Australia's prison population is ageing. But should inmates spend their final days shackled to a bed?

Before Mark Boughey can see his patients, he has to pass through several security measures: locked gates, metal detectors, an eye scan.

But once he's inside the 40-bed hospital ward at Victoria's Port Phillip Prison, Dr Boughey's focus is on those preparing to die.

"As a person going there for the first time, you might find it a little bit stark, and you've just got to accept that is the space, but that's the space for many people that's become very familiar," he says.

"They've got their relationships with other prisoners and guards, and so it is their home and their environment, and so you treat it as such."

In his experience, most prisoners in palliative care would prefer to be here, inside the walls of the jail, rather than being transferred to a hospital — largely because of that familiarity.

As the Australian prison population ages, the demand for end-of-life care and treatment for chronic illness is set to increase.

Prisoners who are transferred to a hospital for palliative care can be shackled to their beds during their final days, attached with leg or hand cuffs.

It's a situation some leading experts in the field want to change.

St Vincent's Hospital Melbourne's palliative medicine chair, Jennifer Philip, is among those calling for an end to shackle use on patients in the final stages of end-of-life care.

Her research has shown there are potential physical impacts, along with emotional ones, for both the prisoner and their family.

"They will see the person that they love in that situation, perhaps their last memory is of that person with a chain on, and they will presumably carry that memory for the rest of their lives," Professor Philip says.

She says it can also cause "distress" to the clinicians, given palliative care seeks "to try to free people up from their symptoms and their other burdens".

"It seems like a small freedom to be able to give them at this time, perhaps not even a freedom — maybe just a visible show of compassion and dignity," she says.

Australia's ageing prison population

The number of Australian prisoners aged 45 and over increased by 79 per cent between 2009 and 2019, according to federal government data.

The report from the Australian Institute of Health and Welfare also found the older patients were 1.7 times more likely than the younger cohort to have chronic illness and "more likely to experience poorer health" and require medical treatment.

Over the decade, Australia's prison population grew overall, from around 29,300 in 2009 to 43,000 in 2019, but the older cohort grew at a faster rate.

As a result, the proportion of older people increased from 18 to 22 per cent of the prison population over the period.

Within the group aged over 45, the oldest cohort — those aged over 65 — increased the most, from 505 to 1225 prisoners, up 143 per cent.

The demographic change is being chalked up to Australia's population generally living longer, changes to things like mandatory sentencing, and the increased prosecution of historical offences, such as child sexual abuse.

Similar trends are being seen internationally.

Age also takes on a different meaning inside, where people are considered 'older' patients earlier — often at 50.

"Their social and lifestyle characteristics, before and during incarceration, mean prisoners experience age-related health conditions earlier than people in the community," the report noted.

Coronial inquest currently examining shackle use in Darwin case

Professor Philip says they "don't really know the full extent" of how often palliative prisoners are shackled to hospital beds, but the issue is attracting attention both in Australia and overseas.

A Northern Territory coroner is currently investigating a Darwin case where a terminally ill prisoner was chained to his hospital bed in the lead-up to his death.

Mati Tamwoy, an Indigenous prisoner, died in November last year from an aggressive form of blood cancer and was restrained for several visits to Royal Darwin Hospital, despite his condition and his protests.

At the time of his death, Tamwoy was considered a "low-security prisoner" and was on remand for stealing and aggravated assault offences, but had a long criminal record, including previously serving time for manslaughter.

Several guards have given conflicting evidence to the inquest about securing prisoners and when restraints could be removed.

One said they were "covering their ass" by using restraints as they needed to follow "standard operating procedure".

The general manager of the Darwin Correctional Centre told the coroner there were inconsistencies in procedures and "we have lost sight of the humanity aspect". 

Tamwoy eventually had a medical episode in prison, was rushed to hospital and died.

There have been similar cases reported in other states, including one investigated by a coroner in South Australia in 2018.

That inquest heard hospital staff at Adelaide's Queen Elizabeth Hospital had repeatedly asked for the restraints to be removed, claiming the shackling was interfering with the prisoner's medical treatment and palliative care.

The man was cuffed to the bed for three weeks, with the restraints removed an hour before he died.

The coronial findings said because he was a prisoner he had to be "shackled to his bed by either hand or foot or both".

"This [was] despite the fact that he was dying, had no means of escape and had been under guard for the entire duration of his admission."

However, the inquest concluded the shackling didn't contribute to his death.

Calls for change and national uniformity

Professor Philip describes the use of restraints as "the default", and a way of "maintaining security for the community" when a prisoner is admitted to a general hospital.

While processes can vary between jurisdictions, clinicians can make formal approaches to prison management to request the restraints be removed.

However, Professor Philip says some clinicians aren't aware of that, and the approval processes can take time.

"We would suggest that under those circumstances, that perhaps the onus of the decision is actually based on standards of healthcare."

Professor Philip is proposing a system be implemented where a level of frailty — known as "performance status" — is agreed upon, where the decision then falls to the clinicians.

Policies changes would have to be made at a state and territory level, but Professor Philip says "national leadership" has moved things forward in the past.

There are other options to avoid the use of restraints; St Vincent's in Melbourne has a secure correctional ward, where shackling isn't required. It is the only one in Victoria.

It is establishing another secure care unit in Brisbane for prisoners who require high-level palliative or nursing-home care — an acknowledgement of the ageing population in Australian jails.

But Professor Philip says these units are uncommon and she'd like the "same level of compassion" to be available to other palliative prisoners.

She acknowledges there is a need for community consultation and that many people, especially those who have been victims of crime, may disagree with the proposition.

"[The prisoners are still] serving their sentence, which is the punishment that society has deemed appropriate, and they're serving the last phase of their life in prison, under custody," she says.

"I think that's a mark of a mature and an inclusive society that we can care for our dying, including care for the people who are dying in prison."

A 'good news' story

There are guards present when specialists like Dr Boughey, or the prison's regular doctors and nurses, are treating patients in Port Phillip Prison.

But it is less obtrusive than in hospital settings, where guards remain near the bedside, Dr Boughey says.

When the hospital ward at Port Phillip was being redesigned about five years ago, more than 18 months was spent planning how palliative care could be provided, but the prison is set to close next year.

Dr Boughey says the set up means people can be treated without the "constraints" that exist in hospital wards that are required for patient and staff safety.

Since the Port Phillip ward opened in 2021, only three palliative patients have been required to be transferred — two because of COVID-19, and one who had finished his sentence and died in a community facility.

Dr Boughey describes it as "quite a good news story" as it allows people the sort of freedoms taken for granted on a usual hospital ward.

The guards were included in palliative care training for the new program.

Dr Boughey says there are several issues that need to be considered around the use of shackling of prisoners, including their safety and that of staff.

"We don't [always] know the full story. We don't know why. Maybe safety is an issue," he says.

However he said doctors usually advocated for the shackles to be removed if prisoners were unable to leave their beds, using the processes that exist.

Dr Boughey works across several sites as a palliative specialist, and while he can see benefits in a clinician-lead process for shackling in later stages of care, he says it would still need to "mitigate risk".

He does believe a "transparent process" nationally would help.

"It's a bit like we have national strategies for palliative care and expectations, or national healthcare standards," he explains.

With additional reporting by AAP