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Guidance for doctors on the use of solitary confinement in the youth secure estate

Isolation, segregation, separation, removal from association, single unlock: these names are used, often interchangeably, across detention settings to describe the practice of solitary confinement, where an individual is physically and socially isolated from others for a prolonged period of time.

Its use is widespread in the youth justice system in the United Kingdom, where it is estimated that up to 38 per cent of boys in detention have spent time in solitary confinement, with stays of over 80 days being reported. Compounding this is a growing practice of holding children in conditions of solitary confinement in their own cells or rooms for upwards of 22 hours a day – largely as a result of staff shortages and increased violence in the youth justice system.

There is clear evidence that solitary confinement can have a profound, and lasting, adverse impact on health and wellbeing. As a result, we do not believe that its use can ever be sanctioned on children and young people.

It is clear, however, that as long as the practice continues, the youth justice system must ensure that the health needs of those in solitary confinement are met.

This resource aims to assist doctors working in these settings to maintain the highest ethical and professional standards.

When facing specific ethical dilemmas, doctors are strongly recommended to seek advice from the BMA Medical Ethics Department, the General Medical Council, or their personal medico-legal defence body.

Download the full guidance

 

Read more below

  • Key points at a glance

    The BMA opposes the use of solitary confinement on children and young people and believes that the practice should be abolished.

    Until this has been achieved, doctors have an important role to play in seeking to minimise the harm to which children or young people are exposed.

    Read our joint position statement

     

    Key points to remember

    • Doctors working in the youth justice system are bound by the same principles of medical ethics as they would be in the community.
    • Doctors should not be involved, either formally or informally, in certifying a child or young person as “fit” for solitary confinement.
    • Doctors should raise concerns where they believe solitary confinement will be particularly damaging for a child or young person.
    • Doctors should visit children and young people in solitary confinement regularly, and raise any concerns they might have about any deterioration in health and wellbeing.
    • Doctors also have a more general duty to raise concerns about conditions which put patient safety at risk, or about practices which are abusive or negligent.
    • Children and young people in solitary confinement retain the same rights as other patients to privacy and confidentiality, but these rights are not absolute. They must be balanced against the risk of danger to the doctors involved in their care, and the need to share information in order to safeguard children and young people.
    • Children and young people at risk of suicide or self-harm should not be accommodated in segregation units, other than in exceptional circumstances wherepsychiatric or psychological assessment indicates that it will reduce that risk.
    • If it is unavoidable, doctors working in these settings should seek to ensure regular interaction with the patient and raise concerns where they feel health is deteriorating.

     

  • Principles to be guided by

    All doctors practising in the UK, including doctors working in the youth justice system, are bound by obligations set out by the General Medical Council in GoodMedical Practice and its supporting guidance.

    Doctors working in secure environments therefore owe the same ethical duties to their patients as all other doctors.

    In situations where doctors find their ethical obligations under pressure, it can be helpful to refocus on their primary obligations, as set out in the following core principles:

    • A doctor’s primary duty is to their patient.
    • Doctors must work to protect and promote the health and safety of patients, and take prompt action if they believe that is threatened or compromised.
    • Medical care should be provided on the basis of clinical need, impartially, and without discrimination.
    • Doctors are personally accountable for their professional practice and must always be able to justify their decisions and actions.
    • Doctors must recognise and work within the limits of their competence, and take steps to keep their professional knowledge and skills up to date.

    Additionally, doctors working in secure settings should also bear the following core principles in mind:

    • Doctors should provide care that is at least of a comparable standard to that provided in the community.
    • Doctors should respect patients’ human rights and be mindful of the ways in which they may be compromised.
    • Doctors should maintain robust standards of professional and clinical independence.
    • Doctors should identify where services or conditions are inadequate and may pose a threat to health, and raise concerns as appropriate.

     

  • Managing dual loyalties

    Dual loyalties, or dual obligations, are the conflicting demands placed on doctors who have direct obligations to their patients, as well as to a third party.

    Whilst all doctors have various professional loyalties – for example, to colleagues, to employers, or to society at large – these largely remain in the background to their primary obligation to the patient and to the public’s health.

    For doctors who work in secure settings, these dual obligations can become more pronounced.

    There is an inherent tension between the two competing aims of the secure setting and healthcare: while the secure setting is a place of punishment, focused on security and deprivation of liberty, healthcare exists to protect and promote the health of those detained.

    Medical involvement in, or proximity to, disciplinary or administrative issues, such as solitary confinement, is an area where that tension can be seen most clearly.

    You may find yourself drawn into processes and procedures designed to meet the aims of the secure setting, with the potential for their ordinary duties and obligations to the patient being overridden.

    It is vital that you remain alert to the ways in which such conflicts can impact on your ability to meet your binding ethical obligations.

     

  • Should doctors confirm that someone is fit to be placed in solitary confinement?

    In the same way as for doctors working in the community, the primary duty of a doctor working in a secure setting is to their patient.

    Being involved in disciplinary or administrative issues within a secure setting would directly contravene that primary duty – and this extends to certifying someone as fit to withstand solitary confinement.

    Various international standards clearly state that doctors should not be involved in “fitting” someone for solitary confinement.

    The relevant legislation in the UK does not require doctors to certify individuals as “fit” for solitary confinement and doctors should avoid being drawn into informal certification processes.

