Examination of Witnesses (Questions 200
MONDAY 9 FEBRUARY 2004
Q200 Chairman: Are you satisfied
that the current level of training for the use of control and
restraint is sufficient for staff?
Dr Ladyman: In mental health environments,
in prison environments or in both?
Q201 Chairman: Both.
Dr Ladyman: We can always do more
training. Let me put that as a caveat first of all. We can never
train fully enough; we can never train widely enough; we can never
do enough to make sure that people understand what their rights
and responsibilities are in these situations. Certainly in the
mental health environment, I think, yes. In the prison healthcare
system, I think we will have to provide more resources and training
in that environment than perhaps we have at the moment, but those
are only instincts that I have. I do not have a major cause for
concern in either area.
Q202 Lord Lester of Herne Hill: Minister,
we have had evidence expressing quite strong concern about the
disproportionate or excessive use of control or restraint against
members of ethnic minority groups. I am sure you are aware of
this concern yourself. Has your department taken any effective
steps to investigate these cases?
Dr Ladyman: I have to say that
we have no data one way or the other to suggest that restraint
is used more heavily against ethnic minorities than anybody else.
There is certainly some evidence that there is a preponderance
of people from ethnic minorities that are detained under the Mental
Health Act, so there is a greater proportion of people from ethnic
minorities detained in the first place and so that might skew
the broad data in terms of the broad numbers that are restrained,
but we have no evidence at this time to suggest one way or another
that the greater proportion of those that are detained are subjected
to restraints if they come from those minority backgrounds. I
think it is an area in which we will have to do some more research
and it is something that we have to keep our eyes open about.
We have some work going on by Professor Louis Appleby that might
inform us in this area in the future, but we have no hard evidence
of that at this time.
Q203 Lord Lester of Herne Hill: I
am sure you are aware from your Home Office colleagues that there
is quite strong evidence that black people suffer disproportionately
in the criminal justice system from bail to sentence and so on.
You have no reason to think that that would not apply also to
the excessive use of force and restraint in this area. Would it
not be quite useful to have really comprehensive statistics on
death in mental health detention, especially looking at the racial
Dr Ladyman: As a general principle,
you can never have too much information and, yes, I do accept
entirely that people from minority ethnic communities suffer unduly
in being involved in the criminal justice system and I have acknowledged
that a greater proportion of them are detained under the mental
health legislation as well. What I do not have hard data about
at this time is whether a greater proportion of those who are
detained suffer restraint and isolation and such techniques as
part of the process of controlling their behaviour when they are
detained and that is something about which I think we could do
with some more information.
Q204 Lord Lester of Herne Hill: Our
concern is with racial stereotyping and profiling but this is
something you are going to look into?
Dr Ladyman: Yes.
Q205 Lord Judd: I would like you
to comment in terms of Convention human rights on two aspects.
One is seclusion and one is medication. On seclusion, you have
said that action has been taken to make seclusion safer, but how
satisfied are you that seclusion is being used appropriately in
terms of human rights and Convention rights?
Dr Ladyman: As I said earlier,
I believe that the guidance we give in Chapter 19 of the guidance
is absolutely in line with Convention rights and it includes very
thorough guidance in terms of seclusion and medication. The guidance,
in my view, is comprehensive; it is easy to understand; it should
not be being misused. So, I am very confident that we have the
right framework that complies with the Convention. Do people sometimes
fail to follow the guidance? Yes, of course. Do they do that maliciously?
Very seldom, in my view. I think they probably do it in crisis,
as a result of poor training and as a result of difficult situations
where they have to react quickly and they make poor errors of
judgment. In terms of documenting what goes on, I think the process
of requiring such events to be documented and audited is absolutely
the right way to go about it. So, do I think that there is a wholesale
failure to comply with the Convention? No, I do not.
Q206 Lord Judd: Perhaps not wholesale,
your word, but is there a failure that is worrying?
Dr Ladyman: The smallest failure
would worry me because it is something that I absolutely believe
we have to comply with. The whole reason why we are transferring,
for example, prison health to the National Health Service is because
we not only want to meet people's Convention rights but we want
to exceed them. We want to mainstream services across the prison
environment. That is something this Government are absolutely
committed to. So, the smallest breach of anybody's rights is something
that concerns me.
Q207 Lord Judd: Would you agree that
one of the issues you are up against in your specialist responsibilities
is the whole institution culture within which you are operating?
Dr Ladyman: Yes.
