Editorial

Citation

Dale, C. (2013), "Editorial", Journal of Intellectual Disabilities and Offending Behaviour, Vol. 4 No. 3/4. https://doi.org/10.1108/JIDOB-09-2013-0018

Editorial

Article Type: Editorial From: Journal of Intellectual Disabilities and Offending Behaviour, Volume 4, Issue 3/4

In this editorial two human rights issues are highlighted which impacts on our client group and remain largely uncommented upon. It is sad that it has been left to the individuals affected by these issues to challenge the “system” by way of judicial reviews to protect themselves or others effected.

The problem with judicial reviews are is that they are expensive; take time to be dealt with; and any changes are limited to the specific circumstances of the issues under review, i.e. there is no requirement on behalf of the government to make any findings more broadly applicable to similar situations even if they lose the case at review.

Each year the CQC produce an annual report on the application of the Mental Health Act in England. In the report published in 2012 it highlighted its concerns at plans to reintroduce night-time confinement of patients to their bedrooms as a cost-saving measure in Rampton High Security Hospital. During 2011/2012, only Rampton Hospital was piloting night confinement on this basis, but the other hospitals are now following suit. CQC has heard at least one of the high secure hospitals express the view that night-time confinement helps to use resources equitably, and as such is consistent with the effectiveness, efficiency and equity principle of the Code of Practice.

On visits to Rampton Hospital MHA Commissioners heard patients fears that the introduction of night-time confinement onto their ward will lead to an increase in self-harming as many say they find time alone extremely challenging yet do not wish to sleep in rooms stripped of their possessions. Staff were unable to provide reassurance about this.

Some patients expressed serious concerns about how being locked in their rooms at night might impact on their mental health. One patient wept when describing how she finds it difficult to tolerate being locked into a room as it brings back memories of the abuse she suffered as a child. When she has been secluded she has struggled and relied heavily for support on maintaining contact with the observing nurse.

The Trust said that patients will be individually risk assessed and observations, support and reassurance provided as required throughout the night, and that removal of belongings will be done on an exceptional basis, just as it was before the night confinement.

However, this is presented it represents patients who are detained under the Mental Health Act being routinely locked in a room for no other reason than the service wishing to reduce costs. Two patients affected by these changes are now challenging this via a judicial review.

Why has the situation even been allowed to get to this point? The CQC as the regulator should have instructed the hospital(s) from the outset that it was in breach of the Code of Practice and to stop immediately. All it seems to have done is capture the events in its annual reports; talk to patients and allow the situation to escalate to the point now when all three high security hospitals are adopting similar plans.

I was part of the team in the early 1990s that did away with this practice. It took some 18 months of hard work and persuasion in the face of a lot of hostility (not least from the Prison Officers Association) to introduce a full night-time service. We saw major improvements in rates of self-harm and patient satisfaction. These latest developments suggest a service, which has lost its moral compass and is solely focused on the bottom line; and a regulator that is inept and toothless.

The second judicial review is being pursued by the husband of a service user who took her own life whilst an in-patient. There were 3,628 deaths in mental health detention (501 self-inflicted) between 2000 and 2010, accounting for 61 per cent of all deaths in state custody (Appleby et al., 2012). Of course many of these deaths will be accounted for by natural causes (although there is increasing awareness of how poor physical healthcare contributes to premature death) but a small number will be a result of adverse incidents where the care provided (or not) may have been a contributory factor.

There are several levels of investigation when things go wrong:

1. Internal investigations – undertaken solely by the organisation where the event(s) occurred and using its own staff.

2. Quasi independent investigations – usually commissioned by the provider or service commissioners where the event occurred and combines people who are internal and external to the organisation.

3. Independent investigations – usually commissioned by an organisation other than the one under investigation and undertaken by a group of experts who are external to where the event(s) occurred.

The death of Janey Antoniou, the service user who had done so much to increase the awareness of mental health and the challenges that people face in dealing with the symptoms of these illnesses, highlights some of the shortcomings of the existing system (Roberts, 2012). Janey was diagnosed with schizophrenia at the age of 30. She was a high profile campaigner on mental health issues and was influential nationally. She also was an energetic trainer and advocate on mental health. In 2010, aged 53, she was admitted to a North London Hospital under the Mental Health Act. Whilst on the ward she died inadvertently following a self-harming incident. The investigation which followed was conducted internally by the NHS Trust which provided the care to Janey (Roberts, 2012).

Janey's husband is calling for investigations into deaths of mental health patients’ to be made public and to be carried out independently (Roberts, 2012). It is evidence that the current system dents public confidence in mental health care in the UK. It should be possible to devise a system which provides relatives, carers and the general public with the assurances they are clearly seeking.

