Who Cares ? The Lived Experience Of Older Prisoners In Scotland's Prisons

In particular I would like to acknowledge the invaluable contribution of Malcolm Smith, Inspector of Prisons for Scotland, who was the lead researcher for this study.

Jim Farish, Deputy Chief Inspector of Prisons for Scotland

Professor Richard Sparks, Professor of Criminology, Edinburgh University Law School

Nigel Ironside, Governor HMP Glenochil

Gabrielle Watson, Centre for Criminology, University of Oxford

Beth Macmaster, Independent Prison Monitoring Co-ordinator

I would also like to express my gratitude to all the prisoners who contributed to this study and to the Governors and staff in Scotland's prisons for their assistance and support in making this study possible.

Introduction

The faces in Scotland's prisons are changing. Whilst recent years have seen a reduction in the number of young people in custody, the number of older prisoners has increased significantly. Within the last year alone, the number of prisoners over the age of 60 has increased by a fifth (SPS statistics).

As HM Chief Inspector of Prisons for Scotland, I regularly inspect the conditions in Scotland's prisons and the treatment of prisoners. It is striking to see the increase in the number of older people in prison and to observe the additional challenges which age and infirmity bring to prison life. This thematic study of the experience of older prisoners was designed to identify these additional challenges both for the prisoners and for those with the responsibility of looking after them. A study of this nature raises profound issues not just for the prison service but for wider society too. How do we want people in prison to be cared for? How do we balance the needs of justice and the need for care? How should the needs for end of life care of older people in prison be met?

What is beyond dispute is that there is a growing number of older prisoners in Scotland and that they are living longer. Much has been written on the subject of older prisoners in Australia, North America and England and Wales^[1]. There has not been a study of this nature in Scotland. For this study, we invited all prisoners over the age of 60 to complete a questionnaire to tell us of their experience in prison. We conducted a number of interviews with individuals who volunteered and we listened to the views of staff working in prisons expressed in two focus groups.

This has allowed us to draw some conclusions for what is needed to address the complexities of caring for older prisoners. There is a pressing need for a clear strategic approach to a subject which has grown incrementally in importance, but without any specific strategy. Such a strategy must clarify where responsibility and ownership lie between the Scottish Government, the Scottish Prison Service, NHS Boards and Local Authorities.

Many prisoners told us of the sense of loneliness they felt and their desire for companionship, with boredom and limited out of cell activity adding to their sense of isolation. They also told us many stories of how well they felt they were cared for by individual members of staff who had gone the extra mile to provide support and care. The study raises important questions about the delivery of complex health and social care, the provision of suitable accommodation for less mobile prisoners, the range of activities available for older prisoners and the importance of positive relationships with family, staff and fellow prisoners.

The Scottish Prison Service is charged with managing prisons in Scotland, but responding to the increase in the elderly prisoner population and the ensuing issues which follow cannot be addressed by the SPS alone. Tackling the increased demands of treating poor health and associated costs, problems around suitability of prisons and overall governance structures around risk and rights arguments require a broader response. My hope is that this report will contribute to Scotland's response to these pressing issues. The question for all of us with an interest in the criminal justice system and wider social justice in Scotland is "Who cares for our elderly prisoners?"

An Overview Of The Cohort

Methodology

In embarking on this review, the first task was to agree on the definition of 'elderly' for the purposes of the study. The literature varies in determining elderly prisoners from between 50 and 65 years of ages, depending on the location of the study^[2]. In both America and Australia the early onset of physical ageing is a factor, and 'elderly' is considered to begin at the age of 50 years^[3]. In this study older prisoners have been specified as all prisoners of 60 years of age and over. This reflects a common sense view of ageing in Scotland in that many of the specific health, mobility and other challenges associated with older age would be more likely to begin to become apparent in those over 60. It also ensured that we were dealing with both a substantial enough cohort but also one which could be managed given the resources available.

The Scottish Prison Service provided details of those in custody who were aged 60 or over across all prisons at the start date of the review process. This amounted to 280 prisoners with the greatest concentration located in HMPs Barlinnie, Edinburgh and Glenochil.

A mixed methods approach involving both a survey and fieldwork interviews was adopted in order to build both an overview of the current situation along with a deeper understanding of specific problems and needs. A questionnaire was designed, piloted and subsequently sent to all those prisoners who fell into the catchment category. Of the 280 questionnaires sent out a total of 164 were returned completed, equating to a near 60% participation rate.

Table 1: Age range of survey participants

Table 2: Number of years in custody for survey participants

Survey participants broadly reflected the overall population of older prisoners.

As part of the questionnaire recipients were asked whether or not they would be willing to be interviewed if selected as part of the on-going study. It was helpful that the number of people prepared to be interviewed was high.

