Internal Audit Reports

Table of Contents

• Executive Summary
• Statement of assurance
• 1.0 Introduction
• 2.0 Review Objectives and Scope
  • 2.1 Review Objectives
  • 2.2 Review Scope
• 3.0 Review Approach and Methodology
• 4.0 Review Findings and Recommendations
  • 4.1 Management Framework for Mental Health Screening at Intake
    • 4.1.1 Policy Framework
    • 4.1.2 Roles and Responsibilities
    • 4.1.3 Training
    • 4.1.4 Timeliness/ Thoroughness of Screening
    • 4.1.5 Monitoring and Reporting
• 5.0 Overall Conclusion
• Annex A
• Annex B
• Annex C
• Annex D
• Annex E
• Annex F

Executive Summary

The Review of Mental Health Screening at Intake is being conducted as part of Correctional Service Canada’s (CSC) Internal Audit Branch (IAB) 2009-2012 Audit Plan. The purpose of this review is to provide moderate assurance that the management framework in place over the mental health screening of offenders at intake meets departmental expectations and is working as intended.

On April 20, 2007 the Government of Canada announced the appointment of an Independent Review Panel to assess the operational priorities, strategies and business plans of Correctional Service Canada (CSC) with the ultimate goal of enhancing public safety. The Panel's report, A Roadmap to Strengthening Public Safety, was released on October 31, 2007 and made recommendations regarding mental health. In particular, they recommended that “a comprehensive and recognized mental health assessment system be incorporated into the intake assessment process”.

The review was national in scope and included the mental health intake practices in five regions for male offenders and in three regions for female offenders. The approach included a combination of interviews of both management and front line staff, and an examination of relevant legislation, policies, processes and information systems. It also included a review of a sample of offender files. This review did not attempt to assess the quality of the health care or screening provided.

The fieldwork was conducted during the period June 2011 to October 2011.

Conclusion

The review concluded that the management framework over the mental health screening of offenders at intake meets departmental expectations and is working as intended, with the following areas identified for improvement:

• Challenges with respecting the timelines for mental health screening at intake;
• No formal mechanism or systematized process in place to convey the status of an offender’s mental health screening;
• No monthly regional reception centre performance reports; and
• No reporting of performance information related to immediate needs interview.

Recommendations have been made in the report to address areas for improvement. Management has reviewed and agrees with the findings contained in this report and a Management Action Plan has been developed to address the recommendations (see Annex F).

Statement of assurance

This mandate was conducted at a moderate level of assurance.

In my professional judgment as Chief Audit Executive, sufficient and appropriate audit procedures have been conducted and evidence gathered to support the accuracy of the opinion provided and contained in this report. The opinion is based on a comparison of the conditions, as they existed at the time, against pre-established audit criteria that were agreed on with management. The opinion is applicable only to the area examined. The evidence was gathered in compliance with Treasury Board policy, directives and standards on internal audit and the procedures used meet the professional standards of the Institute of Internal Auditors. The evidence gathered was sufficient to provide senior management with proof of the opinion derived from the internal audit.

__________________________________
Sylvie Soucy, CIA
Chief Audit Executive

1.0 Introduction

The Review of Mental Health Screening at Intake is being conducted as part of Correctional Service Canada’s (CSC) Internal Audit Branch (IAB) 2009-2012 Audit Plan. The purpose of this review is to provide moderate assurance that the management framework in place over the mental health screening of offenders at intake meets departmental expectations and is working as intended.

Background

On April 20, 2007 the Government of Canada announced the appointment of an Independent Review Panel to assess the operational priorities, strategies and business plans of Correctional Service Canada (CSC) with the ultimate goal of enhancing public safety. The Panel's report, A Roadmap to Strengthening Public Safety, was released on October 31, 2007. In this report, the Panel made a number of recommendations regarding mental health. In particular, they recommended that “a comprehensive and recognized mental health assessment system be incorporated into the intake assessment process, so that a treatment strategy that is fully integrated with programming can be developed¹”.

The Correctional Service Canada’s Mental Health Strategy, dated July 16, 2010, notes that new intakes are presenting with higher levels of mental health issues. It also details new practices in support of the Mental Health Strategy, such as: professional development for correctional and mental health staff; support tools (i.e., guidelines, case scenarios and templates) to support front-line staff; CSC mental health research initiatives; and performance measurement to monitor progress in implementing the strategy.

