Prone restraint in mental health hospital

My partner and I recently finished Season 4 of Orange is the New Black (highly recommend), and one episode particularly resonated with me. In fact, it made me cry, and I’m not a crier.

The episode centred around an inmate named Poussey, who, in the midst of an ‘incident’ within the prison, was forcibly held to the ground by a prison guard for an extended period of time, whilst the prison guard was being tackled by another inmate.

My partner had no idea what the result of this act would be. I knew, through my work within Public Law and mental health, and I knew that the use of such restraint can bring about death.

Prone restraint is where a person is held to the ground in a face-down position and is physically prevented from moving from that position. Too much force and the result can be fatal. The concern is that prone restraint can result in dangerous compression of the chest and airways, thus placing the person being restrained at a huge risk.

The majority of NHS Trust policies on the use of such restraint suggest that it ought to be used only as a last result, following unsuccessful attempts at de-escalation. Unfortunately, I am aware of incidents where prone restraint appears to be used as a first port of call, often on those with severe learning disability, and often in mental health hospital.

I appreciate that professionals within such a setting must keep themselves, the service user and other patients’ safe, but it is frightening that use of prone restraint remains commonplace, and remains the norm, despite policy suggesting that it should be used only in the most extreme circumstances.

There is a reason that prone restraint ought to be used as a final option – in 1998, a 38 year old gentleman named David Bennett was held in the prone restraint position by 5 staff members for a 25 minute period, resulting in his death. An independent inquiry (bbc article 18/06/13) found that Mr Bennett died as a direct result of prolonged face-down restraint and the amount of forced used by staff.

Did this end the use of prone restraint? No. According to Mind (2013), there have been 13 reported incidents of restraint related deaths in the UK since this. This figure is only for those detained under the MHA 1983 and included only those deaths which were actually reported. The figure is therefore likely to be higher, particularly taking into account the years following the study.

Shockingly, as someone living and working in the North East of England, Northumberland Tyne and Wear NHS Foundation Trust responded to a freedom of information request from Mind and stated that, in 2011-2012, prone restraint was used 923 times.

This is not uncommon, however, with Stewart et al (2009) finding that manual restraint is used 5 times per month on an average mental health ward. According to Mind, one Trust which responded to an FOI request stated there had been 38 incidents of prone restraint, whilst another said there had been over 3000 incidents.

Mind’s recommendation from the 2013 research was, of course, that the government ought to end the use of face down physical restraint.

Has this happened? Of course it hasn’t. The figures speak for themselves. Prone restraint continues to be used, on a large scale, and for as long as this is the case, there will be more and more restraint related deaths.

Not only ought the risk of death be enough for professionals to use every possible de-escalation technique available, but the use of such restraint can cause physical injury and psychological harm. Mind (2013) provided a quote from someone who had experienced such restraint; “it made me feel like a criminal, like I had done something wrong, not that I was ill and needed to get better”.

The free reign to use prone restraint is frightening. The fact that it is used to varying amounts across the country is worse, because it suggests either that instances of prone restraint often aren’t reported, or that staff aren’t provided with the same training across the board. I fear that both are correct.

Those detained under the MHA 1983 are in hospital, usually, for assessment and/or treatment. The mental health hospital ought to be viewed as a place of safety, where care is provided to those in crisis. The possibility of attending hospital and dying there due to an excessive use of force by those who were supposed to be caring for you, is a frightening concept, but it is one that is all too real.

Patients need to feel safe in the hospital environment. The use of prone restraint must be ended.

Mental health service closures

Whilst working within mental health and mental capacity law, I’ve found that there are many situations which really strike me personally. In particular, I have developed an interest in wrongdoings within mental health services, because I can see the situation from the perspective of the outpatient service user, having been involved with services since 2012.

Access to services is a huge issue at the moment. I was rather lucky in that I was able to gain access to services quite quickly through IAPT, though, once my course of CBT had ended, I was basically left in the dark.

