The Guardian, December 2004

On the evening of Thursday August 19 this year, a prisoner was locked into his cell in the segregation unit of Wormwood Scrubs prison in west London. This man had been sent to the seg to be held in solitary confinement as a punishment because he had threatened a cellmate. But that was three weeks earlier and, since then, he had settled down and been quite easy to manage. Everything was normal.

On the following morning, August 20, an officer called Dickie Hampson unlocked the door of the the cell, and, without warning, the prisoner pounced on him and stabbed him in the back of the shoulder with a toothbrush which he had sharpened into a rigid blade. Hampson was rushed to hospital where doctors found that the epaulette on his shirt had saved him from the worst of the wound.

Nobody could understand why this prisoner had suddenly turned violent. Immediately after the attack, a group of officers with a riot shield restrained him, handcuffed him and removed him to the 'safe cell', designed to prevent self-harm, while they searched his possessions to make sure he had no other weapon concealed in there. That afternoon, the prisoner was calm again, remorseful and worried about Hampson's condition, and soon he was taken back to his normal cell.

On the next morning, Saturday August 21, a second officer, John Leadley, unlocked the same prisoner to take him to the governor for an adjudication for the assault on Dickie Hampson. As Leadley approached him, the prisoner slipped another sharpened toothbrush out of his shirt sleeve - nobody ever found out where he had got it from - and clawed at Leadley's face: the spike cut down through his eye brow and into his cheek bone, missing his eye ball by less than an inch.

With blood flowing from his face, Leadley too was taken to hospital. The prisoner was moved again to the safe cell. It was several days before the prisoner spoke to the senior officer on the seg, whom he trusted, and explained what had happened: soon after he was locked into his cell on that first night, he said, a black cat had slipped through his window and sat on the bed next to him. This cat had been following him for some time. Now, it handed him a card, the ace of spades, and then dropped down to the floor where it danced for him. There was music. The dance went on for hours, the prisoner watched, and then the cat turned to him to warn him that the next person who came into the cell would be his enemy: the prisoner must kill him. The cat had promised to stay with him to make sure he was all right. The prisoner had started sharpening the toothbrubush.

This man was psychotic, he had already been diagnosed as paranoid schizophrenic. None of the officers who work at Wormwood Scrubs is trained in psychiatry. Yet routinely, they deal with mentally-disordered men. When John Leadley was stabbed in the face, it was the fifth time he had been attacked in three months; every one of his attackers was suffering from a severe mental illness.

There is nothing unusual about Wormwood Scrubs. Every prison in the country now warehouses the mentally disordered: the numbers have been spiralling upwards since the closure of the old asylums. This has reached a point which beggars the imagination: figures from the Office of National Statistics show that, if we diverted to treatment all those prisoners who are mentally disordered and/or addicted to alcohol or drugs, 90% of inmates would no longer be held in jail.

There are now some 75,000 men and women behind bars in this country. The findings of the Office of National Statistics suggest that nearly 50,200 of them have personality disorders; 6,175 are psychotic; and more than 35,000 of them have neurotic disorders. Several tens of thousands of them suffer a combination of disorders. More than 75% of them are intellectually impaired, with IQs below the national average. And these are not figures that the government denies. The prisons minister, Paul Goggins, himself describes these ONS statistics as "our principal source of knowledge about the extent of mental ill health in the prison population." Most mentally disordered people do not end up in prison; but overwhelmingly most prisoners are mentally disordered.

And every one of our prisons suffers from the 'treatment gap' - the gulf between the care that is needed for the mass of mentally disordered men or women within its walls and the care that is actually provided. After years of neglect, when there was no effective mental health care in prisons, the government is finally tackling the crisis, but resources are short, there are real limits to what can be achieved in a prison regime and, worst of all, as the health minister, Dr Stephen Ladyman, told the parliamentary mental health group this year: "It is generally accepted that mental health will deteriorate in prison."

