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Establishing care pathways in juvenile establishments

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In December 2001 the Department of Health and the Prison Service published the Changing the Outlook joint paper. It set out a 3-5 year plan on how mental health services available to people in the prison population would set out to be on a par with those available to the general population.

In December 2001 the Department of Health and the Prison Service published the Changing the Outlook joint paper. It set out a 3-5 year plan on how mental health services available to people in the prison population would set out to be on a par with those available to the general population.

It cited that 90% of prisoners have a diagnosable mental illness, substance abuse problem or often both. Among young offenders and juveniles that figure is 95%.

In Bristol, the response was the formation of a forensic CAMHS (Child & Adolescent Mental Health Service). A consultant psychiatrist and a consultant clinical psychologist provided this service, which covered the local authority secure unit, the local Youth Offending Service and two local prisons, HMPEastwoodPark and HMP & YOI Ashfield.

In April 2004 the team was expanded to include nursing with the appointment of a forensic nurse specialist. The parameters for the role were vague. However, once in post the focus quickly became implementing the care programme approach.

In 1991 a care programme approach was introduced by the mental health National Service Framework to provide a framework for effective mental health care. CPA placed responsibility on mental health services to provide aftercare when sectioned patients were discharged from hospital to the community. At the time this was implemented it focused on community services and not prisons. Changing the Outlook has placed an importance on implementing CPA on release from prison to ensure that prisoners with severe mental illness will receive appropriate community provision through CPA aftercare.

With the nursing role established, community teams were invited to become involved in the young people?s care in the prisons. However, as community teams started to come in, the workload also increased. HMP & YOI Ashfield therefore took the decision to create a new post, which it would fund but would be part of the forensic CAMHS service. In an agreement between the prison and the trust, the role would have a focus on aftercare, something not previously been tried in prisons. The new CPN postholder would have time to attend CPA meetings in the community, offering support to the young person and their community teams following their release from prison. This increase in resource would allow the forensic nurse specialist to apply the same model to the female juveniles in HMPEastwoodPark.

The forensic CPN post was appointed at the beginning of March 2005. During the recruitment process NIMHE (National Institute for Mental Health England) released the Offender Mental Health Care Pathway. This was intended to detail every stage of an offender?s journey through the criminal justice system if they have mental health problems - from the moment of arrest, through court to detention, to release. It also includes transfers to hospital. The document details the agencies that should be involved at each stage and their roles and responsibilities.

Although the model was intended for adult prisoners, the forensic CPN used this document in the establishment of the post. The proposed model between Ashfield and the forensic CAMHS for the CPN post already mirrored what the document outlined.

The key to the success of the model has been the integration by the CAMHS team into the prisons primary care team. Initially there was concern expressed by nurses in the prison?s primary care team at nurses from another team coming into the prison and taking over work that had traditionally been managed by them. Close partnership working with joint MDT meetings has resulted in breaking down those barriers and effective teamwork.

Within HMP & YOI Ashfield the model of care is as follows:
- Referrals are made by anyone within the prison on a specially designed referral form.
- These are taken to the multi-disciplinary referral meeting attended by psychiatry, psychology (both the prisons own forensic psychology and the CAMHS clinical psychologist), substance misuse nurse, education, chaplaincy, forensic nurses and the prisons primary care team.
- Triage assessments are given to the most suitable department with the prisons primary care taking the bulk of these.
- Following triage the MDT decides appropriate pathways and arranges a case manager.
- All current cases are reviewed weekly
- Community teams contacted at earliest opportunity with their involvement being seen as crucial to the care and carrying out joint work where possible.
- Aftercare is arranged with community team and young persons involvement under CPA
- Follow up visits are made under the CPA.

Within HMPEastwoodPark, due to the limited numbers, the forensic nurse specialist acts as both triage and case manager and calls in appropriate services as needed while involving the community teams in the same way as at Ashfield.

Case 1
Pete [not his real name] was 16 when he first came to Ashfield. Pete?s had behavioural difficulties and he was assessed by a forensic child and adolescent consultant psychiatrist for ADHD due to his long-standing history of hyperactivity. Pete was prescribed a trial of Ritalin but released from custody.
When he returned to custody, this time for an 18-month sentence, the Ritalin was recommenced. He experienced difficulties, displaying obsessive-compulsive disorder about washing and clean bedding, constantly complaining about rashes from the washing powder. He also had dysmorphobia about his facial features, which affected his mood and ability to be around people including his family.
Pete was prescribed risperdal to help reduce his anxieties. He was monitored by the psychiatrist with high level of support from CAMHS, which supported him while transferring to an adult prison, with follow up appointments.

