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Women Offender Programs and Issues

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Report on announced inspection in Canada by HM Chief Inspector of Prisons for England and Wales:
Grand Valley Institution for Women

Section 4: Healthcare

Expected outcomes:
Inmates should be cared for by a health service that assesses and meets their needs for healthcare while in prison and which promotes continuity of health and social care on release. The standard of healthcare provided is equivalent to that which inmates could expect to receive in the community.

4.1 In our survey, 73% of women rated the overall quality of healthcare as bad or very bad. No health needs assessment had been carried out to determine whether the services met the needs of the population. Staff shortages were affecting delivery. Systems, particularly for managing the waiting lists, were lacking. There was a high use of prescribed medications and we had major concerns about how directly observed treatments were administered, in particular to women in the maximum security and segregation units. Many women could have their medications in-possession. The healthcare department had links with a wide range of specialists in the community. Mental health services were led by the psychology department, with sessions from a psychiatrist. There was no formal documented sharing of information between the psychology department and the psychiatrist, and we had concerns about the apparent difficulties in transferring a mentally ill woman to a bed in the community.

4.2 The healthcare department was within the main building adjacent to the maximum security and segregation units. There was a treatment room with a hatch to the corridor, a pharmacy store, a dental suite, a consulting room and two rooms where patients could be admitted for observation. One of the latter was a negative pressure room but was also used by visiting healthcare professionals such as the physiotherapist. There was a large fridge for storing Methadone in the pharmacy store; a lock was fitted to it during the inspection. A smaller fridge in the treatment room was used to store vaccines and other medications. There was a book to record minimum and maximum temperatures daily but the records were incomplete. There were staff and inmate washrooms. The psychology department occupied two offices. We were concerned to note that there was no defibrillator.

4.3 The chief of healthcare was a registered nurse (RN). There were three other RNs in indeterminate (permanent) posts, one was on secondment from another federal institution. A fourth RN on a six-month contract had just joined, and a casual RN was employed to cover vacancies when required. These staff worked in the healthcare centre (the floor). Two further nurses, one dedicated to the SLE and the other to the maximum security and segregation units, were on long-term sick leave. All the nurses were required to have a licence to practise in the province of Ontario renewed annually. There was no formal system to ensure that these licences were valid, although all were in date. Nurses who worked the floor had annual appraisals by the chief of healthcare, but those for the nurses on the maximum security/segregation units and the SLE were undertaken by the relevant unit manager.

4.4 The nurses on the floor worked from 8am until 4pm. Three nurses excluding the chief should have been on duty each weekday but this was rarely achieved due to staff shortages. On one day of our inspection, only the chief and a new member of staff were on duty for the whole day. There were two nurses per day at the weekends. The nurses on the maximum security and segregation units and the SLE did not work at weekends.

4.5 None of the nursing staff had received first aid or resuscitation training within the previous two years. None had any formal clinical supervision and formal staff meetings had fallen into abeyance due to staff shortages.

4.6 An administrative clerk worked full time in the department but her duties were split between healthcare and the psychology department.

4.7 A woman general physician (GP) attended the prison every Thursday for the whole day. She had been working at GVIW since May 2005 but had not received any training on security or working with offenders. A psychiatrist undertook one half-day session a week on a Friday, and a liver specialist attended monthly. A physiotherapist, who also worked in the local community, undertook one session a week and a dentist attended one day a week. A dental hygienist also undertook sessions but had been off sick for some time and no cover had been provided.

4.8 Clinical files were stored in locked filing cabinets in the consulting room. The filing system was obscure: files of women seen by the nurses in the preceding week were placed in one cabinet to be reviewed by the GP; back files of current inmates were filed separately from their current record; and the files of women on methadone were in a separate drawer. Records of women who left GVIW were kept for three months before being sent to Millhaven Institution, Kingston, Ontario, for archiving. If a woman returned to GVIW, a temporary clinical record was started and her previous records were requested; these usually arrived within three or four days. The files we reviewed were in a poor state: pages were not secured and the entries were not consecutive. Not all the notes had a major problems list, although we were told that each set should have one. No mention was made of when a woman left the institution. We also witnessed nurses writing in notes retrospectively. The psychologists kept separate case files about each of their clients.

4.9 Current medicine administration records (MARs) were kept alphabetically in ring binders in the pharmacy store. The prescriptions were clearly printed on the form at the dispensing pharmacy, following the receipt of a faxed copy of the doctor's orders from healthcare staff. However, no 'start date' was included on the prescription and in one case there were two doses of the same medication on the same prescription. The MARs comprised a two-page duplicate form, the back copy of which was detached and sent back to the pharmacy a week before a new supply of the relevant medication was required. Healthcare staff sent a medical profile (resident status form) of all new arrivals to the pharmacy regardless of whether they required any medication at that time. The pharmacy held a database of all women at GVIW and details such as allergies were highlighted when an individual was prescribed any medications and were automatically transcribed on to the MAR. Of the MARs we sampled, nursing staff had not annotated all correctly and it was unclear whether women had received the correct medication at the correct time. Nursing staff did not sign the MAR when they administered the medication.

