“My head’s like a patchwork quilt under there,” says Wendy, an inmate at HM Prison Drake Hall in Staffordshire. “He beat me bad, bad, bad… I was just knocked out, unconscious, so many times.”

Before slipping into the criminal justice system, Wendy suffered domestic violence in a four-year relationship. She is now part of a damning statistic; more than six in 10 female offenders have a history of acquired brain injury (AB)).

This is according to research led by The Disabilities Trust, which found that of 173 female offenders at Drake Hall examined against the Brain Injury Screening Index, 64% had a history indicative of a brain injury.

The vast majority of injuries (96%) were traumatic, while a third were sustained before the individual committed their first known offence.

The Disabilities Trust’s findings follow the introduction of the charity’s Brain Injury Linkworker Service at the facility. The service provides support to women with a history of ABI, developing a “sustainable pathway” that supports rehab and helps prisoners to manage the transition between custody and the community.

From the women supported through the service, there were 196 reports of severe blows to the head – 62% of which were sustained through domestic violence.

Nearly half (47%) of the women with brain injuries had been in an adult prison five or more times and 33% sustained their first injury prior to their first offence.

Following its findings, The Disabilities Trust has called for linkworkers – or a similar role with a strong understanding of brain injury – to be accessible to all prisons and probation settings.

To date, the linkworker service has been rolled out into eight prisons, HMP Drake Hall, Preston, Leeds, Aylesbury, Bullingdon, Durham, Deerbolt and Cardiff.

An independent assessment of the charity’s research by Royal Holloway, University of London, found that women seen by the linkworker experienced improved mood and self-esteem, and enhanced confidence and positivity; key factors that have been previously identified as being essential for a woman to engage in rehabilitative programmes.

The linkworker service also offered practical guidance for staff working with women with a brain injury, and alleviated pressure from other service provision such as mental health.

It concluded that a brain injury linkworker service provides a strong framework which will benefit offenders and prisons by identifying and managing brain injury. Offenders helped by the service include ‘Sarah’ who says of her brain injury: “I was becoming very anxious about these problems that I was seeing …not remembering the names of the people I’d spoken to or not being able to express myself properly ‘cause I’m forgetting what I’m saying.”

Another, ‘Helen’, says: “When I was counting screws in the work area I had to count them three times. It gets me very stressed, like when people tell me ‘go and tell this person [something]’ and [I’m] forgetting it.”

As well as the rollout of a linkworker service, or something similar, The Disabilities Trust called for the inclusion of brain injury screening as a routine part of the induction assessment on entry to prison or probation services.

All prison and probation staff should also receive basic brain injury awareness training, it said. The charity also sought assurances that brain injury support would be aligned with “gender-informed” practice. It also recognised that further research is needed to examine the potential effect of brain injury on re-offending behaviour – as well as the role of neuro-rehab in contributing towards the reduction of re-offending behaviour.

The landmark Time for Change report, published in October, made similar recommendations. The report, by the All-Party Parliamentary Group for ABI, called for reforms to criminal justice procedures and processes to factor in the needs of people with ABI.

More ABI training for staff in the police, court, probation and prison services was also urged; as was brain injury screening for children and adults on entry to the criminal justice system. If a brain injury is identified, its impact, severity and related deficits should be measured and “appropriate interventions planned by a trained team”, the report said.

Also, it recommended that all agencies working with young people in the criminal justice system, schools, psychologists, psychiatrists, GPs and youth offending teams work together to ensure individual needs are addressed.

As the APPG report stated, evidence now emphatically links ABI to offending in young people, with prevalence rates for traumatic brain injury (TBI) as high as 60% in some studies (most recently, a 2018 comprehensive review published in The Lancet Psychiatry).

In comparison, UK brain injury charity Headway says only around one in 200 people in the general population has been admitted to hospital with a head injury.

But some experts have warned that it is misleading to suggest brain injury causes crime – and that crime/ABI links are highly complex and must be investigated further. Ryan Aguiar, consultant clinical neuropsychologist at Ashworth Secure Hospital in Liverpool, told the Guardian last year: “Brain injury does not lead to crime even though there are more prisoners with head injury and cognitive impairment per capita, or as a percentage, than there is in the general population.

“Crime is a much more complex condition that is brought about by a myriad of social, environmental, personality, mental health and situational circumstances.

“Head injury is only one among many and not even a first among equals.”

Similarly, Graeme Fairchild, a reader in psychology at the University of Bath, warned: “One of the main problems is that many of the risk factors for criminal offending and violence, eg. being male, coming from a low socioeconomic status background, having ADHD, being physically abused, and abusing alcohol and other substances, are also risk factors for sustaining head injuries, so it is very difficult to disentangle cause and effect here.”

Certainly there is an abundance of evidence of head injury prevalence in prison populations, even if studies unpicking the reasons for this link are lacking.

