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.

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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.

 

Me, myself and Anxiety

“The truth is that anxiety is at once a function of biology and philosophy, body and mind, instinct and reason, personality and culture. Even as anxiety is experienced at a spiritual and psychological level, it is scientifically measurable at the molecular level and the physiological level. It is produced by nature and it is produced by nurture. It’s a psychological phenomenon and a sociological phenomenon. In computer terms, it’s both a hardware problem (I’m wired badly) and a software problem (I run faulty logic programs that make me think anxious thoughts)”               Scott Stossell, ‘My Age of Anxiety’

The major problem when it comes to Mental Health issues is not the person, not the illness, but the fact that such issues are surrounded by a cloud of silence and stigma.

Mixed anxiety and depression is the most common mental health disorder in Britain, with 9.7% of the population experiencing it.

During my second year of University, the pressure of exams was looming and I found myself in a place I had never previously been – one filled with anxiety, feelings of failure and a constant fear that I would never be good enough to embark upon the career that I had worked so hard for.

At the time that my journey with anxiety began, I was putting in 14 hour stints at the library – that seemed like normality for the majority of students at my University. I thought that I was fine, I had always prided myself on my emotional strength. That was, until it came to the date of my Contract Law exam and I had a panic attack in the library whilst I was attempting to read through my revision notes. It had taken me around two hours to read one page and it was clear that something was wrong. I didn’t want to have a panic attack, but I couldn’t stop it and, honestly, I had no idea what was going on. I didn’t know what a panic attack was, but I was left shaking and crying uncontrollably on the quiet floor of the library, 2 hours before what was, in my mind, the most important exam of my life. Of course, it wasn’t- that was the anxiety talking.

I had been revising for around two months – I should have been ready for exams. I was ready, but my brain would not let me pass this wall of panic in front of me.

Funnily enough, I actually had no idea that there was a problem with my mental health until the day that I had that first panic attack. Following that, things started to click in to place and I realised that, for the two months prior to that panic attack, revision had taken over my life and I was rarely eating and barely sleeping. My room was a mess (which was very unlike me) and, in all honesty, I was too.

I sought help from my GP, and utilised the help of IAPT. I was given medication to help to control my anxiety (Citalopram worked really well for me and I, thankfully, haven’t had to chop and change pills to find what suits me). I attended Cognitive Behavioural Therapy which taught me to change the way that I thought. Apparently, doing this means that I am in a minority – a YouGov survey of 2300 adults in Britain carried out for Mental Health Awareness Week 2014 found that one fifth of people who have experienced anxiety do nothing to cope with it. Indeed, fewer than one in ten people have sought help from their GP to deal with anxiety.

At first, admitting that I had a problem made me feel that I was weak. Once I had come to terms with my anxiety disorder and felt that I could tell those closest to me about it, I found that most people’s instant reaction would be to ask ‘Well, what are you anxious about?’ There was absolutely no malicious intent behind that question, it was just a question that simply could not be answered. As Critchley (2009) has stated, “If fear is fearful of something particular and determinate, then anxiety is anxious about nothing in particular and is indeterminate”. It can be difficult to come to terms with the fact that you have anxiety whilst at the same time having absolutely no idea why.

Now that my anxiety disorder is behind me and I have learnt to cope with any feelings of anxiety that I may experience, I feel slightly angry when I look back at that time of my life – that I didn’t know that I had a problem until it was too late. If only more people spoke out about mental health issues, and the help available were promoted further, people may not have to wait for their mental health issues to manifest themselves externally before they are able to receive help.

People simply do not talk enough about mental health issues and, even whilst writing this, I feel a sense of worry that people may look down upon me because of my experience with anxiety. That is wrong.

In the UK, one in four people will experience some kind of mental health illness in the course of a year. That’s a lot of people, and it’s likely that the majority of those people are too frightened to speak about their experiences, for fear of discrimination and being ridiculed.

We need to raise awareness of mental health issues and let people know that it is ok to speak out about their experiences. Speaking of your experiences with a mental health issue, whilst a bit daunting at first, is actually incredibly refreshing and, you never know, you could be the difference between someone suffering in silence or attending their GP and getting the help that they need.