Q208 Lord Judd: And that what needs
to be spelt out far more clearly in terms of the objectives of
the whole operation is the preservation of human rights?
Dr Ladyman: I absolutely agree
with that, but I do also believe that we are doing a great deal
of work to try and get that message over to the people who work
in both environments, both the prison environment and mental health
environment. We are working very hard to get this message over
to make sure that people understand what somebody's human rights
are and what we require of them in ensuring that those human rights
are met with. Can we do more? Of course we can, we can always
do more. Are we working hard to try and make sure that the people
understand what their responsibilities are? Yes, we are.
Q209 Lord Judd: Do you think sometimes
your people who are operating in this situation have to face the
very real psychological tensions of being regarded as "softies"
in the operation?
Dr Ladyman: In the prison environment,
I suppose there is always a temptation to feel that that may be
the way they are being looked at. I do not think that is a general
trend. I have to say that on both sides of this equation, both
the prison health side and the mental health side, the people
I have met and the practitioners I have discussed this with have
never given me that feeling. I have to say that we are always
guilty of stereotyping and the noble Lord mentioned that in term
of minority ethnic communities. I think we are occasionally guilty
of stereotyping when we talk about people who work in the Prison
Service and also in the mental health service. They are not the
Mr Mackay type figures of Porridge. They by and large are people
who very much understand the responsibilities of their jobs and
the need to respect people's human rights, but they work under
very difficult circumstances. They work under circumstances that
you or I would probably not be prepared to work under.
Q210 Lord Judd: I think that is a
very fair answer, but would you agree that just as there is need
for training in human rights and the understanding of human rights
and the importance of human rights with your people, so there
is a great need for more understanding in the Prison Service as
a whole about the needs of mental health?
Dr Ladyman: Absolutely and in
fact I am delighted to say now that as part of prison officer
entry level training, there is a specific course on people's healthcare
needs including mental health needs. We now have continuing training
for all levels in the Prison Service including governor level,
so it is not a matter of just getting your training during your
basic training period and then you do not have any more training,
you have on-the-job training going on. We have also commissioned
a training package and I think it is the University of Bournemouth
that is preparing a training package which is intended for people
who are working on the wings in order that they will have the
knowledge and experience of how to manage people's healthcare
needs and mental health needs and then they can teach their colleagues
of what is going on. So, we are doing a raft of things to try
and make sure that people have the knowledge and training that
they need, but I am the first to say that we can always do more.
Q211 Lord Judd: I would like to spend
a moment or two on medication. Some of the evidence that we have
been given suggests that use of medication is excessive and that
it is sometimes without medical authorisation as required by the
Mental Health Act. How far do you think this is a real problem
and again what about the Convention on human rights here?
Dr Ladyman: I would be very interested
to see that evidence because, from the feedback I am getting,
it is not a widespread practice. We have, for example, the National
Institute of Clinical Excellence guidelines when we have to administer
tranquillisation other than for people's treatment and I expect
NICE guidelines to be followed wherever they exist. So, if this
is a widespread practice, I would be horrified, to be frank with
you, and very surprised. I do not think it is a widespread practice.
Does it happen occasionally? Yes and we would be surprised if
it did not. Again, the process of having to document and audit
any such acts is the way in which we ought to be picking that
Q212 Lord Judd: You said that, if
it happens on a small scale, it is a ground for concern. What
would you do about it?
Dr Ladyman: Every time medication
has to be given in these circumstances, the management of the
institution should be auditing exactly why and should be investigating
and making sure that the people who actually took the decision
to do it took an informed decision for the proper reasons. I think
that management in those institutions ought to take disciplinary
action if they find anybody has been abusing this on a systematic
basis. Of course, when we transfer particularly mental health
inspection to the Commission for Health Audit and Inspection from
April, I think they will provide a mechanism for auditing the
auditors to make sure that we are not missing a trick and that
these things are not being hidden.
Q213 Lord Campbell of Alloway: I
take your point totally. What you are in effect sayingand
correct me if I am wrongis that you expect the guidelines
to be followed and those guidelines are in Chapter 19 of the statute
and those guidelines include medical treatment. What else can
you do in practice as a department apart from training and perhaps
urging people to observe them? What else can you do? Perhaps there
is something, I do not know.
Dr Ladyman: I think there is one
thing that we have to do. We have to make sure that there is a
body in place that can audit what is going on and that is why
the Commission for Health Audit and Inspection has been set up.