The data from the questionnaires was managed utilising a data collection and analysis tool (Questback). This allowed us to produce a series of reports focusing on key themes emerging from the questionnaire returns in order to inform the interview schedule. A total of six interviewers were involved, including Inspectorate staff, an SPS Governor and an experienced academic to test consistency of process and results gathered. Interviews were conducted by teams of two interviewers.

Additional interviews were conducted to probe further into aspects of the enquiry that had not been possible with the initial interviewees selected. For example, amongst the initial tranche of prisoners interviewed there was a limited number who had significant health issues. Initial interviewee selection was based in part on those who had a story to tell. In other words they had put some considerable time and effort into completing the questionnaire, going so far as to add additional sheets containing information they felt was relevant. The second set of interviews was conducted with prisoners who had experienced particular issues of relevance to this study, including health problems.

The data from the interviews with prisoners and the views expressed by staff reflect their perspectives and the experiences that they chose to relate. As with any study of this nature, each perspective is valid in its own right, and contributes to the overall picture created through the accessing of a range of perspectives. Interview data was analysed both individually and collectively resulting in the specific themes chosen for closer examination. This data allowed for the production of the themes which highlight the issues faced by older prisoners in Scotland today.

We considered from the outset of this thematic study that the views of staff who worked with elderly prisoners were essential to develop a comprehensive understanding of the challenges faced in addressing the care needs of older prisoners. Two focus groups with staff were carried out in two separate establishments to ensure that these views were considered and used to inform the study.

Findings

This section presents the information obtained from the questionnaires, interviews and focus group contributions. Based on the personal experiences of the staff and prisoners, five main themes emerged: Relationships, Staffing Issues, Location and Environment, Medical Provision and Personal Care and Prisoners' Fears for the Future.

Relationships

Relationships are as important for people in prison as they are for those in wider society. For the majority of prisoners the relationships which are most important to them are with their loved ones. When a prisoner is asked, 'What is the most important thing to you in prison?' many will say that it is their visits. In other words, for prisoners, the importance of building and maintaining relationships with people out-with the prison is greater than with those who they live with inside it. To most prisoners this will be a wife or partner and their children. It then stretches out to include parents and siblings, and finally friends and acquaintances. Older prisoners are no different in this regard; these relationships matter to them too. However, older prisoners, including people serving very long sentences, may encounter a special and distinct set of issues. This may be exacerbated by the fact that many of them have been convicted of sexual offences.

One long term prisoner interviewed spoke of a sense of loss and helplessness which brought the pains of imprisonment into sharp focus:

"I have been in prison so long I have watched from in here as almost all my family has died. I have nobody left. If I ever do get out I have nobody to go out to. They have all gone. Those that are left I lost contact with a long time ago."

[Prisoner]

This sentiment was typical of those expressed by a number of the prisoners we interviewed. For those prisoners, relationships within the prison took on new meaning. Some said that they had "a couple of close pals" or "there are one or two prisoners I get on with, but they're not real friends". This highlights the awareness of prisoners of the need to co-exist with one another. Prisoners express a need for social contact and companionship within the prison. However they also sometimes encounter difficulties in entirely trusting or relying on their in-prison relationships and sense that these are sometimes contingent and lacking in depth.

Some prisoners were guarded in interviews with our team of outsiders. However on other occasions their responses revealed deep sadness and hopelessness:

"I don't get visits, my family have disowned me and I don't have anyone in here I would call a friend. What's the point?"

[Prisoner]

For many prisoners the isolation from family and the lack of trust and meaningful relationships with other prisoners meant that their relationships with staff took on huge personal significance. Numerous prisoners throughout the study commented in a positive manner on the job staff do. Small acts of kindness were also commented on and were clearly very important to older prisoners:

"An officer could see that I was struggling to collect my food and get back to my cell. I was too proud to ask for help but the officer just came along and spoke to me. He took my plate and walked back to my cell with me. From then on another prisoner brought my food to my cell for me."

[Prisoner]

It was clear when interviewing this prisoner that this officer's actions had a profound effect on him. He was one of many prisoners who became emotional during interview.

Another prisoner told us:

"The staff in here do a great job. They will help you if you need it. Some of them, if they see you are struggling with something, they will come to you. It may not be something massive like to do with your progression, but say you weren't fit enough to get your cell cleaned up, they would get someone to do it for you."

[Prisoner]

Not all comments from prisoners about staff were positive. However when negative comments did arise they were often aimed at staff who weren't used to working in the area which contained the elderly prisoners. This was particularly evident where the prisoner population were sex offenders. One prisoner said:

"You have to remember we are sex offenders in here. I don't blame the staff for not wanting anything to do with us. They have a job to do - fair enough - but most of them have children. Why would they want to have anything to do with us?"