4.10 Dental records were filed separately and kept in the dental suite.

4.11 Nursing staff worked to a variety of standing orders, some of which were local and some national. There were some discrepancies between the two sets and not all were dated.

  Delivery of care
  Primary care
4.12 In our survey, 73% of women said the overall quality of healthcare was bad or very bad. There had been no health needs assessment carried out so managers did not know whether the services provided matched the needs of the population and whether the staff had the appropriate skills.

4.13 New arrivals were seen by a nurse within their first few hours. In our survey, 83% of women, against compared with 72% in the English surveys, said they had had access to someone from healthcare within 24 hours of arrival. A healthcare assessment and the resident status form for the pharmacy were completed. If a woman was on medications, the doctor was contacted and a verbal order given to allow nurses to administer the medications for a week. This order was signed when the doctor next attended. Women also saw the psychologist, who completed separate paperwork relating to the woman's mental state at the time of admission. The inmate handbook detailed the services offered by the healthcare department and a specific healthcare booklet advised women about common health problems and how to manage them. Every new arrival had a two-stage Mantoux test to check for active tuberculosis. If the patient gave consent, healthcare staff contacted her previous doctor for her medical history.

4.14 Anyone wanting to see a member of the healthcare team usually had to submit a written request. Women we spoke to told of long delays in receiving responses to requests. We sampled a small selection of requests, which were all filed in each woman's clinical record (there was no central register of requests and the system was difficult to audit). Of the 14 requests from four patients looked at, the longest wait for a healthcare intervention was 16 days and the shortest was when a woman had been seen on the same day as her request. Nurses appeared to triage the requests based on the information provided by the patient rather than seeing the patient. Women could also contact the department via the master command control post (MCCP) and their request would be passed to healthcare staff who would then telephone the woman on her living unit.

4.15 Healthcare staff sent a response to each request and issued passes for healthcare if a woman had an appointment. Some women told us that they did not receive the passes, which were delivered by primary workers, until after their appointment.

4.16 Nurses saw women and undertook basic tests and blood work at a daily nurses' clinic. They were also able to treat a variety of complaints using previously agreed standing orders. Any treatments given were hand written on the MAR and the consultation was written in the clinical record. The GP then reviewed the records of all women seen by nursing staff.

4.17 Staff shortages meant that there was not always a nurses' clinic on a Thursday, which was when the GP worked at GVIW. The GP saw all new admissions and other patients referred to her by the nurses. She also saw all women prescribed methadone weekly.

4.18 Most women had their medications in-possession. Prescribed medications were heavily used. The pharmacist supplied the medications in blister packs and provided a patient information leaflet (PIL) for each newly prescribed medication. All psychotropic medications were given in seven-day blister packs, while most other medications were issued in 28-day packs. Women had to return used blister packs before being issued with a new one. The women had lockable drawers in their rooms in which to store medications but these were seldom used for their intended purpose. A stock of commonly prescribed medications was kept in the pharmacy store in blister packs. There was a dual-labelling system for re-ordering stock and patient-specific medications.

4.19 Some women had to be directly observed when taking their medications (DOT). Methadone was administered at 7.45am and there were further medication times at 8am, 11am and 2.15pm. Some women prescribed DOT night sedation had to attend the department just before it closed to take their medicine, which was poor practice. However, there was also a good system of using individual locked boxes which allowed the officer in charge of the institution to observe administration after normal working hours.

4.20 Women waiting for methadone lined up outside the healthcare department and there was no interaction with the nurse when they were let in. Each woman entered the treatment room individually to take her methadone. Bottles of methadone were on the counter, as were blister packs of medications. Not all women provided identification. The nurses did not sign the relevant MAR at the time of administration. The process was unsafe. Women waited 20 minutes observed by a primary worker to ensure that they had ingested the methadone.

4.21 Women needing other medication came to the hatch. They told us that, even though nurses were often late in starting the medication administration, they were told they had missed their opportunity if they were even a few seconds late. Most medications were crushed. Again, nurses did not sign MARs until afterwards.

4.22 Women were not able to see a pharmacist to discuss their medications, nor was there a local medicines and therapeutics committee.