A 2015 study of 613 adult prisoners found that 47% reported a history of TBI when screened on admission to HMP Leeds.

It also found that 70% of those offenders reported their first injury before their first offence, backing up previous research linking TBI as a risk factor for offending.

In 2011, a 35-year Swedish population study led by psychiatrist Seena Fazel calculated that people with a head injury on their records had a 9% chance of becoming violent offenders. This compared to the general population average of 2.5%.

Recognising that brain injuries could be related to upbringing, the researchers also monitored the siblings of those with brain damage. They discovered a 4.5% chance of becoming offenders too.

There are numerous older studies linking head injury with the changing behaviour and lack of self-control that could theoretically lead to crime. Among them is a lengthy investigation into brain-injured Vietnam veterans in the US.

It evidenced increased aggression in many veterans who had damaged their frontal lobe in the conflict.

Public debate – and wild speculation – about ABI and crime has been fuelled over the decades by infamous examples of brain injured criminals.

Ian Brady and Fred West both reportedly had some experience of head trauma, while Ronnie Kray was almost killed at age nine by a head injury sustained in a fight with his twin brother Reggie.

No expert has ever suggested that their heinous crimes could be attributed to a brain injury but their medical history has at least raised questions about the impact of neurological injury on behaviour.

Aside from such conjecture, there is now hard evidence – and lots of it – to show a vastly disproportionate level of head injury in offender populations.

The criminal justice system and the many agencies that may interact with an individual on the slippery slope to prison have a series of recommendations they must address – and urgent action is needed.

A promising development in recent years has been Headway’s Brain Injury Identity Card scheme (read more on p20). It is designed to help the police identify brain injury survivors and ensure they are given appropriate support when they come into contact with the criminal justice system.

Brain-injured individuals carry a card which reads “My name is … I have a brain injury”. All the challenges they may experience as a result of the injury – such as fatigue, anxiety and information processing problems – are listed on the card.

The scheme was launched in 2017 with the backing of the NHS, the National Police Chiefs Council, the College of Policing, Police Scotland, The Police Service of Northern Ireland and the National Appropriate Adult Network.

Stories like that of ID card holder Dominic Hurley underline its practicality. He was arrested three times for being drunk and disorderly but in each case, he was simply showing symptoms of his brain injury. His card enables him to avoid these misunderstandings.

Meanwhile, events unfolding in the courtroom, particularly in the US, could potentially see brain injuries become a bigger consideration by jurors in years to come.

A number of papers, including that led by Owen D. Jones of Vanderbilt University in Tennessee, are recognising the growing role of neuroscientific evidence in court.

Jones references the story of Grady Nelson, who, in 2005, brutally murdered his wife Angelina. After stabbing her 61 times, he left a butcher’s knife embedded in her brain.

Later, his own life hung in the balance as the Florida jury that convicted him of murder next had to decide whether he would be executed or spend his life behind bars.

Nelson’s attorney offered to provide neuroscientific evidence, specifically quantitative electroencephalography (QEEG) introduced through the testimony of a neuroscientist, to suggest that Nelson had potentially relevant brain abnormalities.

The jury should hear this evidence, the attorney argued, because although it may not excuse Nelson’s behaviour, it should mitigate his punishment.

In order for wife-killer Grady Nelson to be sentenced to death, seven of the twelve jurors (a simple majority) had to vote in favour of executing him.

Only six did, so his life was spared by the narrowest possible margin. Following the vote, it appeared that the neuroscientific evidence had been crucial.

Two of the jurors who voted against executing Nelson told the press that the neuroscientific QEEG evidence had changed their minds, given that they had each initially favoured his execution.

One of them said: “It turned my decision all the way around. The technology really swayed me. After seeing the brain scans, I was convinced this guy had some sort of brain problem.”

The paper states: “It is becoming increasingly common for lawyers to offer neuroscientific evidence, particularly brain images, in both criminal and civil litigation. In our view, this development is both promising and perilous depending on whether and how well courts can come to distinguish, within the contours of distinctly adversarial proceedings, between justifiable and unjustifiable inferences.

“Neuroscientists have crucial parts to play in a legal system that needs to understand and interpret neuroscientific evidence and to separate the wheat from the chaff.

“The ability of neuroscientific techniques to shed light on important aspects of human cognition has generated hope that neuroscience can help to answer some perennial questions in courts of law.

However, one should keep in mind that it is easier to misunderstand or mis-apply neuroscience data than it is to under- stand and apply it correctly, and this is crucially important when lives and livelihoods depend on it.

Whether courts can successfully navigate these challenging waters will depend on the level of engagement by neuroscientists.”

Neuroscience in court is nothing new, but as brain mapping techniques and evidence on exactly how a brain injury can lead to crime becomes clearer, this development may well give ABI survivors a fairer deal in the criminal justice system.