Learning Disability Screening in Foston and Sudbury Prisons

in Partnership with
16/06/2014 Julie Sankey(Lead Nurse) and Gaynor Ward(Consultant
Nurse, Learning disabilities and Mental Health services)
Offenders with learning difficulties and
learning disabilities - review of prevalence
and associated needs, ’NO ONE KNOWS’
Nancy Loucks (2007)Prison reform trust
Bradley (2009) Lord Bradley’s Review of
People with Mental Health Problems or
Learning Disabilities in the Criminal Justice
System. London: House of Lords.
HMP Brixton
Mcarthy et al have carried out a study on Neurodevelopmental disorders within
HMP Brixton. LD/ADHD/ASD 36% of the prisoners screened in as having significant
neurodevelopmental disorders. They used the LDSQ which they stated had a high
rate of false positives.
HMP Dovegate
Bates and Crocombe (2013) An evaluation of an ASD screening tool constructed for
use in a prison setting. They highlighted that the sample size was small, that there
unable to generalise to conventional prisons settings as all prisoners were from the
prison therapeutic community and unable to assist in prevalence of ASD.
West Yorkshire Police Custody
Middlemiss (2012) carried out LD screening in police custody using the LDSQ tool,
they had a 3% prevalence which was significantly lower then that within the prison
population which is estimated at 7%
All studies carried out so far are small in the numbers of prisoners screened or have
only screened for one neurodevelopmental disorder
The Proposal
To screen for learning disabilities, autistic spectrum disorder,
ADHD and Traumatic brain injury by implementing a variety of
screening tools within HMP Foston and HMP Sudbury, in
conjunction with Derbyshire Healthcare Foundation NHS Trust.
To identify the prevalence of Learning Disabilities,
Autistic Spectrum Disorder, Attention Deficit Hyperactive
Disorder and Traumatic Brain Injury, in a set time period, within
the two local prisons to inform the development of appropriate
pathways and the implementation of reasonable adjustments
To assess a set of screening tools to ascertain if they
are fit for purpose for use by Healthcare during the initial health
assessment (reception) in terms of inter-rater reliability, time to
complete and if they are user friendly.
Learning Disability
‘Learning Disability’ is the term that the Department of
Health use within their policy and practice documents.
In Valuing People (DH 2001) they define a ‘learning
disability’ as a:
•significantly reduced ability to understand new or
complex information, to learn new skills ,
•reduced ability to cope independently,
which starts before adulthood with lasting effects on
(Department of Health. Valuing People: A New Strategy for Learning Disability for the 21st Century. 2001).
Autistic Spectrum Disorder (ASD)
The AQ10 was chosen to screen for ASD as recommended by NICE
Attention Deficit Hyperactive
Disorder (ADHD)
• Prevalence is 3-4% in children,
• Persists with 15% reaching a full diagnosis by
25 years of age,
• 50% retain some symptoms leading to
continuing impairments on daily life,
• Higher rates of recidivism,
• 8 times more aggressive.
Adult ADHD Self-Report Scale (ASRS-v 1.1) Symptom
Traumatic brain injury (TBI)
• An event that could caused a brain injury,
• A period of loss of consciousness or altered
consciousness after injury.
• Or the injury was severe,
• And the presence of two or more chronic
HELPS Brain Injury Screening Tool
Neurodevelopmental Disorders
• Present from early life,
• Affects cognitive, behaviour, social, language
• Genetic conditions, ASD, LD and ADHD
• Lifelong condition.
May 2014
Case Studies
How we’ve made a difference so far
(1). Screen identified a female with LD who required urgent
intervention around capacity, consent and help to access
universal services in relation to a diagnosis by oncology. An
additional clinic and support was offered.
(2). A female prisoner screened positive for ADHD and TBI.
This TBI was sustained before 18 years of age and she
would therefore meet the criteria for learning disability
services. She had some speech pronunciation difficulties
and was recommended to seek an appropriate referral
through the GP.