Based on CSC policies applicable to this area [See Annex B for more detail] the following screening activities are required:

• Immediate needs interview (within the first 24 hrs) – usually administered by correctional officers (CXs) or correctional managers (CMs);
• Intake health status assessment (within the first 24 hrs) – administered by nurses within Health Services;
• Comprehensive nursing assessment (within first 14 days) - administered by nurses within Health Services; and
• Computerized Mental Health Intake Screening System (CoMHISS) testing (administered between 3 days and first 14 days) – administered by staff from Psychology.

The Computerized Mental Health Screening System (CoMHISS) tool is part of the Mental Health Strategy and the Institutional Mental Health Initiative (IMHI). CoMHISS has the following objectives²:

1. Early identification of offenders who are exhibiting symptoms that may be associated with a mental health disorder.
2. Follow-up/Continuity of Care - Once identified, these offenders will be referred for further follow-up and/or mental health assessment and intervention. The information obtained through this assessment will help to inform the correctional plan and case management processes from intake to release planning.
3. Collect accurate mental health data as a basis for mental health interventions and the long-term planning of CSC mental health care.

According to the 2010 Mental Health Strategy document, CoMHISS is fully functional in all 16 CSC intake assessment sites. Intake screening results are documented in CoMHISS, as well as the Offender Management System (OMS) and are put on offender psychology files.

An assessment, including suicide risk screening, is completed by a community parole officer, typically within five working days of the offender receiving a federal sentence, while the offender is in the custody of provincial authorities. However, as this screening occurs prior to the intake process at a regional reception centre, it is outside the scope of the current review.

During the timeframe January 1st, 2011 to March 31st, 2011 a total of 1,880 new offenders (1,785 males and 95 females) entered CSC institutions.  See Table A below for new offender admissions per region during this timeframe.

Note.  Percentages may not always sum up to 100% due to rounding.
Source: OMS query report all the new admissions from Jan 1, 2011 to March 31, 2011.

Legislation and Policy Instruments

The department’s Mental Health (MH) screening at intake process is governed by a number of legislative and policy instruments. The Corrections and Conditional Release Act (CCRA) and the Corrections and Conditional Release Regulations (CCRR)prescribe the way in which CSC manages the custody of offenders. In this legislation, the following sections of law are relevant to this review:

• Sections 85 to 89 of the CCRA legislation; and
• Corrections and Conditional Release Regulations, Section 17 and 102. (1).

In addition to the above legislation, the following CSC Commissioner’s Directives (CD’s) and policy instruments are also relevant to this review:

• CD 705 - Intake Assessment Process;
• Case Management Bulletin, dated October 22, 2010, regarding Psychological Assessments;
• CD 705-5 - Supplementary Intake Assessments
• Computerized Mental Health Intake Screening System (CoMHISS) - National Guidelines;
• CD 705-3 – Immediate Needs and Admission Interviews, including  Appendix A – Content Guidelines - Immediate Needs Suicide Risk Checklist; and
• CD 800 - Health Services
• CD 803 – Consent to Health Services Assessment, Treatment and Release of Information
• CD 835 - Health Care Records
• CD 840 - Psychological Services
• CD 843 – Management of Inmate Self-Injurious and Suicidal Behaviour
• CD 850 - Mental Health Services

The purpose of this review is to provide moderate assurance that the management framework in place over the mental health screening of offenders at intake meets departmental expectations and is working as intended.

The Review Criteria are described in Annex A. The various processes related to mental health screening of offenders at intake are described in Annex B.

2.2 Review Scope

The review was national in scope and included the mental health screening at intake practices, described in Annex B, in five regions for male offenders and in three regions for female offenders. Annex C lists the sites examined. This review did not attempt to assess the quality of the health care or screening provided.

The review included an examination of directions and guidelines, roles and responsibilities, adequacy of training and the reporting and monitoring mechanisms in place for mental health screening at intake.

The fieldwork was conducted during the period June 2011 to October 2011.

3.0 Review Approach and Methodology

The approach included a combination of interviews of both management (in five regions) and front line staff (in three regions), and an examination of relevant legislation, policies, processes and information systems (i.e., OMS and CoMHISS). It also included a review of a sample of 100 OMS files and a sample of physical health and psychological files for new offenders (placed directly from a reception centre), for the period January 1st, 2011 to March 31st, 2011.

