No one would be surprised to hear that standover tactics, bullying and violence are rife in prison. But you may be surprised to learn that prison nurses in New Zealand also engage in this kind of behaviour.  In 2006, management at Corrections were so concerned about bullying by prison nurses, they asked the Health & Disability Commission to investigate.

The HDC dispatched two employees, Dr Elizabeth Finn and Mr David Webber to conduct a series of workshops in prison health centres. The first was held at the Waikeria prison in 2006 and workshops were subsequently held in another 12 prisons.

In 2008, a damning summary of the HDC’s findings was released in a report titled “Team development workshops for prisons nursing services delivered by Dr Elizabeth Finn and Mr David Webber“. In September 2009, a copy of the report was sent to the Ombudsman by HDC chief legal advisor, Nicola Sladden, describing a “culture of horizontal violence and bullying” within prison health centres. It identified the following problems:

Lack of leadership

• “Not all nursing teams had a team leader, and not all of those that had a team leader experienced team leadership… Many teams identified a lack of cohesion in coordination with the team; this appears to occur in the presence of a team leader as well is in its absence.” 

• “Workshop discussions often identified situations where inadequacies in team operation actually or potentially compromise the care of patients and/or safety of members of the nursing team… ”  

• “There is great variation throughout the country (in team morale/culture). In some teams it was excellent and the team obviously was open, respectful and vibrant. In other teams this was identified as being very poor, to the extent that some nurses felt disinclined to come to work. Team culture was characterised by negative attitudes and interactions among nurses, (including) in-fighting, unkindness, backstabbing, and actions intended to discredit colleagues.”  

• “Some nurses experience treatment from custodial officers which shows no respect for them personally or for their role in delivering healthcare. Some nurses speak of having to ‘serve an apprenticeship’ of up to two years before custodial officers will accept them – speak to or respond to them. Some officers may interfere in discussions between a nurse and a patient, possibly ‘winding up’ the patient and making delivery of care more difficult.”

Discouraged medication policy

Another failing identified by Finn and Webber concerned the prescribing of medication by prison doctors. The authors wrote:

“It appears that some doctors are not sufficiently aware of the context of the prison environment and the particular challenges it presents. For example, some medications are inappropriate in this environment because of their potential for use as ‘currency’. Lack of national consistency with respect to provision of medications to patients who are prisoners may lead to stand-over tactics and abuse directed towards doctors in the first instance, and also towards nurses. A robust induction programme for doctors would be helpful.”

From time to time, prisoners have to be taken to hospital with serious injuries or medical problems. Finn and Webber even reprimand doctors in hospital Emergency Departments – apparently for not doing what they are told by prison nurses. The report says:

“(Doctors in) EDs may not be co-operating with advice from nurses that certain medications are not allowable in prisons, and are still prescribing these (codeine, morphine).”

In cases of severe pain, opiates such as codeine and morphine are likely to be the medications of choice. But the HDC seems to believe that, even in medical emergencies, prisoners should not have their pain relieved. Apparently they should continue to suffer – even when the pain is so bad they need to be taken to hospital.

Unfortunately, this ‘discouraged medication policy’ extends well beyond opiate pain relief. All medications including antidepressants and antipsychotic drugs are taken away from prisoners – usually on their first day in prison.  Although this practice varies from one prison to another, often such medications are never reinstated.

Breach of  human rights and medical ethics

Denying patients clinically appropriate medication, especially when they are in severe pain or have mental health disorders, is inhumane and a breach of human rights. It contributes to depression and even to suicide. The reality is that the systematic denial of opiates and other clinically appropriate medication is a form of pharmacological or ‘clean’ torture; it causes serious harm and distress to the prisoner without leaving any visible evidence.

The policy also encourages prison doctors to breach their medical ethics. The New Zealand Code requires physicians to “Consider the health and well-being of the patient to be your first priority” and to “render medical service to that person without discrimination.”  When doctors are coerced into making prison policy their first priority, and discriminate against the patient because he or she is in prison, they risk being struck off for breaching their ethics.

What’s extraordinary is that the Health and Disability Commission seems to condone this practice. For a Government agency with responsibility for promoting safe medical practices, this is truly disturbing. It suggests the HDC is complicit in Corrections strategy to breach the human rights of prisoners and raises serious questions about the integrity of investigations into complaints by prisoners who need these medications.

The Commissioner’s response

In July this year, I wrote to the HDC and asked if they still endorse this ‘discouraged medication policy’. Mr Anthony Hill, the Commissioner, replied:

“It is not HDC’s practice to endorse the policies or procedures of health care providers. This is because I must consider complaints to HDC fairly, with an open mind and free from bias. This may be called into question if I have previously endorsed a policy or procedure that is the subject of a complaint to HDC.”

