Joint Committee On Human Rights Third Report

6 Physical healthcare

153. The sufficiency of medical care available in prisons, in immigration removal centres, and in police cells has been repeatedly questioned in evidence to this inquiry. In psychiatric hospitals, very different issues arise. There, human rights concerns are principally raised by the prescription of unusually high levels of drugs to detained patients, beyond recognised limits. These issues, and their human rights implications, are considered below.

The human rights context

154. The provision of adequate, timely and appropriate medical care to people in detention is an essential element of Article 2, 3 and 8 compliance. Questions of ECHR compliance may arise where a patient's death arises from inadequate medical care,[134] or following a self-inflicted death where psychiatric assessment and treatment has been inadequate.[135] In particular, failures in healthcare or in the response to drug overdoses may breach the detaining authorities' positive obligation under Article 2 ECHR to protect the right to life of those they detain. The Article 2 positive obligation to protect life arises wherever the authorities know or ought to know of a real and immediate risk to the life of a particular person or group of people.[136] This obligation, which is particularly strong in respect of detained persons, is breached if the responsible authorities fail to take reasonable measures within the scope of their powers to avert a real or immediate risk.[137]

155. Medical shortcomings may also breach the right to freedom from inhuman and degrading treatment, under Article 3 ECHR,[138] and the right to physical integrity under Article 8. Inadequate medical treatment provided to a prisoner recovering from heroin addiction was found to breach Article 3 in McGlinchey v UK.[139] In that case, a misdiagnosis resulted in inappropriate treatment, and the patient died shortly after being admitted to hospital. The case makes clear that seriously negligent medical treatment of a detained person, even in the absence of any deliberate mistreatment, may lead to a breach of Article 3.

156. The vulnerability of mentally ill detainees, and the difficulty they may have in articulating their needs or distress, mean that Article 3 will apply with particular stringency to their treatment.[140] In Keenan v UK,[141] the suicide in custody of a mentally ill prisoner was found to breach Article 3, since there had been insufficient monitoring and psychiatric assessment, and the prisoner had been inappropriately detained in segregation in a punishment block.

Police custody healthcare: drug- and alcohol-addicted detainees

157. Medical care in police detention is generally provided by Forensic Medical Examiners.[142] More recently, some police forces have employed "custody nurses" to provide on-site medical care in police cells. Oral evidence from the Police Complaints Authority (PCA) suggests inconsistencies in the standard of healthcare available in police cells, and inadequacies in the knowledge and training both of custody officers and of police surgeons.[143] Custody sergeants themselves have expressed concern at the paucity of their training.[144]

158. Care of vulnerable detainees is now well provided for in guidelines, since the revised PACE Codes of Practice came into force in April 2003.[145] This Revised Code requires a custody officer to ensure that a detainee receives appropriate clinical attention where necessary, and prescribes urgent healthcare intervention where an arrested person fails to meet the following criteria—

  • the detainee can be woken;
  • the detainee can respond to questions;
  • the detainee can respond appropriately to simple commands.

The Code also states that custody officers should take account of illnesses that may be masked by alcohol.[146] It requires detainees to be visited every hour, and for those suspected of intoxication through drink or drugs to be visited every half hour.

159. Grave concerns were expressed by the PCA that these standards and procedures were not adequately applied in practice. These concerns were highlighted in a recent report which found that a significant proportion of custody sergeants had not received adequate custody training in relation to drugs, alcohol and mental health.[147] In a number of the cases studied, custody officers had not been able to assess accurately whether a detainee was intoxicated. Police were also ill-equipped to identify illness which might be masked by alcohol. In a number of cases alcohol-affected detainees were not checked frequently enough, and when they were checked, they were sometimes not sufficiently roused, in breach of PACE Code C requirements and sometimes in breach of instructions given by the Forensic Medical Examiner (FME). The PCA's analysis showed that "by the time police notice illness among drinkers, they are far closer to life being pronounced extinct than among the non-drinking group of cases examined".[148]

160. The PCA report concluded—

    The police service is simply not equipped to deal with the complexity of extreme alcohol intoxication, and does not have the systems in place to offer adequate care to this population. Unless there are vast improvements in custody staff training, detainee risk assessment, the extent and quality of medical support and organisations' commitments to effective detainee management, there is no alternative but to conclude that drunken detainees should not be taken to police stations in other than the most extreme circumstances.[149]

161. The PCA Report stressed that the responsibility lay with police managers to provide custody officers with the tools to comply with PACE, and to provide adequate medical cover. Police forces' obligations under the Human Rights Act serve to reinforce this. Management failures in planning and inadequate provision of training to officers required to deal with these situations, may lead to breaches of Article 2.[150]

162. Medical care in police cells may also be hampered by lack of equipment and resources. The absence of defibulators in custody suites may be one such problem. The Metropolitan Police Service calculate that a defibulator would have helped police officers in 8 recent cases.[151] They are however expensive and officers must be trained to use them.