Annex D lists and describes the techniques used to gather evidence to complete this Review.

The review concluded that the management framework over the mental health screening of offenders at intake meets departmental expectations and is working as intended. However, there are areas where improvements can be made.

4.1.1 Policy Framework

We expected to find that the implemented management framework relating to mental health screening of offenders at intake is consistent with CSC policies.

CSC regional reception centres and institutions have implemented a process for mental health screening at intake that is consistent with CSC policies.

We reviewed CSC policies applicable to this area [see Annex B for more detail].

Our interviews with institutional managers and staff (92%) confirm that the management framework implemented at the reception centre is consistent with CSC policies. The implemented process was also confirmed by our direct observation during site visits.

The file review (sample of 100 OMS files as well as 33 health and 33 psychology files) plus management reports confirmed that all elements are being performed in all regions although there are some identified issues related to timeliness (see 4.1.4).

We conclude that the implemented management framework relating to mental health screening of offenders at intake is consistent with CSC policies.

4.1.2 Roles and Responsibilities

We expected to find that CSC organizational structure, roles and responsibilities are clearly defined and adequate resources are allocated.

CSC has defined and implemented an organizational structure, including roles and responsibilities.

We expected to find that employee roles and responsibilities relating to mental health assessment at intake are clearly defined.

A review of CSC policies and documentation confirmed that CSC has defined an organizational structure, including roles and responsibilities that relate to mental health screening at intake.

Our interviews indicated that 90% of institutional managers and staff believe that roles and responsibilities are clearly defined.

CSC employees understand their roles and responsibilities.

We expected to find that employees understand their roles and responsibilities, as well as performance expectations (i.e., timeliness, thoroughness) with respect to mental health screening at intake.

Institutional managers (95%) believe that employees understand their roles and responsibilities.

Our in-depth interviews with front line staff confirmed that CSC employees understand their roles and responsibilities.

We expected that adequate resources are allocated in order to fulfill their responsibilities.

Our interviews with institutional managers (62%) indicated that allocated resources are viewed as adequate.

Our interviews indicated that 80% of managers in institutions felt that clear guidance was provided regarding mental health screening.

Health Services and Psychology

We expected to find well coordinated mental health screening processes between Health Services and Psychology Services organizations, given that each organization plays an important role in this process.

According to institutional mental health service (primary care) guidelines³:

There is a significant association between mental and physical disorders, and health services have the opportunity to identify mental disorders when people seek help for physical health problems.

In order to provide effective mental health screening at intake, it is therefore important that Health Services and Psychology communicate well and coordinate their activities.

Reporting Structure has created organizational silos

Within institutions, Psychology Services reports to the Chief Psychologist who reports through the institutional chain of command and is accountable to the Institutional Head (and ultimately accountable to the Regional Deputy Commissioner (RDC)). However, Health Services reports to the Chief of Health Services who reports to the Regional Director of Health Services and is ultimately accountable to the Assistant Commissioner, Health Services at NHQ.

By reporting through two different chains of command, the current organizational structure for Health Services and Psychology has created organizational silos. Silos may result in management challenges associated with communication and coordination between the two organizations.

During our interviews with management in the institutions approximately 35% identified problems with coordination or communication between Health Services and Psychology. However, among front line staff working in either Psychology or Health Services, the percentage increased to 78% who identified problems with coordination or communication.

CSC is refining its governance for mental health services

Health Services Branch has been reviewing the role and governance for mental health services and service providers within CSC. As a result, the future delivery and governance for mental health services in CSC will be completed in two phases.

• first phase – the accountability for the delivery of primary and intermediate mental health care, including intake, be transferred from operations to health services sector in both institutions and the community; and 
• second phase – conduct a review of treatment centre operations and governance. 

Issues related to the use of alternative models for psychology and treatment centres have been recognised and are in the process of being addressed by management.

4.1.3 Training

CSC employees did not identify serious gaps in training.

We expected to find that adequate training is provided.

The majority (72%) of interviewees felt that training was adequate although some gaps were identified, the most common being the expanding of mental health training to include Correctional Managers and nurses working in Health Services.

4.1.4 Thoroughness / Timeliness of Screening

We expected to find that mental health screening of offenders at intake is thorough and respects established timelines. We assessed whether the mental health screening at intake process as described in Annex B was followed. We did not attempt to assess the quality of the health care or screening provided.

