Risk and defensive practice in psychiatry

1
Risk and defensive practice in psychiatry

• D B Double

2
David Clark, 1995

• Much has happened since 1983. The number of
  people in mental hospitals over Britain has
  continued to decline. The attitudes of
  denigrating public service, of running down
  public hospitals, building up private enterprise,
  and of mean-minded economising have filtered down
  through the NHS bureaucracy. ... Battered by
  public enquiries and outcries, pressured by
  harassed Ministers, the administrators and
  managers have reverted to the kind of
  administrative behaviour that marked the worst of
  the asylum days - issuing memoranda forbidding
  activities, putting up warning notices, setting
  up disciplinary enquiries and penalising staff
  who take risks or show initiative. Staff have
  learned to be cautious, to get everything in
  writing, to avoid initiative.

3
Origins of community care

• Numbers of people in psychiatric hospitals
  increased until a peak in the 1950s in the UK and
  USA and later in other countries

4
Origins of community care

• Numbers of people in psychiatric hospitals
  increased until a peak in the 1950s in the UK and
  USA and later in other countries
• Motivation was to make the traditional mental
  hospital more therapeutic

5
Origins of community care

• "Dismay and disgust with the old asylum system"

6
Origins of community care

• "Dismay and disgust with the old asylum system"
• David Clarks description of back ward at
  Fulbourn hospital in 1953

7
Origins of community care

• Opening the doors of the psychiatric hospital

8
Origins of community care

• Opening the doors of the psychiatric hospital
• Return to moral treatment

9
Origins of community care

• Opening the doors of the psychiatric hospital
• Return to moral treatment
• Hospital as a therapeutic community

10
Negative process of institutionalisation

• Institutional neurosis (Russell Barton)

11
Negative process of institutionalisation

• Institutional neurosis (Russell Barton)
• Apathy, lack of initiative, loss of interest and
  submissiveness

12
Negative process of institutionalisation

• Institutional neurosis (Russell Barton)
• Apathy, lack of initiative, loss of interest and
  submissiveness
• Total institution (Irving Goffman)

13
Dehospitalisation of mental health services

• Traditional hospitals went into decline

14
Dehospitalisation of mental health services

• Traditional hospitals went into decline
• Alternative services developed (including
  psychiatric units in general hospitals,
  residential homes and day centres).

15
Dehospitalisation of mental health services

• Many old long-stay patients grew old and died in
  hospital

16
Dehospitalisation of mental health services

• Many old long-stay patients grew old and died in
  hospital
• Bed numbers overall have steadily continued to
  decrease

17
Politics of community care

• Many psychiatrists felt threatened by their
  perceived loss of power due to the rundown of the
  traditional psychiatric hospital

18
Politics of community care

• Many psychiatrists felt threatened by their
  perceived loss of power due to the rundown of the
  traditional psychiatric hospital
• Campaigning organisations, such as SANE,
  deliberately exploited public anxieties

19
Politics of community care

• Initial concern was that homelessness was being
  increased among the mentally ill

20
Politics of community care

• Initial concern was that homelessness was being
  increased among the mentally ill
• Tack changed when evidence accumulated against
  this view to concern about public safety due to
  homicides by psychiatric patients.

21
Politics of community care

• New Labour government decided community care had
  failed

22
Politics of community care

• New Labour government decided community care had
  failed
• Debates about community care are no longer as
  polarised as they were in the past

23
Inquiries into mental health services

• Scandals that uncovered mistreatment of patients
  in hospital

24
Inquiries into mental health services

• Scandals that uncovered mistreatment of patients
  in hospital
• eg. Ely Hospital inquiry

25
Inquiries into mental health services

• Scandals that uncovered mistreatment of patients
  in hospital
• eg. Ely Hospital inquiry
• eg. Whittingham Hospital inquiry

26
Inquiries into mental health services

• Political response
• (i) setting up of Health Advisory Service (HAS)

27
Inquiries into mental health services

• Political response
• (i) setting up of Health Advisory Service (HAS)
• (ii) renewal of promotion of policy of community
  care

28
Inquiries into mental health services

• Shift from focusing on abuses and
  over-restrictive practices within institutions to
  anxiety about the lack of control in the
  community

29
Inquiries into mental health services

• Shift from focusing on abuses and
  over-restrictive practices within institutions to
  anxiety about the lack of control in the
  community
• Since 1994 health authorities obliged to hold an
  independent inquiry in cases of homicide
  committed by those who have been in contact with
  psychiatric services

30
Inquiries into mental health services

• Tragic killing of Jonathan Zito by Christopher
  Clunis on London Underground led to the formation
  of the Zito Trust

31
Inquiries into mental health services

• Tragic killing of Jonathan Zito by Christopher
  Clunis on London Underground led to the formation
  of the Zito Trust
• Zito Trust closed following implementation of
  Mental Health Act 2007