163. One means of ensuring that detainees receive prompt medical attention by qualified personnel is to employ "custody nurses" in the custody suite, rather than to rely on FMEs who may take some time to arrive on site. A number of forces are now employing custody nurses, although these remain pilot projects.[152] ACPO's view was that the presence of custody nurses, though they could not cater for all the medical needs of a police custody suite, was beneficial in providing medical back-up to custody officers.[153]

164. If drug- and alcohol-dependent people, and the mentally ill including those detained under the Mental Health Act, continue to be held in police custody suites, it would greatly assist police forces in complying with Articles 2, 3, and 8 ECHR to have custody nurses on-site and able to provide timely, regular and dependable medical care, to assess risk to detainees and to identify more serious cases that might require transfer to hospital. This requires close co-operation between the police and health and mental health services at both national and local level to ensure this. ACPO identify: "a need for consistent national policy, which sets out the roles and responsibilities for healthcare in custody".[154] ACPO told us in oral evidence that—

    a more robust approach is probably necessary in terms of establishing where the responsibilities lie in relation to the treatment and support of individuals who come to the attention of the police or other agencies and require healthcare.[155]

165. In our view, the clear principle that healthcare in custody should be equal to that in the community needs to be rigorously enforced, including in relation to police detention. Where possible some minimal level of qualified medical care should be made available on-site in police custody suites. It is vital to people's well-being and to the realisation of their Convention rights that police custody officers are well equipped to assess on reception the risk detainees pose to themselves or others. It should be ensured that all custody officers receive regularly updated training in basic first-aid and in dealing with drug and alcohol addiction and mental health matters.

166. Difficulties in providing for the often acute healthcare and mental healthcare needs of detainees raise questions of the suitability of the facilities in which they are held. It is clear that police cells are used as an emergency resource to contain people with severe and diverse problems. An alternative solution to one aspect of this problem, the care of intoxicated detainees, favoured by the PCA amongst others, is specialist alcohol treatment centres. The Home Office told the Committee that they saw alcohol treatment centres as having "considerable potential" and that they were studying a pilot centre of this type with interest.[156] We would support the establishment of drug and alcohol treatment centres as an effective means of treating the effects of alcohol abuse and drug use among those in police custody. This would be an effective means of ensuring the well-being of these people whilst in custody and would protect their Convention rights through positive action.

Prison Healthcare: NHS equivalence

167. Prison healthcare has attracted considerable criticism in the past, including from successive Chief Inspectors of Prisons. The Prisons and Probation Ombudsman, in a judgement made on 22 December 2003, upheld two complaints on behalf of the late John Tero, who had been jailed at the age of 72 and who died of a cancer that went undetected while he was in prison. The acting Ombudsman recommended that the governors of the two prisons in question apologise to Mr Tero's family.[157]

168. The Chief Inspector of Prisons' latest Annual Report considers that prison healthcare is improving following transfer of responsibility to the NHS but expresses grave concern about drug and alcohol detoxification and continuing concern about the adequacy of mental healthcare services.[158]

169. Since 1 April 2003 the Department of Health has been responsible for funding prison healthcare in English public-sector prisons. Responsibility for commissioning health services in all publicly-run prisons in England will transfer to local Primary Care Trusts by 1 April 2006. This is a very welcome development and should go a long way to addressing the healthcare deficit that is to be found in so many prisons at present.

170. We recommend that as a general principle physical and mental healthcare in prisons must be of the same standard as provided by the NHS in the community. As the Royal College of Psychiatrists told us, "A right of access to standard health care is no right if the resources to provide that healthcare are not forthcoming".[159] New funding arrangements must ensure that prisons have appropriate and adequate resources to ensure that this equivalence is achieved.

