Select Committee on Health Written Evidence

Memorandum by the Royal College of Psychiatrists (PS 68)


  The Royal College of Psychiatrists is the leading medical authority on mental health in the United Kingdom and is the professional and educational organisation for doctors specialising in psychiatry.


  There is much policy guidance and recent robust evidence concerning issues of safety for patients with mental disorder. Recommendations should be heeded by NHS bodies and progress towards their implementation monitored.

  The problem of violence on wards is a serious one calling for improvements in staff training, reduced bed occupancy levels and better ward conditions.

  The findings of the National Confidential Inquiries into Homicide and Suicide contain important themes for patient safety including the need to improve the transition from hospital to community, to improve observation procedures for vulnerable patients and to develop services for those with substance misuse and mental disorder who are among the most vulnerable patients

  Risk assessment and risk management are features of everyday practice for psychiatrists. All mental health professionals, including psychiatrists, should be trained in these matters. However risk cannot be eliminated and controlled risk taking is part of good practice which promotes recovery for patients. The development of a risk-averse culture has a negative impact on the practice of psychiatry and does not promote patient safety. There should be a national approach to risk assessment and risk management and lengthy risk assessment tools that lack an evidence base should not be routinely used on all patients. They promote a tick box mentality that is not conducive to good clinical practice.

  The issue of patient sexuality, sexual abuse and the problem of sexual boundaries arise in the care and treatment of mental health patients and extant standards should be followed by all bodies with mental health patients.


  1.  Psychiatric patients are a particularly vulnerable patient group. Much policy guidance (including from NICE) to protect vulnerable patients has been provided from a variety of government and professional sources. The new Mental Health Act Code of Practice provides explicit standards for the most vulnerable of patients, those detained under mental health legislation. It covers such topics as seclusion, restraint and the safe and therapeutic responses to disturbed behaviour. These should provide minimum standards for all inpatients on mental health wards. Also reports from the Healthcare Commission, the Mental Health Act Commission and other bodies, including the Royal College of Psychiatrists, have exposed bad practice, commended improvements and good practice and recommended changes to policy and practice where needed. These documents provide ample robust evidence of where improvements are necessary and useful information for this inquiry. They also demonstrate, as the Inquiry puts it, how far the Boards of NHS bodies have established a safety culture.

  2.  Good clinical practice guidance: Good clinical practice is essential to the safety wellbeing and recovery of mental health patients and the College provides guidance and training for psychiatrists. For instance the recent College Report "Vulnerable Patients, safe doctors" sets out principles of good practice in the therapeutic relationship between patient and practitioner. It emphasises the need for psychiatrists to develop self awareness in the service of patients, the need to respect patient autonomy, to share up to date knowledge, to avoid boundary violations, to observe clear roles, to maintain privacy, to manage risk and to develop a contract of mutual respect with the patient. The role of patient and doctor empowerment as well as organisational management and resources in maintaining safety is critical.

  3.  The Reports of Confidential Inquiries into Suicide and Homicide: The Reports of Confidential Inquiries into Suicide and Homicide, most recently in 2006 (England and Wales) and 2008 (Scotland) give detailed recommendations for improving the safety of patients. They are essentially the same as those in previous reports, indicating on the one hand that there is still room for improvement and on the other that exemplary service provision is hard to attain in the real world of a busy and stretched NHS.

  4.  In summary the recommendations include introduction of measures to reduce absconding from in-patient units and to strengthen the transition from ward to community, to improve case management, to strengthen observation procedures on wards, further improve the physical environment on wards, develop services for dual diagnosis patients and give greater emphasis to risk management in older people's services. These are all important issues which affect the safety of many patients, beyond those for whom a tragic consequence occurs. For sudden unexplained deaths the 2006 inquiry called for measures to further improve the safety of prescribing, in particular by avoiding potentially cardio toxic drugs in patients with a history of cardiovascular or respiratory disease, give greater priority to physical health care, particularly on in-patient units adopt strict standards for physical restraint and review each incident follow protocols for rapid tranquilisation ensure that CPR training and equipment are available in all locations where care is provided.

  5.  The Healthcare Commission: The Pathway to Recovery, a Review of NHS Inpatient mental health services (2008) has findings that are directly relevant to patient safety. It focused on the NHS providers of acute mental health wards and psychiatric intensive care units that service adults of working age. A total of 69 mental health trusts, 554 wards, 9885 beds (out of 11,000 beds nationally) were reviewed. This represents half of all NHS beds for adults with mental health problems in England, and 84% of beds registered with the Department of Health (as available for short stay admissions). They investigated, among other things, whether the ward has systems, processes and facilities in place to ensure the safety of service users, staff and visitors. Some of their findings on violence on wards, inpatient conditions and systems failures are mentioned below.

