17. Memorandum submitted by Mind
1. INTRODUCTION
2. The Joint Committee on Human Rights has
called for evidence relating to human rights and deaths in custody.
Mind is concerned about this issue as people with mental health
problems account for a large percentage of the total number of
people in the custody of the State and the number of people who
die in custody. In a recent study, of 172 suicides which had taken
place on 1999 and 2000, 72% of people had at least one psychiatric
diagnosis identified on entry to prison. [192]Mind
believes this inquiry needs to consider people who are detained
in the following settings:
(i) Prisons and police detention
(ii) Mental health institutions. This
should include people who are technically detained under the Mental
Health Act and those who are in effect unable to leave. This may
arise from inability to express a wish either to remain in hospital
or be discharged or from being advised that if they attempt to
leave, they will be detained under the Mental Health Act. These
two groups of people have none of the legal safeguards associated
with formal detention. We would therefore suggest that the inquiry
encompasses all deaths which take place in psychiatric in-patient
settings.
3. In addition, the high proportion of people
from black and minority ethnic communities detained both in in-patient
psychiatric settings and in prisons is a cause for great concern.
For example, a study in south London found that black populations
had a rate of admission to medium-secure units seven times higher
than their white counterparts (28 per 100,000 compared with 4
per 100,000). [193]Following
a number of cases of deaths of people from these communities,
particularly young black men, (for example the death of David
"Rocky" Bennett in 1998), it is evident that the needs
of black and minority ethnic people need particular attention.
4. In response to the questions raised by
the inquiry, Mind would like to make the following points, many
of which apply equally to prisons and in-patient psychiatric settings.
This response will cover the following areas:
— what are the main causes of suicide
and self-harm in custody;
— what are the main causes of other
deaths and injuries in custody;
— investigation of deaths in custody.
The submission concludes with a summary of recommendations.
WHAT ARE
MAIN CAUSES
OF SUICIDE
AND SELF-HARM
IN CUSTODY?
5. Incidences of suicide and self-harm often
arise either due to inadequate care and support available to people
whilst in a detained setting, or when conditions a person has
been detained in are not conducive to minimising anxiety and ensuring
they feel safe. This may result in suicide or self-harm, or alternatively
in increased agitation or aggressive behaviour which may lead
to physical restraint or increased medication being used which
has in the past led to deaths (see section on other deaths in
custody). In addition some forms of detention such as the use
of police cells as places of safety under the Mental Health Act
and the use of seclusion cause particular concern.
6. INADEQUATE
CARE AND
SUPPORT
7. Mental healthcare provision in prisons
is generally poor. Health provision remains dominated by physical
health concerns and the services available for people experiencing
mental health problems have been acknowledged as falling far below
the standard generally available from the NHS outside prisons.
[194]
8. People's general level of mental health
tends to deteriorate whilst they are detained in prison. In addition
to poor services, a number of factors contribute to this which
are detailed below. Many of these also relate to in-patient psychiatric
care. The Ninth Biennial report of the Mental Health Act Commission
found that there are a number of issues relating to conditions
which have human rights implications under Articles 3 and 8, for
example, denial of access to correspondence and family visits.
[195]
9. Isolation from families. Many prisoners
are placed in prisons a long distance from their home and it is
often difficult for families to visit. This leads to increased
social exclusion and can cause great distress.
10. Overcrowding and staff shortages. When
prisons become overcrowded, services which have been put in place
to support vulnerable people become overwhelmed with the result
that some people cannot access support when they need it. Staff
who are overstretched can fail to notice when someone is experiencing
distress. In addition, overcrowding leads to frequent relocation
of prisoners.
11. Disruption due to relocation. If a prisoner
who has mental health problems is moved from prison to prison,
any services or support they are receiving stop and relationships
which they may have built up with support staff are broken, often
at short notice, and similar services may not be available in
the prison they are moved to.
12. Staff training. Prison staff generally
receive little mental health awareness training and often do not
pick up signs that a prison is experiencing distress or be able
to deal appropriately with a prisoner in distress.
13. Lack of information sharing. In many
cases information from NHS health records relating to a prisoner
with mental health needs is not shared when they enter prison,
making it difficult to adequately assess their needs and provide
adequate services for them.
14. The National Confidential Inquiry into
Suicides and Homicides by People with Mental Illness (2003) [196]made
a number of recommendations, including:
— health screening at reception should
be carried out by someone with relevant mental health training;
— information regarding prisoners with
prior mental health service contact should be obtained from GPs,
mental health services and others within 24 hours;
— mental health services and GPs should
accept responsibility to share information with prisons and should
no longer impose charges;
— health and risk related information
should be shared with all members of staff within the prison who
are responsible for the prisoner;
— a family hotline should be established
within each prison to enable family members to obtain and pass
on information regarding suicide risk in prisoners; and
— all prisoners who have a history
of mental health symptoms suggestive of serious mental illness
or a history of self-harm should have a multi-disciplinary care
plan initiated at reception.