32
Homicide inquiries

• Can have devastating consequences for mental
  health services

33
Homicide inquiries

• Can have devastating consequences for mental
  health services
• Reinforces stereotype of the dangerous lunatic

34
Homicide inquiries

• Can have devastating consequences for mental
  health services
• Reinforces stereotype of the dangerous lunatic
• Public fears of the mentally ill are fuelled

35
Luke Warm Luke inquiry (Scotland et al, 1998)

• Two volumes cost 750,000

36
Luke Warm Luke inquiry (Scotland et al, 1998)

• Two volumes cost 750,000
• Luke Warm Luke (formerly Michael Folkes) stabbed
  to death Susan Milner in 1994.

37
Luke Warm Luke inquiry (Scotland et al, 1998)

• Two volumes cost 750,000
• Luke Warm Luke (formerly Michael Folkes) stabbed
  to death Susan Milner in 1994.
• Diagnosed as suffering from paranoid
  schizophrenia, in and out of mental health
  facilities since 1983.

38
Luke Warm Luke inquiry (Scotland et al, 1998)

• Criticised the lack of communication in the
  community care team

39
Luke Warm Luke inquiry (Scotland et al, 1998)

• Criticised the lack of communication in the
  community care team
• Also criticised the decision to discontinue depot
  medication.

40
Luke Warm Luke inquiry (Scotland et al, 1998)

• Criticised the lack of communication in the
  community care team
• Also criticised the decision to discontinue depot
  medication.
• Should have been discharged into a staffed hostel

41
Luke Warm Luke inquiry (Scotland et al, 1998)

• Criticised the lack of communication in the
  community care team
• Also criticised the decision to discontinue depot
  medication.
• Should have been discharged into a staffed hostel
  
• Attacks could have been prevented if admitted to
  hospital.

42
Luke Warm Luke inquiry (Scotland et al, 1998)

• Unclear why Luke Warm Luke killed Susan Milner.

43
Luke Warm Luke inquiry (Scotland et al, 1998)

• Unclear why Luke Warm Luke killed Susan Milner.
• Simple view that schizophrenia is a biological
  illness that determines how a person behaves,
  especially if they are violent

44
Luke Warm Luke inquiry (Scotland et al, 1998)

• History of serious violence, which antedated the
  illness, passed over without comment

45
Luke Warm Luke inquiry (Scotland et al, 1998)

• History of serious violence, which antedated the
  illness, passed over without comment
• Focus on mental health services tends to exclude
  the role of other actors in the drama.

46
Luke Warm Luke inquiry (Scotland et al, 1998)

• History of serious violence, which antedated the
  illness, passed over without comment
• Focus on mental health services tends to exclude
  the role of other actors in the drama.
• Understanding complex cases requires an approach
  that goes beyond blaming.

47
Richard King Inquiry (Norfolk Waveney Mental
Health, 2005)

• Convicted of the manslaughter of his
  mother-in-laws partner on 6 August 2004

48
Richard King Inquiry (Norfolk Waveney Mental
Health, 2005)

• Convicted of the manslaughter of his
  mother-in-laws partner on 6 August 2004
• Known to mental health services in Norfolk since
  1991
• .

49
Richard King Inquiry (Norfolk Waveney Mental
Health, 2005)

• Convicted of the manslaughter of his
  mother-in-laws partner on 6 August 2004
• Known to mental health services in Norfolk since
  1991
• Panel concluded the homicide occurred because of
  mental illness and that although it was not
  predictable, it was preventable because he should
  have been detained under the Mental Health Act.

50
Richard King Inquiry (Norfolk Waveney Mental
Health, 2005)

• Trust panel understood public expectation that
  mental health services should exert some control

51
Richard King Inquiry (Norfolk Waveney Mental
Health, 2005)

• Trust panel understood public expectation that
  mental health services should exert some control
• Report was written to maintain this public
  confidence by identifying mistakes and errors of
  judgement.

52
Richard King Inquiry (Norfolk Waveney Mental
Health, 2005)

• Trust panel understood public expectation that
  mental health services should exert some control
• Report was written to maintain this public
  confidence by identifying mistakes and errors of
  judgement.
• Homicide inquiries are being used to achieve
  political aims?

53
Richard King Inquiry (Norfolk Waveney Mental
Health, 2005)

• The report did not demonstrate that staff acted
  in bad faith, nor without reasonable care.

54
Richard King Inquiry (Norfolk Waveney Mental
Health, 2005)

• The report did not demonstrate that staff acted
  in bad faith, nor without reasonable care.
• Written with the benefit of hindsight bias

55
Richard King Inquiry (Norfolk Waveney Mental
Health, 2005)

• The report did not demonstrate that staff acted
  in bad faith, nor without reasonable care.
• Written with the benefit of hindsight bias
• Nor is it as clear that detention under the
  Mental Health Act was indicated.