4.23 Women in the maximum security and segregation units had their medications taken to them, including bottles of methadone, in an open plastic box. Some had been taken out of their original containers or blister packs and put into envelopes. The nurse did not take the relevant MARs with her. The nurse administered medications from the box at the door of the cell or pod on the unit with two primary workers attending. This was unsafe and did not provide confidentiality. The nurse usually annotated the relevant MARs on return to the healthcare centre, although we found examples where this had not been done. A nurse had to return to the institution in the evening to administer night sedation in the maximum secure unit, or it was given in the late afternoon, which was poor practice.

4.24 The physiotherapist aimed to see five patients per half-day session each week and saw most of her patients once every two weeks, giving them exercises to do between appointments. She had 15 patients. The one woman on the waiting list was located in the maximum security unit. She had been booked for two appointments but staff had not brought her to the healthcare department.

4.25 The dentist saw 10 patients on average at each visit. His appointments were organized by the administrative clerk. Women wrote a request for an appointment and their names were then added to the 'extras' list. They were called to be seen if another booked in patient failed to turn up for her appointment, a system that made it impossible to ascertain how long women waited for an appointment.

4.26 There was a waiting list for the dental hygienist, who had been off sick for some time. Women serving life were entitled to an annual free clean and polish; other women paid $25 for the service (which we understood to be about a third of the cost in the community).

4.27 There were some health promotion activities. We were told that smoking cessation assistance was offered and nicotine patches were prescribed if the reason for giving up was medical; otherwise, women could buy patches from the department, repaying the cost in small instalments over a year. Condoms and lubricants, together with a variety of health promotion literature, were provided freely in the healthcare department and in the private family visits unit. Bleach kits (to ensure safe needle cleaning) were also available from the healthcare department. The house representative could return empty bottles each week and receive replacements. There was a protocol for post exposure.

4.28 No weight management or healthy eating programs were run, although a dietician attended the institution on an ad hoc basis to provide dietary advice. Women could weigh themselves using scales in the corridor outside the healthcare department.

4.29 Pap smears were undertaken every three years (assuming the previous two smears were negative) and mammography was offered to those over 50 or with symptoms that indicated the diagnostic test was necessary.

4.30 Inmate peer education counsellors had received 100 hours of training to deal confidentially with healthcare concerns of other inmates. They were able to provide infectious diseases information, ensure harm reduction supplies were available and provide peer support.

4.31 Community obstetricians and gynaecologists cared for pregnant women and healthcare staff provided post-partum care based on community standards. The department did not have an emergency childbirth kit and an incident investigation carried out in 2003 had commented that there was 'no evidence of medical treatment protocols for pregnancy'. We found a standing order for prenatal care and another for abortions. Any babies or young children without an Ontario health card had their care funded by the CSC until the mother had applied for the card.

4.32 The healthcare department closed at 4pm. Anyone becoming unwell after this time was expected to have purchased items such as cold remedies, cough syrup and painkillers from the canteen. Urgent cases were taken to the local hospital by paramedic services. A nurse was also on call for consultation after hours.

4.33 Anyone requiring observation could be taken to the healthcare department, although some unwell women remained in their living units being cared for by other women. The negative pressure room had apparently never been used to care for a patient with active tuberculosis (TB) but had once been used to isolate a patient pending confirmation. No records were kept of when the rooms were occupied, but if the rooms were used overnight, the primary worker in attendance was given a logbook to record events. A casual nurse was also employed. It was believed that the room had last been used in August 2005 for one night but no one could recall any previous occasions.

4.34 In our survey, women were particularly critical of the attitude of some healthcare staff. Examples included: "The only thing I can not tolerate is healthcare treating us as though all we want to do is drug seek."; "When it comes to emergencies dealing with illness it seems to take a long time to either go to hospital or appointment check-ups. Very careless with our health issues here"; "When you put in a request and you are seriously sick they make you wait until the matter gets worse before answering you."

4.35 An action plan had been produced in response to a recent review of healthcare services in preparation for a forthcoming health services accreditation audit. The chief of healthcare was in the process of establishing a healthcare inmate advisory committee and the inaugural meeting took place during our inspection.

4.36 A medical discharge summary was prepared for every woman discharged from GVIW. If taking any medications, she would be given at least two weeks' worth of the prescription, or more if blister packs had already been made up for her. Anyone taking anti-viral medication or long-term treatment provided by the hospital was given a three-month supply. Staff also provided photocopies of recent blood results and consultation but did not assist women in finding a GP in the community.

  Secondary care
4.37 Most medical appointments were in the community or hospital and were organized by the administration clerk. Women therefore waited as long for an appointment with a specific medical practitioner as they would in the local community. The department had arrangements with a wide variety of specialists, including general surgeons, an urologist, a cardiologist, an oncologist and an optometrist. There were also memoranda of understanding between GVIW and local general and psychiatric hospitals.

