Headlines

• Sickle cell is a lifelong condition that can cause significant pain, fatigue, and other complications, and people in custody may face additional barriers to managing their condition.
• Pain should be taken seriously. Avoid assumptions that someone is exaggerating, seeking medication, or being difficult when they report pain.
• Understanding the person’s usual symptoms, triggers, treatment plan, and individual experience can support better care and earlier intervention.
• Stress, dehydration, cold temperatures, exhaustion, and other environmental or emotional factors can contribute to sickle cell complications and may increase the risk of a crisis.
• Isolation and separation from support networks can contribute to loneliness, stress and depression. Increased psychological distress can have a wider impact on someone’s physical wellbeing and may contribute to factors that increase the risk of a sickle cell crisis.
• Prison environments can create additional challenges, including restricted movement, limited access to family, changes in routine, and difficulties accessing healthcare or maintaining hydration.
• Small things can make a significant difference: access to water, appropriate clothing, warmth, rest, communication, and timely access to healthcare.
• Staff should be curious rather than dismissive — ask what is happening, what is normal for the individual, and what has helped them manage their condition previously.
• Clear and consistent communication between healthcare and prison staff is important so that concerns are recognised and responded to appropriately.
• A person experiencing a crisis may be frightened, exhausted, frustrated or in severe pain. Compassion and calm communication matter alongside clinical care.
• Early recognition of changes in presentation and timely escalation can help prevent a situation from deteriorating.
• Building trust through consistency, listening, respect and follow-through can make it more likely that someone will seek help when they need it.
• Remember that the person is the expert in their own experience. Listening to them can provide valuable information that supports safer and more person-centred care.

Working with People Who Mistrust Services

• Mistrust is often a learned response to trauma, poor experiences, stigma, or feeling unsafe within systems.
• Behaviour such as refusal, anger, complaints, or disengagement may reflect fear, shame, overwhelm, or a need for control.
• Look beyond the behaviour and consider what may be driving the response.
• Trauma-informed practice focuses on safety, trust, choice, collaboration, empowerment, and cultural awareness.
• Sensory factors such as noise, crowding, lack of privacy, and uncertainty can increase distress and reduce engagement.
• Small adjustments, clear explanations, and allowing time to process information can improve engagement.
• Communication should be clear, respectful, consistent, and honest about boundaries.
• Trust is built through reliability, follow-through, and repeated positive interactions.
• Repairing relationships after difficult interactions is an important part of effective care.
• Consistent communication between staff supports psychological safety and engagement.

Balancing Care & Risk (Severe Mental Illness + Addiction)

Assessment often triggered by changes in presentation (e.g. disengagement, self-neglect, unusual behaviour).

Consider dual diagnosis – severe mental illness alongside substance misuse can complicate presentation and risk.

Risk assessment must include both risk to self (e.g. overdose, suicide, command hallucinations) and risk to others (including offending history and voices directing harm).

Risk is dynamic – requires regular review and reassessment, especially when circumstances or engagement change.

Engagement can fluctuate patients may initially present as unwell but improve with support and review.

Symptoms (e.g. voices) may persist but risk can reduce if the person can manage or cope with them.

Substance use may act as a coping mechanism but can also worsen mental state and risk.

Management should be multi-agency and collaborative (e.g. healthcare, prison staff, offender management, pharmacy).

Care planning should be patient-centred, including the person’s goals (e.g. transfer, environment changes, safety needs).

Use structured processes (e.g. ACCT, CPA) to support monitoring and risk management.

Focus on what can be changed vs what cannot, and agree clear, shared plans.

Ongoing communication and information sharing are essential for safe and effective care.

Effective ACCT Practice

• Compassionate, human interaction is the foundation of good ACCT work and must take priority over process and paperwork.

• ACCT should function as a time-limited crisis management tool, supporting individuals to build coping strategies rather than becoming a long-term substitute for care.

• ACCT is a shared responsibility across prison and healthcare services, with safety as a collective goal.

• Strong MDT working is essential – effective ACCTs rely on trust, mutual respect, and understanding of different professional perspectives.

• Staff managing ACCTs should know the individual well, understand their baseline behaviour, recognise red flags, and feel confident acting on professional curiosity and instinct.

• ACCT processes should remain person-centred, avoiding tick-box approaches and blanket actions.

What Good ACCT Management Looks Like

• Always ask the individual what support they want or need and ensure this is clearly recorded and actioned.

• Observations and conversations must be bespoke, proportionate, and tailored to the individual’s risks, needs, and circumstances.

• Ensure the right people attend ACCT reviews, including those who know the individual best and relevant MDT members.

• ACCT reviews should be well-led, with clarity of purpose, clear decision-making, and shared accountability.

• ACCTs should be appropriately closed when they no longer add value, to avoid dependency and stigma.

