Select Committee on Health Written Evidence


Memorandum by Mind (National Association for Mental Health) (PS 40)

PATIENT SAFETY

  Mind (NAMH) is the leading mental health charity in England and Wales.

  Mind's vision is of a society that promotes and protects good mental health for all, and that treats people with experience of mental distress fairly, positively, and with respect.

  The needs and experiences of people with mental distress drive our work and we make sure their voice is heard by those who influence change.

  Our independence gives us the freedom to stand up and speak out on the real issues that affect daily lives.

  We provide information and support, campaign to improve policy and attitudes and, in partnership with independent local Mind associations, develop local services.

  We do all this to make it possible for people who experience mental distress to live full lives, and play their full part in society.

  Being informed, diversity, partnership, integrity and determination are the values underpinning Mind's work.

EXECUTIVE SUMMARY

  Mind welcomes the opportunity to respond to the Health Select Committee's inquiry into patient safety. We make the following comments and recommendations.

    —  General safety—Assaults, threats and feeling unsafe are common problems on mental health wards. The implementation of guidance and training on control and restraint and the prevention and non-physical management of violence is crucial to a safer ward environment.

    —  Sexual safety—The Department of Health should pursue full compliance with its standards on single sex wards as a matter of urgency. Definitions of mixed and single sex accommodation should be reviewed in consultation with service users.

    —  Protection from abuse—Adult protection procedures should be implemented in mental health services to minimise the risk of abuse, and to ensure appropriate interventions if abuse does occur.

    —  Reporting crimes—Violent or abusive incidents are often seen as a hospital matter, rather than a criminal matter to be reported externally.

    —  Complaints—Inpatients are put at risk by poor handling of complaints. Low expectations of being taken seriously, fears of a reprisal, and an institutional culture of resistance to complaints compound problems. The new joint regulator (The Care Quality Commission) must retain their powers to investigate complaints.

    —  Third-party reporting schemes should be set up as an independent, effective and locally accessible recourse for inpatients to report violent or abusive incidents, and to make complaints about mental health services.

    —  Training—Staff should be trained on mental health awareness, effective handling of complaints, managing violence, and sexual safety.

    —  Prescribing practices—Inpatients experience serious adverse effects from neuroleptic medication, especially when administered in high or combined doses. Prescribing practices should adhere to guidelines, ECT should meet ECTAS standards, and inpatients should be supported to make informed choices about coming off medication.

    —  Risk—There is excessive anxiety around the risks posed by people experiencing mental distress, and insufficient concern as to the risks posed to them by poor services.

1.   Safety on mental health wards

    "I was woken up one night by some commotion. A chap in the next room to me was punched in the face while he slept, by his room mate. The room mate was tranquilised and allowed to stay on the same ward. I know for a fact that that incident was never recorded by the hospital, which I found quite alarming."[219]

  1.1  Patient safety on mental health wards has long been acknowledged as a problem—sometimes resulting in serious consequences for patients and staff. In 2004 Mind conducted a survey of current and recent inpatients.[220] Over a quarter of our respondents (27 per cent) said they rarely felt safe while in hospital. 51 per cent of respondents reported being verbally or physically threatened during their stay, with 20 per cent reporting physical assault. The National Audit of Violence 2006-2007 found that 45 per cent of working-age inpatients had been made to feel upset or distressed by another patient's behaviour.[221] 34 per cent of inpatients had been personally threatened or made to feel unsafe, and 18 per cent had been physically assaulted.

  1.2  Physical management of violence may be necessary in some circumstances and high standards of training in physical interventions are essential for patient safety as the deaths of patients during or following restraint testify. The inquiry into the death of David (Rocky) Bennett in 2003 made many recommendations including a national system of training in restraint and control, an audit of the use of restraint and control, and that under no circumstances should any patient be restrained in a prone position for more than three minutes. The Government responded in 2005 and did not agree the time limit but promised definitive guidance and national training (this was being developed by the National Institute for Mental Health in England and the National Patient Safety Agency, when the Government responded to the report).

  1.3  The coroner in the inquest into the death of Geoffrey Hodgkins, who died in 2004 after being restrained face down for 25 minutes, recorded a narrative verdict and said that a string of failures led to his death. He said that he would write to the authorities calling for national guidelines to be introduced as soon as possible. Despite proposals for the training scheme being finalised by the end of 2006, the scheme is not yet live and the definitive guidance has not yet been published, although it is expected later this year.[222] Mind's view is that this work should be implemented as soon as possible and we support the Mental Health Act Commission recommendation for mandatory staff training for all those engaged in physical restraint interventions.

