*that occurred due to care that falls below the standards expected of clinicians in the community'* [49: n.p.].

While the available literature is limited, what is available shows clear patterns of errors of omission and commission for incarcerated people. In terms of errors of commission (where the wrong thing was done) the literature shows that the safety of care for incarcerated people is lessened by factors such as: mis-diagnosis [50–52], medication errors/issues [53, 54] including under-prescribing/ceasing medications before indicated by evidence based practice [55: 506] or over-prescribing particularly in the case of women, as a mechanism for control [56–58] and/or polypharmacy [59].

The list of errors of omission are even longer. Studies show that the quality and safety of care for incarcerated individuals is lessened by: failure to diagnose treatable conditions [60, 61]; failure to treat latent infection [62]; fear/lack of confidence in clinicians inhibiting uptake of treatments [63, 64]; and routine failures to identify and mitigate risk factors (particularly in mental health) [65].

A recurrent theme in the literature on errors of omission in prisons is the effects of delays on patient outcomes, including: delays in testing or diagnosis [62, 66, 67]; delays in treatment [56, 61]; and delayed responses to request for medical appointments issues [54].

Patient safety for incarcerated individuals is also notable for the evidence of two factors associated with the particular experience of incarceration itself. These are prisoners' experience of the negative attitudes of clinical staff [68–71], including failures of privacy and lack of dignity/incivility [53, 54, 72] and the way in which treatment is (or is not) provided including: treatment interruption [73, 74]; lack of continuity of care [75]; and the discontinuation of treatment on release from prison [62, 76–80].
