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What is secure psychiatric care?

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As recent events prompt calls for national standards to define psychiatric hospitals, Helen Mooney investigates the challenges of ensuring security and delivering care

Last week a judge highlighted concerns about security procedures at secure psychiatric hospitals after a patient at Hayes Hospital, a low-secure unit in Bristol, escaped and raped a teenager.

This incident and subsequent media coverage has uncovered wider failings in the current way in which such units are organised and has sparked talk of an urgent need for action.

Sentencing Darren Harkin to be held at the maximum security hospital Broadmoor, Judge Nicholas Cooke QC said alarm bells ought to have sounded regarding a deterioration in Mr Harkin’s behaviour in the weeks leading up to his escape.

Mr Harkin was 12 when he killed his baby stepbrother in a violent knife attack. Originally sent to prison, he was moved
to a medium-secure unit – from which he absconded three times – and finally to the low security Hayes Hospital, run by the National Autistic Society, from where he escaped in February. Following his escape from this unit he raped a 14-year-old girl
at knifepoint.

In court, the judge asked how Mr Harkin had managed to meet Home Office criteria to be housed in a low-secure unit, having a history of absconding and destructive and aggressive behaviour.

The judge also questioned why the hospital had not considered returning Mr Harkin to a higher secure unit when his behaviour became more disturbed and there was evidence that he presented a potential danger to female staff, prior to his escape.

Figures released under the Freedom of Information Act, also published last week, show that at least 116 people absconded from medium and low-security psychiatric hospitals – or while under the escort of hospital staff – in 2007 and that four remain at large.

Sir David Ramsbotham, the former chief inspector of prisons, has branded the figures as ‘horrifying’ and said that it was a wake-up call for the government.

Responding to Mr Harkin’s case and the figures, Louis Appleby, the government’s national director of mental health, admitted that the current system lacked formal structure, recommending that there should be a new definition and set of national standards to which units should have to adhere.

‘These units are something that have evolved in the mental health service,’ he said in an interview on BBC Radio 4’s Today programme.

‘What I think we now need to do is develop a very good definition of what low and medium secure units are for, and what their characteristics are – we need to define that more closely and set national standards for them, we can’t just allow them to evolve in this way,’ he added.

Currently there is a loose definition that patients who are suited to medium security settings are those who present a serious but less immediate danger to others and have the potential to abscond.

Low-security settings are considered necessary for patients who present a less serious physical danger to others. Their security measures are intended to impede rather than prevent absconding, with greater reliance on staffing arrangements and less reliance on physical security measures.

Specialists in the field warn that any shake-up must embody a careful balance between public protection and patient care – something that is not always reflected in media coverage.

‘It is a difficult balancing act between security and providing a therapeutic environment,’ said Peter Atkinson, vice-chairperson of Unison’s national nursing committee and a mental health nurse in West Sussex.

‘I’d welcome a review of medium and low-secure units if it acknowledges the work that these units do but I don’t want it to be a blaming exercise,’ he added.

Despite the media hype that often surrounds the escape of patients from these units, experts note that cases like that of Mr Harkin are extremely unusual. Additionally, they say that most mentally ill people who do escape pose a much greater risk to themselves than to others.

Paul Farmer, chief executive of mental health charity MIND, said it was important to remember that the vast majority of mental health patients in low and medium-secure mental health units had committed no offence at all. ‘The link between violence and mental health problems is grossly exaggerated,’ he said.

‘Over the last 30 years the number of homicides by people with mental health problems in England and Wales has fallen by two-thirds. This can be in part attributed to the improvements that we have seen in treatments and care in the community. We need to see greater investment in such earlier intervention, so that people get the help and support they need before they reach crisis point,’ he added.

The Mental Health Nurses Association, part of public sector union Unite, has long been campaigning for national standards for mental health services. MHNA professional officer Brian Rogers welcomed the mental health tsar’s suggestion that such standards should be introduced for all secure services.

‘Louis Appleby’s comments are a great start but are just that – a start,’ he said. ‘Secure services are a very important and significant part of mental health care. Public confidence demands that high standards are in place to ensure both public safety, as well as the delivery of high-quality patient care,’ he added.

Paul Correy, director of public affairs for mental health charity Rethink, said it was also necessary to look at both the staffing levels and skill sets of staff working in secure units.

He said he agreed that medium and low-secure units had developed in an ad hoc way but warned that any standards needed to be about treating patients effectively rather than simply allaying public fears.

‘Standards should focus on quality of care and staff skills – they should look at whether there is a high turnover of staff and whether staff can build relationship with patients. And then of course they have to include protocols with the police and the community,’ he said.

‘Many people who abscond from these units go on to take their own lives and there are often concerns that come up at their inquests that staff had not alerted the police to the possibility that an absconder is likely to harm themselves,’ he added.

It appears that these units may have been neglected in the past few years with the focus placed on community mental health services.

Stakeholders certainly seem to agree that the spotlight needs to be turned on them again in order to ensure safety and quality of care for patients, that there are adequate staff numbers and levels of training and education, and that public safety is ensured.

‘Staff with key skills have been siphoned off to work in the community,’ said Mr Correy. ‘I think the NHS has taken its eye off the issue generally, particularly in these units.’

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