Rosemary’s MHA Assessment from the Channel 4 series Bedlam

 

This is an extract from a Channel  4 series called Bedlam. This particular episode was first broadcast on 14^th November 2013, and features what I believe is the only actual assessment under the Mental Health Act to have been filmed.

The episode followed Jim Thurkle, an AMHP working in the Speedwell  Community Mental Health Team in South London, as he went about his work in the community. In particular, it focused on Rosemary, a woman with schizophrenia who had stopped taking her medication, and was evading contact.

I have extracted the scenes involving Rosemary, including Jim’s attempts to see Rosemary and his efforts to avoid a formal assessment under the Mental Health Act and the day the inevitable assessment takes place, and edited them together. Because of patient confidentiality, the cameras are unable to follow Jim into Rosemary’s house where the assessment takes place.

You can find a link here to the review of this episode that I wrote for Community Care magazine.

Another inquest for a death in a private mental hospital – why do we even have private hospitals?

 

On 11th June 2019 Brooke Martin, who was 19, was found suspended from a ligature point in her bedroom at Chadwick Lodge Hospital run by Elysium Healthcare. She had diagnoses of Autism and Emotionally Unstable Personality Disorder and had been detained under s.3 of the Mental Health Act. The inquest ended on 1st July 2021.

The solicitor for her family stated that the inquest had revealed “stark failures in risk assessment, information sharing and observation setting in a mental health hospital dealing with an exceptionally vulnerable patient group.”

The inquest heard that only 5 days before her death she had tried to hang herself, but this incident was not properly recorded or communicated with staff and there was no risk assessment or review of her observations. Earlier that evening Brooke was twice found by staff to have something that could be used as a ligature which she had concealed under her duvet. No action was taken as a result of this that could have protected her.

Elysium Healthcare admitted that had they taken appropriate action, Brooke would not have died.

Elysium Healthcare was founded in 2016 and is owned by BC Capital. They bought up several mental health hospitals, mainly from the Priory Group and Partnerships in Care.

For the year ended 2019 Elysium reported a turnover of over £74 million. This came predominantly from either NHS England or Clinical Commissioning Groups – in other words, public money that would otherwise have been spent on services within the NHS.

A couple of weeks ago I reported on the death of Peggy Copeman, who died in a private ambulance on the hard shoulder of a motorway, while being transferred from the Cygnet Hospital in Taunton, another private hospital. She was allowed to leave the hospital despite her being “the most poorly patient on the ward”.

Another major provider of private mental health beds is Priory Healthcare.

In 2017 the Priory Roehampton was rated “inadequate” by the CQC, and there had been little improvement when it was inspected a few months later.

Priory Healthcare also owns St John’s House in Suffolk. This is a specialist unit providing a low and medium secure environment for men and women with learning disabilities. They are all detained under the Mental Health Act.

In December 2020 it was placed in special measures, after a CQC inspection saw CCTV footage showing "a patient being dragged across the floor... a patient being pushed over and the seclusion room door trapping a patient's arm and making contact with a patient's head when closed". On five occasions staff were asleep when they should have been completing patient observations. There was low staffing, with a heavy dependency on agency workers, poor record-keeping and 204 instances of physical restraint in a six-week period.

A subsequent inspection in April 2021 discovered that many issues causing concern “remained unchanged”.  They again found staff were asleep when they should have been observing patients, including all three members of staff assigned to one patient. The CQC said "Our latest inspection found the overall quality of care had not improved and many of the issues we previously raised remained unchanged."

You might think that private psychiatric hospitals would offer levels of care superior to NHS hospitals, since isn’t that what you would expect if you were paying for care and treatment? But frequently the reverse is the case.

A Guardian report from 5th July 2021 revealed that there were 23,447 NHS mental health beds in 2010-11 but only 17,610 in 2020-21, a reduction of 5,837 (25%). This is in spite of the fact that there has been a 21% increase in people involved with mental health services since 2016,  and an increase of 53% of people being detained under the Mental Health Act, 13,437 in March 2016 to 20,494 in March this year. This has inevitably led to a huge increase in people being admitted to out of area beds – this being a euphemism for “private hospitals”. These beds are frequently over 100 miles away.

In March 2021 alone the NHS spent £11.5 million on funding out of area placements.

These private placements can be enormously expensive. As Keir Harding, who has long been a champion of improving servicers for people with personality disorder, has pointed out, a locked rehabilitation unit claiming to be a specialist personality disorder unit will charge around £250,000 a year per patient.

For over 10 years, the Conservative Government has tampered with the NHS and services for people with mental health needs, weakening or destroying effective community based services, cutting funding to local authorities, who are responsible for social care, and forcing the increased use of private hospitals.

You can reduce the numbers of psychiatric hospital beds, or you can cut back on community services, but if you do both, it won’t save money, it will simply put pressure on other public services, such as A&E departments, the courts, and the police and ambulance services. Most importantly it creates misery for people who are denied the care and treatment they need, forcing them into avoidable and traumatising situations.

One example of this is the now discredited Serenity Integrated Mentoring (SIM) scheme, which many areas have been introducing (without any significant evidence of efficacy) as a means of managing people with emotionally unstable personality disorder who appear to be disproportionately coming to the attention of A&E, police and ambulance services. Rather than offering a therapeutic approach to dealing with their distress, the outcome is often to criminalise people and if anything to increase their distress.