The results are deeply worrying. It is not simply that mentally-disordered prisoners may be violent to staff or other inmates. Indeed, they are far more likely to be violent to themselves. On average: every single week in prisons in England and Wales, two prisoners take their own lives and two or three others are resuscitated after trying; and every day, some forty prisoners cut or gouge themselves in their cells. Beyond this, the fact is that we are herding disordered men, women and children into our prisons, storing them there for months and years, and then processing them back into the community with every prospect that their disorder has not been addressed and so they will offend again. They suffer. Those around them in prison suffer. Everybody suffers.

Every afternoon at Wormwood Scrubs, the white prison vans queue up outside the gate, ferrying men back from the courts - the young and surly, the old and confused, the crackhead who was caught shoplifting yet again, the homeless man who set fire to an empty building, the man who thumped a stranger because he looked at him in a funny way, the old Rasta who screams at himself in the park. The reception officers process them and give them a bedroll, a nurse takes them through a health questionnaire: "Have you ever received treatment from a psychiatrist outside prison? Have you ever received medication for any mental health problems? Have you tried to harm yourself?"

Once, several tens of thousands of mentally-disordered men and women were held behind the high walls of the old asylums, but they failed and, in the late 1980s, they were all closed down. Now, those who would have been their patients rely on a network of community care which is notoriously overstretched and, if they fall through its gaps, they are scooped up by police and sent back behind high walls. Those walls protect a crooked structure.

We now have139 prisons. We are already committed to building five more. By the end of the decade, the Home Office plans to incarcerate at leaste 80,000 men and women. If the Office of National Statistics is right, some 56,000 of them will suffer from at least two types of mental disorder. Yet we have only just over 4,000 secure psychiatric beds, which are already full, and no plans to increase them. The whole structure is crooked, because it is built on a crooked foundation - the emotionally satisfying but deeply ineffective idea that if we hurt these people enough, they will obey the law. Hospitals are built with bricks of care, prisons with the plans of politicians.

The old Rasta who screams in the park was arrested for trying to steal a handbag and for exposing himself in a public place. He is soon processed and taken down to A wing. Nobody realises he has lied about his psychiatric history, nor that he has been arrested, charged and now remanded in custody under a false name. Lots of new prisoners conceal their psychiatric history: they don't want the stigma, they are afraid it will count against them, they have forgotten. On the wing, the old Rasta is soon marking himself out as an odd ball, muttering to himself, eating just about nothing, refusing to wash himself or to clean his cell. It gets so bad that one day the officers force him to take a shower: nobody can stand the smell any more.

By chance, a visiting nurse recognises him from the hospital where she works and remembers his real name. The prison doctors contact the hospital's community mental health team for his notes and persuade the old man to take some medication while they wait for them to arrive. Three weeks later, the notes finally reach Wormwood Scrubs, detailing his long history of schizophrenia, but by that time, he has been taken back to court where he is given bail or a non-custodial sentence - nobody bothers to tell the prison - and he is back out on the streets again.

The number of mentally-disordered men and women who are held in our prisons has increased seven-fold since the old asylums were closed. We have talked to staff at every level of the prison service who are alarmed and depressed to find themselves warehousing the sick. The former director general, Martin Narey, now in charge of probation as well as prisons, has publicly described the strain as 'overwhelming'. A senior manager told us it was 'a bloody awful problem'.

The cutting edge of the government's response has been to create 'inreach teams', to deliver care-in-the-community on prison wings. In Wormwood Scrubs, the team consists of one consultant psychiatrist, one social worker and one community psychiatric nurse. They care for a prison holding some 1,167 men at any one time, with some 3,900 coming and going over an average year - 90% of whom they reckon to be mentally disordered. The simple reality is that the Scrubs team spend so much time assessing new patients that they rarely have time to deliver a care plan.

There is also a new Day Care Centre which borrows money from the education budget to run courses in relaxation, art and acupuncture, but staff are so short that sessions sometimes have to be cancelled. An unpaid counsellor comes in once a week, but there is no psychotherapy at all. There are signs that the centre has helped some of the low-end patients, but the service is limited and helpless to deal with the most severely ill who need beds in outside hospitals, which are extremely hard to find. In a special report on nursing in prisons, the Department of Health itself acknowledged that, while staff may do their best, there is a level of care which "prison health care does not and can not provide".