Offenders are screened thoroughly for mental health during the intake process.

For the purpose of this review, a thorough mental health screening would require that an offender receive all four screening activities as described in section 4.1.1 (and Annex B) during the intake process.

Our interviews indicated that institutional managers and staff (89%) felt that offenders received a thorough mental health screening.

Management reports (Health Services Sector 2010-2011 Performance Measurement Plan Summary Report (HSPMP)) indicate (confirmed by our review of a sample of both OMS and health and psychology files) that offenders were thoroughly screened.

We conclude that offenders are thoroughly screened for mental health at intake.

Timeliness of screening

There are clearly established timelines associated with the mental health screening process as described in Annex B.

Our interviews indicated that institutional managers and staff (89%) felt that offenders received timely mental health screening.

Immediate Needs Interview is performed within 24 hours in most regions.

An immediate needs interview must be performed within 24 hours of an offender arriving at a reception centre. When mental health concerns are identified, referrals are made to the Psychology Department in the institution.

We assessed the timeliness of the provision of the immediate needs interview by reviewing a sample of 100 OMS records of offenders received during the period January 1st, 2011 to March 31st, 2011.

Our small sample review indicates that the offenders had an immediate needs interview performed within the first 24 hrs in most regions. However, in one region it was completed late in 55% of the cases and on average it was 3.6 days late [see Table C, Annex E for more detail].

Most Intake Health Status Assessments are performed within 24 hours

Nurses in Health Services are required to offer an intake Health Status Assessment within 24 hours of admission. Management (HSPMP) Table D in Annex E reports (confirmed by our sample review) that most intake health status assessments (95%) are provided in a timely manner.

Challenges with respecting timelines for the 14 day Comprehensive Nursing Assessment (including Mental Health Assessments)

Comprehensive nursing assessments, including mental health assessments, are required to be offered by nurses in Health Services within 14 days of admission.

Management reports (see Table E in Annex E) that there are challenges in most regions with respecting the timelines for the 14 day comprehensive nursing assessment that includes a mental health assessment. Although one region completed 96% on time, and another region completed 29% on time, the average was 55% completed on time.

Challenges with respecting timelines for CoMHISS

According to CSC’s CoMHISS Guidelines, an offer of CoMHISS testing is required between 72 hours and 14 days of admission.

Management reports (see Table F in Annex E) (confirmed by our sample review) that there are challenges in most regions with respecting the timelines for the 14 day CoMHISS assessment. Although one region completed 91% on time, and another region completed 33% on time, the average was 49% completed on time.

Challenges with respecting timelines for referrals for Mental Health Services

We expected to find that offenders receive timely mental health services when mental health concerns are identified at intake and a referral is made.

Institutional managers interviewed (90%) felt that offenders referred for mental health services would receive those services in a timely manner within the reception centre.

Management reports (see Table G in Annex E) indicate that there are challenges with respecting the timelines for the follow up services after being flagged by the CoMHISS assessment. Our review of a sample of health and psychology files of 33 offenders in one region, however, indicated that when an offender is referred for mental health services, the services are provided in a timely manner.

Vacancies of nurses and psychologists make it difficult to respect timelines.

Institutional managers reported (70%) that there are ongoing difficulties recruiting and retaining psychology and nursing professionals in some regions, which create staff shortages and difficulties respecting timelines.

The Health Services Sector prepares an annual report detailing performance entitled “Health Services Sector 2010-2011 Performance Measurement Plan Summary Report” (HSPMP). The attached Table B in Annex E, from the report, provides further information on the regional nature of the vacancies.

This was also recognised as a challenge in the 2011/12 Audit of Staffing Activities.  The audit noted that although plans are in place, regions have indicated they are struggling with the staffing of specific occupational groups such as social workers and psychologists. There are also issues associated with staffing specific occupational groups in some of the more remote parts of the country.

The Staffing audit found that, at a national level, CSC has a regularly updated integrated Strategic Human Resource plan in place, approved by the Commissioner, with identified human resource requirements. Staffing strategies have also been developed to mitigate the identified risks found in the HR plan, and performance indicators have been established to allow CSC to demonstrate, through results, the achievement of its HR staffing objectives.

Given the shortages, based on the results of the current review and on available management information, CSC does not always meet the screening timelines it has laid out for itself.  This is an area where further consideration is required.

