A follow-on study by The Disabilities Trust, examined the prevalence of brain injury within HMP/YOI Drake hall and found that of the 173 women they screened using the Brain Injury Screening Index, 64% reported a history indicative of a brain injury and of those, 96% reported a history indicative of a traumatic brain injury.

It is widely acknowledged that traumatic brain injury (TBI) is over-represented in prison populations, with the likelihood of: increased risk of violence, earlier age of first incarceration, a greater number of convictions, reconviction, mental health problems and a greater number of attempts at suicide.

The needs of somebody in prison with TBI are likely to be complex, and the lack of understanding and identification of a brain injury results in a higher risk of custody and reoffending.

In the first study of its kind, carried out from 2016 to 2018, and funded by Barrow Cadbury Trust and The Pilgrim Trust, The Disabilities Trust introduced a Brain Injury Linkworker Service in HMP/YOI Drake Hall to provide specialist support to women with a history of acquired and traumatic brain injury.  The linkworkers’ role is to develop a sustainable pathway of support for rehabilitation and help prisoners to manage the transition between custody and the community.

From the women supported through the service there were 196 reports of severe blows to the head and distressingly 62% reported they had sustained their brain injury through domestic violence. Nearly half (47%) of the women seen had been in an adult prison five or more times and 33% sustained their first injury prior to their first offence. The trauma in the lives of the women with TBI is evident in the accounts provided by interview participants in the report. Some of the accounts and case studies presented in the independent evaluation written by Royal Holloway, University London are distressing to read.

It was established that a female Linkworker was sensitive to the gender-specific needs of the service users. The women who were seen by the Linkworker experienced improved mood and self-esteem, and enhanced confidence and positivity; key factors that have been previously identified as being essential for a woman to engage in rehabilitative programmes.

The Linkworker service also offered practical guidance for staff working with women with a brain injury, and alleviated pressure from other service provision (e.g. mental health).  The report concluded that a Brain Injury Linkworker service provides a strong framework which will benefit offenders and prisons to identify and manage brain injury.

As a result of these findings The Disabilities Trust calls for:

• The inclusion of brain injury screening as a routine part of the induction health assessment on entry to prison or probation services
• All prison and probation staff to receive basic brain injury awareness training
• The provision of brain injury support; similar to the Brain Injury Linkworker (BLI), in prisons and probation settings
• Assurance that brain injury support would be aligned with gender-informed practice
• Further research to be conducted to examine the potential effect of brain injury on re-offending behaviour, how effective neurorehabilitation can contribute towards the reduction of recidivism and the role of early intervention approaches.

Read the report ‘Making the link: Female offenders and brain injury’

Traumatic brain injury (TBI) is a common and serious health issue. It affects millions of people and carries an economic and social cost of £15 billion a year nationally. People who have sustained a traumatic brain injury have a greater likelihood of mental ill health and of offending, as well as suffering from many other life difficulties.

Barrow Cadbury Trust and Centre for Mental Health recently organised a roundtable for experts from the West Midlands, hosted by the University of Birmingham, to discuss the implications of recent research about TBI and how support might be improved in the West Midlands region.

Addressing TBI in an effective (and efficient) way requires collective action across public services. No agency or sector can deal with it alone. We need a comprehensive approach that includes prevention, early identification and effective support from early childhood and throughout life.

West Midlands Devolution

The West Midlands devolution deal presents a unique opportunity to take a ‘whole place’ approach to TBI. The Combined Authority has already prioritised mental health and youth justice as cross-sector issues it aims to address across the region. Developing an effective response to TBI would contribute to both and to the overall wellbeing of the population.

Preventing head injuries is challenging but action to reduce risk would include measures to tackle domestic violence (the cumulative impact of physical abuse has been noted as a significant problem for women in prison), to promote positive parenting and to tackle bullying in schools. These also have a major impact on emotional wellbeing and future life chances. Improved support for children with ADHD and autism spectrum disorders can also reduce the heightened risk of TBI in these groups of young people. All of these actions should also reduce health inequalities by addressing the greater risks among people in the most deprived and marginalised communities in the West Midlands.

For those who do sustain head injuries, and particularly those who have experienced multiple traumas, identification is vital to ensure that effective support is offered and adjustments are made to reflect their vulnerability. Schools, hospitals, police stations and prisons can all ask simple questions to screen for head injuries. This can help them to ensure they offer support where it is needed, for example to manage a child’s behaviour in school and avoid excluding a young person whose behaviour results from a head injury where some additional support might be of benefit.

TBI and the Criminal Justice System

It is estimated that up to 60% of prisoners have sustained head injuries. It is therefore vital that the whole of the criminal justice system works with an awareness of TBI and an ability to respond effectively. Liaison and diversion teams, for example, can screen for TBI alongside other vulnerabilities. Prisons can offer all of their staff (including not just prison officers but education and other workers) training about TBI as part of becoming an enabling environment. Specialist linkworkers in prisons have also been found to provide effective support to individuals with TBI. And for people leaving prison, robust support is essential to help them to adjust to life outside and cope with the demands and difficulties they will face.

There are a number of initiatives already in place to build upon: HMP Drake Hall provides all staff with training in working with trauma and supports women prisoners who have experienced abuse and violence. The Geese Theatre Company provides ‘safe spaces’ for prisoners to explore their emotional wellbeing and what would help them to get back in control of their lives. And there are specialist services for offenders in the community, including for women, that offer peer support and help with health issues,  that could provide more bespoke support for those with head injuries.

The significance of TBI is only beginning to be understood. But it is now clear that joint action that brings together local authorities, NHS organisations, schools, the criminal justice system and voluntary and community bodies (among others) will be essential to develop an effective response. From public health teams including TBI in local needs assessments and Health and Wellbeing Strategies to schools providing extra support to children who have sustained head injuries, we can bring about a bigger focus on prevention and early help. And by working across the justice system, we can enable some of the most vulnerable and prolific offenders to get their lives back on track.