I read something on twitter the other day from a service user, stating that he’d missed an appointment because the letter from the hospital had taken so long to arrive. I mean, in 2016, how is that still happening? It may seem like a small thing to some, most likely to the hospital, but these appointments, in times of both crisis and calm, provide routine and stability for service users.  When I was making regular trips to appointments with mental health services, it gave me a sense of comfort just to know that I was doing something. Had I missed an appointment because of the appointment letter being sent by carrier pigeon, particularly with my anxiety when it was at its worst, that would have been one of the worst things that could happen; from the outside looking in, it seems that mental health services can’t empathise with this or many others’ experiences.

Access to inpatient services is where this real division of interest is shown. We’re all aware of the distinct lack of beds within mental health units, which are needed by those who are usually in crisis and cannot be treated effectively in the community. Yet despite this known issue, more and more mental health units and hospitals are closing every year.

According to The Kings Fund, ‘Mental health under pressure’ (November 2015) 40% of mental health trusts experienced a reduction in income in 2013/14 and 2014/15. The analysis by The Kings Fund confirms what many of us interested in this area already know – there are more and more people being detained under the Mental Health Act (a 9.8% increase in 2014/15 compared to the previous year); a lot of these actually receive poor care, particularly when in crisis (only 14% of patients say that they received appropriate care in a crisis); the number of beds is decreasing, meaning that services cannot meet the demand; and, despite this, mental health units continue to be closed down. So, what is the outcome from that? People are either left without the help that they need, or are detained in a hospital somewhere far from home, far from normality, and far from comfort. According to a Freedom of Information request by the Community Care and BBC News, 4,447 patients were sent out of area by 37 NHS mental health providers in 2014/15. 88% of the 4,447 were sent out of area due to beds being full.

I have been looking in to closures of mental health units and, even if you just give it a quick google, you can see the scale of the problem. By way of example, in October 2015 Bootham Park Hospital, York’s only public adult mental health hospital, was closed following a report by the CQC, with 5 days’ notice being given. How many people did this affect? 30 inpatients and 400 outpatients. When something like this happens, particularly with such short notice, it must be like being abducted, and ripped away from everything you knew. In February 2016, Outpatient services resumed, after a huge amount of local pressure. However, for those patients in crisis, requiring inpatient care, they, and their families, are expected to travel 50 miles.

50 miles isn’t the worst it could be. There are instances of people being placed 300 miles from home. But, when these patients are very unwell, to be placed in hospital in a completely new area, in my opinion, surely can’t help them in the short term. Whilst detained under the Mental Health Act, a patient can be granted section 17 leave from their Responsible Clinician. I can’t imagine how difficult it must be to enjoy leave in an area you have never been before. Leave is a way of readying patients for discharge, but, certainly for those with anxiety, going out in the community in an unknown area would be incredibly daunting, and could even be a bit of a step-back. It’s hard to see how having leave in a town 100, 200, 300 miles from home is going to prepare you for living in your community.

Another example of mental health unit closures, resulting in patients having to travel, and one that is actually happening right now, is The Welland Centre, in Market Harborough. I came across this closure in an article a couple of weeks ago – The Welland Centre, which provides adult community health services, hosts clinics for up to 450 patients. That’s 80 patients each week and approximately 4000 appointments each year, and patients will be expected to travel elsewhere to access the help that they need.

One patient of the service has developed a petition to save the service – https://petition.parliament.uk/petitions/131744 – which currently has 764 signatures, one of those, of course, being my own. Should the Welland Centre close, patients would be expected to travel for one hour and a quarter to reach the service. For those who do not drive, like myself, this is two bus journeys. When I was having regular appointments with mental health services at Warwick Uni, I had to travel by bus from where I lived in Leamington Spa onto campus. Sometimes, when I was feeling particularly low, I simply couldn’t do it. I had so much anxiety around the University campus, the bus, the students, that I physically couldn’t get on the bus to get to the appointment sometimes. I probably never would have attended any appointments if I had to take two buses.

