Case Study: Recommendations The NPM notes the efforts to provide mental health care to inmates held at Prison M. However, the establishment was accommodating a number of women with severe mental disorders who could not be provided with adequate care in a prison. By way of illustration, according to the information provided to the NPM, between November 2020 and April 2021, there was a 32% increase in the number of women entering the establishment with mental health issues, compared to the previous six months; as community services reduced their activity during the pandemic, access to care in the community became more difficult and many women entered prison in a state of mental decompensation. In the 12 months to April 2021, 52 women had to be transferred to a mental health facility. However, as identified also in the establishments for male prisoners, there had been considerable delays (up to 47 days) in the transfer of these women from Prison M to a mental health facility. As a consequence, of the 14 patients accommodated in the establishment’s inpatient unit at the time of the visit, 13 had been placed there on mental health grounds and the unit was effectively acting as a mental health facility. However, no structured therapeutic activities were offered to the women patients. The situation of four women accommodated in the in-patient unit in respect of whom a referral to a psychiatric facility had been requested was of particular concern to the NPM. It should also be noted that all four women refused to take medication. The first woman was referred by a prison psychiatrist for hospital treatment on 5 May 2021. She was assessed by a receiving psychiatrist from a clinic on 18 May and was regarded as suitable for admission. At the time of the visit, a bed place for admission was being sought. When interviewed by the NPM’s medical expert on 9 June 2021, she was in a psychotic state. The second woman was recalled to prison on 1 June 2021, just a few days after she had been released from prison. On reception to the prison, she was found to be naked in the prison van; and she had urinated inside her cubicle within the van. According to her medical records, she had been diagnosed with a learning disability, bipolar disorder, borderline personality disorder and alcohol dependency. She was referred to a psychiatric intensive care unit (PICU) by a prison psychiatrist; at the time of the visit, she was waiting for a second assessment by a PICU psychiatrist. When interviewed by the NPM’s medical expert, she was acutely mentally ill. The procedure for the transfer of a prisoner to a psychiatric hospital under the Mental Health Act requires a referral by a psychiatrist, an assessment by a receiving psychiatrist to determine whether the criteria for detention are met (i.e. that the mental disorder from which that person is suffering is of a nature or degree which makes it appropriate for him or her to be detained in a hospital for medical treatment); these two medical recommendations are then submitted to the Prisons and Probation Service to issue a warrant. The transfer then depends on the availability of a bed. There is no possibility to administer medication involuntarily in prison. The third woman was being seen by community mental health professionals; she displayed delusions and little insight and affirmed to have been previously sexually abused. Although she was contacted by the court diversion team, she refused to engage with them and was remanded in custody. When admitted to prison on 26 May 2021, she was in a psychotic 34 NPM Toolkit for Asia Pacific NPM-NHRIs