Exploring Medication Safety in Transitions From Prison to Community: A Qualitative Study

BACKGROUND: The prison population in England and Wales exceeds 88,000, with a high turnover - 47% of sentenced admissions in 2023 served less than 12 months. Transitions from prison to the community are recognised as high-risk periods for medication-related harm, driven by complex health needs, short custodial stays, and fragmented healthcare systems. While national and international guidance exists to support safe medication management, implementation during prison-community transitions remains inconsistent, and evidence on both the drivers of unsafe medication practices and potential solutions is limited. AIM: This study explored the human, organisational, and environmental factors influencing medication safety during transitions from prison to the community, as well as potential solutions for improvement, from the perspective of staff involved in these transitions. METHODS: Qualitative semi-structured interviews were conducted with 12 staff members working in roles relevant to transitions from prison to the community, including general practitioners, pharmacists, and prison officers. Participants were recruited through professional networks and snowball sampling. Data were thematically analysed using the Systems Engineering Initiative for Patient Safety (SEIPS) framework. RESULTS: Five main factors impacting medication safety during transitions were identified: release practices, care coordination and communication issues, staffing shortages, IT system limitations, and patient-related factors. Key findings highlighted risks associated with immediate releases, discontinuity in medication regimens, insufficient staffing for discharge planning, and poor information transfer between prison and community healthcare providers. These challenges were further compounded by patient-level issues such as low health literacy, substance use, and housing instability. Staff proposed several improvements to enhance medication safety during prison-to-community transitions, including electronic prescribing for timely access to medication, improved information transfer, dedicated discharge teams to ensure medication follow-up, early discharge planning to address medication needs, and multi-disciplinary meetings to coordinate complex care. CONCLUSION: Medication safety during transitions from prison to community healthcare requires coordinated efforts to address organisational challenges, including short-notice releases and inadequate information transfer, as well as human factors such as communication barriers and staffing constraints. Improvements that clarify roles, enhance processes and technology, and foster cross-system collaboration are essential to ensuring continuity of care and medication safety. PATIENT OR PUBLIC CONTRIBUTION: Two people, one with lived experience of care transitions and one carer, contributed to study design, recruitment strategies, participant materials, and the analysis plan through quarterly input. Findings were shared with a wider group of lived experience representatives, carers, professionals, and policy makers, who informed interpretation and dissemination. While PPI members did not directly participate in coding or analysing the data, their input ensured that the study design and interpretation were informed by real-world perspectives.