Even at the lowest end of the scale of mental disorder, this leaves the neurotics with their phobias and anxieties and panic attacks hiding quietly in their cells, not eating and/or not sleeping and/or being punished for low-level disobedience. In the outside world, they might end up on the general ward of a local hospital; here, their disorders frequently pass unnoticed in the muddle of daily life. Sometimes, they are prescribed something to help them; sometimes it is stolen by other prisoners. The parliamentary mental health group has taken evidence on the victimisation of mentally-disordered prisoners who report being robbed, bullied and indecently assaulted.

Others with neurotic disorders are screamingly obvious. A man was shipped into the Scrubs from Highbury magistrates in north London a few months ago. Suffering from depression after the break-up of a relationship, he had slapped a police officer. Within four hours of arriving, he had cut his throat from ear to ear including his jugular and slit both wrists. All the prison could do was to rush him into Hammersmith Hospital to tend his wounds for four days and then beg the Home Office to allow them to transfer him to a local psychiatric ward to treat his anxiety. They refused: the courts had ordered that the man be held in custody awaiting trial and they deemed the security in the local hospital was inadequate.

Some of the psychotics too can be withdrawn - "quietly mad" in the language of doctors - and likely to remain undiagnosed and untreated. To untrained prison officers, they may seem irritating, asking the same question over and over again, or simply weird, like the man who was frightened of water. He would sit on one of the wings at the Scrubs staring at a splash of water on the floor, worrying that it was evaporating too quickly. It was two weeks before he clumped a member of staff, triggering a process that diagnosed his paranoid schizophrenia and eventually transferred him to an outside hospital. (His worry about water was that it was poison and he would die if he drank it.)

Once they are spotted, the psychotics can often be stabilised. There is a young schizophrenic in the Scrubs at the moment: his father lives abroad; his mother has been evicted from her home and is sleeping rough somewhere; he ended up living on the streets, cold, hungry, hallucinating and finally trying to steal a woman's handbag. He is on remand awaiting trial and he is now stable and relatively secure in a single cell with a television. His main worry is that the court may take pity on him and put him out. The big problem with psychotics is that, if they refuse medication, the prison - unlike a hospital - has no right to treat them against their will.

One of the staff at the Scrubs told us about a psychotic man who refused to be treated. The prison wanted to transfer him to an outside hospital, but there was no bed. Without medication, the man's condition started to deteriorate. Soon, he took to standing on the sink in his cell, holding his arms out sideways and swallow-diving head first on to the concrete floor. His face was soon broken and bleeding, and staff were then able to use their limited power under common law to tranquilise him by force for long enough to stitch his wounds. Then the law required them to stand back and let him carry on swallow-diving. At one point, they got special permission from the Home Office to hold him in a padded cell in a strait-jacket (something which officially is no longer done in UK prisons). Finally, an outside hospital bed was found for him.

The most disruptive are those with personality disorders. Technically, they are not suffering from a mental illness, but their behaviour is distorted by traumatic experience, usually in childhood: one out of every three men who is remanded into custody by our courts has been in care as a child; one in three women has been sexually abused; one in ten men has been sexually abused. They may be withdrawn, mistrustful, aggressive, anti-social. At the top end of the scale, they may be grossly callous and cruel. In prison cells, they cut themselves, they bang their heads against the wall, they manipulate, they protest, they swallow pills like sweets. But, from the doctors' point of view, although they may be mentally disordered, they are not 'ill' and are often dismissed as untreatable. The daily strain of the treatment gap, dealing with so much mental disorder without the resources or skills to match the challenge, produces some real tensions in the prison.