[Prisoner]

Discussion and Recommendations

In any prison, it is clearly important that positive relationships exist between staff and prisoners and amongst prisoners themselves^[4]. Prisoners live in close proximity and there is a general acceptance and understanding that they try to get along for everyone's benefit. When relationships start to break down then positive staff involvement can go a long way to solving this. When staff at all levels invest time in their relationships with prisoners then the ability to intervene before problems occur is significantly enhanced.

Our investigation suggests that positive staff relationships are particularly crucial for the wellbeing of older prisoners. Clearly staff are not there to befriend prisoners. Yet without caring staff, some elderly prisoners would have no one who cares about them at all. It is to the credit of many staff that they go beyond what is expected of them and show that they demonstrate real compassion for the prisoners they are charged with looking after.

Given the importance of maintaining positive family relationships, staff training, facilities and provisions, relating to visits, should reflect the specific needs and requirements of older prisoners and their visitors.

Staffing Issues

Staff in one establishment felt that the job they did with elderly prisoners was not considered in the same light as working with the 'mainstream' elements of the population. They evidenced this by saying that they were almost always short of staff:

"I couldn't tell you the last time we had a full complement of staff down here. It means we can't get these old guys out to socialise with one another as much as we should be able to."

[Staff]

In their view, this shortfall of staff prevented them from offering a consistent, meaningful regime in their area. As a result, elderly prisoners were spending long periods of time in their cells watching television. They pointed out that this unfortunately bears some resemblance to the (perhaps stereotypical) image of the elderly in a mediocre care home all sitting in front of a television watching daytime television.

It is interesting to note that a number of prisoners defended the staff regarding the regime and how much time they got out of their cells:

"We seem to be locked up a lot. It's not the staff's fault. They are always short and they have a lot of paperwork and stuff to do so if there's not enough of them we seem to be locked up."

[Prisoner]

The staff appeared to be well aware of the differences involved with working with elderly prisoners. They also indicated that these demands were sometimes at odds with the wider expectations of the role of a prison officer. They are not - as one put it - employed to be "some sort of care assistant". In another prison staff spoke openly of their willingness to step outside their usual role to help the prisoners. Examples were shared where staff acted in a manner more usually expected of carers than prison officers, helping prisoners to the toilet or into bed when they were struggling. There also appeared to be an acknowledgement amongst some staff that their colleagues ought on occasion to show a bit more common sense:

"I had one old guy on my flat and he was going to go to the visits. He had on his slippers because his shoes were hurting him. He was stopped and told you're not going unless you get some shoes on. I mean, come on, there comes a point when common sense has to come into it surely? That's just nonsense and undoing any good work we're trying to do with these guys."

[Staff]

Amongst some staff there appeared to be a willingness to go beyond the role and really develop a relationship with prisoners which enriched their experience of life in custody:

"Obviously it's a different job that we do down here as opposed to working up the stairs. You're not facing the same risks in terms of violence but some of these old guys have committed horrific crimes, they're not in here for stealing motors."

[Staff]

Discussion and Recommendations

The Scottish Prison Service have stand-alone strategies and training packages for staff who manage distinct prisoner populations namely, sex offenders, young people in custody, women offenders and dementia awareness. Specialist training packages could also be developed and delivered to equip staff with the skills and knowledge to meet the complex needs of caring for older prisoners.

It is also important to acknowledge that not all staff are equally suited to working with elderly prisoners. This role demands some particular qualities, experience and skills. Suitable officers should be selected for the care of older prisoners and provided with appropriate training.

In society at large there are special arrangements in place to deal with elderly people who require additional support. This may be in the form of housing adaptations or specialist healthcare arrangements. Similar measures should be in place in prison for dealing with elderly prisoners as part of a long term strategy for their management.

Providing for appropriate socialising opportunities for elderly prisoners is clearly a problem. It was apparent from both the staff and prisoner perspective that outside influences such as staff shortages were having an impact on relationships. Staffing levels for this section of the population should be reviewed to ensure that appropriately trained staff are available and to provide for as much continuity in staffing as possible. It may be that the solution lies in defining more clearly the role of staff working with elderly prisoners. It is important for both staff and prisoners that the care and treatment of elderly prisoners is seen as a valued role within the prison service.

Location And Environment

During the course of the interviews the topic of location was discussed in some detail. Specifically, prisoners were asked if they would rather be located solely with elderly prisoners or in a mixed age environment. None of the older prisoners wanted to be living with only the elderly population:

"No I quite like some of the young guys. You get a bit of banter with them and it kind of keeps you going a bit."

[Prisoner]

Some were in favour of a mixed age population, but with some reservations:

"I'd prefer to be with a mix of people but some of the younger guys you know to stay away from. If I did get any hassle I'd hit them with my stick."