Communications with the receiving institution

We expected to find that there is good communication between the reception centre and the receiving institution when mental health concerns are identified at intake.

According to institutional mental health service (primary care) guidelines⁵:

• Transferring an offender with mental health problems who is receiving care involves facilitating continuity of mental health care by establishing communication between the two institutions in question; and
• To facilitate continuity of care, consultation and sharing of information across mental health teams should occur in advance of the transfer. 

Institutional managers and staff (84%) felt that there were good communications between the reception centre and the receiving institution when mental health concerns were identified at intake

4.1.5 Monitoring and Reporting

We expected to find that monitoring practices and controls are adequate to ensure compliance with the management framework for mental health screening of offenders at intake.

Institutional monitoring practices and controls need improvement

Prior to transferring offenders from the reception centre to the receiving institutions where offenders will continue to serve out their sentence, institutional managers rely on management attention (by Correctional Managers and Chiefs of Health Services and Psychology) and a variety of sources of information (such as ad-hoc spreadsheets or other information systems) in order to assure themselves that mental health screening has been performed in a timely and thorough manner. However, there is no formal mechanism or systematized process in place to convey the current status (from a mental health screening perspective) of an individual offender.

The information contained in CSC databases should be used to track the achievement of screening timelines for offenders. Information on exceptions could be used to issue an “alert” to the responsible manager in order to ensure prompt corrective action is taken.

The information on the status of the screening of each offender could also be aggregated at the reception centre level to produce a monthly performance tracking report. This would allow the institutional managers to compare performance on a monthly basis and identify recent trends in performance. NHQ could compare the performance trends of regional reception centres as well as make inter-regional performance comparisons.

Measurement and reporting of performance information

We expected to find that performance information is regularly measured and reported.

The Health Services Sector prepares an annual report detailing performance entitled “Health Services Sector 2010-2011 Performance Measurement Plan Summary Report (HSPMP)”

The HSPMP is reported annually to EXCOM for information.

From the perspective of mental health screening at intake this report includes information on Health Services performance and CoMHISS (Tables B, D to G in Annex E). However, the report does not include information on performance related to immediate needs interviews as detailed in Table C in Annex E.

In order to provide a complete picture of the performance related to mental health screening at intake, the HSPMP should include performance information related to immediate needs interviews.

Inclusion of this information would enable reporting of integrated performance measures such as:

• Percent of offenders who receive thorough mental health screening at intake (i.e. all four screening activities were offered); and
• Percent of offenders who receive timely mental health screening at intake (i.e. all four screening activities were offered within established timelines).

5.0 Overall Conclusion

The review concluded that the management framework over the mental health screening of offenders at intake meets departmental expectations and is working as intended.

The review has also identified areas for improvement and recommended actions.

A Management Action Plan addressing the recommendations is found in Annex F.

Identified areas for improvement include:

• Challenges with respecting the timelines for:
  • the immediate needs interview in one region (24 hours);
  • the comprehensive nursing assessment (14 days);
  • the CoMHISS assessment (14 days); and
  • follow-up services flagged by the CoMHISS assessment process.
• No formal mechanism or systematized process in place to convey the status of an offender’s mental health screening;
• No monthly regional reception centre performance reports; and
• No reporting of performance information related to immediate needs interview.

Annex A

Annex B

Immediate (Mental Health) Needs Interview

Every offender should be interviewed within 24 hours of arrival at the institution to identify areas of need that require immediate attention including suicide risk and self-harm. This information is entered as “alerts”, “flags” or “needs” in the Offender Management System (OMS) as required.

Intake Health Status Assessment (24 hrs)

Within 24 hours of arrival at a CSC institution, every offender must be offered an assessment. The intake assessment must, at a minimum, screen for the following and make any necessary referrals to the appropriate health care professional: (mental health focus)

• acute medical or  mental health conditions;
• conditions requiring continuing treatment (including mental health) ; and
• activity limitations⁸

Comprehensive Nursing Assessment (14 days)

Within 14 days of arrival at a CSC institution each offender must be offered a comprehensive health assessment. The comprehensive health assessment consists of: (mental health focus)

• inmate's health status (present, historical and family);
• health education and promotion programs to meet the identified health needs of individual inmates and specific inmate groups; and
• referral to other health care professionals if deemed appropriate.⁹

Computerized Mental Health Intake Screening System (CoMHISS)

Within 14 days of arrival at a CSC institution (but after the first 72 hours)  each offender must be offered CoMHISS which is 3 computerized tests intended to provide a standardized approach to identifying offenders that require a more in-depth mental health assessment and/or intervention¹⁰.