(3). A female prisoner screened positive for ASD and TBI
and acknowledge she had addition memory retention
deficits. She is currently receiving a service from the
specialist PD service (CAMEO). Consent was received to
share the screening with all involved to consider the
possibility of misdiagnosis and/or ensure reasonable
adjustments are implemented.
(4).A male prisoner screened positive for ASD. He has
service over his tariff and he appears to be having issues/
problems directly related to his communication and
understanding of issues. Further assessments and
screening have been undertaking and a recommendation
for a full diagnostic assessment has been made.
• (5). A female prisoner, who was referred by healthcare, attended the
screening but unfortunately had difficulty with engagement. ASD
characteristic had been suggested by a previous CAMHs service and
were noted at point of screening. She was therefore referred to the
Mental Health In-Reach team for an LD and MH joint assessment. No
mental illness was identified but once again ASD characteristics were
identified. Further assessments are planned.
• (6). A female prisoner has been having difficulties with completing a
fluid intake and out put chart requested by the GP. Previously a nurse
and a doctor had talked through the requirements of completing the
chart but she was having difficulty with comprehending their requests.
An accessible/ easy read version was developed and the GP has
asked to carry out a joint appointment.
• (7). A male prisoner made a self-referred as he had received a
diagnosis of ADHD 2 years ago by a clinic in his local area but he
didn’t have a copy of the assessment. He gave permission to obtain a
copy of the report and his screen identified symptoms highly
consistent with ADHD. A letter was written to his work area
supervisor/prison officer offering advice and information on reasonable
adjustments for people with ADHD.
Patient Journey
A female prisoner screened in as having experienced
traumatic brain injury. She told the assessor that she had
developed speech difficulties after the injury but never
received any help for this. She asked for a referral to the
GP to discuss if there was any help she could now get.
A consented one to one journey was undertaken to
ascertain her experiences. Within her narrative she said:
‘. . . . the LD screening has given me hope that
someone will help me now with moving forward and the
screening tool has helped me and Healthcare to have
better understanding of my needs as an individual…..’
Lessons learnt
•Recognition that the LD screen needs to be completed before the
other assessments otherwise the LD will skew the other tests giving a
false positive (e.g. AQ10 is not valid on the LD population),
•All tests can be completed within 20 minutes,
•We have completed work on the inter-rater reliability
•A higher percentage of female prisoners have been identified as
having additional needs. However the initial numbers are small and the
male and female population is very different: HMP Sudbury is a cat D
male open prison with end of term sentenced prisoners whereas HMP
Foston is a closed female prison with both remand and sentenced
•More female prisoners have been identified with GBH and violent
crimes in all conditions. No other correlation has been made.
Recommendations for Prisons
• All 41 people found to have additional needs to have follow-up
assessments completed by a Learning Disability Clinician.
• The LD (Neurodevelopmental) screening tools to be made
mandatory on prison reception, health professionals based at the
prison to complete.
• NHS England to commission LD support into the prisons.
• LD referral pathway to be identified inline with Positive Practice:
Positive Outcomes recommendations.
• Speech and Language Therapists to assist in the assessment of
communication needs specifically related to development of specific
person centred offender programmes working in partnership with the
prison based forensic psychologists.
• All staff receive training on neurodevelopmental disorders and
Recommendations for CJS
• To pilot the screening tools.
• To improve staff knowledge and
awareness of neurodevelopment
• Mandatory training for custody sergeants.
• Adopt the a definition of learning
Further work
• To offer diagnostic assessments to all prisoners who
screened positive for a neurodevelopmental disorder.
• To develop appropriate diagnostic pathways for all
• To develop appropriate adapted offender programmes
for all groups.
• Develop staff training in areas such as communication,
reasonable adjustments and neurodevelopmental
• To liaise with the Forensic Psychologists on adaptation
of rehabilitation programmes.
Further work
• The screening tools took 20 minutes
to complete by a LD Clinician, it may
be beneficial to carryout the same
screening pilot locally within a
custody suite. This would then
highlight if the screening tools could
be used at first contact with Criminal
Justice Services.

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