Independent reviews of each and every death within the mental health setting would place a huge strain on budgets and resources and would probably be unnecessary. One of the key points in the Janey Antonio case was that she was detained under the Mental Health Act and this was therefore technically a “Death in Custody”. Had Janey died under any other form of detention (such as police custody) this would have automatically triggered an independent review. It is difficult to see how detention under the Mental Health Act gives the people and their families less rights to independent scrutiny. There are process changes that could be enforced that would ensure cases like Janey Antoniou's received independent scrutiny. Issues could be identified and dealt with which could help maintain or even restore public confidence in the system.

Deaths in prison and police custody have been independently investigated since 2004. The government argues this is not required for MHA deaths because that job is carried out by a coroner and, on occasions, a jury.

Victoria McNally, Janey Antoniou's caseworker at INQUEST summed up the situation when she said that: “Some trusts do a good job of internal investigation, some are absolutely appalling”. At the current time there is little external scrutiny which identifies the good from the bad and what missed opportunities for learning results from these (Roberts, 2012).

In this edition of the journal we have a rich mixture of research and practice articles. Ian Hall outlines the results of applying a cognitive neurological rehabilitation approach in the therapeutic management of patients with learning disabilities who exhibit the extremes of challenging behaviour and aggression.

The paper explores the remarkable progress made by two patients for whom services seemed to be at a loss with as regards meeting all but their basic needs. The catalyst for both their journeys from a situation of hopelessness to one of optimism and hope he suggests lies in the application of a cognitive neurological rehabilitation approach to care delivery.

Kerensa Hocken outlines the use of the Structured Assessment of Risk and Need (SARN) tool with intellectually disabled sexual offenders. This research highlights the importance of the risk assessment process in producing an accurate assessment of risk in sexual offenders with ID. The author suggests that although this research focused entirely on the SARN risk tool, the findings are applicable to any structured clinical risk assessment used with ID offenders the principles of which could be adopted by anyone carrying out risk assessments with ID offenders.

Clare Whitton's paper explores psychological supervision and consultation for nurses in a Learning Disability Forensic Service. Her findings suggest that ward-based nursing staff have benefitted from having the opportunity to attend and engage in consultation and the psychological, supervisory process. The supervisory process appears not only to have had a more positive impact on participants’ nursing role, but has also enhanced their well-being (e.g. in terms of managing difficult, evoked emotions and stress) and the care in which they provide to forensic service users.

Pamela Inglis's paper deals mainly with the topic of violence, aggression and de-escalation. It defines de-escalation; describes the techniques commonly used; and questions the evidence base for the techniques.

Glen Batey and Theresa Comer's paper addresses the “Development of an internet risk awareness group for learning disabled offenders”. Glen and Teresa argue that the internet has become an integral part of modern life and for the vast majority of users its benefits far outweigh the potential consequences. However, here is concern that it could influence behaviour and induce or support pathological thinking. It was with these issues in mind that they developed an internet risk awareness group for individuals with a learning/developmental disability and a forensic background. They conclude that there is a clear need to develop effective interventions for people with a learning disability to access the internet in a manner that promotes independence, reduces vulnerability and minimises risk.

Colin Dale

References

Appleby, L., Kapur, N., Shaw, J., Isabelle M. Hunt, David While, Sandra Flynn, Kirsten Windfuhr and Alyson Williams (2012), “National confidential inquiry into suicide and homicide by people with mental illness”, annual report, England and Wales, available at: www.bbmh.manchester.ac.uk/cmhr/research/centreforsuicideprevention/nci/reports/annual_report_2012.pdf

Roberts, Y. (2012), “She was a person not a diagnosis”, The Observer, 26 May, p. 9

Further reading

Care Quality Commission (2013), “Monitoring the Mental Health Act in 2011/12”, presented to Parliament by the Secretary of State for Health pursuant to section 120D(3) of the Mental Health Act 1983, Care Quality Commission, London, available at: www.cqc.org.uk (accessed 20 September 2013)

Department of Health (2005), Independent Investigation of Adverse Events in Mental Health Services, Department of Health, London, available at: www.dh.gov.uk/assetRoot/04/11/35/74/04113574.pdf

Francis, R. (2013), Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry, The Stationery Office, London

Health Select Committee (2013), “2012 accountability hearing with the Care Quality Commission”, available at: www.publications.parliament.uk/pa/cm201213/cmselect/cmhealth/592/59205.htm (accessed 20 September 2013)