On Saturday August 21 - the same day that John Leadley was stabbed in the face - there was another prisoner on the segregation unit who was causing trouble. He had been moved there from B wing, where he had been cutting himself, and now he was standing on the water pipes of his cell with a ligature around his neck, threatening to hang himself. Just a fortnight earlier, a prisoner had succeeded in committing suicide in the seg, so the senior officer there was in no doubt about what he wanted: this man had to be transferred immediately to the prison's health care centre, where there are seventeen cells for acutely ill prisoners. He called the centre, and one of the doctors came down.

To the senior officer's horror, the doctor refused to take the prisoner. He said the man was suffering from a personality disorder, which was not treatable, and that this behaviour was simply a self-harming gesture. The senior officer became agitated, reminding the doctor that two weeks earlier, they had cut down a body which had then laid in the cell all day while the investigators did their work: "I'm not going to engage in semantics with you. Suppose it happens again. You just can't take the chance." The doctor stood his ground. The senior officer reluctantly backed down but told the doctor: "If this goes wrong, I guarantee you I will stand up in coroners court and point the finger at you". Then he recorded all that had happened in the seg's observations book.

In the event, the man did not hang himself. The friction passed. But the problem remains. Just like the officers in the seg, the staff in the health care centre see themselves struggling to deal with an impossible problem. Apart from the shortage of specialist psychiatric help, the prison has12 unfilled vacancies for general nurses, leaving only 28 to cover the whole prison, day and night, for all forms of illness. Sometimes, they try to fill some of the gaps with agency nurses, but they are expensive and can wait up to a month for security clearance. They have only 17 in-patient beds for the whole prison. And, running through all this, they are medical staff working in a prison which has different priorities and understandings and even language.

Are these men prisoners or patients? Who should win the argument if prison officers want to search a man's cell but health staff say it will aggravate his mental disorder? What should happen when health staff want half-a-dozen prisoners out of their cells for some group activity, and security staff say they cannot do that without three officers - who are not available? How can prison officers be expected to understand the mental disorders of the men they are looking after, if generally they have no psychiatric training and are not even allowed to read their medical notes? How can health staff provide regular care when their patients are suddenly snatched from their surgeries and sessions because there has been an incident and prison officers are locking down the wing?

The diagnosis of mental disorder is difficult - and made more difficult by the possibility of prisoners trying to manipulate the system. Certainly, there is some manipulation: a prisoner at the Scrubs this summer repeatedly evaded his court appearances, because he knew that if he got into the prison van and cut himself - even superficially - the security company would refuse to transport him. It was a prison nurse - not an officer - with years of experience who told us that some prisoners manipulate the regime for preventing suicides: "Let them hurt themselves, let them cut themselves, it's their responsibility. I have stood outside a cell and watched an inmate tear up his clothes and make a noose and put it round his neck; And I've said 'Yeah? Go on then, do it.'"

The bottom line is that, with difficult patients, poor resources, and the culture clash between security and care, prison staff can be stretched to breaking point by some of the people in their care. Look at what happened in September with Terry Moreton. He has a history of violent crime, including a serious attack on a teenaged girl at a railway station, but he was in the Scrubs awaiting trial for a fairly minor offence. The Inreach team had spotted him and diagnosed him as suffering from bipolar illness (manic depression) as well as personality disorder and they had given him some medication. But he had stopped taking it. For several days, he had been thumping his head against his cell wall in B wing, and officers had opened an F2052SH form, which is kept for any prisoner who is deemed to be at risk of self-harm. That Friday night, Moreton ran out of tobacco, threatened to kill himself if he was not given some, assaulted his cell mate and barricaded the cell.

During the night, officers managed to get in and took him down to the seg. On Saturday morning, the senior officer came in and said Moreton did not belong there: only 48 hours earlier, the doctors had said his illness was so bad that he was not fit for segregation, and there had been no doctor on duty the previous night to 'fit' him. He called health care and, before long, a doctor came along with the duty governor. By now, Moreton had sharpened the end of a metal flask, which is used to give the prisoners hot water, and was threatening to slash anybody who came into his cell. The duty governor wanted him restrained. The seg officers said they could not do that: if he was not deemed fit for the seg, they would be guilty of assault if they restrained him. The doctor suggested he could now fit him, and so the officers went in.