[Prisoner]

Whilst this prisoner was happy to be mixed with a variety of age groups his response demonstrates a concern about his own safety in a mixed age context. The concentration of elderly prisoners located in particular prisons appears to have happened incrementally or by the nature of offence in some cases and not necessarily as part of a strategic approach. This has created challenges in terms of both resourcing and offender management. However there is overwhelming evidence from this study and other studies that older prisoners have better relations when they are managed by a consistent staff group^[5].

The majority of prisons in Scotland are in good shape. Most sites have been completely rebuilt or enhanced in the last 15 years. They are bright, modern, well equipped buildings with lift facilities and open areas for prisoners to move around in. There do, however, remain three prisons which are Victorian in style and design. Whilst there have been some adaptations in these prisons, such as in cell toilets in HMP Barlinnie, they are far from modern or comparable with the remainder of the estate.

However there are significant numbers of elderly prisoners in HMPs Barlinnie and Dumfries - two of the sites which have not yet been redeveloped. The numbers in HMP Inverness on the other hand are small both literally and in terms of the percentage of the overall population. Staff at Dumfries raised concerns about the suitability of the design of the prison for elderly prisoners:

"This prison wasn't designed to house older prisoners. At the moment it's not too bad because we are fortunate these guys are well. They are in for long sentences most of them. What happens when they are unwell and we are trying to manage them and provide for their needs in these facilities?"

[Staff]

These staff were conscious of the fact that the majority of their prisoners were currently well but still some of them struggled getting around the prison:

"It's too awkward for me to get to some areas in the prison so I just don't bother."

[Prisoner]

In this prison the numbers of elderly prisoners represented 12% of the prison population, so the numbers are not small. This is a significant proportion of the overall population.

Table 3: Exercise

How often do you take time in the fresh air (exercise)?

Eating and Sleeping

Staff were conscious of the fact that many prisoners spent long periods of time without leaving the area where their cell was located because it was not feasible for them to do so. Interviews with prisoners confirmed this:

"We get our meals brought to us in the section because we can't go to the dining hall."

[Prisoner]

Effectively this means that this particular group of prisoners are isolated from the others within the prison to some degree. They are unable to participate in social dining which is traditionally seen as a means of meeting and mixing with other prisoners, but particularly important in building social networks. This in turn can lead to building positive relationships and a constructive means of relaxing away from the residential environment. Their meals are brought to the residential area within the prison so that they can eat there without having to go through what they described as a nightmare to get to the dining hall.

It is true that a number of prisoners prefer to eat alone in their cells. However, many prisoners in places like HMP Dumfries, where the dining hall is seen as a valued facility, view meals as quality time out of their cell. It is also viewed as a more normal eating experience, being able to sit at a table with all the regular features of eating a meal with other people. There is also something in this about being able to enjoy a social atmosphere which can have a positive impact on an individual's wellbeing and mental health.

Some prisoners were clearly struggling with inappropriate sleeping facilities:

"I'm seventy two and on the top bunk. I'm a lot fitter than my co-pilot, that's why I'm up there.. I am a bit worried that I could fall and hurt myself when I'm trying to get in and out of my bed."

[Prisoner]

It surely cannot be appropriate to locate anyone in their 70s on a top bunk, irrespective of their apparent or assessed capacity to do so.

Staff were also very concerned about this situation, but felt helpless to do anything about it:

"You've got no idea how difficult it can be trying to place some of the elderly prisoners. At times when we are trying to figure out where to put somebody we are literally having to make an assessment as to who can and who cannot make it up and down to the top bunk. Surely it's not right to put a seventy two year old in the top bunk?"

[Staff]

In prisons where there were pockets of elderly prisoners, they gave mixed responses in terms of their living accommodation and ability to get around the prison. There was a willingness amongst this prisoner group to put a brave face on things but when pressed, it was a different story. It wasn't clear whether this demonstrated a willingness to adapt to the surroundings or a man trying to retain some dignity in a situation which verges on the unacceptable.

Access to facilities

Some interviews were undertaken in modern facilities. These are fairly large sites with some considerable distances between the residential areas and the visits room. This presented difficulties for prisoners with limited mobility. In addition to the distance, some prisoners disclosed other age-related factors inhibiting their participation in activities. For example, one prisoner explained:

"It's a bit embarrassing but half the time I wouldn't go anywhere because I need to make sure I can get access to the toilet. When I need to go I need to go there and then, it's embarrassing."

[Prisoner]

A large number of prisoners referred in interview to dignity issues in relation to access to the toilet. How staff responded to this varied depending on whether or not, according to the prisoners, the staff member was used to working with the older men:

"Some of the staff are great, they'll say things like, 'Don't worry about it old yin, there's no rush.' Whilst others just march off down the corridor and stand at the other end waiting on you!"

