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Young lives behind bars

'Young Lives Behind Bars' highlights that, although the origins of offending behaviour are complex, many of the children and young people in detention represent a failure by the individuals and agencies whose job it is to care for and support them.


The youth prison population

In 2012-2013 the average population of young people in custody in England and Wales (under 18s) was 1,544. In the 12 months to March 2013, 2,780 young offenders were placed in custody.

Many of these young people come from chaotic home lives, often characterised by violence, abuse or neglect, and are not thriving socially, emotionally or physically.  

John Chisholm

Dr John Chisholm,
chair of the BMA Medical Ethics Committee

Many of the children and young people who end up in the criminal justice system come from chaotic backgrounds, and are often victims of violence, abuse or neglect.

They are unable to thrive socially, emotionally or physically, and are among the most vulnerable individuals in our society long before they reach detention.

  • Three quarters of children and young people in custody have lived with someone other than a parent and 40 per cent had been homeless in the six months before entering custody. 

  • 24% of boys and 49% of girls, aged between 15 and 18 and in custody, have been in care. 

  • Of 300 children and young people in custody and on remand, 12% were known to have lost a parent or sibling. 

  • Approximately 60% of children in custody have ‘significant’ speech, language and learning difficulties ; 25-30% are learning disabled  and up to 50% have learning difficulties.  

  • Over a third of children in custody were diagnosed with a mental health disorder.  

Young lives behind bars

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How does this concern doctors?

Children and young people who enter the criminal justice system present with multiple and complex health and social needs prior to entering detention.

We must ensure that problems in children and young people are identified as soon as possible, and that they receive the necessary ongoing support and help they need, in order to minimise and mitigate the underlying social causes of offending.

If the child enters the criminal justice system it is essential that they receive healthcare of an equivalent standard to that in the community, in order to allow them to rehabilitate and thrive.

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  • Doctors working in the community

    Children and young people who enter the criminal justice system are an extremely disadvantaged group, who, prior to detention, present with multiple and complex health and social needs.

    Identifying problems as soon as possible in the developing child can minimise and mitigate the underlying social causes of offending and promote resilience. Medical professionals should remain vigilant in recognising risk factors and seizing opportunities for intervention.

    Early screening and identification of risk factors such as mental health problems – including post-natal depression – and substance abuse amongst parents and carers, and referral to appropriate services and support have a critical role in addressing factors linked to child wellbeing.

    Reducing childhood neglect and abuse is crucial to reducing childhood behavioural problems which might manifest themselves in offending behaviour. Health professionals must be aware of the signs of neglect or abuse and of their safeguarding responsibilities.

    Health professionals should have access to appropriate training and support to ensure they are confident in dealing with children and young people.

    Doctors attending police stations should be aware that they may be called upon to examine minors, and should be familiar with the specific issues pertaining to capacity and consent.
  • Doctors working in the secure estate

    Children and young people in secure settings are entitled to receive healthcare of an equivalent standard to that in the community, and have the same rights as patients in the community to dignity, privacy, confidentiality and consent.

    Doctors should be aware of the limits of the assessment tools used for reception health screenings, and ensure that a full and in depth health assessment is carried out.

    In secure settings, the aims of security and health can come into conflict. Doctors can be put under pressure by competing obligations to their patient and their employer.

    It is only by acknowledging that these pressures exist, and being sensitive to the human rights of children and young people, that these conflicts can be properly managed and doctors can focus on their primary duties to patients.

    Advocating for patients

    In addition to their role in providing healthcare, doctors are patient advocates.

    They have an important role to play in raising standards of healthcare and in highlighting concerns about the treatment of children and young people, and a positive obligation in working with senior management to ensure conditions are in place to enable young people to make healthy choices.

    Practitioners should consider how best to encourage involvement and interaction with healthcare services, in a manner that is appropriate to the needs and concerns of children and young people in custody.

    The doctor's role

    Doctors should make it clear that they are independent from prison officers and should not carry out custodial officer tasks or be directly involved in disciplinary proceedings.

    Doctors are in prison to act in a clinical and welfare capacity, and acting outwith this can erode trust, undermining the willingness of a young person to access healthcare and damage the doctor-patient relationship.

    Doctors should only carry out intimate body searches with the consent of the detainee. The only exception to this is where a patient lacks capacity and an intimate examination is thought to be in his or her best interests.

    Doctors should not be involved in solitary confinement procedures, other than those necessary for therapeutic reasons, or for prevention of harm, such as where a young person poses a suicide risk.  

    Joint working

    The new healthcare structures enable greater engagement with a variety of colleagues across different sectors in the community.

    Doctors should take advantage of the opportunities for joint working these new structures, in order to alleviate much of the professional isolation often reported by those working in secure settings.

    Plans for release

    To ensure effective resettlement in the community, doctors working in secure settings must ensure that a young person’s healthcare plan takes into account and plans for release from the outset.

    Children and young people leaving custody should be equipped with the necessary information, in plainly accessible form, for accessing healthcare services in the community.

    A summary record of a young person’s health, including recommendations for future treatment should be sent to the young person’s GP.

    Doctors may also wish to consider the sharing of other relevant information where appropriate. Information must be shared with the consent of the young person in question.

  • Commissioners

    In the community

    No single service or professional can address the factors underlying offending behaviour. Services and policies should be designed and operated in partnership with other relevant community agencies.