Drug and alcohol treatment and detoxification in prison

171. Published data such as that from the Criminality Survey and the Office for National Statistics shows between 40 and 55 per cent of new receptions into prison to be problematic drug misusers. The Prison Service told us that indicative feedback shows some prisons reporting up to 80 per cent testing positive for opiates on reception. They also reported that they have "the greatest concentration—assessed to be as high as 60 per cent—of problem drug misusers present in one place at one time either in the healthcare or criminal justice systems. With an annual through-flow of around 130,000 offenders, an average 70,000 problem drug-misusing prisoners may be in custody during the course of a year—with around 39,000 being present at any one time".[160]

172. The Prison Service noted that drug misuse amongst offenders received into custody is on the increase, reflecting the continuing high levels of drug misuse generally in the community. This was echoed by Stephen Shaw, the Prisons and Probation Ombudsman, who said that: "The levels of opiate addiction and the use of crack cocaine amongst offenders and therefore amongst those entering prison is on a scale which was simply not known … 15 years ago".[161]

173. Drug misuse and the detoxification process has implications for Convention human rights in two ways. Firstly, inadequacies in detoxification treatment may lead to breaches of Article 2 or Article 3 ECHR. The human rights implications of failures in treatment for drug addiction were made clear in McGlinchey v UK,[162] where a breach of Article 3 ECHR was found when a prisoner died as a result of inadequacies in drug detoxification treatment.

174. Secondly, the care and treatment of drug-addicted prisoners is an important element of the positive obligation to protect against self-harm and suicide of vulnerable prisoners. While the Prison Service does not collect information on the proportion of self-inflicted deaths who had been problem drug misusers, it does appear both that drug misusers are more vulnerable to self-harm and suicide, and that the process of detoxification itself can be particularly stressful and make people especially vulnerable and at risk of self-harm.

175. The Confidential Inquiry into Suicides in Prisons 1999-2000 found that 62 per cent of those who died had a history of drug misuse and 30 per cent had a history of alcohol misuse.[163] The Royal College of Psychiatrists, in a 2002 report, stated that "drug withdrawal occurs when prisoners with problems of substance misuse are admitted to prison and this may play an important part in generating suicidal behaviour".[164]

176. The Prison Service's review of prevention of suicide and self-harm in prisons recommended that special attention be paid to the safe management of prisoners in the early stages of custody in a prison—including detoxification units. The Prison Service also told us that: "[a] broader range of clinical responses to drug dependence—such as extended detoxification and maintenance programmes—can help to reduce incidents of suicide and self-harm amongst those most at risk: particularly prisoners with co-existent drug and mental health problems".[165]

177. We were told by the Prison Service that they intended to introduce a wider range of treatment options, including "the expansion of maintenance prescribing for opiate-dependency to those prisoners for whom management of withdrawal symptoms alone is unrealistic".[166] As we have seen previously the links between those on short sentences with drug or alcohol problems and potential for suicide are strong. In order to reduce deaths in custody and adequately care for those imprisoned we fully endorse the expansion of drug maintenance programmes in prison for addicts to help relieve the distress of getting off drugs and the risk of overdose on release. We recommend that high quality drug maintenance programmes are readily available in all prisons in England and Wales to all those prisoners who require such a programme.

178. While there was widespread recognition of the challenges faced by the Prison Service and the progress made in expanding the provision of prison drug treatment, concerns were also raised about the adequacy of drug and alcohol treatment. We make recommendations on this point above. The issue of treatment for short-term prisoners was also raised. The Revolving Doors Agency made the point to us that: "People on short-term sentences or remand, who are significantly over-represented in suicide figures, are particularly badly served by the Prison Service. They are excluded from many of the core aspects of the regime … One key concern is that short-term prisoners are frequently unable to access drug and alcohol treatment programmes".[167] We recommend that if people are sent to prison on short sentences or on remand, drug and alcohol treatment must be made readily available for them.

179. The Prison Reform Trust was particularly concerned about the lack of alcohol treatment in prisons and the absence of ring-fenced funding for such treatment. This concern was shared by the Chief Inspector of Prisons who told the Committee that she thought "alcohol withdrawal is a significant cause of distress that can lead to suicide and self-harm".[168] The issue of alcohol addiction is often overlooked in prisons. We recommend that there should be an expansion of alcohol misuse treatment with ring-fenced funding, and that standards should be set for the provision of alcohol detoxification and treatment in custodial settings.

