The invisible injury behind the prison door

A woman misses an appointment in prison. She forgets an instruction, loses her temper or cannot explain clearly what has happened. It is easy to decide that she is difficult, evasive or unwilling to engage. It takes more thought to ask whether she may be living with the effects of a brain injury that nobody has recognised.

In my work with people affected by brain injury, I have seen how easily memory loss, fatigue and poor concentration can be mistaken for carelessness. Someone may appear not to be listening when, in reality, they cannot process information quickly enough. They may agree to something and then forget it altogether. In the rigid and pressured environment of a prison, those misunderstandings can have serious consequences.

In 2019, The Disabilities Trust, now Brainkind, published research based on the screening of 173 women at HMP/YOI Drake Hall. Sixty-four per cent reported a history indicative of brain injury. Of that group, 96% reported a history indicative of traumatic brain injury (TBI).

This is where the often-repeated claim that “64% of women in prison have a TBI” comes from. But it is crucial to remember that the women were screened in one prison for a possible history of brain injury; they were not all clinically diagnosed, and Drake Hall cannot represent the entire female prison population. Nevertheless, the finding is striking—almost two-thirds of the women screened reported experiences consistent with brain injury.

Brain injury is also strikingly common among men in prison.

A 2010 study led by Professor Huw Williams of the University of Exeter surveyed 196 adult male prisoners. Sixty-five per cent gave accounts consistent with TBI of varying severity.

A 2021 overview by Hope Kent and Huw Williams summarised the evidence as suggesting that around 60% of adult male prisoners may have experienced some form of TBI, with roughly 15% reporting a moderate-to-severe injury.

The 2010 study found associations between TBI and younger entry into custody, higher rates of repeat offending and more time spent in prison.

Brain injury does not inevitably lead to offending. More often, it sits alongside childhood adversity, violence, substance misuse, poverty, disrupted education or poor mental health. No single event or diagnosis explains how someone came to be in prison.

What the research does tell us is that brain injury is not a rare complication at the edges of the prison population. It is something prison staff are likely to encounter every day, whether or not they realise it.

Because studies use different definitions, populations and screening methods, it is unsafe to draw a neat prevalence comparison between men and women. The clearer difference lies in how women’s injuries happen.

Among 100 women referred to the Drake Hall Brain Injury Linkworker service who reported TBI incidents, 62% said they had sustained an injury through domestic violence. One woman described years of assaults and repeated loss of consciousness, saying her head felt “like a patchwork quilt”. The Disabilities Trust, Making the Link.

“A patchwork quilt” says more than a prevalence figure can. For many women, there was no single accident followed by treatment and rehabilitation, but repeated assaults over years, with the damage never properly recognised.

A larger Scottish study involving 109 women across four prisons found that 78% had experienced a significant head injury. Forty per cent of those women had an associated disability. Of the 71 women with significant head injury who reported repeated injuries, 63 of them (89%) identified domestic violence as the most common cause.

Across both studies, the pattern is the same—for many women in custody, brain injury is inseparable from a longer history of abuse.

Recent research shows why looking only for a blow to the head misses part of the problem. Acquired brain injury may also result when the brain is deprived of oxygen during non-fatal strangulation—a particularly dangerous form of domestic abuse commonly used to frighten, dominate and control.

Brainkind’s Complex Lives study involved 70 women in contact with the criminal justice system in Wales. Ninety-five per cent had experienced domestic abuse. Eighty per cent reported a history indicative of acquired brain injury, while 78% reported having been held in a way that prevented them from breathing. Just over half of the women—51%—reported losing consciousness as a result.

Many of these incidents may never have been recorded as medical emergencies. A woman may not have gone to hospital or realised that losing consciousness could injure her brain, and fear, shame or coercive control may also have kept her silent. Years later, prison staff may see the effects without knowing the history behind them.

TBI can affect memory, attention, planning, communication, impulse control and emotional regulation.

A woman may forget an appointment or lose track of several instructions given at once. She may struggle to follow a long explanation, particularly in a noisy or stressful environment. She may become overwhelmed, react impulsively or find it difficult to put her account into a clear sequence.