15. In addition, Mind recommends:
— the quality of mental health care
available in prisons should be an equal level to that available
generally in the NHS;
— a range of services should be available
and prisoners experiencing mental distress should have access
to a choice of treatments including talking treatments such as
counselling and psychotherapy;
— training for all prison officers
should include a mental health awareness component;
— clear procedures should be in place
for prisoners to seek advice or assistance with regard to mental
distress they are experiencing;
— prisoners engaging with mental health
services involving a therapeutic relationship should not be relocated
unless this is unavoidable;
— prisoners using mental health services
should not be relocated unless it is established that adequate
services to meet their needs will be available in the new location.
16. ENVIRONMENT
IN WHICH
A PERSON
IS DETAINED
17. The physical environment in which a
person is detained is a key component of developing a calm atmosphere
in which a detained person can feel safe and increased anxiety
can be minimised. The Royal College of Psychiatrists has issued
guidelines for the design of mental health units with this in
mind, [197]which
Mind believes should be implemented.
18. These recommendations include:
— all areas are kept clean and tidy;
— reception areas are well planned;
— there are separate/designated areas
for patients with police escorts;
— there is adequate natural lighting
and fresh air;
— noise levels are controlled and crowding
avoided;
— there is a perception of space;
— private space and rooms are provided;
— private toilet, bathroom and single
sex areas are provided;
— private staff rest areas are provided;
— ambient temperature and ventilation
are adequately controlled;
— safe activities inside and outside
are provided, ensuring an access to fresh air;
— non-smoking and smoking areas are
provided; and
— personal effects are safe and accessible.
19. PLACES OF
SAFETY
20. Under section 136 of the Mental Health
Act (1983), a person who is detained under section 136 may be
taken from a public place to a "place of safety" in
order that the person can be assessed by a doctor and interviewed
by an Approved Social Worker. Local policies should be in place
to define how this should take place, and the Code of Practice
states that "as a general rule it is preferable for a person
thought to be suffering from a mental disorder to be detained
in a hospital rather than a police station".[198]
21. In research undertaken by the Revolving
Doors Agency in 1995, however, even where local agreements had
nominated a hospital as the usual location to be used as the place
of safety, police cells were still often used. [199]Problems
arise as police officers do not have the experience and training
to deal with this situation, and police cells are not designed
in such a way as to provide a suitable or therapeutic environment
for someone experiencing mental distress.
22. Mind recommends that:
23. Police cells are not used as a place
of safety under the terms of a new Mental Health Act, and that
in all areas, local agreements are made as to which locations
are to be used as places of safety. In all cases, individuals
requiring a place of safety should be taken to a proper clinical
setting.
24. SECLUSION
25. Seclusion is the supervised confinement
of a person in a room which may be locked. It is highly distressing
for individuals being held in this way. The Mental Health Act
1983 Code of Practice gives guidance on how seclusion should be
used and in a recent case, it has been established that these
guidelines should be followed in in-patient psychiatric care and
breach of this could constitute a breach of human rights (Articles
3 and 8). [200]The
majority of the guidelines outlined in the Code of Practice are
also relevant to prison environments. These include:
26. The sole aim of seclusion should be
to contain behaviour which is likely to cause harm to others.
It should be used as a last resort and for the shortest possible
time. It should not be used:
— as a punishment or threat;
— as part of a treatment programme;
— because of shortage of staff; and
— where there is any risk of suicide
or self harm.
27. Mind recommends that in relation to
seclusion, hospitals and prisons should:
— have clear written guidelines on
the use of seclusion which ensure the safety and well being of
the person being detained;
— specify a suitable environment for
seclusion to take place;
— set out the roles and responsibilities
of staff; and
— set requirements for recording, monitoring
and reviewing the use of seclusion.
28. CAUSES OF
OTHER DEATHS
OR INJURIES
IN CUSTODY
29. Mind is aware of a number of cases where
death has been linked to management of aggressive behaviour involving
restraint or medication. Several of these incidents have taken
place when a person has been detained in a police station prior
to transfer to another setting, as well as in prisons, special
hospitals and other in-patient psychiatric settings.
30. Mind believes that in the management
of aggression of people who are detained, and particularly those
who are experiencing mental distress, staff should take a holistic
and preventative approach. If any intervention is needed then
treatment used to prevent violence must be neither hazardous nor
irreversible.