180. The issue of high levels of deaths, often due to drug overdose, amongst newly released prisoners was also raised with us. Frances Crook of the Howard League for Penal Reform stated that people who have undergone detoxification in prison are at risk of overdose if they come out and go straight back onto drugs and that as a group "they are hugely neglected, very vulnerable people who desperately need services [and] support".[169] Although this inquiry deals with deaths in custody, rather than following release, the Convention human rights obligations of detaining authorities do not end on release. The positive obligation to protect life under Article 2 ECHR requires that reasonable steps should be taken to protect those whose lives are known to be at risk. Newly-released prisoners with known vulnerabilities should therefore be afforded appropriate support. We also recommend that the Prison Service should collect statistics on whether prisoners who undergo detoxification while in prison go on to commence and complete drug treatment.

Communicable diseases

181. Because a high proportion of prisoners have a history of injecting drug use, there are disproportionately high incidences of communicable diseases amongst the prison population. According to the Social Exclusion Unit, HIV infection of adult male prisoners is 15 times higher than in the general population and Hepatitis B and C infection of female prisoners is 40 and 28 times higher than in the general population respectively.

182. We asked witnesses about the adequacy of measures to prevent the spread of communicable diseases in prisons. Mr Goggins told us that "[t]he Prison Service's drug strategy and other measures have achieved considerable success in reducing drug misuse in prison".[170] One of these measures is the reintroduction of disinfecting tablets for injecting drug users to use in order to clean needles. Disinfecting tablets were initially distributed in Prison Service establishments in England and Wales in September 1995 but were withdrawn later that year after concerns were raised about their safety. Following tests by the Health and Safety Executive, the Prison Service re-introduced disinfecting tablets on a trial basis in 11 sites in 1998/99. This pilot project was evaluated by the London School of Hygiene and Tropical Medicine, which judged it to have been successful. Disinfecting tablets are being introduced at all prisons under a rolling programme.

183. There are not currently any needle exchanges in prisons. Mr Ladyman told the Committee that he was open minded about the idea of needle exchanges, though previous experience had not been particularly successful.[171] The Director General of the Prison Service, Mr Phil Wheatley, stated that needles were rarely used in prisons and that the introduction of needle exchanges could do more harm than good, though he added that the Prison Service was committed to monitoring developments both at home and abroad, including existing practice in the community, policy and practice in custodial settings and the effectiveness of needle exchanges over other harm minimisation measures.[172]

184. The Scottish Prison Service is currently considering proposals to introduce needle exchanges in order to reduce communicable diseases—a proposal which would require a change in prison rules but not a change in the law. We recommend that the Prison Service and the Department of Health should give further consideration to whether needle exchanges could be effective in reducing the spread of communicable diseases in prisons.

185. There are no reliable statistics on the number of gay prisoners in England and Wales, or numbers engaging in homosexual sex while in prison. At present, any prisoner who wants access to condoms has to get them from healthcare. The Prison Service confirmed that they had no plans to make condoms available to prisoners other than through healthcare professionals. However, prisoners may be concerned about implications of going to see a healthcare professional for condoms and may therefore be more likely to engage in unsafe sex. The Prison Service should commission an independent review into whether its current policy on the availability of condoms is doing enough to prevent the spread of HIV/AIDS amongst the prison population and therefore to protect the right to life.

Prescription of medication in Mental Health Act detention

186. Concern has been expressed that medication is being administered inappropriately and at excessive levels, and sometimes without adequate medical authorisation, to those detained under the Mental Health Act, contrary to guidelines set by the British National Formulary (BNF). The BNF sets limits on the levels of drugs that may be prescribed, though these are not legally binding on medical personnel. MIND's written evidence states that these recommended levels are routinely exceeded in the treatment of detained patients, for purposes of restraint or correction, and in some cases to compensate for staff shortages. It expresses particular concern about the simultaneous prescription of several different drugs (polypharmacy) at high doses and about the higher doses of medication administered to Afro-Caribbean men. MIND warns that excessive medication is being used in such a way as to "increase the risk of adverse effects which may be disabling or life threatening".[173]

187. MIND raises particular concern that 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".[174] It suggests that such discrepancies may result from racial stereotyping and unjustified perceptions of dangerousness and aggression in black male patients.[175]