    Those involved in commissioning services must address the specific needs of adolescents, and reshape or create services and pathways which are responsive to them.

    Active steps should be taken to ensure that children and young people are fully informed of their rights and responsibilities with regard to healthcare.

    Those responsible for designing and delivering health services must have clear plans in place to engage socially excluded groups, such as young offenders and ex-offenders, and to ensure their needs and interests are met in service design.

    Healthcare providers must continue to deliver high quality and accessible drug and alcohol treatment services and sexual health clinics.

    Every effort should be made to ensure that cuts to frontline services are minimised.

    In custody

    Children and young people in secure settings are entitled to healthcare of an equivalent standard to that in the community, and this should be the guiding principle for those commissioning healthcare in the secure estate.

    Consideration should be given as to how best to encourage young people to access health services, and to ensure that it is as easy as possible for them to do so.

    Arrangements should be in place to ensure that young people can access specialist services if necessary.

    Due to the prevalence of mental illness in the young offender population, and the high rates of suicide and self harm, the development of high quality mental health services should be a key priority for those responsible for commissioning healthcare in the youth secure estate.

    Healthcare providers should have clear information sharing strategies and opportunities for joint working between community and custody services to ensure:

    • accurate assessment of the health needs of children and young people at the point of entry
    • continuity of care upon release and resettlement.

    Healthcare must interact with other relevant bodies in the community, and commissioners should develop clear information sharing strategies and joint working to ensure that resettlement is effective.

    Greater clinician involvement should be sought in the planning and transfer process to adult prisons.

  • Policy makers

    We express concern over the low age of criminal responsibility currently in place in the UK, and ultimately, concern over the suitability of imprisonment in dealing with youth offending.

    Long term, we call on the government to carry out an in-depth review of the youth secure estate and conduct further research into more welfare based alternatives.

    We call for an end to the practice of holding children and young people aged 17 and under overnight in police cells.

    We call on the Youth Justice Board and individual institutions to take steps to effect a culture change to end the casual use of restraint and force, including, but not limited to, developing clear policy with mechanisms for policing its use.

    Clear policy and monitoring procedures should be developed for the use of segregation across the youth secure estate, with particular regard to safeguards for use on those with mental health problems.

    Health and wellbeing of children and young people should be seen as concerns for all those working in the secure estate, not just healthcare professionals. To this end, all staff working in the secure estate must be adequately trained and supported in identifying and reporting health concerns.

    The government and Youth Justice Board should address the treatment and care of looked after children in the secure estate, and ensure that they receive the necessary support required to thrive.

  • Sara's story

    The journey into detention, age 10

    When Sara was 10 she was forced to leave the family home with her mother and sister because of domestic violence. Sara found the change difficult. She missed her father, at one point returning to live with him, but she had to leave when he again became violent.

    By the time she was 13 she was struggling at school, she was truanting, mixing with older men, drinking and taking drugs. Social services eventually took her into local authority care although she ran away and stayed with friends. She had also started to harm herself, sometimes quite badly.

    Her mother tried repeatedly to get Sara a referral to mental health services and she was eventually given a short voluntary placement in a psychiatric hospital to safeguard her. Sara improved and was discharged with the promise of an intensive support package. Unfortunately the support did not materialise and Sara returned to her abusive and risky behaviour.

    Following conviction for grievous bodily harm, Sara spent nine months on remand before a forensic psychiatric assessment was finally funded. The assessment concluded that due to her age, Sara’s problems were not yet clear cut enough to meet the criteria of the Mental Health Act.

    Despite the recommendation that she be placed in a therapeutic residential placement, Sara was given an extended sentence of three years in custody.

    The revolving door - in and out of detention, age 17

    Sara struggled in the secure training centre (STC). She refused to leave her cell for the first six weeks and was eventually moved to a smaller 15-bed female unit. After establishing a close relationship with the youth offending team (YOT) worker she improved, managing her anger better and she began to reflect on her future.

    Sara was released on parole at the age of 17 but was recalled following an angry outburst at one of the YOT staff. She spent a further nine months in the same small unit and again made good progress. She was released into supported accommodation and was offered 25 hours intensive support a week from the YOT.

    She was also promised the support of a child care social worker (because of her period spent in care) to help her look for independent accommodation. Again, little of the promised support materialised. In addition, Sara was unable to build on the educational progress made in custody because she was refused access to local colleges due to her history of violence.

    After six weeks back home, Sara got drunk with an older male who then assaulted her. The YOT took the view that Sara was not vulnerable but just ‘badly behaved’ and had brought the assault on herself because she had been drinking. No new offences had been committed but Sara was taken back into custody.

    Sara’s custody worker felt that, among other services, Sara needed additional child and adolescent mental health service (CAMHS) input. The secure unit had itself struggled to commission a service from CAMHS, although this changed during Sara’s second return to custody when they took on a specialist CAMHS worker for the first time.

    Beyond detention, beyond childhood, age 18

    With her 18th birthday approaching, Sara faced a number of further potential setbacks, including the departure of her trusted YOT worker from the smaller unit and a move to an adult female unit within the same prison. Just before her move, having not self-harmed for years, Sara tried to take her own life.

    She didn’t know why but said that everything had suddenly got on top of her. She was then assessed by a CAMHS psychiatrist and a mental health diagnosis was indicated for the first time.

    Sara had by this time spent two and a half years in custody, and was likely to remain there for some time.