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Patients with autism spectrum disorder (ASD) present with specific assessment, specific difficulties, needs and therapeutic issues and therefore are a challenging group for forensic services. Given the challenge that individuals with ASD present to forensic services, the suggested increase in the number of this group within this setting and the relatively little amount of research which suggests they face a number of difficulties within the prison environment, the purpose of this paper is to identify and review all the studies which have been carried out investigating any aspect of ASD in relation to secure hospital settings.

Seven internet-based bibliographic databases were used for the present review. The review followed the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines.

A total of 12 studies were included in this review; 3 looked at the prevalence of ASD in secure psychiatric hospitals. One study evaluated the clinical utility of the AQ screening tool to assess self-reported autistic traits in secure psychiatric settings. Three explored any type of characteristics of patients with ASD detained in secure psychiatric hospitals. One study investigated the experiences or quality of life of patients with an ASD detained in secure psychiatric care. Two studies investigated awareness, knowledge and/or views regarding patients with ASD held by staff working within secure psychiatric hospitals. Lastly, three studies (one of which was also included in the prevalence category above) looked at the effectiveness of interventions or treatment of patients with ASD in secure psychiatric hospitals. Clinical recommendations and future research directions are discussed.

To the author’s knowledge, this is the first review to explore what research has been carried out looking specifically at patients with ASD in relation to secure forensic settings.

There are high levels of psychiatric morbidity amongst people in prisons. In England and Wales, prisoners who present with the most acute mental health needs can be transferred to hospital urgently under part III of the Mental Health Act 1983. This project reviewed all such transfers within one region of England, with an emphasis on differences across levels of security.

Over a six-year period (2010–2016) within one region of England, 930 psychiatric referrals were received from seven male prisons. From these referrals, 173 (18.5%) secure hospital transfers were required. Diagnostic and basic demographic information were analysed, along with hospital security categorisation (high secure, medium secure, low secure, psychiatric intensive care unit and other) and total time to transfer in days.

There were substantial delays to urgent hospital transfer across all levels of hospital security. Prisoners were transferred to the following units: medium security (n = 98, 56.9%); psychiatric intensive care units (PICUs) (n = 34, 19.7%); low secure conditions (n = 20, 11.6%); high secure conditions (n = 12, 6.9%); other (n = 9, 5.2%). Mean transfer times were as follows: high secure = 159.6 days; other = 68.8 days; medium secure = 58.6 days; low secure = 54.8 days; and psychiatric intensive care = 16.1 days.

In keeping with the wider literature in this area, transfers of prisoners to hospital were very delayed across all levels of secure psychiatric hospital care. Mean transfer times were in breach of the national 14-day timescale, although transfers to PICUs were quicker than to other units. National work, including research and service pilots, is required to understand whether and how these transfer times might be improved.

This paper extends the available literature on the topic of transferring prisoners with mental illness who require compulsory treatment. There is a small but developing literature in this area, and this paper largely confirms that delays to hospital transfer remain a serious problem in England and Wales. National work, including research and service pilots, is required to understand whether and how these transfer times might be improved. This could include different referral and transfer models as a component of service-based and pathways research or combining referral pathways across units to improve their efficacy.

A significant number of people held within the secure forensic hospital estate in this country suffer from neuropsychological deficits (e.g. Lowings, 2010; Williams et al., 2010). These deficits, many of them cognitive, have a detrimental impact on patient's abilities to benefit from psycho-educational materials thereby slowing the progress of their rehabilitation. Understanding these difficulties enables interventions to be more effectively targeted and facilitated to the patients’ cognitive strengths. It was against the backdrop of the evidence that a review was commissioned into neuropsychological activity at Rampton Hospital.

The review of the neuropsychological assessment activity was confined to the male patients residing within Mental Health Services (MHS) and the National High Secure Learning Disability Service (NHSLDS) of the hospital. With regards to the MHS, 129 patient files were examined in order to identify the volume of neuropsychological assessment previously undertaken and the make up of the neuropsychological test batteries administered with the current patient group. With regard to the NHSLDS 48 files were similarly examined. In addition, MHS psychologists were surveyed to assess their knowledge of patients within that service who to their knowledge had previously suffered an acquired brain injury (ABI) or had suffered a significant neurological illness likely to have resulted in cognitive impairment.