Private, for profit, hospitals should have no place in the effective provision of mental health services. The only solution is reinstating proper funding for health and social care. The new Health and Social Care Secretary, Sajid Javid, has an opportunity to rectify this. As MarkTrewin recently said in Community Care:

"We have a new Secretary of State who has the opportunity to put right some of the mistakes of the past. Let’s have a social care reform plan before the end of this year that is creative and radical, that includes mental health, younger people and autism and that is designed with people who use services to genuinely improve the lives of all those people with mental health issues currently struggling within the system, and the hard-working professionals who work with them."

Rectifiable & non rectifiable errors on MHA forms

 

This fascinating yet also informative post is all about how to fill in statutory MHA forms correctly.

This is vitally important, as an invalid form could lead to the patient being subject to unlawful imprisonment and they could sue.

It’s all in the Mental Health (Hospital, Guardianship and Treatment Regulations) 2008, which were amended in 2020 to accommodate electronic production and transmission of forms. This states that there are certain statutory forms that have to be used for compulsory admissions and other legal aspects of the MHA, and these regulations give the wording that has to be used on the forms.

Traditionally, these forms are pink, although they don’t have to be. It’s the wording on the forms which is statutory, not the forms themselves – you could write them out by hand if you wanted, as long as you used the wording set out in the Regulations.

These forms present the information that has to be provided to the managers of a hospital in order for them to be able legally to receive and detain the patient. As the Code of Practice says:

People who sign applications and make the supporting medical recommendations must take care to comply with the requirements of the Act. People who act on the authority of these documents should also make sure that they are in the proper form, as an incorrectly completed or indecipherable form may not constitute authority for a patient’s detention.

The Code goes on to say:

If admission documents reveal a defect which fundamentally invalidates the application and which cannot, therefore, be rectified..., the patient can no longer be detained on the basis of the application.

Because of the potential risk of a form being invalid, it tends to be best practice to go with, or at least to follow, the patient to hospital, and then not leave until someone authorised to do so has scrutinised the documents and made sure they are legally sound. That way, if there are any mistakes, at least on the AMHP’s form, they can be rectified while the AMHP is still there.

The current chronic shortage of psychiatric beds has meant that patients often have to be transported long distances to mainly private hospitals, so this can make going with the patient impracticable. In those cases, it’s a good idea to fax or email the forms to the hospital beforehand, so that they can be checked and approved before the patient arrives.

There are rectifiable and non rectifiable errors, and s.15(1) MHA allows 14 days for rectifiable errors to be corrected.

Many years ago, the CQC issued useful guidance on scrutinising and rectifying statutory forms. It gives examples of errors that can be rectified (although it’s a bit more vague when it comes to defining non-rectifiable errors). This document says that:

Documentary irregularities fall into three broad groups:
♦ Those that are both incapable of retrospective correction and sufficiently serious to render the patient’s detention invalid.
♦ Those that may be rectified within 14 days after admission, but which, if not rectified, are sufficiently serious to render the application invalid at the expiry of that period.
♦ Errors and omissions that, even if they are not corrected within the statutory period, are not sufficiently serious to render the admission application invalid.

Rectifiable errors are usually fairly minor things, like minor errors in the address or name of the patient, or not crossing out things that needed to be, or leaving blank spaces where you should have written something. An example might be not crossing out the bit on the application referring to being unable to identify the nearest relative, when in fact you have identified the nearest relative. But they can be bigger errors, such as two doctors from the same clinical team providing recommendations. But as long as you get another medical recommendation within 14 days, you’re all right.

Non rectifiable errors include things like naming the wrong hospital, or failing to sign a form. Another one would be a form completed by someone not authorised to complete the form, for example an application made by someone who was not actually an AMHP.

Another would be using the wrong forms. I can remember an occasion when I was called out to do an assessment by a GP. However, by the time I arrived at the patient’s home, the patient had already gone off to hospital in an ambulance. When the ambulance arrived at the hospital, the patient was brought onto the ward, clutching a single piece of pink paper in their hand. This turned out to be a Nearest Relative Application form. The Nearest Relative had completed the first part of the form, and the GP had then written in a space on the back “I certify that this person should be detained under the Mental Health Act” and had then signed it.

But anyone can make a mistake, especially when things get a little bit out of control. I’ll tell you about an occasion in which I made a fatal error.

One day, I was called to assess a patient who was well known to me, and who had been detained several times before under s.3. I set up the assessment at her house, and arranged for two doctors to meet me there. When I arrived, she was in the street behaving in an erratic manner. The police had been called, and took her to the police station under s.136.

I let the doctors know before they arrived, and they then went to see her at the police station, which was being used as a place of safety.

By the time I got there, they had already assessed her, and gave me a completed joint medical recommendation. I then assessed her myself, completed an application under s.3, and arranged for an ambulance to take her to hospital.

I followed in my car, with the pink forms on the passenger seat, I happened to glance at the paperwork as I was driving, and realised with horror that the doctors had completed a form for a s.2, not a s.3, as I had assumed. So I pulled into the next layby and hurriedly completed an application for a s.2 to make the whole thing legal again.