  1.4  Hospital staff can play a crucial role in preventing and managing violent incidents on wards. In its recent review of acute mental health services, the Healthcare Commission found that only about two thirds of staff nationally had received training in preventing or handling violence.[223] However, the proportion of staff who had received training in the last 12 months varied between trusts, from 39 to 85 per cent. All front-line staff were due to have had training on the prevention and non-physical management of violence (Promoting Safer and Therapeutic Services) by March 2008. Although the data collection for this survey finished before this deadline, we are concerned that front line staff have not had this training. Mind recommends that trusts should be required to confirm that all staff have received this mandatory training and that systems are in place to ensure refresher training and training for new staff on an ongoing basis.

  1.5  A negative hospital environment represents a false economy for Trusts. It hampers the recovery of patients, which in turn leads to longer inpatient stays and a greater reluctance for voluntary patients to return to hospital, if necessary. The recruitment and retention of staff in mental health wards is also problematic as a result of this.

  1.6  A therapeutic environment for patients, on the other hand, has been found to enhance recovery and reduce boredom and violence in mental health wards. "Star Wards"[224] offers numerous suggestions on how to alleviate boredom and improve safety for all those on an inpatient ward, both staff and patients.

2.   Sexual safety on mental health wards

    "My bed had just a curtain round it. Even though facilities were segregated, male patients and male staff were still allowed in the female half of the ward."

  2.1  Mind has long campaigned for single sex accommodation in mental health wards. In 1996 Tony Blair, as leader of the Opposition, said that it should not be "beyond the collective wit of government and health administrators" to eliminate mixed-sex wards from the NHS.[225] However, repeatedly we hear that the Government is not meeting its own targets on this. The Healthcare Commission found that 68 per cent of mental health patients were accommodated on mixed sex wards last year.[226] In 2006 the National Patient Safety Agency (NPSA) report on ward safety uncovered disturbingly high rates of sexual harassment and assault, including 19 allegations of rape.[227]

  2.2  Mind would like the Department of Health to pursue full compliance with its standards as a matter of urgency and definitions of mixed and single sex accommodation reviewed in consultation with service users.

  2.3  The Healthcare Commission (2008) have also found that risk assessments for sexual vulnerability were the least likely risk assessments to be done in mental health wards.[228] 30 per cent of trusts said that none of their ward-based staff had training in sexual safety awareness during 2005-2007. Mind believes that ward-based staff must have training in sexual safety awareness.

3.   Protection from abuse

  3.1  Witness, the organisation that campaigns against abuse by health and social care workers, reports that abuse by people working in mental health accounts for more calls to its helpline than any other sector.[229]

  3.2  We share Witness's concerns that the Government should have responded fully to the findings of the Kerr/Haslam inquiry, published in 2005. William Kerr and Michael Haslam, both NHS consultant psychiatrists, were found to have sexually assaulted at least 77 of their patients over a 20-year period.[230] According to the inquiry, Kerr had raped or molested at least 67 women between 1965 and 1988. Thirty eight of the women complained to nurses and 11 GPs but were dismissed as "fantasists". The inquiry found serious failings on the part of local health authorities and concluded "that substantial risks remain that patients and staff who raise concerns or complaints will not be heard, and we are not persuaded that their concerns will even now, in 2005, be speedily and appropriately addressed."

  3.3  For many years, Mind has called on the Department of Health and regulatory bodies to ensure substantive measures for public protection from malpractice and we welcome the anticipated statutory regulation of those providing psychological therapies in the NHS.

  3.4  The Government is about to launch a consultation on the reform of its guidance on adult protection procedures. No Secrets, the current guidance, puts a duty on health, social care and criminal justice professionals to work together to ensure that "vulnerable" adults—including people receiving mental health services—are not at risk of abuse and that where abuse occurs, appropriate services intervene.

  3.5  The definition of "vulnerable adult" must clearly include mental health service users. We have heard reports of people with mental health problems not being referred to adult protection teams because the current definition of eligibility—which includes people who "are or might be in receipt of community care services"—is interpreted to mean people who meet the high levels of need required for access to local authority social care services. However, the circumstances of many mental health patients can be vulnerable—when they are particularly unwell, when they are detained in wards and when they are isolated in the community with few social networks. People in this group might not meet social care eligibility criteria but they will be receiving services from a mental health team or their GP. Mind will be calling for mental health services to be drawn into adult protection culture through establishing more clearly the duties on mental health professionals

4.   Reporting crimes in mental health wards

    "It is my experience that people with mental health issues are seen as unreliable witnesses and therefore prosecutions are not followed through." —Support worker[231]

    "It's a different world in there. Things that are unacceptable outside are seen as par for the course in there."— Former mental health inpatient[232]