  6.  The Mental Health Act Commission (MHAC) Risk, rights and recovery Twelfth Biennial Report 2005-2007 is relevant to this inquiry as it deals with the situation of detained patients in inpatient wards. The Report was particularly concerned about the pressure on admissions and the problem of bed occupancy rates. Over-occupancy—where a ward has more patients on its admission list than available beds—remains a key problem in mental health. This lack of bed space can result in serious difficulties in terms of admitting new patients, discharging them on short term leave or transferring them to a more appropriate ward or hospital. It can hinder patient treatment and well-being, and it may affect ward atmosphere and patient safety.

  7.  Inpatient conditions: The MHAC found

    "The busy acute wards that we visit appear to be tougher and scarier places than we saw a decade ago. Something needs to be done about this. It is scandalous that we are forcing vulnerable people onto mental health wards that are frightening and dangerous places. This should not happen at all, but it should be a matter of extreme priority that children are not placed in such situations, and that women's safety from sexual harassment, abuse and assault is addressed within the mental health service".

  8.  Healthcare Commission and the Royal College of Psychiatrists, National Audit of Violence 2006-7. The Final Reports of Older people's services and Working age adult services give a detailed picture of the current state of provision in mental health services and indicate where improvement is required for the safety of patients and staff. A total of 69 NHS Trusts and independent sector organisations took part, representing 78% of all eligible participants in England and Wales. Their conclusions on issues of environmental safety, ward communication systems, staff training supervision and support, reporting systems and the provision of meaningful occupation in the wards and patient mix are particularly relevant to this inquiry. While both reports revealed a mixed picture there is considerable cause for concern on all these issues.

  9.  In the following parts of the document we address specific issues raised by the Committee and we highlight relevant issues which have been raised in recent Reports and research findings by the College. They concern particularly the role of risk assessment and risk management in clinical practice and safety in mental health wards and in acute and emergency care


How far clinical practice can be risk-free; the definition of "avoidable" risk; whether the "precautionary principle" can be applied to healthcare

  10.  Good clinical care by definition must include good risk assessment and management. It involves the assessment and management of risk in order to avoid harm and at times controlled risk taking in order to benefit the patient. Managing risk to the patient (and to other patients) is integral to all psychiatric practice; for instance even weighing the effects vs. the possible side effects of any medication for mental illness, involves an assessment of risk. Given the powerful nature of these drugs and the potentially damaging impact of side effects (including in some cases an increased risk of suicide) the safety of the patient is inextricably bound up with effective and careful prescribing practice, and good medical record keeping.


  11.  The incidence of violence: The incidence of violence in mental health services is not infrequent particularly in inner city areas. The UK700 study found physical assaults had been committed by 20% of patients over a 2-year period and 60% had behaved violently over the same period. The Healthcare Commission found that 43% of service users on acute wards had felt upset or distressed, 31% had been threatened or made to feel unsafe and 15% reported being physically assaulted. On average, 11% of all service users were assaulted in 2006. (2006-07 National Audit of Violence). This review states that one in six trusts were significantly above this average and that this is unacceptable in a 21st century service and would not be tolerated in other walks of life. Conditions on wards—including overcrowding, lack of fully trained staff and inadequate opportunities for meaningful activities are major contributors to these problems. It is also the case that with the move towards community care those patients who are in hospital are often acutely ill. There is also a small but significant association between some types of serious mental illness and a propensity to violence to others or, rarely, homicide. People with mental illness or learning disability may also be victims of violence. There is a link between mental illness and self harm (and in rare cases suicide). Where violence by people with mental illness, either to themselves or others, is related to their mental health condition professional care and effective treatment can reduce the risk of violence, thus enhancing the safety of the person and other patients. Risk assessment and risk management are also an important part of minimizing the risk of violence.

