Adapted from the report of the inquiry supplied by Pat Fitzgerald, of Southern Derbyshire Health. Mounted as HTML by Chris Evans C.Evans@sghms.ac.uk, 24.xi.96 within the Section of Psychotherapy pages

Names and some details have been changed. Where names have been changed the substitutions are consistent, where places have been changed this is not necessarily the case.


REPORT OF THE INQUIRY INTO THE CARE OF XXX XXX

SOUTHERN DERBYSHIRE HEALTH AUTHORITY & DERBYSHIRE COUNTY COUNCIL

August 1996


CHAPTER THREE

CONCLUDING REMARKS

The primary purpose of independent inquiries such as this is to determine if there are any lessons to be learned and to identify remedial actions that should be taken. Immediately after the tragedy we have examined, the relevant authorities, very properly, began to review what had occurred and to initiate a programme of changes, to remedy any perceived weaknesses. It was our task to look at the matter widely and to make independent suggestions for improvement where this appeared to be necessary.

It appears to us, after our enquiries, that there are three levels at which weaknesses in the detection and treatment of mental illness can occur. The first, and most important, of these concerns the organisation of the different levels of care and the instruction and training of the professionals concerned in its provision. The second and more difficult area concerns the relationships and responsibilities which are meant to ensure that the necessary care and attention is identified, and put in place. This involves the acceptance that certain responsibilities have to be accepted by the professionals concerned, the levels of care determined and above all the various individuals and agencies involved effectively co-ordinated. Finally, and more difficult to assess, in the light of many current attitudes and assumptions generally accepted in society, those having the task of looking after those with mental illness must be prepared to ensure that the correct level of control, advice and guidance are available to patients who are temporarily suffering from severe mental illness and consequently unable themselves to make decisions that ensure their own safety and well-being and the safety of others. Recent emphasis, both of political principle and legal regulation, has tended to stress the rights of the individual to an extent that might be thought to inhibit action which is restrictive but is proposed solely and responsibly with the protection of the patient in mind. It is the task of those reviewing situations, such as those that we have been concerned with, to emphasise that the duty of society to protect those with mental illness, both from harming themselves and doing harm to others, is paramount. Such action has to be taken within a clear code of conduct - which appears at the present time to be somewhat lacking - but those charged with care should not be unnecessarily inhibited from doing what their professional training, carefully applied, deems essential.

There is no doubt that the most difficult aspect of the problems posed is the reconciliation of fair and humane treatment of the patient and protection of those who may be harmed if the control is inadequate. Too restrictive an approach will undoubtedly curb unnecessarily the freedom of most patients, whilst ensuring greater security overall; too little may lead to an unacceptable number of 'incidents' which are likely to cause public outrage and a call for stricter controls. Inevitably the extent of controls deemed to be reasonable will depend initially on professional judgement. That judgement will be generally based on standards adopted by the professions concerned, which must inevitably involve some flexibility in the hands of individual practitioners. Additionally, the attitude of the public will have a powerful influence, but it will oscillate quite considerably. When an incident occurs, such as the one dealt with by this report, there will be pressure for stricter rules and regulations: where an individual case leads to publicity condemning excessive restriction and control of a patient there will be pressure for a more liberal attitude. As is so often the case there has to be an effort to maintain a sensible balance. The occasional failures that do occur, and it would be idealistic to believe that they can be completely avoided, give an opportunity to review that balance, which is one of the underlying aims of this report.

If those general principles are accepted, certain actions are important to try to ensure their most effective implementation.

1. Rules and procedures

Increasingly, and properly, greater attention is being paid to putting into place systems which lay down and ensure as far as possible the best practice. The recent emphasis on the Care Programme Approach is an excellent example of that. In the areas we have examined, although a considerable number of amendments to the system have been recommended, the position as we found it was by no means seriously deficient and had been under continual review.

The majority of our recommendations deal with specific weaknesses we have found. We are confident that they will be seriously considered and speedily implemented. We have noted that a number of such suggestions have already been receiving attention by the appropriate agencies.