188. Expert evidence to the inquiry into the death of David Bennett raised similar concerns about the over-medication of black patients, and stressed the need for further research on the nature and extent of the problem.[176] The Mental Health Act Commission also expressed particular concern that emergency medication was being administered in some cases without the authorisation of a doctor as required by the Mental Health Act, and supported strict adherence to recommended dosage limits in emergency situations.[177]

189. In response to concerns about prescription of medication, Mr Ladyman doubted that such practices were widespread.[178] Our impression, however, is that, in practice, although BNF limits are only rarely exceeded in respect of the dosage of a single drug, limits are routinely exceeded as a result of the administration of several drugs simultaneously. At Broadmoor, for example, at the time of our visit,[179] only four patients were being prescribed a single dosage in excess of BNF limits, but staff estimated that in the region of 80 patients were receiving drugs in excess of BNF limits as a result of combinations of drugs.[180] We were assured that patients on such high levels of medication were very closely monitored, and the combination of drugs and changes in prescription were carefully recorded, and incorporated in the patient's care plan.[181]

190. Mr Ladyman pointed out that the new Commission for Health Audit and Inspection would have a role in ensuring that guidance was complied with.[182] In regard to current practice, however, the Mental Health Act Commission (MHAC) pointed to limitations in its mandate and resources which prevented it from exercising a very careful scrutiny of the administration of medication. It was not in a position to monitor the levels of medication in individual cases, since it did not have a continuous presence in hospitals. Asked whether he considered that the MHAC should have the remit and specialist staff to review prescription of medication, the Chief Executive of the MHAC, Chris Heginbotham, was cautious about the MHAC challenging clinical judgment, stating that further consideration would need to be given to this.[183] However, he recognised that the absence of scrutiny of medication levels limited the MHAC's effectiveness in protecting Convention rights.

191. MIND argued that "there should be absolutely no reason why somebody should go over a BNF maximum [in prescribing medication to detained patients]. Going over that should make an individual accountable".[184] It recommended legislative provision to make it unlawful to administer doses above the maximum recommended within the British National Formulary Guidelines, pointing out that these maxima were often already well above the recommended dose.[185]

192. Against this it may be argued that considerations of flexibility, and the need to tailor prescriptions to the particular needs of a patient, may require that BNF limits be exceeded in some cases. The draft NICE guidelines on the Short Term Management of Disturbed Behaviour in Psychiatric Inpatient Settings accept that BNF limits may legitimately be exceeded in some cases, for example, where rapid tranquillisation is used to restrain a patient. The Guidelines state that the rationale for exceeding the recommended limits should be recorded in the care plan, and the patient should be frequently and intensively monitored where BNF limits are exceeded.[186]

193. Excessive or unregulated administration of medication, in particular where it is administered without consent for purposes of restraint or correction, raises issues under Article 8 (the right to physical integrity); Article 3 (freedom from inhuman or degrading treatment);[187] and potentially the right to life under Article 2. Any clearly established difference in the level of drugs prescribed to patients of one ethnic group, would be discriminatory in breach of Article 8 and Article 14 ECHR, unless the difference could be objectively justified in regard to the needs of each patient.

194. Proportionate interference with Article 8 rights requires that standard medical practice should not be departed from in actions such as the administration of medication without consent which impinge on the physical integrity of the patient. Where carefully defined departures from BNF limits are permitted by guidance such as that issued by NICE, this should not lead to a breach of Article 8. Any such departures from BNF limits would however need to be closely justified as necessary and proportionate in the particular circumstances of the case, in order to comply with Article 8. There is a particular need for such close justification, in light of the perception (which remains statistically unproven) that drugs may be disproportionately administered to patients from some ethnic minorities.

195. Whether prescription in excess of BNF limits will breach Convention rights will depend on the circumstances of the individual case. Where such medication can be shown to be a therapeutic necessity in the circumstances of the case, then it is unlikely to breach Article 3 or Article 8. However, in our view, the departure from accepted guidelines set by the BNF would require very close justification, in particular in any case where such medication is implicated in the death of a detained patient. There will be a risk of Article 2 violation where medication is prescribed in excess of BNF limits, either through a combination of drugs or a single dosage, as a matter of routine or without clear justification on the basis of exceptional circumstances. We recommend that levels of prescription should be closely monitored by health authorities in light of these human rights considerations, and that the Commission for Health Audit and Inspection should have a role on review of levels of medication. We recommend that there should be a statutory obligation to record and report on dosage over BNF limits. Under the Race Relations (Amendment) Act 2000 there is a positive obligation on NHS authorities to ensure race equality, including in the administration of medication. We recommend that health authorities should monitor prescription of medication to detained patients having regard to ethnicity, and should take steps to address any discrepancies found.