  4.1  The available evidence suggests that violent or abusive incidents on wards are seen as a hospital matter and not as a crime to be reported externally. Mind's Ward Watch report found that fewer than half of victims even tell a member of staff.[233] A report by the National Patient Safety Agency found that, though incidents were investigated locally, there was little evidence to suggest they were reported to the police.[234]

  4.2  In 2007 Mind's Another Assault campaign asked about people's experience of reporting crimes in institutional settings.[235] Our research highlighted a series of barriers that block inpatients' access to justice, from victims' low expectations of reports being dealt with, to the failure of staff or police to treat incidents as genuine crimes. Respondents' testimony suggests that they were often discouraged from reporting a crime to the authorities by their carers and health professionals. Seventeen per cent of respondents were concerned that the services they receive might be threatened if they caused a fuss. In many cases, people said they told their nurse or another member of staff about an incident but this person did not encourage them to take the matter further.

  4.3  The issue of credibility is a particular concern where the perpetrator of a crime is in a position of power. It makes it very difficult for people with mental distress to make complaints against members of staff in healthcare settings. As one of the former inpatients quoted in our Another Assault report put it, "He is a well-known "professional" and I am nobody." Being disempowered can be part and parcel of being in hospital, particularly when a person is detained under Mental Health Act powers.

  4.4  One solution to this power imbalance is for an independent third-party reporting scheme to be available to patients in institutional settings. Local third-party reporting schemes should have the power to direct complaints to the appropriate institution or to report to the police, if the victim so wishes. Additionally, such reporting schemes could feed into national reporting, with the joint regulator able to investigate. Mind would also like to see a strengthening of the obligations of health services to work with criminal justice agencies so that people in potentially vulnerable situations have the same right to a fair investigation where a crime has been committed.

5.   Reforming complaints procedures in mental health wards

    "With mental illness you have to take a few knocks—you can't go running to the hospital all the time."[236]

  5.1  Mental health inpatients, in particular, are put at risk by inadequate handling of complaints. Our Ward Watch survey found that they frequently felt unable to complain due to a fear of reprisal and a lack of confidence that their complaint would be taken seriously.[237] Mental health inpatients should be actively supported to make effective complaints, rather than being deterred or intimidated by the institutional setting.

  5.2  In 2007 Mind responded to the Government's proposed new arrangements for handling health and social care complaints.[238] We argued that the proposals were not sufficient to address the culture of resistance (even hostility) to complaints. Many of the problems in handling complaints appeared to be localised in the systems or institutional cultures of particular hospitals. Mind are concerned about proposals to reduce the role of the Healthcare Commission (or the Care Quality Commission), given its potential to provide a nationally consistent recourse, which would in turn support the "local resolution" of complaints. We also support the proposals that the current Mental Health Act Commission retain its powers when the joint regulator comes into being.

  5.3  Complaints system should be supported by an advocacy service tailored to the needs of different groups, for example black and minority ethnic communities, refugees and asylum seekers, and people with learning difficulties. Generic advocacy for vulnerable patients is not sufficient.

  5.4  Mind calls for all health professionals responsible for the handling of complaints to receive training on mental health awareness and on complaint procedures, so complaints are handled in an effective, fair and non-discriminatory manner. Appropriate "whistleblowing" procedures should also be in place in mental health wards.

6.   Prescribing Practice

  6.1  Neuroleptic (antipsychotic) medication can have serious adverse effects, especially when given in high or combined doses. Treatment guidelines recommend that, with one or two exceptions, they be prescribed at standard doses and not in combination. In an audit of trusts participating in a quality improvement programme run by the Prescribing Observatory for Mental Health (POMH UK),[239] just over a third of service users on adult acute wards were on doses above the recommended maximum and around 40 per cent were on more than one antipsychotic drug.[240]

  6.2  A major contributory factor to combined and high dose antipsychotic prescription was the use of "prn" (pro re nata, or "as required") medication. This is when a prescriber authorises the use of an antipsychotic on an "as required" basis, in addition to the regular daily dose, and it is left to ward staff to decide if it is needed. The most frequent reason is to "control disturbed behaviour". It is clearly vital for the health and safety of mental health inpatients that prn prescribing be reduced.

  6.3  Even within guidelines psychiatric drugs can have serious adverse effects. These need to be recognised, minimised and/or managed, but also where people wish to try reducing or coming off medication they should be supported to make informed choices to do so as safely as possible. Mind's study[241] shows that service user perspectives on psychiatric drugs are often not understood by prescribers and that people do not get the support they want in this situation. Mind would like to see more negotiated decision-making about medication and NICE's forthcoming guideline on medicines concordance may assist in this. Mind also recommends more training of doctors in service user perspectives on medication and supporting safe withdrawal.