31. A holistic approach should address:
— advocacy, support and information
provision to detained people and family;
— the environment within which a person
is detained;
— risk assessment, taking a multicultural
approach;
— staff training on guidelines for
carrying out control and restraint;
— documentation of the measures used
for the purposes of restraint; and
— debriefing and learning outcomes
for staff from each episode.
32. Further explanation of what Mind believes
should happen in relation to some of these key areas is given
below.
33. RISK ASSESSMENT
34. Mind recommends that guidelines on conducting
risk assessments when a person is believed to be experiencing
mental distress must take into account:
— an awareness that behaviour is often
misinterpreted as aggressive or threatening, while these actions
may in reality be about a need to exercise the right to express
views about care and treatment;
— the patient or prisoner's personal
preferences on how they feel they would be better able to deal
with their mental health problem;
— awareness of the patient or prisoner's
individual and cultural needs;
— anti-discrimination policies and
practice;
— the history of the person's involvement
with mental health services; and
— previous diagnoses and medical records.
35. GUIDELINES
ON CONTROL
AND RESTRAINT
36. Existing guidelines give detailed recommendations
for the management of control and restraint, such as in the Mental
Health Act 1983 Code of Practice which states conditions for intervention.
There are further guidelines in the National Institute for Clinical
Excellence's Core Interventions in the Treatment and Management
of Schizophrenia in Primary and Secondary Care.
37. In addition to the measures contained
in present guidelines, Mind recommends training should be mandatory
for staff who are likely to be involved in using control and restraint
and should include:
— conditions under which control and
restraint may be used with specific training based on existing
guidelines;
— examples of how control and restraint
measures can go wrong or have been abused;
— procedures to consult the person's
nearest relative or in their absence the person's advocate where
they have one; and
— all staff who may be involved in
control and restraint should receive training in emergency first
aid including CPR which is kept up-to-date.
38. USE OF
MEDICATION FOR
CONTROL AND
RESTRAINT PURPOSES
39. The British National Formulary, National
Institute for Clinical Excellence guideline on schizophrenia and
the Mental Health Act 1983 Code of Practice together provide a
framework for preventing the over-medication of patients. However,
the law does not prescribe limits and it is clear that guidance
is not enough.
40. There is evidence that:
— polypharmacy (prescription of more
than one drug from the same BNF class) is routinely used and BNF
levels are regularly exceeded;
— medication is used for the purposes
of restraint;
— medication is used as a corrective
measure;
— medication is used to compensate
for staff shortages; and
— restraint is employed beyond the
mandate of the Mental Health Act Code of Practice, that is other
than:
— to save a patient's life;
— to prevent deterioration;
— to alleviate suffering; and
— being the minimum necessary.
41. At present, limits for prescribing are
set out in the British National Formulary, and this is reinforced
by the Mental Health Act Code of Practice, but there is no legal
requirement for medical personnel to prescribe within BNF levels.
These levels are generally the doses for which the drugs are licensed
to be used, but clinicians may prescribe outside the licence,
albeit taking on greater personal responsibility in doing so.
42. It should also be noted that maximum
stated doses in the British National Formulary are often well
above recommended regular dose levels. With some medications,
Mind believes, maximum recommended dose levels have also been
shown to be above a therapeutic threshold where an increase in
dose does not produce an additional benefit. Furthermore, adverse
effects are usually dose related so increases in dose do increase
the risk of adverse effects which may be disabling or life-threatening.
There is a clear pattern of African Caribbean male patients in
secure psychiatric settings who have died having been given emergency
sedative medication which exceed British national Formulary levels
or due to polypharmacy. Poor monitoring of the deaths of detained
people perpetuates the problems and mistakes which lead to such
deaths.
43. Mind believes there are several possible
measures which may address this situation:
— the Mental Health Act be amended
to prohibit giving doses above BNF levels without informed consent;
— parts of the Code of Practice relating
to polypharmacy and maximum BNF levels should be given full statutory
force;
— while doses above BNF levels are
allowed without consent under the Mental Health Act, a multi-disciplinary
second opinion process must approve this treatment, including
the input of a mental health pharmacist;
— there should be time limits on high
dose therapy with physical checks, and time limits which trigger
a full reassessment of treatment in all cases;
— consistent and detailed record keeping
and adequate monitoring is needed especially when compulsory powers
have been used; and
— documentation of whether medication
was prescribed for treatment or restraint and acknowledgement
if the "double effect" was intended.
44. CULTURAL
ISSUES
45. Black and minority ethnic communities
are over-represented in all secure settings, including prisons,
police cells, remand centres, young offenders institutions, detention
centres as well as locked psychiatric wards. They also tend to
have more coercive routes into psychiatric care or custody such
under Section 136 of the Mental Health Act 1983.
