Joint Committee On Human Rights Minutes of Evidence

Examination of Witnesses (Questions 168 - 179)



  Q168  Chairman: Welcome, Mr Heginbotham. Thank you very much for coming today. On behalf of the Committee, may I say that the evidence we have had from you in relation to this inquiry and to the inquiry under the Human Rights Commission was in our view a model example of a human rights based approach from a public body so we would like to offer our congratulations.

  Mr Heginbotham: Thank you very much. Could I say thank you to my colleague, Mat Kinton, who drafts much of our work. He should share in that accord.

  Q169  Chairman: What would you say were the significant factors in relation to deaths in Mental Health Act detention, looking at self-inflicted deaths, inadequacies in health care and the use of control and restraint?

  Mr Heginbotham: All unnatural deaths are obviously a concern, but perhaps some are more preventable than others. We must remember that a large number of the detained population, unlike other custodial groups, are in custody often because they are a risk to themselves as much as to other people. The majority of people with mental illnesses are much more likely to be a danger to themselves than to others. There are two criteria in answering your question. The first is the sheer numbers involved and the second is whether an issue is preventable. If I take the first, the answer to your question would be, on the basis of numbers, it would be those who are liable to suicide or self-harm. What we know is that most of the deaths of detained patients are from natural causes, approximately 80 per cent. The other 20 per cent due to unnatural causes encompass suicide, misadventure and so on. What we have seen is that approximately 50 per cent of that 20 per cent happen immediately after discharge or when a patient goes absent without leave. We know from the literature, from research, that there is good practice, not in being able to prevent suicide and self-harm but certainly to ameliorate it or to minimise it. What we see perhaps is insufficient attention being given to the needs of the patients at a time of discharge or if they do go absent. In terms of total numbers, the place to start would be with suicide and self-harm. If we are concerned with what is genuinely preventable, I think we would be concerned with control and restraint. I know this is a matter that the Committee is concerned about. That is a major concern, although the number of times that control and restraint has been implicated directly in the death of a patient at the time of the death is in fact quite rare. Our evidence suggests that only one patient per annum over the last seven years has died when control and restraint was being used at that time. There are approximately 15 patients per annum where control and restraint has been used in the seven days previous to the death but only one per annum implicated in the death. Even that one per annum is clearly a death of a patient and that patient, in our view, need not have died at that time. Therefore, there is good reason to want to do something about improving control and restraint: improving procedures, ensuring that staff are properly trained and so on.

  Q170  Chairman: You are satisfied that in the compilation of the statistics on deaths in Mental Health Act detention deaths are categorised as from natural cases when in fact control and restraint has been a causative factor?

  Mr Heginbotham: We cannot be certain about that. We do not have really good data on any of this area. The Commission's collation of these statistics began essentially because no one else was doing it and it is quite possible that data collection might be improved in the coming years. For example, the National Patient Safety Agency hopefully will be taking on a role in adverse incident monitoring. Maybe we will get better data there. No, I cannot be too sanguine that we know that all either natural deaths or unnatural deaths which apparently do not feature control and restraint did not, in fact, feature control and restraint because the data quality is not as good as we would want.

  Q171  Lord Judd: I do not want to over-simplify a very complex and difficult area but would you say that the use of control and restraint is proportionate or not?

  Mr Heginbotham: Do you mean proportionate to the challenge at that moment?

  Q172  Lord Judd: Yes.

  Mr Heginbotham: That is very difficult for me to say because we are not there usually at the time when that occurs. I guess the evidence that I have given you so far would suggest that on occasions it clearly is not proportionate.

  Q173  Lord Judd: You mean it is over-used?

  Mr Heginbotham: Or that it is done in such a way as to lead to an injury to the patient. We know, for example, that the David Bennett inquiry is about to report. This was leaked last Friday. I have not seen the final report, so I cannot comment on it directly but clearly David Bennett died during a period of control and restraint. One might therefore argue that the way in which that was applied was disproportionate in your terms, if I understand what you are saying correctly.

  Q174  Lord Judd: Do you think that support and training for staff in this context is right? Are there things that should be done in the training of staff in this context, particularly around the human rights dimension?

  Mr Heginbotham: Our view is that there is insufficient training and that we need improved education but also we need to enforce more fully both the Code of Practice and any other guidelines in relation to control and restraint. We would like to see improvements in the way in which staff are trained but we would also like to see statutory guidelines brought in to enforce certain minimum standards in relation to control and restraint. That would include, for example, the training of staff, the way in which control and restraint was recorded, a review of the incident following the use of control and restraint, and notification to the Commission of any injuries resulting. We have recently put in place for a period of six months just such a notification to try and understand what is happening. Even within the first month, we have had quite a number of incidents reported to us. I think there are some very good reasons why minimum standards need to be applied.

  Q175  Lord Judd: You would say therefore that statutory guidelines are pretty central to it?

  Mr Heginbotham: Yes. I would make a distinction there though with the Code of Practice. We are not suggesting necessarily that the Code of Practice is made statutory in that sense, because we still need a code of good practice. We need a framework within which good practice is administered. We need to encourage. We need to educate. We need to support, but at the same time we need some minimum standards against which services are measured.

  Q176  Lord Judd: I am not wanting to put words in your mouth but you are saying that all this is important but the culture of the service is absolutely crucial?

  Mr Heginbotham: Yes, I think that is correct.

  Q177  Lord Campbell of Alloway: The statutory guidelines and the code of practice are two totally different things?

  Mr Heginbotham: Yes. That is the point I am making.

  Q178  Lord Campbell of Alloway: The code of practice is a code of good conduct which does not have legal efficacy; whereas your statutory guidelines, you say, are to control staff. I am very interested in the sort of control and the sort of legal effect.

  Mr Heginbotham: I do not think I said "control staff" or at least I certainly did not intend to. What I said was to provide those minimum requirements on the way in which control and restraint is applied. For example, statutory regulation would require certain post-control and restraint action including debriefings of staff, reviews and reporting to a monitoring body. It would also require certain minimum levels of training to be applied for all staff involved who might be undertaking control and restraint.

  Q179  Lord Campbell of Alloway: What is the difference between that and your code of practice?

  Mr Heginbotham: What I was seeking to do was to describe that a moment ago. I think there are two different issues here. One creates a culture, a framework of good practice, in which we would want to see services provided. The other provides certain minimum standards against which services can be measured and which services would be expected to perform.

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