During Cognitive Behavioural Therapy, I learnt more about what a panic attack was, and what the early signs of an attack were for me personally. Some techniques which helped me included focusing on something other than the attack. It used to be that I would be so worried and anxious that I would have a panic attack that I brought one on myself. My therapist told me to focus on colours, perhaps the colours of different leaves on a tree. I personally preferred to rub tea tree oil or some other scent on my wrists and simply focus on smelling that. It sounds so simple but it really did work.

Another simple thing that can make a huge difference is to talk about any issues you may be having with those around you. I was able to talk to my friends and my partner who were incredibly helpful and, as some of my friends also had mental health issues of their own, I was able to use some of their advice (the smelling scent distraction actually came from my best friend whose mum is an aromatherapist).

I also really like ‘The Quiet Place’ at http://thequietplaceproject.com/thequietplace which had the effect of basically bringing me back to normality. For me, my anxiety was mainly linked to exam stress and the general hardship of life. The Quiet Place is great as it allowed me to take a step back and really put my fears into perspective, the majority of which were totally irrational.

Mental Health is no longer something that should only be spoken about behind closed doors and I hope that we, as a society, are now moving in the right direction towards a better understanding of mental health issues and a more accepting approach towards those who suffer. In talking about mental health issues, we raise awareness and it is that awareness of such issues that will help those suffering to get the help that they need.

I have struggled with anxiety and have overcome it, hopefully by speaking out we can help others to do the same.

Mental Health under the Tory Government

In their election manifesto, the Conservative Government reaffirmed the commitment made under the Coalition that Mental Health Services would be put on a par with physical health. On top of this, the Conservatives stated that they would ensure that there are therapists in every part of the country providing treatment.

The manifesto stated that funding for Mental Health care would increase, though no details were given to actually support this bold statement. Indeed, according to the BBC in March 2015, the budgets for Mental Health trusts in England fell by more than 8% over the course of the Conservative Lib Dem Coalition – 8% may not seem like a great deal, but it equates to around £600m. According to Paul Farmer, Chief Exec of charity ‘Mind’, “the treatment gap for Mental Health is huge- 75% of people with Mental Health problems get no help at all… the next government will need to hit the ground running on Mental Health. We need to see a permanent increase in the NHS Mental Health budget of at least £1bn if we are to reverse the damage caused by years of neglect and recent cuts”.

5 days ago, David Cameron proposed 7 day hospital services and 7 day extended hours GP access, with 5000 more GP’s. Whilst this would be fantastic for me – it is a nightmare trying to get a doctor’s appointment when working full time and a good one hour away from the doctor’s surgery – where is the money for this going to come from? NHS England’s Five Year Forward View called for £8bn more annually (along with efficiency savings of £22bn) but, according to The King’s Fund, whilst “a seven day NHS is the right ambition… delivering it by 2020 will be a tall order”, £8bn “will not pay for new initiatives such as seven day working”.

Personally, I attended my GP for my anxiety disorder as I was not aware of any other services available for Mental Health issues. It appears that I am not alone in this, with around 90% of people with Mental Health problems receiving all of their treatment from primary care services rather than a specialist Mental Health service.

With regard to Mental Health specifically, the Conservatives touched upon “enforcing access standards” and increasing funding, but they went no further.

For now, then, we are left a little in the dark and it remains to be seen what will happen with our Mental Health Services. What I do know is that services for Mental Health need to be more readily available and that people with Mental Health issues need to feel confident that they are able to access such services without judgement. Clearly, there is disparity between the number of people who have a mental health issue and the number of people who get treatment or seek help for a mental health issue – In Britain, it is estimated that only around one quarter of people with a Mental Health problem receive ongoing treatment. With longer GP opening hours, more people with mental health issues will have the opportunity to attend their GP and get the help that they need. But is it extra hours that we need, or more confidence so that we are comfortable telling people about our mental health issues with no worry of stigma being attached?

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.