  6.4  Electroconvulsive therapy (ECT) is a highly controversial treatment. Its critics describe it as a crude treatment that causes brain damage, while its supporters defend it as an effective and life-saving technique.

  6.5  Whatever view is taken of its validity and effectiveness it is essential that where ECT is used it is as safe as possible. The ECT Accreditation Service (ECTAS) is another quality improvement programme at the Royal College of Psychiatrists that assesses ECT clinics against a set of quality standards. While many clinics are showing high standards, some have their accreditation deferred until they put various deficiencies right. In debates on the Mental Health Bill 2006 the minister Lord Hunt said that regulation was the role of the Healthcare Commission, adding, "it would be in everyone's interest if all providers took advantage of the accreditation scheme".[242] The Healthcare Commission has included registration with ECTAS as an indicator in its review of acute units. However, in the recent Healthcare Commission review of mental health acute units, about a quarter of trusts had no ECT clinics accredited or registered.[243] Mind believes it is unacceptable that people may have ECT in units that may not meet quality standards and considers that registration with ECTAS should be expected.

7.   Public perceptions of risk and mental health

  In a recent report, Mind examined the way narrow evaluations of risk have impacted on the lives of people with mental distress.[244] Discussions of risk and mental health have tended to grossly exaggerate the risk of violence posed by people with mental distress to others in society, while ignoring the risks that poor services pose. In the media and in popular opinion, mental health inpatients are characterised as violent and dangerous but in fact, the vast majority of violent crime is committed by people who do not have mental health problems. More investment in evidence based services; timely assessments when people are unwell; and appropriate and joined up services that are responsive to individual's needs can help to prevent people's condition deteriorating to the point at which they might pose a risk to themselves or, in a small number of cases, to other people.

September 2008








219   Quote from a respondent to our survey in Mind (2007) Another Assault: Mind's campaign for equal access to justice for people with mental health problems Back

220   Mind (2004) Ward Watch: Mind's campaign to improve hospital conditions for mental health patients Back

221   Healthcare Commission and Royal College of Psychiatrists (2007) National Audit of Violence 2006-2007: Final Report-Working age adult services Back

222   Recommendation 17 in Mental Health Act Commission (2008) Risks, Rights, Recovery, Biennial report 2005-07. Back

223   Healthcare Commission (2008) The Pathway to Recovery-A review of NHS acute inpatient mental health services Back

224   Star Wards (2008) Star Wards 2: the sequel Back

225   See http://www.independent.co.uk/life-style/health-and-wellbeing/health- news/mixedsex-wards-pressure-grows-to-end-scandal-776165.html Back

226   Healthcare Commission (2007) Count me in 2007: Results of the 2007 national census of inpatients in mental health and learning disability services in England and Wales Back

227   National Patient Safety Agency (2006) With Safety in Mind: mental health services and patient safety Back

228   Healthcare Commission (2008) The pathway to recovery-A review of NHS acute inpatient mental health services Back

229   From Mind (2007) Mind's response to Public Administration Select Committee Consultation Public Services: putting people first? Back

230   Department of Health (2005) The Kerr/Haslam Inquiry: Full Report Back

231   Quoted in Mind (2007) Another Assault: Mind's campaign for equal access to justice for people with mental health problems Back

232   Quoted in Mind (2004) Ward Watch: Mind's campaign to improve hospital conditions for mental health patients Back

233   Mind (2004) Ward Watch: Mind's campaign to improve hospital conditions for mental health patients Back

234   National Patient Safety Agency (2006) With Safety in Mind Back

235   Mind (2007) Another Assault: Mind's campaign for equal access to justice for people with mental health problems Back

236   Quote from a mental health inpatient in Mind (2007) Mind's response to Making Experiences Count Back

237   Mind (2004) Ward Watch: Mind's campaign to improve hospital conditions for mental health patients Back

238   Mind (2007) Mind's response to Making Experiences Count Back

239   POMH UK is based within the Royal College of Psychiatrists' Centre for Quality Improvement. The baseline audit was carried out in January 2006. Back

240   C Paton et al (2008) High-dose and combination antipsychotic prescribing in acute adult wards in the UK: the challenges posed by prn prescribing, British Journal of Psychiatry, 192(6):435-9. Back

241   J Read (2005) Coping with coming off: Mind's research into the experiences of people trying to come off psychiatric drugs. Mind. Back

242   15 Jan 2007: Column 489 Back

243   Healthcare Commission (2008) Pathways to recovery. Back

244   Mind (2008) Chance would be a fine thing: Reassessing risk in mental health. Mind. Back


 
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