46. Evidence from Inquest, anecdotal evidence
and the actual numbers, though they are said to be too small to
hold any statistical significance, suggest that people from Black
and minority ethnic communities have an increased likelihood of
death in custody, whether it be psychiatric, police or prison.
In fact, off the 11 verdicts of unlawful killing or prosecutions
following deaths in custody since 1990, nine involved the death
of a person from the black and minority ethnic community and none
of these resulted in a successful prosecution.
47. Several deaths of people from the black
and minority ethnic community in psychiatric care or custody have
occurred due to the use of control and restraint. These concerns
have been raised on several occasions, including on the deaths
of David Bennett and Roger Sylvester.
48. It should also be borne in mind that
being in psychiatric care or custody is a traumatic experience
in itself and the effects of inappropriate interventions, conditions
or treatment cannot be underestimated. These conditions may relate
to diet, cultural values, religion, language (whether this is
about use of terminology or the use of different languages) and
family circumstances.
49. Mind recommends that:
— training in specific cultural awareness
issues should take place for prison officers and medical staff.
This should include:
— an understanding of Trust or prison
anti-discrimination policy;
— the history of black and minority
ethnic people's involvement with the psychiatric system and their
overrepresentation in detained settings;
— an understanding of multicultural
and acculturation processes; and
— family liaison workers should be
trained in notifying bereaved family members and be aware of culturally
specific practices after death.
50. INVESTIGATIONS
OF DEATHS
IN CUSTODY
51. Mind is particularly concerned about
deaths which occur in hospitals, as there is a lack of funding
for legal representation for families at inquests. This is in
contrast to the extensive resources routinely made available within
statutory service providers to ensure they have full representation.
Without this funding, it is extremely difficult for relatives
to take part in the legal process and in many cases the only information
they receive is a letter detailing the outcome of proceedings.
52. Guidance issued by the then Lord Chancellor's
department provides that funding should only be available for
exceptional cases where it is strictly necessary for evidentiary
purposes. This does not take account of the needs of the bereaved
family who have a legitimate interest in being included as a matter
of course in proceedings. This is an issue under Article 8.
53. Mind recommends that:
54. Guidance be amended to allow access
to legal aid funding for relatives to take part in investigations
and inquests following the death of a close family member in the
custody of the state.
55. SUMMARY
56, It is important that the inquiry should
pay particular attention to mental health issues, due to the high
proportion of people in detained settings—prisons, police
custody as well as in-patient psychiatric settings—who experience
mental health problems. Mind's main recommendations are that:
57. Adequate care and support should be
available for people experiencing mental distress. Many aspects
of the prison system such as isolation from families, overcrowding,
relocation can exacerbate the distress experienced, and so these
should be addressed.
58. Prison officers should undergo mental
health awareness training, and mental health services available
in prisons should be on a par with those available outside prison.
59. Environments where people will be detained
should be designed to induce as little anxiety as possible. Police
cells should not be used as a place of safety under the Mental
Health Act, and the use of seclusion needs to be carefully monitored
and guidelines adhered to.
60. A preventative approach should be taken
towards control and restraint. Where control and restraint is
necessary, staff should have been trained in methods used as they
can cause injury and death. Restrictions should be placed on the
use of polypharmacy and high doses of medication.
61. The particular needs of people from
black and minority ethnic communities need to be taken into consideration
due to their over-representation in detained settings and the
high numbers of deaths of people from these communities which
have occurred.
25 September 2003
192 Shaw J, Appleby L and Baker D, (2003) Safer Prisons:
A National Study of Prison Suicides 1999-2000 by the National
Confidential Inquiry into Suicides and Homicides by People with
Mental Illness, Department of Health. Back
193
Guite, H et al (1996) Diversion from courts and prisons
to psychiatric care in a district. Unpublished report, Department
of Health and Epidemiology, Kings College London. Back
194
Reed, J L (2000) Inpatient care of mentally ill people in prison:
results of a year's programme of semistructured inspections. Back
195
Mental Health Act Commission (2001) Ninth Biennial Report, HMSO. Back
196
Shaw J, Appleby L and Baker D, (2003), ibid. Back
197
Royal College of Psychiatrists College Research Unit (1998) Management
of Imminent Violence: Clinical Practice Guidelines to support
mental health services (Occasional Paper OP41) London, Royal College
of Psychiatrists. Back
198
Mental Health Act 1983 Code of Practice. Back
199
Revolving Doors Agency (1995) The Use of Section 136 Mental Health
Act in Three Inner London Police Divisions. Back
200
R (Munjaz) v Mersey Care NHS Trust; R (S) v Airedale NHS Trust
[2003] EWCA Civ 1036, Times 25 July 2003. Back
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