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These are shocking figures

25 Sep, 09 | by Steven Reid, Evidence-Based Mental Health

This was the response of a spokesman for the charity Rethink to the results of the national survey of mental health inpatient services published today by the Care Quality Commission (the regulator of health and social care for England). You can see both the national results and those for individual trusts here. Of course, his comments were not a reaction to the three quarters of patients who rated their care as good, very good or excellent. Or the 85% who felt they were made welcome on admission. No, the headline findings are that the majority of respondents felt unsafe at times during their stay on a psychiatric ward, information about their care was lacking, and that only a minority were offered any sort of talking treatment.

I tend to view these surveys with scepticism. The questions are often worded ambiguously and how representative can you be with a response rate of 28%? Yet, the results here surely come as no surprise. It was only last year that the president of the Royal College of Psychiatrists, Dinesh Bhugra, lambasted inpatient units, calling them unsafe, overcrowded and uninhabitable: ‘I would not use them, and neither would I let any of my relatives do so.’

So why are mental health wards so unsatisfactory? Inpatient psychiatry has been neglected as a consequence of the emphasis on community care, a development not limited to the UK (see a previous post ‘A Place of Greater Safety’). Resources were diverted from comparatively expensive inpatient units, with a reduction in bed numbers leaving room only for the most severely ill: in the inner cities detention under the Mental Health Act is almost a requirement for admission. This has led to overcrowded, high-turnover wards filled with patients at their most unwell – is it any surprise that people feel unsafe at times? And faced with this pressure cooker environment the most talented and motivated staff soon joint the flight to fashionable, well-resourced, specialist teams in the community.

The Care Services minister Phil Hope is, um, hopeful: “We will make sure that the experiences people have shared in this report feed into New Horizons, our new vision for mental health.” Of which more later…

Do we need yet another homicide inquiry?

17 May, 09 | by Steven Reid, Evidence-Based Mental Health

Last week NHS Yorkshire and Humber released the findings of an external investigation into the care and treatment of Benjamin Holiday. You can find the report here. In January 2005 Holiday, a young man with schizophrenia, killed a pregnant woman, Tina Stevenson, stabbing her in the street close to her home. He was under the care of a community mental health team and living at home with his mother. Having no recollection of the attack he pleaded guilty to manslaughter with diminished responsibility and has been detained indefinitely in a special hospital.

Department of Health guidelines (shouldn’t that be directives?) call for a series of reviews when a homicide has been committed by a person who has been in contact with mental health services:
1) A fast-track (72 hours) investigation to identify any necessary immediate action
2) An internal mental health trust investigation (within 3 months)
3) And finally, an independent investigation commissioned by the Strategic Health Authority.

The reasons for an external investigation are obvious: lessons must be learned to prevent such events happening again. But do they work? They certainly provide a revealing insight into the day to day care of someone living with a severe mental illness, affording a degree of transparency for relatives and carers that is rarely available elsewhere. And outcomes? There have been at least 400 homicide inquiries in the last 15 years yet the rates of homicide by people with mental disorder remains unchanged: 30-50 from 800 homicides annually, with fewer than 10 committed by people with a psychotic illness (the remainder largely related to personality disorder and drug misuse). The recommendations have become familiar too: improved risk assessment, better communication and better record-keeping. Another report isn’t needed to tell us that. The Holiday Inquiry illustrates their inefficiency. Tina Stevenson was killed in 2005; the inquiry reports four years later in which time things have changed. We have a new Mental Health Act, community treatment orders, crisis resolution teams and I’m sure that like elsewhere, services in Hull have been completely reorganised. The authors acknowledge that much of what they say was reported in 2006 by the mental health trust’s internal review.

Much has been made of bringing an end to the ‘blame culture’ in the NHS which encourages staff to cover up errors for fear of retribution. The new focus is on systematic factors that allow such errors to be made. It is human nature, however, to search for a scapegoat and in this inquiry: “…if we are allowed to indulge in one piece of viewing this investigation through a ‘retrospective-scope’ we would conclude this was a missed opportunity to possibly break into the cycle”. What they are referring to here is the decision by a social worker not to complete an application to detain Holiday under Section 3 of the Mental Health Act two months before the homicide. At the time however, he was agreeing to an informal admission, and following his discharge one month later he was seen by a nurse on two occasions and given his depot antipsychotic injection. It is just as plausible that by detaining him at that time he may have become less cooperative with treatment and disengaged completely – a classic example of hindsight bias.

Of course these points have been made before. In 1999 the DoH’s Safer Services report recommended that homicide inquiries be scrapped but they keep on coming. Clearly they fulfil a social need. The Department of Health guidelines state that mental health services must ‘be seen to investigate’ any serious incident and though not explicit, the allaying of the publics’ anxiety about the mentally ill is key. We used to have asylums to contain the mad, but now we have community care – an idea that now attracts as much vilification as political correctness. The fear of mental illness is as potent as ever and homicide inquiries serve to remind us that whilst they may live among us, they remain alien and dangerous – as illustrated by headlines such as this: Crazed Killers – trust’s failings exposed.

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