[Prisoner]

Throughout the interviews prisoners were complimentary about the staff working with them regularly, saving their negative comments to refer to staff who worked with them on ad-hoc basis. Staff themselves during focus groups showed a good level of awareness in relation to the differences between working with the elderly and the general prisoner population. There was however an element of frustration evident with some staff. They had recognised that because of the prison environment there wasn't much for the prisoners to do and had been creative with innovative ideas for prisoners to pass some of their time which were age relevant. One example of this was a club on a specific day of the week where the prisoners could get to the area fairly easily where it was being held. They had the chance to chat and listen to music that they liked. The staff member was very positive about how the prisoners had responded to the club. Unfortunately the club had been stopped and the member of staff wasn't sure why but was left demotivated as a result of this.

Mobility

In all of the sites we visited there were issues with the environment which impacted on the living experience for the elderly prisoners. One example was an elderly prisoner who had to use a wheelchair to get around, yet the wheelchair did not fit through the cell door. He told us that he has to get himself out of the chair, collapse the chair, drag it into the cell, open it up again and get back into it. He explained that most of the time this was done with the assistance of another prisoner.

Staff and prisoners feel the current accommodation and buildings which are available are unsuitable. Prisoners interviewed reported that they feel staff are doing the best they can for them in a difficult situation. This extends to both their cellular accommodation and engagement in purposeful activity.

Discussion and Recommendations

For all prisoners, it is the responsibility of all prison staff to ensure that their treatment and conditions are appropriate. Older prisoners may need to be treated differently because of their age or infirmity, in order to ensure that their needs are met. Creating specialist provision for older prisoners in particular locations would enable the Scottish Prison Service to make suitable adaptations to the environment and create teams of staff who are dedicated and trained to work with the elderly.

In general, the Scottish Prison Service should be applauded for its estates redevelopment programme which has modernised the overall facilities. However, prisoners, prison officers and managers express difficulties in trying to make do with facilities which are less than adequate for an elderly population. Whilst there appears to be a reasonable level of good will to make the best of difficult situations, inappropriate facilities are creating risks. These include:

risks to injury of inappropriate sleeping arrangements and lack of accommodation for prisoners with poor mobility;
loss of dignity for prisoners with health problems leading to incontinence;
lack of access to meaningful activity; and
reduced access to social engagement with visitors and other prisoners.

In an era where there seems to be litigious action taken by groups of prisoners more readily than before, then there is certainly the possibility of challenge from the ageing population over aspects of their care.

This review found evidence of prison officers taking the initiative to develop activities tailored to the needs of elderly prisoners. Staff and prisoners were positive about the impact of the music and social club yet it was removed from the regime. It would appear that a combination of poor communication between elements of the staff group and pressure on resources led to the termination of an activity seen as beneficial both for, and by the population concerned.

With a small number of elderly prisoners these difficulties whilst unacceptable, are being managed - often because both staff and prisoners go out of their way to ensure the prisoner gets the assistance they need. However as the population gets older and there are larger numbers of elderly prisoners this will place greater pressure on the accommodation available. This should be anticipated in future estate development plans.

Medical Provision And Personal Care

This report does not seek to provide an assessment of the medical care and treatment given to prisoners who are over the age of 60. It does however report on the views of the prisoners in relation to their perception of care in a medical context and the views of staff spoken to who manage elderly prisoners on a regular basis.

The prisoners interviewed and the respondents to the questionnaire generally commented favourably on their dealings with healthcare professionals. However there were negative comments about getting their normal prescribed medication. Some spoke about their experiences of waiting, sometimes days to get their medication sorted out:

"When I was transferred into my last establishment from Barlinnie, I had to wait three days to get medication which I had been getting and needed at Barlinnie. I was eventually given what I needed but I felt like it was a case of just get on with it, we're busy."

[Prisoner]

Table 4: Are you on a prescribed medication?

A number of prisoners voiced concerns in relation to the way in which medication was managed and issued:

"You have to put in your requests for medication on a weekly basis. To be honest, it's a bit of a joke. Half the time there's a problem and you have to go back to them or get an officer to phone up and see what the problem is."

[Prisoner]

Table 5: What medical aids do you require?

Dementia care

Staff stated that there is often not enough for the prisoners to do in order to keep themselves occupied in a meaningful manner. A number of older prisoners said that they want to work even though there is no requirement for them to do so. One prisoner summed it up as follows:

"I might be nearly 70 but I enjoy getting up and going to the work shed. Ok it's not exactly hard graft but I enjoy it. I want to keep going as long as I can and try and keep my mind working."

[Prisoner]

Clearly for this prisoner, the fear of losing his mind was a very real possibility and he felt if he could work and get out of the hall, then this was helping to stimulate his mind. He explained that this fear arises from witnessing other prisoners who he believes fall into this bracket. Staff may not be equipped to recognise the onset of dementia, nor are trained to offer appropriate dementia care.