    Legislation generally requires a healthcare professional to be informed that an individual is being placed in solitary confinement, either before, or immediately after it has happened. The role of the healthcare professional in these circumstances is to provide a healthcare assessment as part of standard clinical care in the detention setting.

    Assessing the patient’s health and wellbeing should be distinguished from “fitting” someone for solitary confinement, as the decision to place someone in solitary confinement has already been made.

     

  • Should doctors object to the use of solitary confinement on certain individuals?

    Although doctors should not be involved in certifying someone as “fit” for solitary confinement, they may have a protective role to play in raising concerns about individuals who may be particularly vulnerable to harm.

    Most of the relevant UK legislation contains provisions to that effect.

    The idea behind this principle is that there are some individuals for whom solitary confinement will be particularly harmful.

    The best way to prevent harm to children and young people inflicted by the use of solitary confinement is to cease the use of solitary confinement, and we have been actively calling for such a policy change.

    We believe, however, that as long as it continues to be used, doctors have an important role to play in protecting the health and wellbeing of children and young people by raising concerns which should, if the doctor’s advice is heeded, ensure that harm is kept to a minimum.

     

  • Do young people and children lose their rights to healthcare?

    Children and young people in solitary confinement do not lose their rights to healthcare.

    They should be visited regularly by a healthcare professional for the duration for which they are confined. This is typically done on a daily basis. Children and young people in solitary confinement should also be able to request medical attention and to receive clinically appropriate treatment and care.

    Children and young people in solitary confinement also retain the same rights to confidential medical examinations and confidentiality of their medical files.

    Medical examinations should be carried out in a manner which respects the patient’s right to privacy and allows for confidentiality to be maintained.
    The need to preserve the patient’s rights to privacy and dignity must, however, be balanced against the risk of danger to the doctor and other members of the healthcare team.

    The aim should be for doctors to see the young person either alone or with another member of healthcare staff.

    If deemed necessary, a member of prison staff may be within discreet proximity, but out of immediate earshot. Doctors should be mindful of considerations of both safety and confidentiality, and should discuss arrangements with management if they feel that either priority is not being met.

    There may also be circumstances where doctors may be privy to confidential health information which they may need to share in order to protect detained children and young people – for example, where a child or young person confides in the doctor that they wish to harm themselves.

    Doctors need to share this information with the relevant staff members so that appropriate safeguarding arrangements can be made. Doctors should observe the general principles relating to the disclosure of information, by ensuring that only relevant health information is shared, and on a strict “need to know” basis.

     

  • Should doctors raise concerns?

    At all times, the doctor’s role should be focused on protecting and promoting health and wellbeing, and taking prompt action to prevent that from being threatened or compromised.

    If, during the duration of the solitary confinement, doctors become concerned about the health and wellbeing of the child or young person, or identify a deterioration in their health, they should report their concerns to those responsible for reviewing the solitary confinement decision.This should prompt consideration of whether solitary confinement should be maintained.

    Respect for confidentiality should never be seen as an insuperable barrier to raising concerns, but wherever possible, the patient’s consent should be sought before information is reported to the relevant person.

    Doctors also have a more general duty to raise concerns about conditions which put patient safety at risk, or about practices which are abusive or negligent.

    All organisations should have clear mechanisms in place for reporting concerns, and in the first instance, doctors should speak to the governor in charge of the establishment. Where this is not practicable, doctors may need to contact the relevant area manager, or a senior colleague within their Trust.

    In the event that those concerns are not addressed, doctors may wish to consider going beyond reporting their concerns to a wider disclosure.

    The key question for doctors is whether their responsibility to protect and promote the health of patients can best be discharged by pursuing their concerns. These decisions can be very difficult for doctors and are often best taken through discussion with colleagues or relevant medical defence bodies.

     

    Need more help?

    If you are thinking about raising a concern read our guidance on raising concerns

    BMA members can contact our employment advisors for advice on these issues by phoning 0300 123 1233 or by email

     

  • What if there is disagreement between doctors and other staff?

    We believe that where a doctor is of the view that a child or young person should not be subject to isolation, and makes a recommendation to governors to that effect, that recommendation must be respected and acted upon.

    If, after discussion, agreement still cannot be reached between healthcare staff and other staff as to the appropriateness of solitary confinement, doctors should express their concerns about the health and wellbeing of an individual in the strongest possible terms, and press for alternative arrangements to be made.

    In the event that their concerns are not adequately addressed, doctors may wish to explore other options for voicing their concerns, as outlined in the section above.

     

  • Should solitary confinement be used with children at risk of suicide or self-harm?

    We are increasingly concerned by reports of solitary confinement being used to manage children and young people at risk of self-harm or suicide, or experiencing other mental health crises. The environment of the segregation unit is a far from therapeutic environment for individuals experiencing a deterioration in their mental health.

    We believe that children and young people at risk of self-harm or suicide should not be isolated in segregation units other than in exceptional circumstances, for the shortest possible time, where psychiatric or psychological assessment indicates that there is no other way of managing the risk.

    Doctors have a crucial role to play in raising concerns with management and pressing for more appropriate arrangements to be made.

    Where it is simply unavoidable, doctors should ensure they maintain regular contact and interaction with detainees in order to mitigate the harmful effects of segregation as far as possible.