Case 2
Norman [not his real name] caused concern on his arrival at Ashfield. After an initial detoxification for heroin abuse he presented a number of bizarre symptoms. The most significant was a delusion that he had halitosis. Extensive medical and dental assessment found no evidence of this. This false belief was unshakeable and Norman isolated himself and at times felt desperate about his situation.
The gustatory hallucinations were having a profound impact on his life, causing him to avoid contact with people. He was diagnosed with depressive psychosis/schizo-affected disorder; however the consultant psychiatrist was unsure whether his condition was created by his drug use, due to evidence of a premorbid history of his substance misuse.
He was admitted to the healthcare wing and supported by the health care team with intensive work from the CAMHS team, monitoring his suicide risk. He was prescribed an anti-depressant and anti-psychotic medication. The forensic CPN organised a CPA meeting, with an intensive community treatment package on his release. This included a community CPA meeting to review the treatment post release.

Case 3
Helen [not her real name] was a 17-year-old girl remanded to HMPEastwoodPark for stealing a bottle of vodka. She was a prolific self-harmer since the age of 14 and had a long history of shoplifting, which fed her alcohol dependency. During her first period of custody while working with the forensic nurse specialist, Helen accepted the link of her alcohol abuse and her self harm to a history of sexual abuse.
On her return to custody following a trial placement at home there was a marked deterioration in her mental state. Helen became suicidal. The magistrate took the decision to remand Helen in order to keep her alive. This was due to her local CAMHS services stopping at 16 unless someone was in full-time education, and adult services would not consider admitting her to hospital, as she was under 18. Helen had intensive support from the forensic team and sterling work from the prison officers whose close observations kept her alive.
A referral was made to a specialist adolescent service and in liaison with them, the court, the family and the youth offending team a transfer was arranged under Section 37 of the Mental Health Act. On transfer, the forensic nurse specialist escorted Helen to the hospital with prison officers she knew well. The forensic team continued contact under the Care Programme Approach, attending review meetings.

Aftercare pathway
On Helen?s first release from HMPEastwoodPark, the forensic nurse specialist was in frequent contact with the Youth Offending Team CPN and YOT worker. This was in the form of telephone advice and support in finding services to engage with Helen. Although this contact did not result in persuading local services to meet the needs of Helen, it did result in the FNS knowing about Helen?s return to HMPEastwoodPark before she had even left the court.

This good relationship with local teams is something the forensic team has worked hard to achieve. The care pathway constantly reiterates the need for good communication links, and the relationships that the team has built up allows that.

The benefits of joint working were shown in the case of Norman, who was identified by the prisons primary care team during the health screening on arrival in prison. This resulted in an early intervention by the CAMHS team. The CPN undertook an initial assessment, which identified a range of mental health needs and arranged for Norman to be transferred to the healthcare wing for closer observation and assessment by the forensic psychiatrist.

The importance of communication between the teams cannot be stressed enough. Norman had a long history of involvement with community services. Good communication links with outside teams enabled the collection of that background information more easily.

The FNS coordinates the transfer of those young people who need hospital while the CPN coordinates the care of those who are being released into the community. Naturally on occasions there is overlap, and the close working and clear communication through the multidisciplinary team meetings help ensure a clear pathway. The Forensic CPN immediately identified a community team for Norman as he only had a short sentence. Joint working was arranged with the community CPN coming in to the prison and build a therapeutic relationship prior to release. This then resulted in a smooth transition with the CPA meeting, as the community were already aware of Normans needs and able to plan an intensive support package ready for his release.

When young people do require transfer to hospital, the coordinator of the transfer will go on the escort. This ensures a smooth transition and ensures that a detailed handover can be given and any questions about their care can be answered. Perhaps more importantly, it helps the young person. The nurse who has been coordinating the move, keeping the patient informed trying to win their cooperation in a traumatic move is vital in being there for the patient on transfer. This gives them the reassurance and support throughout the often long journey and the initial trauma of arrival at hospital.

Another form of transfer is when young people turn 18 and move to adult establishments. This can also be traumatic, especially if the young person has attendant mental health needs. They can be very institutionalised by this time. In Pete?s case both the Forensic team and the prisons healthcare team had worked with him for nearly three years and the culture shock of moving to an adult establishment away from the productive but dysfunctional relationships he had formed with officers and nurses.

The CPN facilitated Pete?s transfer working with the sentence planning team and the deputy governor in identifying a suitable adult establishment to cater for his mental health needs. The CPN then liaised with the receiving prison?s healthcare department to provide a comprehensive handover. To ensure effective continuity of care was provided to Pete, on the day of transfer the CPN accompanied Pete.

To provide ongoing integrated and affective aftercare as stipulated in the pathway, the CPN visited Pete a month later to review his mental health and discuss any issues or concerns with the adult establishment. This support enabled Pete to integrate into the adult population effectively, even though his support was much more limited than within HMP Ashfield.

In conclusion, the CAMHS service in the establishment of HMP Eastwood Park and HMP & YOI Ashfield has developed a model of care that focuses on ensuring the young person is not forgotten when they are admitted to custody, but has a clear pathway into community services.

The authors
Gary Risdale is a forensic nurse specialist working in HMPEastwoodPark and HMP & YOI Ashfield.Emma Mowling is a forensic community psychiatric nurse working in HMP & YOI Ashfield.
Both work for United Bristol Healthcare Trust.

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