A few staff commented positively on some training that they had received to identify signs of the onset of dementia. They acknowledged this is an area of management of prisoners which they may have to deal with in greater numbers in the future:

"We've got prisoners in here suffering from dementia. Surely this isn't the right place to be putting these people. What are we supposed to be doing with them? We're not really trained nor do we have the time to spend on individuals who require that increased level of support. That's a job for a nurse or at least a medically trained person you would think."

[Staff]

"Ok we've had an insight into this but it's a bit of a minefield to be honest. The thing about it is you are being asked to deal with these prisoners in a setting where you also have prisoners who are young, fit and healthy."

[Staff]

Complex care needs

This observation shows that staff are acutely aware of the risks involved in the population management issues which are applicable to many of the elderly prisoners in their care. They are effectively being asked to manage prisoners with very complex care needs in a setting where they also have prisoners who are exactly the opposite - fit and healthy. This requires a constant change in approach from the staff managing them. Many staff and prisoners commented on the kindness they had seen from prisoners towards the elderly who are struggling with aspects of their personal care in prison.

Where care assistants are employed to support older prisoners, staff spoke in positive terms of their work and contribution. They argued that this provision should be increased and clarity around roles and responsibilities improved:

"What happens when there is no care assistant available? Who do they think deals with these guys? That's not what I'm here to do."

[Staff]

In another establishment a member of staff displayed a very high level of care and compassion:

"There's no point asking guys who are not interested in these guys to work with them. Some of these prisoners are incontinent. Now to me you just can't leave some of these guys sitting around in that state. I cared for someone who was like that in the latter stages of their life so I know what I'm doing and to be honest I've not got an issue with that."

[Staff]

This example demonstrates the positive lengths some staff would be willing to go to in order to care for elderly prisoners. It is notable that almost every prisoner we interviewed named specific staff members who they felt went above and beyond what was expected of them in their approach to care:

"X (officer's name) is a really decent officer, whereas when certain individuals are in the hall you just get the feeling from them they are not interested and don't even want to speak to you, never mind deal with any of your care or medication issues."

[Prisoner]

Lack of decent and humane treatment

Prisoners in several establishments reported that they felt either their medical or general care needs were not treated in a decent and humane manner. It was clear that some prisoners had experienced some very distressing treatment and two prisoners were each in tears when they related the following two examples.

A seventy five year old man spoke of an experience which occurred to him whilst he was out at court that he found very distressing:

"I was going from the cells up to the court and I had previously told the turn-key that when I needed the toilet I really had to go there and then. I tried to explain in as decent and respectful a manner as possible that if I didn't get to the toilet when I asked I would end up messing myself. I was told in no uncertain terms that I would get to the toilet as and when they could let me go, end of story. Sometime later I was being taken to the court and I asked to go to the toilet. This was met with some unhelpful comments and a refusal at that time. The inevitable happened and I ended up messing myself. I didn't go to court and had to be put in to a paper suit. When I was being taken back in the van all the other prisoners were shouting at me. I felt totally humiliated. I know what I have been convicted of even though I never done it, but is that really any way to treat a seventy five year old man who was only asking to go to the toilet. It's not as if I am going to try and get away or anything. I mean I literally have to be close to a toilet or that's what happens."

[Prisoner]

Another prisoner was very distressed when relating this incident:

"I woke up after having heart surgery and found myself handcuffed to a turn-key. I mean is that some kind of sick joke. I'm in my seventies I can hardly walk never mind run. I'm not exactly a threat to them physically so why on earth am I handcuffed. Then when I go to the toilet trying to push a stand with my drip on it I am also handcuffed. I have never felt so humiliated in my life. The other thing is when you are out at hospital, trying to get clean clothes or stuff from the canteen is just a nightmare. They are just not interested and the fact you are an old man it's as if they think they can treat you any way they like. I know I am a convicted sex offender but surely that's all a bit over the top in terms of security. Where am I going to go even if I could get away? Nobody is interested in me."

[Prisoner]

At this point the prisoner broke down in tears in front of the research team. He clearly accepted his guilt and felt that he did not deserve to be treated with any exceptional care by anyone. Yet he was hoping to be treated with minimal human decency, but felt that this was sadly lacking.

A number of prisoners raised issues with the research team about the care they received when under escort at hospital. Several other prisoners also described instances where they awoke to find themselves handcuffed to an escort after receiving major surgery in hospital.

Finally, one further issue of concern regarding medical care was brought to the attention of the research team by a prisoner interviewed. During the course of the interview the individual was asked about his experiences with the healthcare team within the prison. Although interviewers reported that he was reluctant to criticise anyone, he did offer up the following insight into his particular situation:

"I am waiting to go out to hospital for an operation. In advance of that operation a number of tests have to be carried out. I have been scheduled to have these tests now on three occasions. The previous two have been cancelled due to staffing issues, or so I am told. What these people don't seem to understand is the fact that I am sitting here not knowing if I have something seriously wrong with me and these tests are part of the way I will find out. It's as if they just don't care but I am the one who has to live with the stress of it all."