That’s the whole point. The Finn Webber report is quite clearly an endorsement of Corrections discouraged medication policy and my letter therefore questions the integrity of all HDC investigations into prisoner healthcare in the last five years. Since Mr Hill refused to acknowledge the bias in the HDC’s position, I have now written to the Ombudsman suggesting that if the HDC does not endorse this particular policy, then the Ombudsman should encourage the Commissioner to write to Corrections and tell them so. Otherwise, the Finn Webber report gives the Department every reason to continue medication off prisoners – thereby leaving them in pain and distress – and believing the HDC endorses this unethical practice.

I also suggested to the Ombudsman that he/she should persuade the Corrections Department to change this practice and remove it from their Medicines Policy. This is because New Zealand is party to the Convention against Torture and Cruel, Inhuman or Degrading Treatment or Punishment  which requires Governments to take effective measures to prevent the torture and ill treatment of people who are detained by the State.  And since 2007, when New Zealand signed the Optional Protocol to the Convention against Torture (OPCAT), the Ombudsman became one of the monitoring bodies with responsibility to ensure that New Zealand meets its obligations under the Convention. If he does not intervene, then by failing to act, the Ombudsman is also condoning and endorsing the torture and ill treatment of New Zealand prisoners.

On Tuesday, 1st October 2013, Geoff Robinson (photo) interviewed  Roger Brooking on Morning Report about the Corrections Departments Medicine Policy. It runs for 4.30 minutes. This is the full transcript of the interview:

Geoff Robinson: Some doctors are calling for a major review of the way prisoners’ health is managed.  Dr Wayne Cunningham, a former Otago prison doctor says the emphasis on security over health when he worked at the prison meant it didn’t work well.  And he says it was a miracle no one died on his watch.  Last week, Radio New Zealand revealed that the police are investigating accusations that a prisoner received substandard care at the Otago prison before he died in February 2011 and they’re reviewing another patient’s suicide four months earlier.  Those investigations are underway after a complaint from a Wellington drug and alcohol counsellor, Roger Brooking, and he joins us now.

So this suggestion from Dr Wayne Cunningham that there should that there should be a review of the whole health needs of prisoners and how they dealt with, would you agree with that?

Roger Brooking: I absolutely would.  The Corrections Department has a number of policies and practices which make it very hard for doctors and nurses in the prison system to provide what I would call proper or equivalent health care (to that which is available in the community).  One of the policies that the Department has is the Medicines Policy.  It has a particular section, 6.1, which I refer to as the “discouraged medication policy”.  Basically what that says is that prison doctors are “actively discouraged” from prescribing benzodiazepines, opiate painkillers, and any other medication which may be tradable or have currency in the prison environment.

Geoff Robinson: these are medications which are normally provided to patients by the health service throughout the country but doctors in prison are actively discouraged from prescribing them?

Roger Brooking: That’s right.  And this has significant impacts on the prisoners.  There are violent incidents in prison;  prisoners like anyone else get sick; occasionally they have to go to emergency departments – the policy even extends to the point that doctors in hospital emergency departments are discouraged from prescribing opiates to a patient, a prisoner, who may have broken his leg or been stabbed or whatever it is.  To me, I regard this as a kind of enhanced pharmacological torture.

Geoff Robinson: Is it a question then of whether the prisoner or the patient has the drugs in his or her possession and is able to take them as appropriate and may possibly try and trade them to some other prisoner – or is it something that the prison authorities could hand out as necessary?

Roger Brooking: Well, that’s exactly how they do it.  They don’t give the prisoner a handful of pills or a bottle or a little box like you would get in the community; in the prison environment, especially for medications like opiates, those are dispensed in my understanding on a daily basis. The prisoner has to go to the prison health centre and the nurse would give him the pill and he has to swallow it in front of the nurse. And so I don’t see that there’s too much of a problem there.

Geoff Robinson: And so you believe therefore that prison doctors should not be actively discouraged from prescribing them because there’s enough safeguards in the system to prevent them being traded?

Roger Brooking: Yes.  And I would also add that this policy encourages prison doctors to actually breach their medical ethics.  Because prison doctors, like any other doctor, his first priority is to provide a duty of care to the patient.  Now if the doctor basically gives in to this ‘discouraged medication policy’ and doesn’t give the prisoner medication which is clinically appropriate in that particular situation, then he is breaching his medical ethics – and could be struck off.

Geoff Robinson: So the doctor is paid by the Corrections Department to provide care to the prisoner?

Roger Brooking: Yes.

Geoff Robinson: And the doctor’s first responsibility is to the patient, the prisoner, rather than the person who’s paying him?

Roger Brooking: Under his medical ethics, yes, his responsibility is to the patient.  But what appears to happen is that in the prison environment, because doctors and nurses are contracted to the Corrections Department that interferes with the patient doctor relationship.  And in many cases from my experience, many doctors find this very difficult.  I think it is a difficult situation for them because they’re caught between a rock and a hard place and it depends on the integrity of the doctor.  Some doctors will put the patient first; some doctors will put the prison policies first.

Geoff Robinson: Thank you for joining us. That’s Roger Brooking. He’s a Wellington drug and alcohol counsellor.