A growing crisis in custody

The review found that unacceptable delays in transferring acutely mentally unwell prisoners to secure hospitals was causing suffering and harm, not only to desperately ill men and women, but to their peers, nurses and prison staff. In the cases we examined, fewer than 15% of patients had been transferred within the required 28 days.

Two years on, the situation has not improved, and in fact seems to be getting worse. Kellie Reeve, lead inspector for court custody facilities and Shaun Thomson, health and social care inspector and mental health nurse, share their concerns.

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Shaun: Lately I’ve been thinking a lot about the quiet crises that unfold out of sight – behind the heavy doors of prisons, in the corners most people never see. One of the issues that sits heavily with me is the long delay mentally unwell prisoners face before they’re moved to hospital for treatment. It’s one of those problems everyone seems to agree is unacceptable, yet somehow it keeps happening, and it’s getting worse.

Kellie: The consequences are profound. The longer a mental health episode goes untreated the increased likelihood of cognitive damage, impaired functioning and long-term harm. But the risks are not only to the detainees. They also add pressure on already-stretched court custody and prison staff, and a system buckling under responsibilities it was never designed to carry.

Shaun: There’s something heartbreaking about the way people seem to quietly disappear into the delays. If someone in the community were experiencing psychosis or self‑harming to the point of serious injury, they would almost certainly end up in A&E and receive urgent psychiatric care. But in prison, urgency competes with security, staffing shortages, high caseloads, and the constant crisis management that defines so much of custodial life.

Kellie: The problem begins early in the criminal justice pipeline. When we inspected court custody facilities across London and the Lincolnshire, Leicestershire & Rutland and Northamptonshire regions in 2025, it was clear that there were systemic issues that custody staff could do little to solve.

A shortage of beds in mental health hospitals and a lack of community-based alternatives to imprisonment meant detainees in crisis were held for prolonged periods while awaiting assessment or were sent to prison for what was frequently described as ‘for their own safety’ – a practice we’ve repeatedly deemed inappropriate, because prison isn’t the right place for these vulnerable people.

Our inspections continue to reveal a concerning number of mentally unwell people being sent to prison rather than hospital to receive the medical treatment they so desperately need. For example, in the 12 months before the Lincolnshire, Leicestershire & Rutland and Northamptonshire inspection, at least seven acutely mentally unwell detainees were sent to Lincoln prison alone. We were told that there was a lack of appropriate facilities and that approved mental health professionals often refused to attend court to complete Mental Health Act (MHA) assessments, leaving no viable pathway to divert people from prison.

There were similar problems at London magistrates’ courts. Detainees were brought back to court from prison on numerous occasions in the hope that an assessment would be completed, only to find it wasn’t. This meant some severely mentally ill people spent days locked up in tiny court cells with nothing to do, before returning to prison again, still, if not more unwell.

Shaun: I’ve met prisoners in the grip of florid psychosis, terrified of things only they can see, or so withdrawn they barely speak. Prisoners mutilating themselves in response to voices only they can hear. Prisons are not hospitals, and they’re certainly not equipped to serve as holding bays for people in crisis. The prison staff do their best, but they are not mental health clinicians, and they’re trying to manage risk, behaviour, safety, and human distress all at once. It’s a lot to ask of anyone. For the prisoner, each day waiting for a hospital bed can be a day of escalating voices, deepening paranoia, or worsening depression. For staff, it can be a constant balancing act of compassion and crisis management.

Kellie: We consistently see court custody staff and prison officers demonstrating care and compassion for prisoners and detainees, but many describe frustration and distress at being unable to secure the help these men and women clearly need. They are not trained mental health professionals, yet they are often the ones managing individuals in acute crisis, which can be extremely traumatic.

At Birmingham prison, we found a significant rise in the number of seriously mentally ill men. Detainees showing clear signs of psychosis were no longer being assessed under the MHA before going to court and between May and September 2025, 12 were remanded into prison with no assessment of what health care they required.

Many of these men could not be housed in the health care unit because it was full, leaving them on ordinary wings, supported not by mental health professionals, but by prison officers with no clinical training. Patients who were unwilling or unable to comply with treatment simply went without it, leading to further suffering. The approach was not only unsafe, but in some cases potentially dangerous and degrading.

Shaun: If someone in custody reaches the point where a psychiatrist decides they’re too unwell to stay in prison safely, the system is supposed to act quickly. In theory, transfer to a secure hospital should happen within a tight, humane timeframe. In practice, the wait can stretch into weeks or even months.

When we inspected Hewell in September 2025, we found that 27 patients had been transferred to a secure mental health hospital under the MHA in the previous 12 months. Despite escalation and weekly teleconferences with commissioners and bed managers, around half waited over 28 days for transfer. The longest wait was 247 days. Four patients were waiting for transfer during the inspection and two were in segregation, which was very concerning.

At Leeds, in October 2025, of the 18 transfers to hospital under the MHA in the last 12 months, only two were transferred within 28 days and the longest took 252 days. Leaders had put escalation procedures in place but there were no available beds. At the time of the inspection, a further five acutely disturbed patients were waiting for transfer.

The reasons for the delays are not hard to trace, and that almost makes it worse. A shortage of secure hospital beds. Bottlenecks in assessment pathways. Stretched NHS capacity. Paperwork and processes that were designed for systems without today’s pressures. No one part of the machine is malicious – just overwhelmed.

The scale of the problem is enormous. We published 39 prison inspection reports in 2025–26; in 33 of the prisons, MHA transfers occurred in the year before inspection, but only one managed to complete these transfers within 28 days. That’s hundreds of prisoners with acute mental illness left suffering unnecessarily in their cells.

Prisons cannot legally provide treatment under the MHA, meaning that every day of delay is a day when someone isn’t getting the care the law says they must receive. It’s a system stretched to breaking point – one so strained that courts sometimes send severely unwell people to prison instead of hospital, not because it’s appropriate, but because there simply are not enough community resources.

Kellie: Prisons cannot and should not be expected to operate as mental health wards.

Shaun: There are glimmers of hope. The Mental Health Act 2025, which overhauls the 1983 Act, will introduce a statutory 28-day transfer limit to reduce unnecessary delays and prevent courts from using prisons as a ‘place of safety’ for people in mental health crisis. But the transfer limit is only expected to come into force after 18–24 months, meaning tangible change is still too far away for many acutely unwell prisoners and the prison staff caring for them.

Kellie: Improvement is desperately needed. Without urgent reform the cycle of inappropriate custody, harm, and systemic strain will continue. Until that happens, HMI Prisons will continue to shine a light on the problem and demand better treatment and conditions for these particularly vulnerable prisoners.