  12.  Substance misuse: On a population level the risk of violence is increased once substance misuse is taken into account. Substance misuse presents enormous problems and challenges for mental health services. Any service dealing with mentally ill patients who misuse substances may have to expect to encounter an increased rate of violent incidents and have the appropriate level of training to minimize the risk. Primary care mental health services should provide education about the damage caused by substance misuse, including psychological damage and violence. Mentally ill patients with a history of substance misuse should be offered the appropriate help, if necessary through referral to drug or alcohol services. The recent Healthcare Commission Report cited above (Para. 5) found that despite high levels of co-morbid mental health and substance misuse problems, only 26% of clinical staff reported having had training in assessing services users' use of substances and only 22% had received training on how to deal with service users who may be under the influence of drugs/alcohol.

  13.  The need for a multi-agency approach for substance abuse: The management of patients at risk of violence who misuse substances is further complicated and compounded by other factors including multiple disadvantages arising from illness, histories of childhood adversity, personality disorder, high levels of social exclusion. Mental health services will have little impact on other potent factors contributing to risk. This has led to the Social Exclusion Unit recommending a multi-agency approach to the management of individuals with complex problems recognising that no one agency by themselves can effectively manage risk in complex cases. National policy needs to respond more directly to this serious contributor to lack of patient safety.


  14.  College work on risk: Recent and ongoing work in the College is focussed on patient risk, covering both risk to others and risk to self. The Risk Report Rethinking Risk to Others in Mental Health Services was published in July 2008. (This followed the CSIP Risk Management Programme Report Best Practice in Managing Risk in June 2007, the conclusions of which the College supports.) The conclusions of the College Report are based partly on a survey of College members undertaken in 2006. Other findings are based on published evidence which can be found in the bibliography to that Report.

  15.  There is a developing consensus among practitioners, academics, service users and their families that what work best in reducing risk are personalized, intensive services with good communication between services. On an individual level a detailed understanding of the patient's mental state, life circumstances and thinking is a major contributor to prevention of harm. The College believes that this is best achieved by well-trained professionals operating in a well-resourced environment.

  16.  Role of risk assessment: First, risk cannot be eliminated. While it might be possible to predict and minimise risk in some settings the risks posed by those with mental disorders are much less susceptible to prediction because of the multiplicity of and complex inter relation of factors underlying a person's behaviour. Secondly, this does not mean that the use of evidence based structured risk assessment systems is not useful in routine clinical practice. When systematically applied by a clinical team trained in their use within a tiered approach to risk assessment their use can enhance clinical judgement. Risk assessment should then be seen as an assessment of a current situation, not itself a predictor of a particular event. Its critical function is to stratify people into a group (low, medium or high risk), which will help dictate the appropriate care and treatment and risk management strategy. This will contribute to effective safe service delivery.

  17.  Risk assessment and risk management are thus accepted as essential skills for all practitioners. The College Report stated

    "Improvements are required in the training which psychiatrists and other members of the mental health team receive in risk assessment and management. There was agreement that both should become core, mandatory competencies in the curriculum for specialist training and psychiatry and in the training of other mental health professionals. There were also calls for continuous training, better mentoring arrangements and testing of psychiatrists on risk through examinations".

Whether adequate measurement and assessment is undertaken and acted upon

  18.  The use of risk assessment tools: Government policy on risk assessment has promoted in England the development of a raft of "local" risk assessment tools designed internally by mental health Trusts. These are in use in most Trusts and in most cases are compulsory for all patients, irrespective of whether they are in a high risk group. There is evidence that in identifying risk factors they vary greatly in their content and their complexity. They also differ in the extent to which they rely on tick boxing. College Faculties are concerned as to the utility of these forms. They lack a rigorous scientific, statistical or evidentiary basis and thus arguably do not meet the Government criterion of "clearly defined factors derived from research"(Dept of Health 2006). Nor are they always validated on local populations from which patients are drawn. They were described by survey respondents as bureaucratic and lengthy documents, made up principally of "tick boxes", consuming a disproportionate amount of psychiatrists' time. Different Trusts were producing forms of varying quality. This posed problems and dangers of misinterpretation of findings for clinicians moving across Trusts.

  19.  The absence of a body of research evidence that these existing risk assessment tools actually reduced or prevented adverse incidents was also of concern. 87% of participants in the survey concluded that SRA completion provided a false sense of security that risk had been adequately assessed, despite the lack of an evidence base. More than one-in-two (58%) participants observed that the use of SRA forms was primarily the result of a defensive organisational and medical culture, rather than serving an evidence-based clinical or care function. A "file and forget" culture was emerging. There was limited follow through from the assessment to a robust management of risk. Those forms that employed tick boxes were frequently cited as eroding meaningful clinical decision making. The over emphasis on form filling was seen to be potentially at the expense of patient engagement. The Report recommended that Mental Health Trusts should ensure that all risk assessment forms in use in their organisation are validated for use with each specific patient group and reflect the current evidence base.