Annex C

Annex D

Review Methodology

Interviews:  Interviews were conducted with the Warden, Deputy Warden (DW), Assistant Warden, Interventions (AWI), Chief of Health Services, Chief Psychologist, as well as a cross section of front line workers who were involved in the screening process, i.e., Correctional Managers (CMs), Correctional Officers (CXs), Nurses (physical and mental health) and Psychologists. Meetings were also held with the Assistant Commissioner, Health Services and Directors General, Health Services and Clinical Services and members of their staff at the National level.

Review of Documentation:  Relevant documentation such as: CDs, process documentation, procedure manuals and management reports were reviewed.

Testing/File Review: Review of the Offender Management System (OMS) and CoMHISS records and management reports; and review a sample of physical health and psychology files for new offenders (direct from reception centre) for period January 1st , 2011 to March 31st , 2011, in order to determine if treatment had been identified and provided.

During the period January 1st, 2011 to March 31st, 2011 a total of 1,880 new offenders (1,785 males and 95 females) entered CSC institutions. A sample of 100 OMS records for male offenders from all five regions was reviewed. With the exception of the Prairie region, males typically spend 90 days in a regional reception centre undergoing screening before being sent to an institution to serve their sentence.

Female offenders usually receive mental health screening at the institution, which are all multi-level, where they start serving their sentence. Due to the much smaller numbers of female offenders coupled with the different resourcing levels in Women’s institutions, new female offenders have a lower risk to receive inadequate mental health screening than the male offenders. For these reasons and given the possible implications on a larger number of offenders, the focus of the OMS samples and health/psychology file review has been on male offenders.

Sample and Site Selection

Due to the moderate level of assurance required for this review, the review team used a judgmental sampling approach when defining sample size and location.

Reception centers for men and the multi-level institutions responsible for women offenders were examined in three regions: Pacific, Prairie, and Atlantic. In Ontario and Quebec regions, only management interviews at the men’s reception centres were performed.

Due to the small sample sizes, the sample results should be viewed as indicative and not statistically significant. As the primary purpose of the samples was to confirm the reasonableness of data included in the various management reports, this report primarily presents the information included in the management reports.

We also examined health files and psychology files in order to determine if offenders who are referred for mental health services receive the services in a timely manner at both the reception centre and after they are transferred to a receiving institution where they will start serving out the remainder of their sentence. In the region we tested, the majority of new offenders go from the regional reception centre to one receiving institution. In order to test follow up care, we selected a sample of 33 offenders who entered into the reception centre (during the period January 1st, 2011 to March 31st, 2011) and began serving their sentence at the primary receiving institution. The psychology and health files were examined in order to determine if referrals were made and follow on treatment was received.

Note. Percentages may not always sum up to 100% due to rounding.
Source: Draft Health Service Sector 2010-2011 Performance Measurement Plan Summary Report.

Source: OMS File Review

Note. Percentages may not always sum up to 100% due to rounding.
Source: Draft Health Service Sector 2010-2011 Performance Measurement Plan Summary Report.

Note. Percentages may not always sum up to 100% due to rounding.
Source: Draft Health Service Sector 2010-2011 Performance Measurement Plan Summary Report.

Note.  Percentages may not always sum up to 100% due to rounding.
Source: Draft Health Service Sector 2010-2011 Performance Measurement Plan Summary Report.

Note. At least 71.7% of offenders identified by CoMHISS received follow-up services. As per CD 705, supplementary mental health assessments shall be completed 50 calendar days after admission or 40 calendar days from referral. As such, some offenders flagged by CoMHISS would not be expected to have received institutional mental health service until after the March 31, 2011 cut-off considered in this report.
Note.  Percentages may not always sum up to 100% due to rounding.  
*Note: Offenders were excluded from the analysis if their identifying information such as their FPS number, name and date of birth could not be validated against OMS data. Those excluded were subtracted from the denominator of the number of offenders flagged by COMHISS before calculating follow-up compliance.
Source: Draft Health Service Sector 2010-2011 Performance Measurement Plan Summary Report.