We also of course have to make sure that there is a route for
people to be able to complain if they think their human rights
are being breached.
Q214 Lord Campbell of Alloway: But
you do not want them to have statutory force; there is no need
Dr Ladyman: I do not believe there
is a need for them to have statutory force. Of course, I will
take cognisance of any advice that this Committee produces on
that matter but, at this stage, I do not believe they need statutory
force. I think that people have understood the system since the
'83 Act and there is a little bit of me which thinks, "if
it ain't broke, don't fix it", but of course I am waiting.
If people have evidence that it is broken, then of course we will
take that onto account.
Q215 Lord Campbell of Alloway: You
section people with severe mental disabilities, as I understand
thisand correct me if I am wrongif they are treatable
but, if they are not treatable, you cannot section them; is that
Dr Ladyman: I think I would probably
have to write to you with the exact legal position but, broadly
speaking, that is correct.
Q216 Lord Campbell of Alloway: We
heard evidence to that effect. I am putting it in very simple
languageI know that much more beautiful language was usedand
what happens is that the ones who cannot be sectioned because
they are not treatable are sometimes not in as bad a mental state
as the others, if you follow what I mean, and what happens is
that very often one of these people who has been sectioned because
they were treatable is then transferred from one prison to another
prison to be treated but then they behave in such an aggressive
and terrible fashion that they then decide that they not treatable
and they are transferred back to the prison from which they came.
I am not joking, this is the effect of the evidence that we have
heard and I, and I think some others of us, were shocked about
this when it was referred to by Anne Owers, a very distinguished
person in this field, as "sale and return prisoners"
as they were known in the Prison Service. Have you heard this?
Dr Ladyman: I have heard the characterised
pathway you are describing; I would be very interested to see
some case studies where it actually has happened in quite that
dramatic a way.
Q217 Lord Campbell of Alloway: I
am sure that, if you write to Anne Owers, she will give you chapter
and verse because she gave the impression of knowing exactly what
she was talking about and was a very good witness. What are we
to do with this? This is very unsatisfactory position. If you
do not know very much about what is going on here, what do you
think should be done about it?
Dr Ladyman: One of the reasons
why we are reviewing the mental health legislation at the moment
is precisely because we recognise that there are some flaws in
it. So, we will try and address those legislative flaws in the
new Bill when we finally put it before Parliament. So far as the
treatment of people in the Prison Service is concerned, I think
the Chief Inspector is certainly right that there are some people
in prison with serious mental illness and of course, amongst the
various things that we are trying to do is to try and stop them
getting into prison in the first place. So, we have a range of
measures in place now where people go to court and we try and
assess whether they have mental illnesses, whether they would
be better treated outside the Prison Service. We are providing
a wider range of sentencing options to the courts and some discretions.
The second thing we are trying to do is upgrade within the Prison
Service the healthcare system across the board, which is why we
are transferring it to the National Health Service. We have mental
health in-reach teams, for example, to help people in the Prison
Service. We have a wide range of initiatives to try and improve
both the physical environment for people with mental health problems
in Prison Service as well as the treatment options that are available
to them and of course we are making sure that the staffing in
the Prison Service and training is sufficient to recognise and
deal with people with mental health problems. One of the suggestions
that the Chief Inspector put forward which was debated fairly
hotly over the Christmas period was the idea of creating some
new institutions for people with mental health problems and I
am not convinced myself that that is the way forward and I think
she recognised this herself when she made her comments. In doing
so, we would be in danger of recreating the old asylum structures.
So, I think that is something that I need to be convinced about
before we would go down that route.
Q218 Lord Lester of Herne Hill: Minister,
as you will know, there have been some very welcome changes made
by the Government, first in establishing an independent Police
Complaints Commission and then extending the Prison Ombudsman
powers to investigate deaths in prison. In the light of that,
do you not think that the absence of a system of independent inquiries
into deaths in Mental Health Act detention is now starkly anomalous?
Dr Ladyman: I do not believe it
is starkly anomalous.
Q219 Lord Lester of Herne Hill: So,
it is just anomalous?
Dr Ladyman: I believe it is different
and I believe that there are mechanisms in place for investigating
deaths in mental health institutions including the Mental Health
Act Commission and including the normal process that would be
gone through by a corner and the criminal justice system as well
if somebody has died under suspicious circumstances. So, I believe
that there are mechanisms and I remain to be convinced that we
need further mechanisms to investigate such deaths, but again
it is not something that we have a closed mind over.