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.

 

Welcome back

So, it has been a loooong time since I have posted a blog, and there are many reasons why.

I think one of my last posts surrounded my attempt at positivity after discovering that the law firm I worked for in mid 2015 was making redundancies. To cut a long story short, I loved the job and had been getting to grips with mental health law – the firm shut down, and I was left with no clue what would happen next.

I felt so strongly about my wish to work within mental health law, but, at the time, there was a distinct lack of such roles in the North East. I had loved working within mental health law; representing the vulnerable and ensuring that their rights are upheld, I feel, is one of the most important things that we, as a society, ought to do.

In November 2015, everything took a turn for the better, and I took a role at a national law firm in Newcastle. I have been there since that date and, whilst I didn’t think it was possible to better my previous job, it is amazing. The role is Public Law Paralegal, meaning that I assist directly on cases, and get to have a lot of client contact, which I love. I hadn’t had experience of public law, though my role within it centres largley around Community Care and Mental Capacity. I feel just as passionate in this role, as, again, I view it as being incredibly worthwhile. I do also still get to do some mental health work, which, obviously, I love!

Mental Capacity is an incredibly interesting area of law, and involves those who lack capacity to make a certain decision for themselves, and a decision being taken in their best interests. I’ll post a lot more about this in later blogs.

So, another reason I haven’t posted is because life has simply gotten in the way. I have just finished first year of the Legal Practice Course, having taken (and aced may I say) a module in Mental Health Law, and, now I have gotten fully to grips with my new job, I feel that I’ve got a good balance. I’ve even taken on afew voluntary roles, which I’m really happy about – currently, I work with Parkinson’s UK, Tiny Lives and Rethink Mental Illness.

I hope that you can forgive my disappearance, and I’m looking forward to writing more blogs and getting to grips with all things mental health, mental capacity, and law.

Thanks for having me back!

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Oh the places you’ll go…

“You have brains in your head. You have feet in your shoes. You can steer yourself any direction you choose. You’re on your own. And you know what you know. And YOU are the one who’ll decide where to go…”
Dr. Seuss, Oh, The Places You’ll Go!

For those who regularly read my bog and twitter feed (@AC_MentalHealth) you will have noticed that there has been a distinct lack of posts recently.

Lying in bed last night, I stumbled across the above quote and felt that it was more than apt to my current situation. Things may not go to plan, but it is me in the driving seat and I have control of which way I steer.

It’s pretty obvious that I absolutely love my job. I started working in a regional office of a London firm in March of this year as an Admin Assistant. The hope was to work my way up with the firm and, in a perfect world, secure the elusive training contract that every law graduate in the country would also be applying for.

Six months on, I have worked my way up to the position of Mental Health Caseworker with Admin responsibilities. When I tell people my role, a lot of people have absolutely no idea what it means. A few of my family, through no fault of their own, simply lack of knowledge, thought that mental health law meant that someone with mental health issues had committed a crime and mental health lawyers try to ‘get them off’.

The role of a mental health lawyer is to ensure that the rights of those with mental health problems are upheld. For me, it’s about protecting the most vulnerable in society. Now, some people with mental health problems are detained under the Mental Health Act if they are really unwell, but that doesn’t at all mean that the person has done something wrong. There is something called a ‘forensic section’ which deals with those who have committed crimes, but, generally, those detained under the MHA are just like you or I and Doctors simply feel that they ought to be in hospital for assessment (section 2) or treatment (section 3). There are other sections but these are the most common.

Now, on Facebook recently, a fellow Warwick University Graduate who works as a mental health paralegal in London, posted a status saying that he was representing someone detained under the MHA at a Hospital Managers’ Hearing the next day. It’s safe to say that I was incredibly jealous! Then, someone who I don’t know, commented on the status saying that he was a junior doctor in psychiatry and asked why the person was detained. My friend said that the gentleman had schizophrenia with paranoid ideations. To this, the JUNIOR DOCTOR IN PSYCHIATRY replied “then why are you contesting it. Dude needs help”. Well, that got me angry, because help isn’t always a hospital.

The role of the mental health solicitor/paralegal is to advance the rights of the client, so if they say that they would like to be discharged from hospital then this is what we tell the Tribunal or Hospital Managers’ when the person appeals their section, with arguments added that discharge would be appropriate. We’re not ‘getting people out’.

For some people, being in hospital can make them worse. Especially if the ward is particularly disruptive, and where drugs are rife that can make things a lot harder. Assessing/treating those with mental disorder should not be about keeping someone in hospital until a doctor decides that they’re better. It’s about the individual, who may find it helps more to be at home with community psychiatric support, than in the often chaotic surroundings of a ward.