Moreton was taken to the seg's safe cell and strip-searched. The doctor then suggested that he might not be fit for seg after all, which was bad news for the seg officers if it meant that they had committed an assault, but good news if it meant they got rid of him. Late that Saturday, Moreton was finally taken to the in-patient health care cells where he proceeded to tear the plastic lid off the toilet, break it into shards, wrap one of them in a torn shirt and threaten to slash anybody who came near him. He then smashed his sink, broke the water pipes and flooded the whole health care unit in two inches of water. The health staff now said he was, in fact, fit for seg and sent him back.

The following morning, an officer outside the seg saw him sharpening his breakfast spoon on the window. The senior officer persuaded him to hand it over. That night, Moreton made a dummy out of his bedding, hung it from the window and hid himself under the bed, apparently hoping to ambush any officer who came in. He spent the next day literally gibbering in his cell, while those in neighbouring cells threatened to kill him, because he had now kept them awake for three nights.

Seg officers were fed up with the health care staff. They felt their unit was being used as a dumping ground, that a solitary cell was the worst possible place for somebody who was mentally ill, that it was absurd that the man could be unfit for seg one moment and fit the next. Health staff were just as fed up. They, too, felt that their unit was being used as a dumping ground and that, although Moreton had a history of bipolar illness, he also suffered from a personality disorder - which was not treatable - and that it was the disorder, not the illness, which lay behind his behaviour. They explained that he lurched between being fit and unfit for seg simply according to whether or not he was taking his medication. And both groups felt they suffered from decisions made by night staff and weekend staff who were not equipped to make these decisions. The truth, >>> Of course, is that they are both right: they are both being used as a dumping ground; the whole prison system is.

For years nobody really bothered about the mental health of prisoners. Only four years ago, research published by the British Medical Journal found: no doctors who were in charge of prison inpatients had psychiatric training; only 24% of prison nurses had mental health training; patients were locked up for between 13 and 20 hours per day; services for the mentally ill in prisons fell far below standards in the NHS; patients lives were restricted and access to therapy limited.

In the last few years, as the problem has grown into a crisis, the prison service has started moving the mountain. Three years ago, they published a joint report with the department of health, Changing the Outlook, which frankly admitted: "There are too many prisoners in too many prisons who, despite the best efforts of committed prison health care and NHS staff, receive no treatment, or inappropriate treatment for their mental illness, from staff with the wrong mix of skills and in the wrong kind of setting." The prison service adopted the 'principle of equivalence', that prisoners should have the same health care as any other NHS patient, and took the historic step of handing over the commissioning to local Primary Care Trusts.

Since then, they have funded 300 community psychiatric nurses to work on Inreach teams, like the one in Wormwood Scrubs, providing a care-in-the-community service for prisoners; adopted the Care Programme Approach which should link their work with community teams before and after a prison sentence; and set up new screening for prisoners on their first night to do a better job of identifying mental disorder (the old system was found to be missing 75% of cases.) But can a prison pretend to be a hospital?

Some of the culture clash between care and custody can be dealt with. There is a new programme to teach prison officers how to spot the symptoms of mental disorder. In principle, the rules may be changed to allow officers to read some of the medical notes of their inmates, which are currently hidden from them on grounds of confidentiality. There is some hope that the new NHS computer system will cut the number of prisoners who turn up with no medical notes.

But there are other problems which are harder to reduce.The Mental Health Commission last year warned of the limits of community care in a prison: "The prison 'community' cannot offer any real equivalent to the support and care available outside prison, and any assumed equivalence between prison and the community outside greatly under-estimates the isolation and bullying of the mentally ill in prison and the stigma of mental illness in such a situation."