A scoping exercise identified that a significant amount of neuropsychological assessment was being undertaken, albeit in an unstructured way. This led to a number of patients being subjected to a significant delay before the need for neuropsychological testing and rehabilitation possibilities became apparent. There was a huge variance on when a patient was tested ranging from one month to 14 years and the size of the test battery used, with the number of tests conducted per patient ranging between one single test to 16 tests during a patients stay at the hospital.

Opportunities to more appropriately place patients based upon their abilities could be achieved if the hospital were to adopt a policy of conducting neuropsychological assessments, including cognitive functioning, for all patients upon admission to the hospital. A proportion of patients were known to have had a ABI or a significant illness likely to have resulted in cognitive impairment. This was considered to be an underrepresentation and the taking of a thorough history specifically covering ABI and specific illnesses known to have an impact on cognitive ability and behaviour was also recommended.

In light of this review, services are to take a more systematic approach to assessing neuropsychological difficulties. Consideration is being given to neuropsychological screening becoming part of the admission process.

The first NHS forensic low secure unit for adolescents, the Westwood centre, opened in 2004. This paper seeks to focus on service utilisation and initial outcomes for the young people admitted in the first 45 months compared with young people accessing a neighbouring open adolescent unit.

In order to understand service utilisation and initial outcomes, the clinical profiles of young people admitted in the first 45 months were evaluated. This included demographics, locality, admission status, length of stay, medication use, presenting problem, diagnosis, previous and discharge destination. The profiles of young people accessing the low secure unit were then compared with young people accessing a neighbouring open adolescent unit. Clinical profiles were ascertained from available healthcare records and service data. These were inspected and analysed using descriptive statistics.

Thirty (54 per cent) of the 56 Westwood young people were male, the mean age at admission was 16.3 years and mean length of stay was 202 days. Twenty‐five (44 per cent) young people had a discharge diagnosis related to psychosis, the remainder having primary problems relating to emotional and/or conduct problems. 26 (47 per cent) were discharged to another hospital setting and 20 (35 per cent) returned to their home of origin. Young people accessing the low secure unit were significantly older at admission and there was a trend for a higher proportion of females to be admitted to the open setting. In addition, the low secure unit had a greater proportion of young people with psychotic disorders and longer lengths of stay. Case examples illustrate a pilot of initial outcomes.

There were time differences in comparison of low secure and open unit and retrospective use of health care records.

Clinical profiling is useful as a basis to consider clinical outcomes, pathways, utilization of a service, service/training needs and development. Comparisons between inpatient units provide further evidence to the areas above and help dispel myths that may otherwise guide decisions, e.g. about which diagnoses or gender affecting length of stay. Most young people progress positively from the low secure service onto open or community settings. Improving future outcomes for young people include such as through diversion from custody, length of admission, reduced symptoms/risks and planned progress to suitable community placements or home.

The paper provides a clinical profile of young people accessing a low secure setting in comparison to an open unit. This has relevance to other secure and inpatient adolescent units and is important in considering pathways and outcomes.

The purpose of this paper is to explore the nature and prevalence of bullying behaviours and victimisation experiences among mentally disordered offenders within a medium secure unit (MSU).

In all, 35 adult male patients completed the Direct and Indirect Patient behaviour Checklist-Hospital Version (DIPC-H).

Indirect aggression was reported more frequently than direct aggression, although there was no statistically significant difference between the prevalence estimates. The most prevalent DIPC-H categories were the pure victim and not involved categories followed by bully/victim and pure bully. Membership of the pure bully category was predicted by being on a particular ward.

Given that the study was a preliminary investigation into the nature and prevalence of bullying behaviours in a MSU, the sample size is limited. Consequently, it is difficult to generalise the findings. It would be useful for future research to focus on differences between levels of security using larger sample sizes to enable a greater understanding of the prevalence of bullying in secure settings and associated factors.

Further evidence is provided by the current research that indirect bullying and victimisation behaviours are reported more frequently by patients. The importance of anti-bullying procedures and interventions in secure settings is emphasised and recommendations that can be applied across various forensic settings are described. Better-informed interventions can then be implemented with the aim to manage bullying behaviours in secure settings. The one “pure bully” in the current study was on a rehabilitation ward. This highlights that such behaviours occur on lesser secure wards and serves as an important reminder to ensure that staff do not become complacent.