2. Practice

The system, however, showed some real weaknesses in the implementation of the accepted practices that had been laid down. Reality does not always correspond to the assumption of the planners. An example or two might make this point clearer. The key participants - the GP, the Counsellor, the Consultant, the Named Nurse and the Community Support Nurse, for example - in general carried out their roles efficiently and effectively. Yet it is apparent that effective communications between them were often delayed or even lacking. The system was adequate for the routine, but lacked the flexibility to enable urgent or difficult cases to be identified and dealt with with urgency. Most of the reasons for this are clear and understandable. All cases cannot be 'fast-streamed' - that would defeat the object. Yet, for many reasons, there was a lack of ability to distinguish the urgent cases. One very obvious example is the placing of responsibility on individuals whose status, training and length of service makes them hesitant to press for action and unlikely to be successful promptly if they do so. For example, the role of a sole "named nurse" (or even a team if that is adopted) can only be effective if the system recognises as a whole their responsibilities and ensures that the structure enables action recommended to be taken quickly. Absence from the decision-making reviews - Multi-Disciplinary Meetings and Ward Rounds - detracts from their perceived status and must inhibit them from properly fulfilling their role, especially in the occasionally special case, such as the one we are considering. The fact that Dr CCC was job-sharing work with another consultant has to be mentioned. It appears to have had no deleterious effect in the situation we have considered but it is a complication in the chain of authority and necessitates care to ensure that it is effectively managed. The passing of information between the hospital and the G.P. is another area where potential weaknesses are apparent. In these days of telephones, faxes and E-mail, important summary details can be speedily transmitted even if the longer, more thoughtful assessments take a longer time. It is not certain that letters from G.P. to consultant on admission and in the opposite direction on release are regarded as deserving prompt attention and despatch - there is an underlying feeling of compartmentalisation that needs to be broken down. Similar considerations arise from the experience of the CSN who visited XX and reported his worries. The system seemed to be weak and vacillating in dealing with a clear potential danger, as was the refusal by XX to accept his medication by injection.

It should be impressed on every person with professional responsibility that he or she should think deeply about each case and, as well as complying with the procedures - the boxes to be ticked on documentation - should be expected to raise any special features or problems that are felt to need attention. Once these are raised, there has to be a readiness to act speedily and in an other than routine fashion. If, as is inevitable, there is a 'false alarm', no harm is done and the system is seen to be alert.

3. Patients' rights

Finally, as we have indicated, especially in Chapter 2, there are general pressures which have a profound effect on the way in which patients are treated. These have sprung largely from a necessary and proper emphasis on the rights of individuals. Gradually, however, they have become so powerful as to induce in professionals a fear of the law to an extent that may inhibit action. This can have dangerous consequences in a small number of cases and a proper balance has to be maintained.

Many examples of this are clear from our discussions above. XX was an adult young man, living at home, but undoubtedly independent. There must have been some ambivalence as to how far the professional workers caring for him were able to involve his family, especially without his permission. Yet it is an undoubted fact (which has little to do with theories or rights) that a person with a serious psychiatric illness is under a disability which is likely to affect his judgement. In those circumstances, where safety and well-being are at stake, the health and safety of the patient must surely permit appropriate liaison with those who need to know or who can offer additional support. It would have been a great deal more satisfactory if XX had been regarded from the outset as a person who needed support from his family and its availability should have been assessed as soon as possible so that additional assistance could have been given if necessary. Similarly it must have been clear that he would have to face a considerable number of difficulties when he left hospital. Social support would not have been an infringement either of his rights or of his freedom.

* * *

The facts we have been considering are especially tragic in that all the necessary elements for its avoidance were in place. XX's illness had been quickly and correctly diagnosed, his G.P. had shown an understanding of his needs in the reference to counselling before his first rank symptoms appeared, the community psychiatric team were alerted to his release and reasonably quickly realised that he was in need of further care.

For reasons that we have indicated, no-one fully realised the extent of his illness and the urgency of the need for fuller investigation and greater control. XX himself appears to have presented as a pleasant and reasonably co-operative young man. The signs of the strength of his delusions and his resistance to medication were only tardily realised.

That said, the system markedly lacked the ability to react quickly, upon the initial recognition of the warning signs and subsequently in the reaction to them once they were clear. With hindsight, there are many concerned who would have acted differently and will deeply regret their failure to do so. No serious blame, however, can be attached to any one person but no doubt all who were concerned in the events we have reviewed will be able to see how the tragedy might have been averted and learn from the experience.


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