From the outside, that can look like laziness, manipulation or defiance.

I have seen the same misunderstanding outside prison—people are treated as though forgetting were a choice or judged for an emotional reaction without anyone asking what caused it.

In prison, the stakes are higher. The system depends heavily on compliance with appointments, instructions, routines and programmes. Behaviour may affect privileges, disciplinary decisions, access to rehabilitation and parole planning. A neurological difficulty can therefore lead to punishment at precisely the point when support is needed.

A 2025 qualitative study interviewed 13 women living with TBI in prison. Again and again, the women said they wanted one thing—to be understood. The researchers found that the stigma of brain injury was compounded by the stigma of imprisonment and by the traumatic circumstances in which many of the injuries had occurred. Some women had also internalised that stigma, making them less likely to ask for help.

The Drake Hall pilot showed what can happen when the possibility of brain injury is taken seriously.

A Brain Injury Linkworker, supported by clinical neuropsychology, helped women understand their symptoms and develop practical ways of managing them. These included diaries, structured planners, behavioural plans and techniques for recognising and regulating emotions. Prison staff also received brain-injury awareness training.

None of these strategies was elaborate. Their value lay in starting from the woman’s difficulty, rather than assuming a poor attitude.

The evaluation recorded severe anxiety in 18 of 29 women—62%—at admission and five of 25—20%—at discharge. Severe or moderately severe depression was recorded in 16 of 29 women—55%—at admission and five of 25—20%—at discharge.

Because this was a service evaluation rather than a controlled trial, it cannot show that the Linkworker service alone caused the improvement. The results are nevertheless encouraging: recognising brain injury and adapting support appeared to help. Brain Injury Linkworker Service Evaluation: Technical Report.

At the time of writing, Brainkind lists Linkworker services in seven prison settings in England and Wales, including the women’s prison HMP Send. Its South Wales evaluation at HMP Cardiff and HMP Swansea also reported improvements in understanding, participation and emotional wellbeing. Brain Injury Linkworker Service Evaluation Report.

The difficulty is that this kind of specialist provision is still not available everywhere.

There is no readily available national dataset showing how many people in prison are screened for brain injury, diagnosed, referred for neuropsychological assessment or offered specialist rehabilitation. Without that national picture, it would be wrong to claim that men consistently receive one level of support and women another. What is clear is that provision varies sharply between prisons.

In 2025, HM Inspectorate of Prisons reported that Neurodiversity Support Managers had been introduced widely and highlighted encouraging practice in several women’s prisons. At Styal, inspectors found individual support plans. Drake Hall had introduced a neurodiversity passport to help staff understand and respond to individual needs.

Yet the wider picture remained inconsistent. Training, identification and reasonable adjustments varied, while good practice was often driven by committed individual members of staff rather than embedded throughout the prison. Four years on: Neurodiversity in prisons.

Support should not depend on the luck of meeting one informed officer, healthcare professional or Linkworker.

General neurodiversity provision is valuable, but it is not a substitute for a clear, informed brain-injury pathway. Screening is only useful if it leads somewhere: to appropriate assessment, clearer communication, reasonable adjustments and, where needed, rehabilitation.

In their 2026 Academic Insights paper, Hope Kent and Professor Stan Gilmour argue that existing prison and probation assessments may fail to identify women’s acquired brain injuries, particularly where those injuries result from repeated domestic abuse or non-fatal strangulation.

They recommend routine screening, clear referral routes, better staff training and practical adjustments to communication, appointments and programme delivery.

Recognising brain injury does not excuse offending, and not every instance of difficult behaviour has a neurological cause—it simply allows the system to respond more accurately.

When somebody cannot remember, process information or regulate emotion in the way the system expects, repeating the instruction more loudly will not repair the damaged function. Punishing the failure may make matters worse.

Brain injury is common throughout the prison population, but its causes, visibility and consequences are profoundly gendered. For many women, the injury forms part of a much longer history of violence that began well before they entered custody.

Recognising that history gives staff a better chance of understanding what they are seeing, and the woman herself a better chance of leaving prison with more insight and support than she had on arrival.