In many countries, health services for citizens in prison are not always subject to the same standards of quality set for other parts of the health care system. In Denmark, for example, multiple inspections, reports, and assessments have documented patient safety lapses in the prison and probation service during the past 20 years. One of the problems identified is the lack of patient safety systems and processes. These conditions are obviously problematic for citizens in prison since they often have significant health problems, and we have risked exacerbating these problems by neglecting to act on long-established knowledge of these health inequities.
At the Danish Society for Patient Safety (PS!) we find this unacceptable. We see a number of opportunities to improve patient safety for those in prison or on probation. The following is a summary of a recently published opinion paper proposed by PS! and adapted, adopted, and co-signed by the Danish Nurses Organisation, Danish Medical Association, Danish Institute Against Torture (DIGNITY), and a group of Danish patients.
The List of Challenges Is Long
The issues regarding patient safety and health services in the prison and probation service in Denmark are not new. They have been pointed out by the Danish Parliamentary Ombudsman, the Danish Authority for Patient Safety, the European Committee for the Prevention of Torture and Inhuman or Degrading Treatment or Punishment (CPT), and by independent consulting groups for many years. There has also been a constant call for action from nurses and doctors working within these services.
In 2019, 12 out of 20 prisons or detention centres received an injunction from the Danish Authority for Patient Safety declaring that there were “major” or “critical” patient safety problems. Amongst the problems identified were examples of citizens in prison receiving someone else’s medications and a lack of medical recordkeeping and documentation.
The 2019 assessment was supplemented in 2020 by a report from the CPT to the Danish government. This report outlined many additional challenges. These included long waiting times to see a doctor or dentist and inadequate staffing of health professionals, especially during off-peak hours and weekends. There was also a lack of systematic health screenings, poor oversight of those receiving medication, and an overall lack of clear structure and accountability.
Potential Risks to Many
The lack of systematic health screenings can, among other things, lead to missing the citizens at risk of developing symptoms related to alcohol or drug addiction. It may also mean that the prison and probation service do not have a clear sense of which citizens within their custody are particularly vulnerable due to one or more somatic or psychiatric morbidities.
This problem concerns citizens in prison, prison and probation employees, and the organisations managing these facilities. Medication errors and lack of proper management of health-related issues can result in unrest and potentially aggressive behaviour. Consequently, episodes can occur that put other citizens within the prison or staff in vulnerable situations and may lead to physical harm or damaged property.
No Culture of Learning
Unlike the rest of the Danish health care system, the health division within the prison and probation service are not legally obliged to report on adverse events. Consequently, they also do not have a system for learning from errors and harmful incidents.
In the non-prison Danish health care system, the reporting system for adverse events is crucial for continuous learning from errors and potentially harmful events. It strengthens openness and contributes to a culture of learning. Therefore, we at PS! are strong advocates for requiring the health divisions of the prison and probations service to follow the same adverse events reporting requirements as the rest of the Danish health system.
Electronic patient journals (also known as electronic health records) are a key pillar of the Danish health care system. However, large parts of the prison and probation service are without this resource. This means that unnecessary resources are spent on making physical copies of paper records. This increases the risk that health care professionals in prisons do not share all the necessary information with other health care professionals across the health care system.
For these reasons, the Danish Prison and Probation Service institutions should be required to introduce electronic patient journals. We believe this is a priority which has significant resource and health care equity implications.
Health Equity for All
Improving the delivery of health care services within the prison and probation service in Denmark is not only about patient safety. It is also relevant to systematic population health issues and equity in health and care. Not being able to deliver health and care to the best of your knowledge and standard of care can also put undue stress on the well-being of prison staff.
For all these reasons, we at PS!, in consultation and collaboration with other interested parties, call on the Danish government and Parliament to act to improve patient safety in prisons, particularly in connection with the budget negotiations on the multi-year agreement for the prison and probation service.
All patients in Denmark — regardless of background and history — should experience the best possible treatment and care. This is not the case today and this needs to change.
Christian Vestergaard, MedScD, is a Medical Advisor with the Danish Society for Patient Safety.
You may also be interested in:
JAMA Viewpoint - COVID-19, Decarceration, and the Role of Clinicians, Health Systems, and Payers: A Report From the National Academy of Sciences, Engineering, and Medicine by Emily A. Wang, MD, MAS; Bruce Western, PhD; and Donald M. Berwick, MD, MPP