attempts. Higher levels of social support were associated with more suicide attempts, an observation potentially attributable to the cross-sectional nature of the study. Interventions should focus on protective factors and context-specific interventions emphasizing community history, values, and strengths.

Throughout the COVID-19 pandemic, concerns were raised regarding the vulnerability of prisoners to infection from the virus, leading to numerous changes to prison regimes and healthcare delivery. A nominal group was conducted exploring the experiences and views of prison staff involved in supporting older adult prisoners in England and Wales during times of COVID-19, including considering improvements in prison healthcare that can be applied beyond the pandemic. The group included seven participants with relevant knowledge and experience, comprising two consultants in public health, four heads of prison healthcare, and a prison governor. Three key themes emerged from the analysis of the group discussions: 1) Impact and uses of technology; 2) Changes to prison regimes; and 3) The importance of purposeful activities. Further research is needed to understand the impact and effectiveness of digital technologies in prisons during the pandemic, specifically telemedicine, including understanding which circumstances and patient groups these provide most benefit in. Furthermore, prisons should ensure that the health and social care needs of older adults are considered when designing prison regimes and offering educational and recreational activities.

Many people are living in prison with a range of social care needs, for example, requiring support with washing, eating, getting around safely, and/or maintaining relationships. However, social care for this vulnerable group is generally inadequate. There is uncertainty and confusion about who is legally responsible for this and how it can best be provided, and a lack of integration with healthcare. We used realist-informed approaches to develop an initial programme theory (IPT) for identifying/assessing social care needs of, and providing care to, male adults in prison and on release. IPT development was an iterative process involving (a) an initial scoping of the international prison literature; (b) scoping prison and community social care policy documents and guidelines; (c) full systematic search of the international prison social care literature; (d) insights from the community social care literature; (e) stakeholder workshops. Information from 189 documents/sources and stakeholder feedback informed the IPT, which recommended that models of prison social care should be: trauma-informed; well integrated with health, criminal justice, third-sector services and families; and person-centred involving service-users in all aspects including co-production of care plans, goals, and staff training/awareness programmes. Our IPT provides an initial gold standard model for social care provision for people in prison and on release. The model, named Empowered Together, will be evaluated in a future trial and will be of interest to those working in the criminal justice system, care providers and commissioners, local authorities, housing authorities, voluntary groups, and service-users and their families.