Anyway, I digress. What I’m trying to say, and what I could have said in eight words is, I really love working within mental health law.

And that’s when the rug of contentment was pulled right from underneath my feet…

All employees at my Firm were recently given notice of redundancies. Such an unexpected life-changing shock isn’t the best for someone with anxiety disorder. For the past week, I have had the worst headaches, and I never get headaches. Although, interestingly, there was no headache on Wednesday when I had my University day. It’s difficult because I got to the point where the stress of not knowing what was going on was really starting to become an issue, but I felt that I couldn’t say anything because of that fear of mentioning anything related to my own mental health having a detrimental impact on my future, as if it would show that I “can’t hack it”. Of course, that’s me being ridiculous but it is how the vast majority of those with mental health issues feel.

When I told my Grandma that I was potentially losing my job, she said “well you’ll just have to get another one won’t you”. God, if only it was that simple! Basically, there are no mental health paralegal jobs being advertised for in the whole of the North East, so that isn’t looking great.

All I can hope is that I will be able to continue doing the work that I love, wherever that may be. For now, I need to focus on my own mindfulness and wellbeing. One thing is for sure though, I won’t give up because I’ve worked too hard for that.

Dr Seuss is right, and every time I see my #semicolonproject tattoo, I’m reminded that I can conquer anything.

semicolon project

Mental Health and Exercise

Whichever mental health charity or self-help website you visit, there is always a common factor – exercise is good for your mental health. Ever since I was diagnosed with generalised anxiety and panic disorders in 2012, I have been scouring the internet looking for ways to not only understand mental health, but to aid my medication through natural remedies.

Unfortunately, exercise has never been a strong point of mine. I really, really am not a fan. So, even though I was seeing constant advice on the benefits of exercise in mental health, I didn’t bother. Surely exercise couldn’t help THAT much. I think my downfall here was that I saw the word ‘exercise’ and immediately presumed that that referred to a 10 mile run, which I am most definitely not capable of. I did find that a short walk to the shops helped to clear my mind and, when my anxiety was at its worst, going for a ten minute walk at a certain time each day gave me structure and was a little bit of an escape route from the stress of the future.

It has only now dawned on me that these small ten minute walks count just as much as a 10 mile run – exercise is great for mental health, but that doesn’t mean that you need to push yourself to become a bodybuilder. Whatever you feel capable of, perhaps like me it is only a ten minute walk, it really can help.

I read an article today entitled ‘Going on nature walks is good for mental health’. Coincidentally, I have just returned from a lovely long weekend away with my incredible partner. We went to the Lake District and some of the scenery was simply breath-taking, really putting all of life’s worries and anxieties into perspective.

lakes

The article focused on a study which has found that taking a walk in a natural environment can bring about positive changes in the brain and may help fight depression. Previous studies had already found a link between walking in a natural environment and an improved mood and decrease in anxiety.

It seems that I had been doing the whole ‘exercise’ thing right this whole time, I just didn’t know it. So, if like me you do not plan to become an Olympic athlete any time soon, take a 10 minute walk. And, if you decide to walk for longer, then all the better. Sometimes we just need to get away from the hustle and bustle of life, a nature walk can do you the world of good and really does take very little effort. My advice would be to set a time slot, one that you do not deviate from, in which you can go for a walk – whether to the shops, to a beauty spot or just to the park – and make this time slot ‘your time’.

Because my anxiety and panic disorders truly came to fruition during University, I had very little structure at that time. Exams were over, there were no lectures to go to and I really was left to my own devices. That is dangerous, because if you have nothing (or think you have nothing) to get out of bed for, then that’s where you’ll stay. During cognitive behavioural therapy, my therapist stressed the importance of structure and suggested that I have a set routine each day. This way, it would make me less panicked about the unknown, as I had a plan of what I was going to do each day and when I was going to do it – my therapist liked the idea of having meals at certain times of the day, waking up and going to sleep at the same time each day. That was difficult to do at University and I didn’t really listen to my therapist as much as I should have, thinking that going to sleep at 10pm one night and 3am the next surely couldn’t impact upon my mental health. Now that I have entered the big bad world of employment, there is a natural structure to my day – I have to get up at the same time each day, I take my lunch at the same time each day and I get home from work at the same time each day. So I have naturally created a routine for myself and it really helps a lot!

I certainly believe that structure is important when living with mental health problems. At the time of my diagnosis, I simply did not have the willpower or the energy to create a routine for myself. I have found that I have gradually slipped into a routine and that it has been the best thing possible for my mental health. Exercise can easily be factored into this routine and that can be as little or as much exercise as works for you.

Personally, I find walking to be very calming and, if the study that I have read today is correct, I had better find some more beautiful places to walk – I’m not going to complain about that!