134   Anguelova v Bulgaria, App No 38361/97, 13/06/2002- the failure to provide timely medical care in police custody breached Article 2; McGlinchey v UK App No 50390/99, 29/04/2003 Back

135   Keenan v UK (2001) 33 EHRR 38 Back

136   Keenan v UK, op cit; Osman v UK (2000) 29 EHRR 245 Back

137   McFeeley v UK (1980) 3 EHRR 161 Back

138   McGlinchey v UK App No 50390/99, 29/04/2003 Back

139   App No 50390/99, 29/04/2003 Back

140   Keenan v UK, op cit; Herczegfalvy v Austria App No 10533/83, 24/09/2002 Back

141   [2001] 33 EHRR 38 Back

142   Formerly known as police surgeons Back

143   Q 381 Back

144   Dr David Best and Amakai Kefas, The Role of Alcohol in Police Related Deaths, Police Complaints Authority, March 2004 Back

145   Home Office, Police and Criminal Evidence Act 1984 Codes of Practice A-E, Revised Edition, April 2003 Back

146   including diabetes, epilepsy, head injury, drug intoxication or overdose; or stroke Back

147   Dr David Best and Amakai Kefas, The Role of Alcohol in Police-Related Deaths, Police Complaints Authority, March 2004. Back

148   ibid., p. 18 Back

149   ibid., p. 25 Back

150   McCann v UK (1996) 21 EHRR 97 Back

151   Meeting with the Metropolitan Police Service Professional Standards Directorate, 7 July 2004 Back

152   First Report of Session 2003-04, op cit, Ev 7. A recent Home Office report reviewed the operation of a pilot project in Kent found that the scheme had been successful and made recommendations for further development of the role of custody nurses, in partnership between police forces and health authorities (Gannon S, Assessment of the Kent Custody Nurse Scheme, Home Office, November 2002). Back

153   Q 415 Back

154   Ev 135 Back

155   Q 413 Back

156   Q 259 Back

157   Prisons censured over cancer inmate, The Guardian, 23 December 2003 Back

158   HM Inspectorate of Prisons for England and Wales, 2004, Annual Report of HM Chief Inspector of Prisons for England and Wales 2002-2003, TSO, London  Back

159   Ev 186 Back

160   Ev 100 Back

161   Q 100 Back

162   App No 50390/99, 29/04/2003 Back

163   J Shaw, L Appleby and D Baker, Safer Prisons: A National Study of Prison Suicides 1999-2000, The National Confidential Inquiry into Suicides and Homicides by People with Mental Illness, May 2003 Back

164   Royal College of Psychiatrists, Suicide in Prisons, Council Report CR 99, February 2002, London Back

165   Ev 102 Back

166   Ev 102 Back

167   Ev 183 Back

168   Q 86 Back

169   Q 44 Back

170   Ev 98 Back

171   Q 237 Back

172   Q 374 Back

173   First Report of Session 2003-04, op cit., Ev 111 Back

174   ibid., Ev 111-112, QQ 140-141  Back

175   QQ 139-141  Back

176   Norfolk, Suffolk and Cambridgeshire Strategic Health Authority, Independent inquiry into the death of David Bennett, December 2003, p. 49 Back

177   First Report of Session 2003-04, op cit., Ev 42-43  Back

178   Q 211 Back

179   16 September 2004 Back

180   Out of a total of about 222 patients Back

181   This is in accordance with West London Mental Health Trust's Medicines Policy, 2004 Back

182   Which is to absorb the functions of the Mental Health Act Commission Back

183   Q 193 Back

184   Q 142 Back

185   Q 158 Back

186   National Institute for Clinical Excellence, Draft guidelines on the short term management of disturbed (violent) behaviour in in-patient psychiatric settings, para 1.10.29 Back

187   R (Wilkinson) v Broadmoor Special Hospital [2002] 1 WLR 419 Back

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