Examination of Witnesses (Questions 168
MONDAY 9 FEBRUARY 2004
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
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
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
Q177 Lord Campbell of Alloway: The
statutory guidelines and the code of practice are two totally
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.