Now, putting my legal hat on, one big issue for me in situations involving closures of services, is that patients, families, and those who simply have an interest, do not know that the law can assist. When people are informed that their service, usually a service they have used for many years, is closing, they can feel alone. People generally don’t know (and, to be honest, why would they) that there are possible ways to legally challenge the decision to close the service – to go back to Bootham Park hospital in York (https://www.theguardian.com/society/2016/mar/14/the-nhs-mental-health-hospital-closed-with-just-five-days-warning), lawyers are representing the families of some former patients of the hospital and are seeking a judicial review of the “forced closure” of the service.

Judicial review is where a case is taken to the High Court, and it is argued that a decision of a public body is unlawful. This could be that the body has acted beyond its powers, or has not taken something into account etc. Obviously, there is no guarantee that any challenge would be successful, but I think that it is vital that there is something that can be done legally, at least to try to stop any decision to close a service.

That is why I really enjoy working within this area of law. Despite all of the issues with mental health services, and despite the general thought that lawyers are cold and can’t help real people, I like to think that in this area we actually could make a difference and, if a difference can’t be made, it is always nice to say we tried.

 

Nicholas Salvador – not guilty by reason of insanity

Today’s news has been filled with the face of Nicholas Salvador, a 25 year old gentleman who, last year, killed two cats before going on to behead an 82 year old grandmother in her own back garden.

Nicholas Salvador is a paranoid schizophrenic. He has today been found not guilty by reason of insanity and will spend an indefinite amount of time in a secure psychiatric hospital. What is not discussed in the news is how such a verdict works in practice. Well, officially, Nicholas Salvador will be detained under section 37/41 Mental Health Act 1983.

Section 37 is a hospital order and it operates as an alternative to a prison sentence. Section 41 is a restriction order and this is something added by the Crown Court if there are concerns regarding public safety and the patient’s own risk. Prior to someone being admitted to hospital in such circumstances, two medical practitioners must carry out assessments of the person. For a judge to give a restriction order, one of these medical practitioners must speak in court.

It is possible that Mr Salvador will have to spend some time in prison whilst waiting for a bed to become available for him – the procedure is that the Hospital Managers should find a patient a bed within 28 days.

The reason that the newspapers are stating that Mr Salvador will be detained indefinitely is because, since 2007, a section 37/41 does not have a time limit, meaning that it can run for as long as necessary with no need for it to be renewed.

Although unlikely to happen, it would be possible for Mr Salvador to appeal against today’s order of the court to the Court of Appeal, but this would need to be done within the next 28 days.

A section 37/41 is naturally strict – a patient detained on this section cannot leave hospital without the agreement of the Secretary of State for Justice. When the person’s Responsible Clinician (the doctor in charge of their care) thinks that the patient is well enough to be discharged from hospital, he will ask for the Secretary of State’s agreement. The reasons for such strict rules are clear – the person, had they not been suffering from a mental disorder, would have been sent to prison. It is section 41 that places these extra restrictions on the detention. Even if the patient wants leave from hospital, and a request for leave is made by the responsible clinician, the Ministry of Justice must agree to grant that leave, and it may simply be leave to go to the local shop.

Once the hospital order has been in place for six months, the person detained may apply for a Tribunal. With a Tribunal, a successful appeal of a section would mean that the patient can be discharged. Such discharge can be either absolute or conditional. With absolute discharge, the person will be released from detention. It is unlikely that someone who has been subject to a forensic section i.e. a section 37/41, will be granted absolute discharge. Conditional discharge is much more likely as it allows the person to remain subject to the Mental Health Act whilst living within the community. Should any of the conditions specified be broken, the patient can be recalled to hospital by the Secretary of State. As soon as a patient on a section 37/41 is recalled to hospital, there is an automatic tribunal within the first month of discharge. Following this, the section must last for six months before the patient is able to apply to the Tribunal himself.

