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This chapter is an introduction to ethical issues in the treatment provision within secure settings. Most of these ethical issues are not unique to secure hospitals. This chapter covers both generic ethical issues and those more relevant to forensic psychiatry, which arise from the interface between health and the criminal justice system.

Background Despite improved mental health services in prisons in England and Wales, there are often delays in transferring acutely mentally ill prisoners to hospital, particularly in the London area. Aim To establish whether clinical pathway interventions can reduce such transfer delays. Methods Two clinical pathway interventions – one based in a medium secure forensic hospital and the other in a remand prison (pre-trial/sentence) – were independently introduced to manage referrals of prisoners with acute mental illness in London, UK. Time taken to transfer to hospital was measured for each and compared with the best available estimates for time to transfer prior to the new pathways. Results Both interventions produced significant reductions in prison to hospital transfer times. Conclusions/implications for practise The nature of the projects precluded ideal research design, but despite small sample sizes, provision of modestly funded small but dedicated elements of service to target the specified problem of transfer to hospital delays showed a significant advantage for such provision, whether hospital or prison based, psychiatrist or nurse led. Further research is now required to examine the whole pathway. More secure psychiatric beds may be required, at least in the short term, to support diversion policies and enable compliance with national policy directive, and to establish whether redesigned pathways can enhance treatment and behavioural outcomes for acutely mentally ill prisoners on a larger scale. Copyright © 2013 John Wiley & Sons, Ltd.

Previous studies have demonstrated high rates of psychiatric morbidity in the female prison population and difficulty in transferring women to psychiatric hospital. This study examines whether female prisoners found by consultant forensic psychiatrists to need hospital are admitted and explores the factors affecting this. All women referred to a specialist prison forensic mental health in‐reach service during 2003 were identified and written documentation from assessing consultant forensic psychiatrists was obtained. This was used to identify demographic, offence, clinical and outcome data. Missing data were sought from the prison database, and individual clinicians were interviewed to clarify clinical records. 119 women were referred for assessment. Of these, 50% of those with personality disorder were rejected compared with only 38% of those with a psychotic illness. A sizeable minority of those identified by specialist forensic mental health in‐reach services as needing treatment in hospital were not transferred. There appears to be a particular problem for those with personality disorders. Long delays in transfer to hospital remain a problem for prison mental health services.

Aims and MethodTo investigate whether children are in contact with their forensic in-patient parents and whether they are offered support regarding their parent's mental health and offending issues. A questionnaire was completed on in-patients in two medium secure units.ResultsOnly 69 of the in-patients surveyed had children aged 18 or under, but only 25 had contact with their children. Support was offered in 14 cases and accepted in 10. Many patients had lost contact with their children.Clinical ImplicationsChildren of forensic in-patients appear to be a neglected group, with limited attempts made to support them. In the absence of specific difficulties of their own, the onus may be on forensic mental health services to initiate contact.

Proposals to reform fitness to plead legislation have been published by the Law Commission in England and Wales; they include a new test of decision making capacity and a new psychiatric test that has yet to be fully developed. Although proposals have met with some support, there have also been detractors. The history of fitness to plead is reviewed and current case law (including the 1836 Pritchard criteria) is examined. Although existing arrangements have been criticised, this may be attributable to inconsistent practical application, rather than inherent conceptual flaws. The Pritchard test has largely stood the test of time and has emerged relatively unscathed. Fitness to plead is not a medical construct, but rather a legal entity and any new test would be likely to introduce its own difficulties. A capacity based assessment could enhance debate and disagreement and increase court time in many cases, presenting new resource implications with questionable benefit. As the existing Pritchard criteria, amended by case law, already include a five limb test that closely resembles a capacity assessment (ability to plead to the indictment, to understand the course of the proceedings, to instruct a lawyer, to challenge a juror and to understand the evidence) and given the difficulties in introducing a functional test format in other jurisdictions, the Law Commission's proposals should now be set aside, perhaps for another day: reconsideration may be possible some decades hence, pending enhanced scientific developments within psychiatry and better understanding of the mind.

Despite improved mental health services in prisons in England and Wales, there are often delays in transferring acutely mentally ill prisoners to hospital, particularly in the London area.To establish whether clinical pathway interventions can reduce such transfer delays.Two clinical pathway interventions - one based in a medium secure forensic hospital and the other in a remand prison (pre-trial/sentence) - were independently introduced to manage referrals of prisoners with acute mental illness in London, UK. Time taken to transfer to hospital was measured for each and compared with the best available estimates for time to transfer prior to the new pathways.Both interventions produced significant reductions in prison to hospital transfer times.The nature of the projects precluded ideal research design, but despite small sample sizes, provision of modestly funded small but dedicated elements of service to target the specified problem of transfer to hospital delays showed a significant advantage for such provision, whether hospital or prison based, psychiatrist or nurse led. Further research is now required to examine the whole pathway. More secure psychiatric beds may be required, at least in the short term, to support diversion policies and enable compliance with national policy directive, and to establish whether redesigned pathways can enhance treatment and behavioural outcomes for acutely mentally ill prisoners on a larger scale.

In their paper, Kosky & Hoyle[1][1] use a postal questionnaire to consider the provision of secondary mental healthcare in prisons. They conclude that ‘there is generally no correlation between input and prison capacity, although there was some evidence of correlation in the high secure... estate

Wilson et al [1][1] highlight the delays in transferring prisoners to hospital, including a suggestion that a ‘postcode lottery’ operates. Although we agree with much of the article, we would contest the statement that ‘Given the extensive development of mental health in-reach services, and