[Prisoner]

Discussion and Recommendations

The testimonies of prisoners interviewed for this review reveal large inconsistencies in their experience of medical and personal care. There appear to be wide variation in the levels of basic human decency and humane treatment of prisoners.

This raises both practical and moral issues for the criminal justice sector in addressing the management of elderly prisoners. These could be tackled through the introduction of a personal care plan for every ageing prisoner. The care plan should highlight the specific care needs of the prisoner and how these should be met. Plans should be readily available to the relevant staff and should accompany the prisoner if they are moved to another location.

A personal care plan should form part of the specification of contractual obligations with other parties who are involved in the management of prisoners for the Scottish Prison Service. In this way problems such as incontinence and the implementation of escort during medical treatment can be managed sensitively, appropriately and consistently to ensure that elderly prisoners receive humane treatment.

When prisoners are transferred from one prison to another, the delays in the provision of medication should be minimised. There is a need to ensure that the care for prisoners taken under escort to hospital appointments is appropriate.

Prisoners' Fears For The Future

Throughout the course of this piece of work a common theme which emerged was the prisoner perception that no-one cared about what was going to happen to them either in prison or when they were released. A number of prisoners clearly felt as if no-one was really bothered about them regardless of their age or what they were physically capable of doing. It wasn't just that staff within the prison setting did not care, but rather prisoners felt that society as a whole - including, in a number of cases, family members - didn't care about them.

"I'm here doing a long sentence, and to be honest I think what's the point? Nobody is bothered about me. There is nothing for me to go out to and what's left of my family have disowned me. I don't even have anywhere to live if I was to be released and I'm too old to be living rough at my age."

[Prisoner]

The participants were asked in the questionnaire to identify their biggest fear associated with being in prison. The three most common responses were "dying in prison", "worsening health" and "loss of family contact".

Table 6: What is your biggest fear?

Table 7: Has your health deteriorated since being in custody?

The prisoner cohort involved in this study did not seem to understand how their housing needs would be met when they were released from prison. This was a further cause of anxiety for them.

Two of the individuals interviewed had been brought back from another country because of crimes they had committed decades ago. One of these prisoners was very emotional when explaining his story:

"Since I have been arrested and brought back to Scotland I have had some serious health issues. I have been in hospital for major surgery and haven't seen my family now for quite some time. The worst thing though is that my wife has died and I will never get the chance to see her again. I don't even know if I get released if I will be able to go back to my family [overseas]."

[Prisoner]

This quote illustrates the sense of helplessness felt by some of the elderly prisoner population.

Family visits

Many of the older prisoners involved in the review were not receiving regular visits, and expressed the way that this reinforced the sense that no one cared about them. As a research team we had to modify our initial questionnaire after the test phase to take into account this common experience of receiving few visits. Elderly prisoners receive visits from elderly people who may also have special needs in respect of their own mobility and the processes they have to endure when they arrive at the prison:

"My wife has visited me but it has been only on a few occasions. She has to travel quite a long distance and she is also incontinent. When she arrives she requires somewhere to wash and change and to be honest it's proving quite difficult."

[Prisoner]

Another prisoner wanted to discuss a visit he had expected but hadn't received and the impact this had on him:

"I am probably going to die in prison given both my age and sentence. My brother who is elderly and lives in another country came to the prison to visit me. It was to be the last time we would see each other. On the day of the visit there was a mix up and although there was space in the visit room he wasn't allowed in. I was devastated that he had come all that way so we could see each other one final time, only for him to be refused entry to the prison."

[Prisoner]

Examples such as these increase the feelings amongst the prisoner group of being isolated, marginalised and ultimately left with a sense that no one cares.

Discussion and Recommendations

This study has demonstrated multiple factors affecting older prisoners that are likely to reinforce a sense of being forgotten and uncared for. This in turn may well undermine their health. Their fears of loneliness, isolation and dying alone suggest that the SPS ought to put in place appropriate arrangements to ensure that prisoners have support and companionship in their final years.

Prisoners who are due for release should be prepared to face life outside the prison and in particular informed that housing will form part of their release plan.

It is clear that visits are of particular significance when either the prisoner, or their visitor, or both, are coming towards the end of their lives. When a prisoner misses a visit at any time it is a difficult situation to accept, but when the prisoner feels that he or his relatives may not have long to go and he may not see them again this must increase the impact of the event considerably. Prison staff have a duty of care to ensure that visits are facilitated effectively.

Conclusion

It is clear from the work undertaken in preparing this report that older people in prison experience a high degree of loneliness and boredom, and possess a strong sense of dread and fear about what the future holds.

