Impact case study database

In the UK, roughly a million people go through courts and around four million people are affected by crime each year. Following the discovery that up to 50% of the UK prison population has some form of TBI, that young offenders have TBI at five times the rate of normal population, and that the associated behaviours produce a highly vulnerable group of people, Williams has spent several years engaging with policy makers to ensure the justice system accounts for Traumatic Brain Injury. With national (England and Wales) and global (via the UN) reach, this highly engaged body of work has: 1) placed neurodisabilities (ND) and TBI on the agenda of judicial systems; 2) led to major restructuring of judicial policies for minors; 3) led to mandatory ND screening, enhanced support, and staff training for adult prisons; and 4) implemented new sentencing guidelines to account for ND.

Placing Neurodisabilities (ND) and TBI on the agenda of judicial systems

The work of Williams and colleagues has been instrumental in placing TBI as a key focus for judicial policy makers. For example, England’s Director of Health and Justice NHS Justice, confirms:

“The research by Williams and colleagues demonstrated that there was a very high level of traumatic brain injury (TBI) in prison populations, and, that it was associated with early and repeated violence and mental health issues - particularly suicidality….As a health condition, TBI, therefore became an important focus for the judicial system.” [ 5.1].

This, she explains, has led to changes throughout the entire system, prompting the re-design of services that integrate trauma-informed perspectives into policies around crime [ 5.1].

In 2017, the NICE guidelines on Mental Health of Adults in the Criminal Justice System were updated to include provisions around TBI [ 5.2]. Williams, drawing on insights gained through his body of research, received specific acknowledgement of his provision of expert testimony to the guidance committee [ 5.2]. The new recommendations covered all occasions where individuals come into contact with the criminal justice system and highlighted the need for staff training on TBI issues, provisions for the recognition and assessment of TBI via a ‘Head Injury’ screening at custody reception, and recommendations on ensuring appropriate interventions particularly in relation to managing suicide risk [ 5.2].

Responding to evidence from Williams a review of the UN Convention on the Rights of the Child in Justice settings concluded that children with neurodisability (ND) should not only have their needs met whilst detained, but should not be made at risk of being imprisoned in the first place [ 5.3]. The new convention states:

“Children with developmental delays or neurodevelopmental disorders or disabilities... should not be in the child justice system at all, even if they have reached the minimum age of criminal responsibility.”

They recommend the 187 signatory member states of the convention support children and young people with ND to be enabled to be in society (2019) [ 5.3].

Major restructuring of judicial policies for minors

All young people (under 18) in custody (~3,000/year) in England and Wales are now assessed and treated for TBI and other neurodisabilities (ND) [ 5.4]. England’s NHS Justice, with Williams as an advisor [ 5.1], adopted a ‘Secure Stairs Model’ for Young Offender Institutions, to provide therapeutic resources for those who are classified as vulnerable, including those with ND and TBI. The model was launched by NHS England in 2018 [ 5.5] and represented a move towards integrated healthcare and rehabilitation in the prison system that creates a better environment for rehabilitation success. England’s Director of Health and Justice confirms the paradigm shift it represents, stating that the programme is being implemented across England,

“to replace traditional incarceration…to ensure that children and young people are provided with therapeutic community approaches informed by evidence base on trauma and neuro-disability” [ 5.1].

Led to mandatory ND screening, enhanced support, and staff training for adult prisons

In adult prisons, it is now mandatory to screen for TBI, provide key-workers, and train staff to identify and support brain injury issues. Exeter worked closely with the All Party Parliamentary Group on Acquired Brain Injury and their recommendations led to all prisons conducting mandatory screening for TBI, confirmed by the both the Secretary of state and the Under-secretary of state for Justice & Lord Chancellor [ 5.4]. This change impacts 83,000 (Offender Management Statistics Bulletin, England and Wales, ONS) currently sentenced prisoners and approximately 60 000 entrants into the criminal justice system each year. In addition, specialist health referrals to assess for TBI are now made when a prisoner displays symptomatic behaviour, to determine appropriate treatment pathway, where previously a personality disorder diagnosis would have been made [ 5.4].

Drawing on evidence from Williams and his team, the UK parliament’s Justice Select Committee [ 5.6] concluded the need for wholesale reform of the prison system to reduce violence and manage suicide risk in young adults. Their recommendations focused on restorative justice and trauma-informed approaches, which included accounting for TBI and the development of appropriate support systems such as specialised link workers piloted by the Exeter Team [ 5.4].

In response to the recommendations from the Justice Select Committee, the Ministers of Prisons, implemented measures to ensure, ‘[ a]ll civil, remand and sentenced people in prison will have a dedicated prison key worker’ by March 2019 [ 5.7 p.5-6] and funding for this initiative has been received by ten prisons so far [ 5.4].

In 2020 the Ministry of Justice confirmed the extent to which Acquired Brain Injury (which includes TBI) has now been integrated into the justice system [ 5.4], in part a response to recommendations set out by a report [ 5.4] authored by Williams and colleagues. The Under Secretary of State for Justice, explains,

“Individuals with ABI are within scope for NHS England’s Liaison and Diversion (L&D) services, which provide assessments and referrals to support for vulnerable people in contact with the criminal justice system. L&D services have been rolled out across police custody suites and magistrates courts in England… [and there is a] similar system in Wales” [ 5.4].

Furthermore, basic awareness training on Acquired Brain Injury (ABI) is now included in the Prison Officer Entry Level Training, “providing all new prison officers with an overview of what an ABI is, what may cause it, and what symptoms might result from it” [ 5.4].

Implemented new national and global sentencing guidelines to account for ND

Sentencing guidelines in England and Wales now recommend that judges account for developmental maturity and TBI. The Sentencing Guidelines were updated first in 2017, and again in 2020, incorporating evidence from Prof Williams, to account for “Any experiences of brain injury or traumatic life experience (including exposure to drug and alcohol abuse) and the developmental impact this may have had” [ 5.8]. The latest Sentencing Guidelines have added Acquired Brain Injury to the list of mental health disorders to consider in sentencing, confirming recognition of ABI and TBI in the criminal Justice system [ 5.8].

Furthermore, the UN office on Drugs and Crime requested Williams become an advisor to develop new guidelines for judges worldwide to account for developmental maturity and TBI. The 2018 and 2019 manuals [ 5.9] created urge judges in the UN’s 187 signatory states to consider how brain injury and trauma contribute to crime and the need to address neurological disorders and development to reduce future crimes. When reflecting on the growing awareness of TBI issues throughout the justice system, the former Chief Inspector of Prisons says the following:

“I can only say that the transformation in understanding is remarkable. For this I give most credit to Professor Williams, whose research is not only highly regarded by Ministers and officials…It is the best example I know of academic research leading to positive results in terms both of policy and practice” [ 5.10].