As there is only one published study to date that has focused on bullying behaviours in a MSU, the current study will contribute to the dearth of literature in this area and assist professionals working in secure settings to better understand the nature and prevalence of bullying behaviours among mentally disordered offenders.

Abstract High secure services treat patients who may have very complex clinical needs under conditions of security. Until very recently such services were run and managed on the periphery of the structures and accountability arrangements put in place for the rest of the NHS, becoming isolated from modern thinking and evidence‐based therapeutic practice. A high percentage of patients in the high secure system were assessed as no longer requiring that level of security.Following an inquiry at Ashworth hospital which reported in 1999, steps were taken to bring these services into the mainstream of the NHS, to decentralise further the commissioning and performance management and to develop the capacity and capability to enable discharge of patients to lower levels of security. New partnerships and new relationships have resulted in an NHS Plan target of 400 patients discharged from high security.The inclusion of high security services within Health & Offender Partnerships creates a framework for managing proposed and ongoing changes. High security services are a necessary part of our mental health system and should be valued and developed. This paper outlines how quality improvements will be enabled and embedded.

The purpose of this paper is to report on the introduction of a Leavers’ Preparation Group in an Intellectual Disability (ID) Secure Service. In the context of reductions in ID inpatient beds and reductions in restrictive practices, discharge and transfers out of hospital settings are increasing. The current group was established to provide support and preparation for service users as they approach discharge/transfer from hospital. The current paper provides example outcome data and reflects on the experience and learning points in delivering such interventions in secure contexts.

The Leavers’ Preparation Group is an eight-session preparatory, recovery focussed group intervention focussing on supporting service users as they approach discharge/transfer to lower levels of security. The intervention has a multi-disciplinary approach, focussing on psychosocial aspects of current and future risk reduction.

Overwhelmingly service users reported that they experienced the group as positive and beneficial. Personal reflections of the authors are offered on service user attitudes to discharge/transfer, the contextual impact of restrictive systems and the benefits of this type of group intervention.

This paper reports on clinical practice, which involves multi-disciplinary intervention, co-production with service users and relevant stakeholders, and provides a description of the group intervention. It also offers critical reflection on tensions in this area of service provision, such as control and choice, freedom and responsibility, limitations and restrictions and power imbalances.

In 2019, the world was hit by a life threatening severe acute respiratory syndrome causing a global pandemic; Coronavirus disease (COVID-19). In the UK, a nationwide “lockdown” of public isolation and reduced social contact followed. The experience of COVID-19 and the lockdown for forensic secure mental health patients is yet to be understood. This study aims to explore this phenomenon from the patients’ perspective.

A qualitative approach was taken. Semi-structured interviews were carried out with six patients from a low secure unit in the UK, between November 2020 and March 2021.

Interpretive phenomenological analysis generated three superordinate themes from the data, providing insight into patients’ experience: “treading water”; how they managed: “learning to swim”; and what was helpful during this time: “in the same boat”.

Further consideration should be given to creating a sense of safety in wards, along with ways to continue to address the power imbalance. Interestingly, social connection may be cultivated from within the hospital setting and would benefit from further research.

To the best of the authors’ knowledge, this is the first study to explore secure patients’ experience of COVID-19 from the patients’ perspective, within a population often neglected within recovery research.

This paper aims to describe the experience of a secure learning disability service in participating in the national Shared Pathway pilot project in secure services.

Some background drivers to the project are explored as well as the experience of service users and staff who were involved in the pilot project. Recommendations on service‐wide implementation of the Shared Pathway are made.

The Shared Pathway will lead to considerable changes in practice. This will also have resource implications.

The paper shows that the Shared Pathway may be useful in ensuring evidence based outcomes are routinely used by clinicians in secure services in collaboration with patients. It may also clarify to patients what their role is in engaging in treatment that helps them in moving through secure services.

Thirty‐five patients who had received at least one year's treatment in a learning‐disability medium secure unit were followed up for a maximum of five years. A good treatment outcome was more common in those with significant learning disability. At the end of follow‐up, 21 subjects (60%) were living in the community with support. The early months after discharge were a peak period for relapse. A very low level of reconviction was found, affecting only one subject. Patients who were older on discharge were less likely to re‐offend. The two deaths that occurred during follow‐up, and the three patients who required special (high security) hospital referral, are reported in detail. The findings are contrasted with the only comparable study (Day, 1988).