Over a quarter of the population of prisoners over the age of 60 are serving a sentence of five years or more. This has long term consequences for those managing prisons in Scotland, who may now expect to be looking after an increasing number of elderly prisoners well into their 70s and 80s. The number of men convicted of historic sexual offences is continuing to rise, suggesting that the increase in older prisoners serving longer sentences will continue for some time. As a consequence there will be an increasing need for social care for prisoners as well as medical care.

There is an urgent need for the SPS and the Scottish Government to consider how to balance the issues of custody and care. Appropriate social and health care must be provided within the context of secure custody.

Significant challenges face the SPS, the Scottish Government, local authorities and health and social care providers in relation to providing older people in prison with the care and support they are entitled to. The issues raised in this report demand close co-operation and joint working across all parties with responsibility for ensuring that the needs of older people in prison are met, both within the prison and subsequently on release.

The current degrading treatment experienced by some older prisoners cannot be allowed to continue. Older prisoners are too often isolated and receive inadequate healthcare. There is an urgent need for change.

My hope is that this study will support rapid and effective change in the treatment of older prisoners in Scotland. HMIPS will continue to monitor the treatment and conditions for older prisoners and how the needs of this population are being met.

David Strang

HM Chief Inspector of Prisons for Scotland

July 2017

The Evidence Gathered During This Process Points Towards A Number Of Key Areas That Need To Be Addressed.

The health care and other needs presented by this population should be a primary determinant of the accommodation and regimes provided to them. This may require the development of non-traditional units for at least some older prisoners whether within, or outside the grounds of existing establishments.
The SPS should ensure that staff who work with older prisoners are identified as suitable for the role and appropriately trained. They should be provided with the training necessary to support them in their tasks, including specific training in dementia care and other age related health subjects. Their work should be valued and supported in prisons, with sufficient resources committed to provide the necessary care for these prisoners.
Prisoners should be supported to maintain positive contact with their families and arrangements made to encourage family visits.
The range of work and activities available within prisons needs to be tailored to the physical abilities of an older population and with a particular emphasis on ensuring that 'social time' is built into the daily regime.
The SPS should develop and implement a clear strategic policy position on the management of elderly prisoners. A systematic appraisal of all available options in light of international experience and research evidence would assist this development.
The SPS needs to review the prisons estate to ensure that the facilities that are provided not only match the needs of the population, but also those of the service providers working with them. Communal areas and in particular cells need to be designed in such a way to ensure that they provide the space to allow nursing and care staff to maintain their professional standards and operate safely.
The SPS and Scottish Government need to agree a joint approach on the location and management of these prisoners. The prisoners involved in this survey were generally of the view that an age specific population was not desirable. Nonetheless it seems inevitable that a rising population of ageing prisoners in SPS custody will begin to present distinct and more concentrated needs and challenges. It may be that alternative accommodation should be considered, which maintains the level of security that a prison sentence requires, but is suited to the provision of appropriate health and social care for this population. Local authorities and NHS Boards, too, have a key role to play in the care of older prisoners.

Footnotes

1. Baidawi, S, Turner, S, Trotter, C, Browning, C, Collier, P, O'Connor, D, and Sheehan, R, 'Older Prisoners - A Challenge for Australian Corrections' (2011) Trends & Issues in Crime and Criminal Justice no. 426. Canberra: Australian Institute of Criminology, Australian Government; Crawley, E, and Sparks, R, 'Older Men in Prison: Survival, Coping and Identity' in Liebling, A and Maruna, S (eds.) The Effects of Imprisonment (2005); House of Commons Justice Committee, Written Submission on Older Prisoners from Dr Elaine Crawley (2013). Available at: www.publications.parliament.uk/pa/cm201314/cmselect/cmjust/89/89vw19.htm

2. Prior to any fieldwork being undertaken an extensive literature review was undertaken by Gabrielle Watson, from the Centre for Criminology at the University of Oxford. This literature review can be found on the HMIPS web site https://www.prisonsinspectoratescotland.gov.uk/publications

3. Aday, RH, Aging Prisoners: Crisis in American Corrections (2000); this position is disputed by both House of Commons Justice Committee (2013) above note 1, and Crawley and Sparks (2005) above note 1, who suggest a determinate age of 65 years.

4. Liebling, A, Price, D, Elliot, C, 'Appreciative Inquiry and Relationships in Prison' (1999) Punishment & Society 1(1) 71 - 98.

5. Crawley, E and Sparks, R, 'Hidden Injuries? Researching the Experiences of Older Men in English Prisons' (2005) The Howard Journal of Criminal Justice 44(4) 345-356.

SCT03172875161.pdf

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Who Cares ? The Lived Experience Of Older Prisoners In Scotland's Prisons