4.38 The number of escorts that could leave the institution on any one day was limited and determined by the security status of the woman and the distance to be travelled. The administrative clerk understood the system well. Over the previous three months, 22 appointments had been cancelled, of which eight were because the woman refused to attend and five were because the woman was no longer at GVIW. Only one had been due to staffing problems.

  Mental health
4.39 Mental health services were managed by the psychology department. There were three staff in post: one was licensed as a forensic and clinical psychologist, one was a psychology assistant and the third was an offender counsellor. They saw all new arrivals within 24 hours and anyone needing to be seen was added to the waiting list. Women could self-refer or be referred by staff. Waiting times were potentially longer than six months, although the psychologist accepted that the waiting list was not a reliable indicator of the workload of the department. It reacted to 'crises'. The psychologists attended the daily management meeting to obtain details of any woman who might require their services immediately. They also met women within the institution informally and made them an appointment, so the waiting list was skewed and unreliable. Women described the system as a 'lottery'. Most women who saw a psychologist had six sessions of therapy.

4.40 When a woman was discharged, the psychologists either concluded the therapy with her or recommended future sessions in the community. The National Parole Board could impose ongoing psychology sessions as a condition of the woman's release but the psychologists did not know how often it did so.

4.41 Women could request to see the female psychiatrist or be referred by the GP or the psychologist. There was no formal, documented liaison between the psychologist and the psychiatrist and they did not have access to each other's records.

4.42 Women were seldom transferred to mental health beds in the community. We were told that transfers were difficult to arrange and the hospitals were reluctant to take offenders, particularly if they required an escort.

4.43 The SLE provided intensive intervention for women identified as having problems coping in the general population. A nurse with mental health knowledge and skills was assigned to the unit but had been off sick for several weeks before our inspection.

  Action points
4.44 A health needs assessment should be carried out to determine whether the services meet the needs of the population including mental health needs. This should include a workforce and skill mix review.

4.45 There should be a formal system to check the licences of all healthcare professionals.

4.46 All healthcare staff should have appropriate clinical supervision.

4.47 All healthcare professionals working at GVIW as indeterminate, determinate, casual or contract staff should have training on security issues and working with offenders.

4.48 Training in resuscitation, first aid and 'first on scene' for all staff should be annual.

4.49 An automated external defibrillator and an emergency childbirth kit should be provided.

4.50 Provision should be made for annual leave and sickness cover for all healthcare staff.

4.51 All medicine administration records should be annotated at the time of the administration of the medication.

4.52 Records of requests, waiting lists and other healthcare-related activities such as the use of the observation beds should be easily auditable.

4.53 Triage algorithms should be used and triage assessments should involve the patient, rather than being undertaken solely from a written request.

4.54 Provision should be made for all women (including those in the maximum security and segregation units) to receive night sedation at an appropriate time.

4.55 The administration of all medications, including to women in the maximum security and segregation units, should be undertaken in a safe manner to ensure that medicines are secure at all time and neither the patient nor staff are subject to unnecessary risks.

4.56 Women in the maximum security and segregation units should have confidential access to nursing staff.


Women should be able to speak to a pharmacist about their medication if they wish to do so.

4.58 Medical, nursing and security staff should develop a local drugs formulary and audit the use of prescribed medications.

4.59 Women's access to healthcare services should not be restricted by their security status.

4.60 Health promotion activities should include weight loss and healthy eating programs.

4.61 There should be a formal system of liaison between the psychologists and the psychiatrist to ensure continuity of care to women seen by them.

4.62 Clinical notes should provide a continuous, contemporaneous record of interventions.

4.63 All prescriptions should include a start date.

4.64 The system for delivering passes for healthcare appointments should be audited to ensure that women are receiving them with enough notice to be able to attend the department.

  Housekeeping points
4.65 Minimum and maximum temperatures of all fridges used to store thermolabile medications should be recorded daily. These medications should be stored between 2 and 8 degrees Celsius.

4.66 The filing system for clinical records should be reviewed; previous sets of notes should be kept with the current set.

4.67 Standing orders should be signed, dated and based on evidence-based practice.

  Good practice
4.68 The resident status form that was sent to the pharmacy for all new arrivals provided an audit trail and method of cross-checking for prescriptions.

4.69 The fact that most women were able to have their medications in-possession and that they received a patient information leaflet meant that they were able to manage their medications as they would in the community.

4.70 The system to allow night sedation to be administered when nurses were not available was a pragmatic solution to the problem and allowed women to make decisions about their medications.

4.71 The use of inmate peer education counsellors and the new healthcare inmate advisory committee provided useful conduits between healthcare staff and women.