  20.  The Report also recommended the adoption of a national standard approach:

    "A standard approach to risk assessment should be developed throughout all mental health services nationally, with adaptation to suit different patient groups. The development of guidelines would require a framework for the assessment and management of risk, underpinned by a set of key principles. The framework should constitute a tiered approach containing a standard set of questions. The need for further tiers would be determined by responses to an initial screening process as well as the context in which the psychiatrist works and their particular patient group (speciality and lifespan)".

The role of public perceptions of risk in determining NHS policy

  21.  Over the last ten years, the risk posed by mental health service users, particularly to others, has been brought into the spotlight by the government and media as homicide inquiries have suggested failings in the risk management of some mentally disordered patients. Suicide inquiries have also highlighted systems and individual failings.

  22.  Psychiatrists are conscious of the immeasurable impact of homicides and suicides on families and recognize their responsibility to their patients and the wider public to use their professional skills in reducing risk. They are personally affected by such tragedies and are often professionally involved in dealing with the trauma suffered by family members and other associates of the person who has died. However psychiatrists also feel the pressure of a blame culture which has arisen as a result of the growing public and political preoccupation with the risks posed by people with mental illness. They have become the primary targets for blame following a homicide by a mentally ill patient. While professional accountability is rightfully central to any psychiatrist's practice the effects of this culture can be counterproductive, leading to defensive practice, undermining professional morale and recruitment into the profession.

23.  Members of the Scoping Group and psychiatrists responding to the College survey reported that risk was dominating their practice. They argued that they were increasingly expected to function as "agents of social control" which was having a damaging impact on their clinical practice undermining meaningful clinical decision-making and making engagement with patients more difficult. Moreover service users from the College Service Users Recovery Forum also reported to us their preference for safety enhancement rather than risk reduction as a more empowering approach to discussing risk.

  24.  Concern was expressed about the consequences of attempting to eliminate risk completely. It was felt that preoccupation with risk and a consequential tendency towards risk averse practice was stifling creativity and innovation. Members of the Scoping Group emphasised that risk taking was a vital part of a patient's rehabilitation and that risk averse practice was detrimental to this process.

Systems failures

  25.  The Risk Report states that communication often broke down between mental health teams when patients moved from one service to another and that this hindered gaining a full picture of a person's history and, therefore, the assessment of risk. Communication between mental health teams, the community and patients' families was essential to effective risk assessment. The Report recommends that discharge letters to GPs, copied to patients and carers (as agreed) must include details of Risk to self or others; diagnosis; treatment; indicators of relapse; details of any agreed risk management plan. The importance of sharing information between MHTs and criminal justice agencies, particularly the police, was also emphasised in some circumstances. Many members stressed that there was a need for better procedures for ensuring information about patients was exchanged and properly recorded.


  26.  The College Report "Sexual boundary issues in psychiatric settings" (2007) deals with sexual boundaries, an issue that is particularly pertinent for some mental health patients and in some settings. More than in other medical settings the psychological relationship between staff and patient is an essential part of the treatment in psychiatry -the staff member must be close enough to the patient to elicit the trust necessary for sharing of personal material and yet retain the skill of clinical detachment. The possibility to transgress professional boundaries must be guarded against. Some forms of treatment can provide the opportunity for abuse (for instance one to one sessions in isolated places or times). The question of understanding and observing proper boundaries with vulnerable patients is therefore a regular feature of professional practice.

  27.  The College Report concludes that Trusts should have evidence bases and protocols for treatments. They should be aware of therapies being undertaken by all staff, through supervision, appraisals and job plans. A register of treatments could be a useful mechanism for recording treatments and approved protocols; it could also include chaperone requirements, and specify training and supervision requirements for each treatment. Trusts need to ensure that there is an organizational culture in which clinical supervisors and managers understand the causes and recognition of sexual abuse and are aware of the situations in which abuse is more likely to occur. Staff induction programmes should include clear instructions about what behaviour is acceptable and what is unacceptable. In the recent Health care Commission Report (Para.5) nearly a third of trusts said that none of their ward based staff had received training in sexual safety awareness.

  28.  Patients with acute or chronic mental illness may lack capacity, they may be sexually disinhibited and invite from another or propose to another, inappropriate sexual behaviour. Others may be vulnerable to the sexual approaches of others. The problem is compounded in situations, such as acute wards, where the patient mix is very broad. The placement of young people on adult wards is particularly unacceptable but it still occurs.