There are limits also to what can be done with medication in prison, because prisons cannot treat inmates against their will, which means that those who reject their medication can deteriorate rapidly. But, with few exceptions, we have found prison health staff are deeply opposed to allowing compulsory treatment in an institution which is not a genuine hospital: the risk of accident and the temptation for disciplinary prescribing are too great. The Mental Health Commission last year said it was "deeply concerned" about the "extremely serious risk" of unrecognised or unchallenged coercive treatment in prisons.

Beyond that, it is hard to see how prisons will find the cash to reverse years of neglect, and there is a real fear among governors that the Treasury have stored up trouble by failing to ring-fence future funding for prison health, leaving Primary Care Trusts free to divert the money to patients who are more popular than offenders. The treatment gap will not be closed, and yet the problem will persist.

Prisons are the wastepipe down which other institutions send their rejects. The flow of mentally-disordered men and women into custody is being pumped not simply by the failure of the Department of Health to organise effective care in the community. Within the criminal justice system, the police and the courts have special systems to divert the mentally-disordered. They don't work.

Police can remove them to a place of safety for 72 hours for assessment - but only if they are in a public place and not if they are being charged in the police station, and only if their illness is recognised by the officers and not if it involves drug abuse, and only if they are in immediate need of care and control and not if they are merely ill, and only if the police have time to go through the procedure rather than simply processing them for court.

The courts, too, have powers to send people to prison or hospital to be assessed - but only if they are told that a bed is available. In 1990/1, all the courts in England and Wales between them used this power only 412 times. Since then, despite the massive increase in the charging of mentally-disordered people, they have used it even less: in 2000/1, they sent only 168 defendants to be checked for mental illness. Two years ago, the Home Office studied its court diversion schemes and found that "many schemes are currently ineffective" - patchy in geographical availability, peripheral to local psychiatric services, poorly designed, "inadequately supported" by local hospitals and "unpopular with local psychiatrists." Juliet Lyon, director of the Prison Reform Trust, earlier this year said the network of 136 schemes had "virtually fallen apart".

So, at a prison like Wormwood Scrubs, they can find themselves dealing with a man like Manuel York who was agitated, unpredictable and hallucinating sounds, visions and physical sensations. A visiting psychiatrist at the prison immediately recognised that he was profoundly disturbed and diagnosed hebephrenic schizophrenia, a particularly disorganised version of the illness. And yet that man, who had been arrested for making unwanted phone calls to a woman, had passed straight through the police and the courts without anybody stopping to ask if he was ill, let alone diverting him for treatment.

And the failure is repeated when it comes to their release. There was a man at the Scrubs recently who tried to hang himself three times in a week; he also bit, punched and spat at staff. Then he left the prison - and nobody knows where he has gone. Research two years ago found that 96% of mentally-disordered prisoners were put back into the community without supported housing, including 80% of those who had committed the most serious offences; more than 75% had been given no appointment with outside carers. And yet Department of Health policy requires all mentally-disordered prisoners to be given a care plan on release.

When the Home Office researched mentally-disordered defendants in court, they found that: "The majority were not career criminals who had become mentally ill. Most appear to have offended in the context of mental illness and social exclusion, having fallen through gaps in community care." When the Home Office recently reviewed the care of those men and women in prison, the researchers concluded by quoting an earlier survey: "It seems that mentally ill offenders will be as much at risk from society, as they will be a risk to society." The white prison vans still roll up outside the prison gates.

* To protect medical confidentiality, names and some identifying details of prisoners have been changed

Additional research by Roxanne Escobales

See below statistics of mental disorder in prison

Mental disorder in prisons -

Source: Office of National Statistics

Suicide and self-harm among prisoners -

Source: Office of National Statistics

Mental disorder includes
* mental illness such as psychosis or severe depression, often occurring as an episode in an otherwise healthy person and liable to respond to treatment;
* personality disorder, such as antisocial or paranoid, occuring as a continuing pattern of abnormal behaviour, sometimes the result of childhood experiences, generally difficult to reverse;
* neurotic disorder, such as anxiety and phobias, occurring at a level likely to interfere with normal activity, generally amenable to treatment;
* learning disabilities, usually involving significantly impaired intellectual functioning.