• ACCT must sit within a wider support framework, complementing (not replacing) other prison and healthcare interventions.

Common Barriers to Effective ACCT Working

• Gaps in staff knowledge, confidence, and understanding of the purpose of ACCT.

• Compassion fatigue and staff overwhelm, often exacerbated by limited supervision and support.

• Limited time and resources to gather information and prepare meaningfully for ACCT reviews.

• Documentation challenges that encourage task-focused rather than person-focused practice.

• Stigma associated with ACCT, which can negatively impact engagement from both staff and individuals.

Symptoms can include pain, discolouration, warmth or swelling in a unilateral leg (rarely both legs).

Utilise NICE guidelines and the Wells DVT score to assist with management and next steps. Be thorough when using the Wells DVT score to ensure it is properly aggregated.

Be mindful that 30% of patients presenting with a DVT can also have a pulmonary embolism – a severe blockage in a vessel in the lungs that can prove life threatening.

Above knee DVT’s are very common – roughly 60%.

Send a d-dimer for a Wells score of only 1 – these patients have a low risk of a DVT and the test is used to rule out the condition - ensure the sample bottle is properly filled.

A venous doppler is the definitive test to diagnose a DVT. Ensure a doppler scan is arranged for a patient with a Wells score of 2 or more – ideally within 24 hours – transfer to secondary care is the main way of gaining a doppler scan.

As per NICE guidelines, anticoagulation should ideally be commenced within 4 hours.

Immobility, obesity and a history of drug misuse are major risk factors for developing a DVT

– Ensure a full examination is conducted and consider the patients past medical history – be clinically curious.

Sepsis

Sepsis arises when the body’s response to infection spirals rapidly out of control, injuring its own tissues and organs.

Sepsis can be triggered by an infection in any part of the body – even an ingrowing toenail.

It is indiscriminate and potentially deadly.

Reacting quickly and treating fast, rapidly improves survival rates

Key things to look out for - especially if unwell with infection or has a wound that looks inflamed – think could this be Sepsis?

• Very high or low temperature
• Uncontrolled shivering
• Confusion
• Passing less urine than normal
• Blotchy or cold arms or legs
• Patient reports feeling like they are going to die sometimes with extreme pain and sense of impending doom

What can we do?

Prevention of infection

• Keep vaccinations up to date
• Keep wounds clean
• Practice good handwashing
• Take anti-biotics as prescribed – always finish the course

If you suspect sepsis

• Establish the patient’s baseline and be alert to differences.
• Stay curious – don’t assume presentation is due to MH disturbance or drug use – it could be sepsis.
• Calculate NEWS-2 score – act accordingly.
• If you are worried, ensure full and prompt assessment and escalate early if required.

• Clear and accurate documentation is a crucial part of patient care. It facilitates information sharing between healthcare staff, allowing teams to contribute to ongoing risk evaluation, and can be used both clinically and legally.
• Records should be prompt, accurate and legible. They should be structured with subheadings to help others quickly find the information they need. 
• Records of patient interactions can be broken down into three stages: 
  • 1. Incident background (Context or reason for them being seen)
  • 2. Patient assessment and treatment 
  • 3. Care planning.
• Common pitfalls with documentation include: using colloquial or judgemental language, omitting essential background information - assuming that others are aware of the wider context or that the information is captured elsewhere – and forgetting to include specific templates relevant to patient assessment.
• Tips for improving documentation practices:
  • Document as if handing over to a colleague who has never met the patient.
  • Practice documenting under subheadings / following the structure above
  • Set up systems for the safe handover of patient information e.g. high-risk patient folders and regular schedules for review.

• The ACCT (Assessment, Care in Custody and Teamwork) is a prison led care planning process for individuals at risk of self harm or suicide.
• This process is just one part of multiagency risk management.
• Sometimes decisions around whether someone is on the ACCT process can be complex and nuanced.
• When making difficult decisions, always seek support and document your decision making clearly.
• Also consider other possible risk management strategies and interventions such as engaging with the gym, families, peer support, Chaplaincy, Samaritans and substance misuse teams.
• If you're in the healthcare team, always talk to and involve your prison colleagues and vice versa.
• It can be easy to get caught up in the process, always keep the person at the centre of what you're doing.

• If suspecting someone of using SPICE, stay curious, they may be drowsy because of other prescribed medication, check for recent changes.
• See SPICE use as an opportunity to educate the patient in a non-judgemental way about risks, especially if also taking anti-psychotics.
• If declining to administer medication because you suspect the person may be sedated or intoxicated, contact the prescriber and share your thoughts.
• If you are a prescriber and your patient is regularly using SPICE consider taking ECG measures and alternative prescribed medications that may be safer.
• When SPICE use is suspected, avoid quetiapine and other antipsychotics that prolong QTc; studies show that aripiprazole and olanzapine are the most cardiac safe in this scenario.