56
Richard King Inquiry (NHS East of England, 2008)

• Looking through the reeds - inherent difficulty
  of reconstructing past events

57
Richard King Inquiry (NHS East of England, 2008)

• Looking through the reeds - inherent difficulty
  of reconstructing past events
• Professional consequences for Trust staff

58
Richard King Inquiry (NHS East of England, 2008)

• Looking through the reeds - inherent difficulty
  of reconstructing past events
• Professional consequences for Trust staff
• Six points in time which were missed
  opportunities for professionals to take an
  overview of the deterioration in mental state

59
Richard King Inquiry (NHS East of England, 2008)

• No individual and no single act or omission led
  directly to the killing

60
Richard King Inquiry (NHS East of England, 2008)

• No individual and no single act or omission led
  directly to the killing
• On the balance of probabilities better quality
  care and treatment would have substantially
  reduced the increasing risk of a violent act.

61
Richard King Inquiry (NHS East of England, 2008)

• No individual and no single act or omission led
  directly to the killing
• On the balance of probabilities better quality
  care and treatment would have substantially
  reduced the increasing risk of a violent act.
• But the frenzied killing could not have been
  reasonably foreseen.

62
Richard King Inquiry (NHS East of England, 2008)

• Cannot agree with conclusion, that had Richard
  King been detained under s.3 he would probably
  have spent longer in hospital and would not have
  been given early home leave.The report gives the
  impression that the homicide could have been
  avoided if Richard King had been detained and not
  discharged in July 2004. We take the view that
  the shortcomings so evident in his care and
  treatment were longstanding and deeply rooted.

63
Richard King Inquiry (NHS East of England, 2008)

• Recommendations may appear to replicate the
  rather imprecise recommendations and exhortations
  of the first inquiry, but they do not. All are
  addressed to the Trust or to specific individuals
  in order to bring about changes in practice.

64
Richard King Inquiry (NHS East of England, 2008)

• Recommendations may appear to replicate the
  rather imprecise recommendations and exhortations
  of the first inquiry, but they do not. All are
  addressed to the Trust or to specific individuals
  in order to bring about changes in practice.
• Relationship between the factors described in the
  report and the homicide was cumulative and
  complex no simple direct causative link. No
  single individual can be held responsible.

65
Risk and mental health

• Homicide inquiries have made modern mental health
  services defensive

66
Risk and mental health

• Homicide inquiries have made modern mental health
  services defensive
• Ever more rigid and bureaucratic interpretation
  of Care Programme Approach and risk assessment

67
Risk and blame

• Someone has to be blamed for misfortune

68
Risk and blame

• Someone has to be blamed for misfortune
• Increasingly technological society switches blame
  onto services

69
Risk and blame

• Always a political question about what is
  acceptable risk

70
Risk and blame

• Always a political question about what is
  acceptable risk
• Taking risks may be an opportunity for growth not
  just something to be avoided

71
Complexity of healthcare

• Uncertainty in clinical practice

72
Complexity of healthcare

• Uncertainty in clinical practice
• Guidelines and procedures cannot eliminate
  clinical judgement

73
Complexity of healthcare

• Greater consistency and invariance cannot cope
  with the unexpected

74
Complexity of healthcare

• Greater consistency and invariance cannot cope
  with the unexpected
• Illusion created that can be effective in
  preventing individual tragic outcomes

75
Defensive practice

• Fear that things may go wrong distracts from the
  task of how to make things better

76
Defensive practice

• Fear that things may go wrong distracts from the
  task of how to make things better
• Follow procedures more for the purpose of
  protecting staff than helping patients

77
Examples of defensive practice

• Admitting patients overcautiously

78
Examples of defensive practice

• Admitting patients overcautiously
• Placing patients on higher levels of observation
  than necessary

79
Sensible accountability

• Accountability needs to be applied sensibly

80
Sensible accountability

• Accountability needs to be applied sensibly
• Improvement needs to be authentic and not façade
  for placating societys fear

81
Sensible accountability

• Fear of being criticised and unfairly judged does
  not lead to creativity

82
Sensible accountability

• Fear of being criticised and unfairly judged does
  not lead to creativity
• Excellent leadership provides ethos where staff
  are valued and supported

83
Conclusion

• Possibility of rational risk governance in fact
  an elaborate technocratic fantasy and a
  bureaucratic defence against anxiety of disorder

84
Conclusion

• Possibility of rational risk governance in fact
  an elaborate technocratic fantasy and a
  bureaucratic defence against anxiety of disorder
• Psychiatry should know because of its history in
  the asylum