Improving patient care Improving patient care Patient safety

Improving patient care

Improving patient care Patient safety or patient risk? The case of people who are mentally ill Penny Rhodes Bradford Institute for Health Research

Freed mentally ill prisoners could 'bump someone off' - but they should NOT be in prison, claims Ken Clarke Daily Mail 13 December 2010 Increasing the risks to the most vulnerable elements of society, such as children, by releasing offenders with mental disorders could be argued as challenging common sense? Daily Mail 13 December 2010

People with severe mental illness are responsible for one in 20 violent crimes, researchers say. http: //www. suite 101 Friday, 28 July 2006 People with severe mental illness Every year, 100 people are killed Every year, 100 people are responsible for one in 20 by someone who has mental killed by someone who violent crimes, researchers say. health problems. has mental health Daily Mail 13 December 2010 problems. http: //www. suite 101 Friday, 28 July 2006 Daily Mail 13 December 2010

Crisis Resolution and Home Treatment teams • offer an alternative to hospital care • provide intensive, time-limited, home-based treatment • act as a “gatekeeper” to mental health services whereby individuals are referred to the most appropriate service • provide a 24 hours a day, 7 days a week multi-disciplinary, community-based treatment service • be actively involved in discharge planning • provide intensive care at home to enable early discharge • ensure that individuals are treated in the least restrictive environment and as close to home as possible Department of Health 2001

We found: • When asked about safety, workers spoke about staff safety. • Workers seemed not to understand what we meant by ‘patient safety’. • Instead, they talked about ‘risk’

The discourse of safety related almost entirely to staff safety. The discourse of patient risk superseded that of patient safety.

Patients at risk • they may be disoriented or confused as a consequence of their illness and/or medication • their views may be discounted on grounds of mental incapacity • physical symptoms may be missed or wrongly attributed to mental illness

Patients at risk • increasing administration of medication in community, as opposed to more controlled environment of hospital • increasing treatment against patients’ wishes (compulsory treatment orders) • antipsychotic drugs among those most frequently associated with severe harm

National Patient Safety Agency (2006) report on incidents in mental health services • Majority of incidents from inpatient services • Most incidents concerned: patient accidents; disruptive / aggressive behaviour; self-harming behaviour; absconding or missing patients. • MH trusts report lowest average number of medication incidents, except for ambulance trusts and PCTs.

National Patient Safety Agency (2006) report on incidents in mental health services • Antipsychotics among the medicines most frequently associated with severe harm. • Likely to be significant under-reporting. • Reports about medication, clinical assessment and treatment may be particularly underreported. • Bias towards reporting more serious incidents

MIND (2008) submission to the House of Commons Health Select Committee on Patient Safety • general safety: assault, threats and feeling unsafe on mental health wards • sexual safety on mental health wards • reporting crimes (in hospitals)

MIND (2008) submission to the House of Commons Health Select Committee on Patient Safety • protection from abuse (from staff) • complaints poorly handled • need for third-party reporting schemes • need for training for staff • prescribing practices - serious adverse effects

" excessive anxiety around the risks posed by people experiencing mental distress, and insufficient concern as to the risks posed to them by poor services".

Safety from staff Safety from the general public Safety from poor services

Risk management for whom? • to protect patients from harming others or themselves • to protect the service’s back e. g. from liability claims • to protect the service from adverse publicity • to satisfy politicians responding to media and public pressure • national policy drivers e. g. suicide reduction

What are the ways forward?

Ways forward? 1. See safety as a wider issue 2. More research about how MH practitioners practice safe care 3. Better reporting of safety incidents and better feedback and learning

Ways forward? 4. Less punitive approach to error 5. Refocus debate onto independent living and support in the community 6. Litigation a double-edged sword? 7. Public protection should not overshadow patient safety

e h t n f o o e t h e h s p a o w r p Why ? The ‘ itated ts p e e a f i e c r r e t e s d n e o T h n w i God’ woman 2011 ‘Schizophrenic kills brother, h ay s i m t i 4 r 9 , w 1 B ith a kitchen knife’ e n i l n O Mail Feb 2010 Fury at escape of killer schizo The 25 st killer gave guards the slip when allowed out of a secure mental hospital WITHOUT handcuffs. Sun 17 Nov 2009 Sun 20

Public Health Perspective Data from a representative sample of 1, 151 remanded offenders who underwent a full structured diagnostic interview RESULTS About 3% of violent offenses could be attributed to individuals with a principal diagnosis not related to substance use. An additional 7% of violent offenses could be attributed to individuals with a primary diagnosis of a substance use disorder. CONCLUSION ‘Public perceptions of mentally ill persons as criminally dangerous appear to be greatly exaggerated. ’ Stuart & Arboleda-Flórez, 2001

Murder risk 'higher for mentally ill' The mentally ill are: • frequently victims of violent crime • six times more likely to be murdered than the general population • have higher death rates from suicide and accidental causes. http: //www. suite 101. com Friday, 21 December, 2001