  29.  Singe sex accommodation leads to a perceived improvement in safety according to anecdotal evidence and the Mental Health Act Commission, in its latest Biennial Report (Para 6) drew attention to the lack of safety, and perceived lack of safety for those detained patients who remain in mixed sex wards. The new Mental Health Act Code of Practice (16.9) stipulates the separation of facilities for men and women that should be attained for detained patients but this is not yet being achieved. According to a recent Mind survey almost a quarter (23%) of recent inpatients in England and Wales had been accommodated in mixed sex wards and 27% of respondents said they rarely felt safe while in hospital. The College considers the safety of vulnerable patients makes this a crucial issue for the Inquiry and calls for the implementation of the Code of Practice for all patients, not only those who are detained.

  30.  Each inpatient unit must have a policy with respect to allegations of sexual harassment, sexual abuse and rape, whether this is by another

patient, by a staff member or by a visitor to the ward. The policy will

address the duties of staff, immediate action, evidence, support to the

complainant, when and how to involve the police and/or social services,

incident reporting and investigation, and disciplinary procedures. There should be regular audit concerning the numbers of incidents, complaints and allegations, patient attitudes to policies, and staff attitudes, knowledge of and adherence to policies.


  While it is recognized that children and young people should not be placed on adult psychiatric wards, and there is a government pledge that this should be outlawed by this year, this continues to occur. Recent data from 52 of 72 NHS Trusts allegedly reveal that 26 children under 16 were treated on adult wards in 2007-8 and there were 390 young people aged 16-17. In January 2007, the Children's Commissioner published a report, Pushed into the Shadows: Young people's experience of adult mental health facilities, which is based upon the findings of a consultation carried out by YoungMinds with young people who had been admitted on to adult in-patient psychiatric facilities. The report shows that young people are still being admitted inappropriately onto adult psychiatric wards. Many of the young people in the "Pushed into the Shadows" report said that they did not feel safe on the wards; some describing how they had been harassed by other patients with little or no attempts by staff to address this, while others felt threatened or intimidated by staff. There should be measures to protect children from suicide and self-harm. Some of the young people stated that they were able to engage in harmful practices such as misusing drugs or self-harming whilst on the ward. These incidents suggest that staff lacked training in, and/or experience of, working with children and adolescents. The latest Report, "Out of the shadows" (2008) identifies areas of continuing concern for young people who are still being admitted to adult wards. To ensure safety young people need to have care and support from appropriately trained staff, but this is not the case in most wards. While the Children's Commissioner and YoungMinds keep monitoring this situation there needs to be proper monitoring at a government level and statistics should be recorded and made available.

Selected References

  Mental Health Act Commission (2006) In Place of Fear? Eleventh Biennial Report 2003-2005, London: TSO

  Mental Health Act Commission (2007). Risk, rights and recovery. Twelfth Biennial Report 2005-2007. TSO: UK.

  Sainsbury Centre for Mental Health (2005). Acute care 2004: A National Survey of Adult Psychiatric Wards in England. London: SCMH.

  Appleby et al (2006) National Confidential Enquiry into Suicide and Homicide by people with Mental Illness

  Department of Health (2007) Best Practice in Managing Risk. Principles and Evidence for Best Practice in the Assessment and Management of Risk to Self and Others in Mental Health Services. Department of Health.

  The Healthcare Commission National Audit of Violence 2006-7

  Final Report—Older People's Services;

  The Healthcare Commission National Audit of Violence 2006-7

  Final Report—Working Age Adult Services

  Children's Commissioner for England, Pushed into the Shadows: Young people's experience of adult mental health facilities, October 2007.

  Children's Commissioner for England and YoungMinds, Out of the Shadows?, October 2008

  Royal College of Psychiatrists

    —  Report CR145 "Sexual boundary issues in psychiatric settings"

    —  Report CR150 "Rethinking Risk to Others"

    —  Report CR146 "Vulnerable Patients, safe doctors"

    —  "Raising the standard" (2006)

  Higgins, N., Watts, D., Bindman, J., et al (2005) Assessing violence risk in general adult psychiatry. Psychiatric Bulletin, 29, 131-133.

  The Healthcare Commission: The Pathway to Recovery, a Review of NHS Inpatient mental health services (2008)

  Mind (2004). Ward Watch.

September 2008

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