Alternatively, if the conditional discharge goes well and all conditions are complied with, the patient may wish to apply for absolute discharge, although they do have to wait at least one year. If the application for absolute discharge following one year of conditional discharge is not successful, the person is only able to apply two yearly.

Nicholas-Salvador-_3349677b

Ta-dah! Hopefully this explains what all of the newspapers are talking about and the process involved when detaining Nicholas Salvador.

Police cells as ‘places of safety’

According to an article in today’s @guardian Home Secretary Theresa May has pledged up to £15m to provide health-based alternatives for the 4000 people per year who spend time in detention in police cells under the Mental Health Act.

Currently, people detained under the MHA can be held in a hospital or a police station for up to 72 hours, with the premise being that a police station is a place of safety.

police-cell

Section 135 empowers police officers to enter private premises (with a warrant) to remove a person suspected of needing an urgent mental health assessment. Section 136 gives power to the police to remove someone from a public place to a ‘place of safety’ where, under the Mental Health Act, they can be detained for up to 72 hours. In around one third of cases, the ‘place of safety’ is a police cell.

Under the new policing and sentencing bill which is due to be released next week, the use of police cells to detain children with mental health problems will be banned.

This comes soon after research published by the Centre for Mental Health in late 2014. The research was commissioned by the Department of Health and the Home Office and found that for many people, being detained by the police was a frightening experience. That does not really come as a surprise – I know that I certainly wouldn’t choose to spend time in a police cell and Theresa May appears to be on the right track that people with mental health issues should not be ‘locked up’. This is particularly so given the report’s statement that “we found broad agreement among all those who worked with or had been subject to sections 135 and 135 that police custody should seldom if ever be used as a ‘place of safety’… there was widespread agreement that the use of these sections with children and young people was especially problematic”.

Whilst this Tory plan to put more funding into creating more suitable places of safety for young people with mental health issues came as a nice surprise to me, it does only apply to children. The new legislation will, however, ensure that police cells are only used as a place of safety for adults if the person’s behaviour is so extreme that they cannot otherwise be safely managed. Immediately, my mind asks what on earth ‘so extreme’ refers to and whose call it is as to when behaviour meets that threshold. I guess only time will tell with that one.

I think that it would be a good starting point to have age-appropriate places of safety. Of course, the legislation discussed above is more concerned with people under the age of 18, who are therefore classed as more vulnerable. But what about older people? I can say with conviction that a police cell absolutely would not be a suitable place for my 81 year old grandma.

We won’t know the exact ins and outs until the bill is set out in next week’s Queen’s speech but for now it is suggested that the bill will reduce the current 72 hour maximum period of detention and will enable places other than police cells and health-based alternatives to be ‘places of safety’.

In utilising police cells for the purpose of detention under the Mental Health Act, it automatically feels as though the person detained has done something wrong when, of course, in the vast majority of cases they have not. When you think of a police cell you don’t think of it as a place of safety, you think of it as a place for punishment, regardless of what its purpose actually is. I understand that sometimes there simply aren’t enough beds to go around but surely a prison cell can’t be the only alternative? Imagine how daunting it would be to be taken from a public place and put into a prison cell, ostensibly for your own safety. I know that I would be beside myself and would probably be quite scared that I was being accused of some sort of a crime. Do people with mental health issues really need these extra levels of hardship when what we should be doing is re-assuring them that they are safe and protected, but also that they have done absolutely nothing wrong. This could be particularly important given the fact that after the detention period there will be a mental health assessment. We ought to be reducing stress-levels, not increasing them.

If those with a physical illness were turned away from hospital due to overcrowding and were taken to a police cell, there would be a massive outcry. Shockingly, it is estimated that between 20% – 40% of police time is spent dealing with people with mental health issues. Needless to say, the correct place for someone with a mental health problem is not a police cell and the best people to look after them are not police officers.

Let us hope that Theresa May puts her words in to actions and we see more health-based and perhaps community-based places of safety for the mentally ill.