Sunday, November 19, 2006

Patient rights verses patient safety

June - October 2002

On Thursday I came across this news item which highlights a problem that unfortunately Mr Man and I are all too familiar with.

It is unclear whether the patient in this article discharged himself from the secure unit at the hospital*, was given home leave, or whether he escaped after being given permission to walk around the hospital grounds, as several articles (all from the same news website) differ slightly in details, but whatever the case, one thing is clear: he had not been assessed adequately to determine whether he was a risk to himself or others.

Once again I am moving into an area that I wasn’t planning on blogging about yet, but during Mr Mans first hospital admission this was just one of the ongoing problems that we had. Again and again Mr Man was released into my care for home leave, placing me under unimaginable pressure for days at a time, as he was very suicidal, but also he suffered from command hallucinations telling him to kill others. The problem was partly that the consultant and some of the nursing staff simply refused to accept that Mr Man was even suffering from psychosis, despite an assessment proving otherwise**, but also, just as the news article explains regarding the patient John Barrett:

"…too much emphasis was placed on [the patients] wishes and he was not assessed adequately."

In Mr Mans case, he wanted to go home as often as possible since he didn’t believe that he was ill, as is common with all Schizophrenia sufferers, but also, due to his psychosis he believed that the staff were working for “the company” and trying to control him with the use of medication. Due to these feelings he was understandably very keen to go home each time the consultant or other staff members suggested home leave, but that doesn’t mean that he was well enough to. Often he asked for home leave himself, and the staff never refused as it was thought to be a “good sign” that he wanted to go home. It was very difficult for me to say no, as I was always asked in front of Mr Man, and of course I had to be careful that I didn’t end up looking like the “baddy” who was forcing him to stay in the hospital against his will, and thus lead him to believe that I too was working for “the company”.

Although he had been through an assessment to determine whether he was truly psychotic, to my knowledge he still hadn’t been through a risk assessment at this point, despite being admitted due to feeling suicidal. He had already been in hospital for nearly four months before a risk assessment was finally carried out on him after he had cut his arm with a razor blade within the hospital grounds, and he was found to be a high suicide risk***. These results were largely ignored much like the results of the other assessment, particularly by the consultant on the ward. Just one week after being assessed as a high suicide risk the consultant said Mr Man could go home for some leave. Thankfully his primary nurse, who had conducted the assessment, ignored the consultant and only allowed Mr Man home leave for a few hours. Two weeks later Mr Man made a serious suicide attempt whilst on the ward.

From these experiences it is easy to see why some psychiatric patients who are released from hospital go on to commit serious crimes, or commit suicide. Often patients are not adequately assessed, and even when they are a number of problems can arise:

  • There is a lack of communication between staff members (including consultants) about the level of risk.
  • Staff members (including consultants) do not update themselves by reading patient notes.
  • The responsibility is wrongly placed on the shoulders of an unqualified carer.
  • Staff members (including consultants) disagree on diagnosis or treatment including whether home leave is beneficial or not.
  • For a completely unknown reason to myself, risks are ignored by staff members (including consultants).
One factor that staff members fail to take into consideration is that whilst a patient may not be a serious risk to others or themselves whilst on the ward, the level of risk drastically increases once the patient leaves the hospital. This is largely due to the fact that the patient now has access to things previously not available to them whilst on the ward, such as knives, medication, alcohol, rope, and even privacy. This is one reason why the role of the carer is substantially more difficult than the role of the staff member, not to mention the fact that staff members work in shifts, whereas the carers role is an impossible 24 hours a day.

It was mentioned in one of the articles that the staff failed to heed the warnings of Johns partner. This is another problem that we faced often. In the days leading up to when Mr Man attempted suicide on the ward I had desperately tried to get someone to take my concerns seriously about his safety. Unfortunately no one did. This is something I will write about in more detail another time, but as Mr Mans current consultant has said recently “It’s a mistake not to listen to the carer”.

* One article states that John, the patient, could not be held at the hospital against his will, which is completely untrue. An “informal” patient, or someone who is in hospital voluntarily, can be detained for up to 6 hours by an authorised psychiatric nurse, whilst waiting for the doctor in charge to make an application to detain the patient for 72 hours under section 5 of the Mental Health Act 1983. Before the 72 hours has elapsed the doctor can then arrange for the patient to be held for a further 28 days under section 2, or 6 months under section 3.

** At the time it was explained to me that the assessments were “scored” out of 4; 1 being the lowest and 4 being the highest. In the psychosis assessment Mr Man “scored” 4, showing that he was suffering from a very high level of psychosis.

***In the risk assessment Mr Man “scored” 3, showing that he was a high suicide risk. The nurse who conducted the assessment explained that the only detail which prevented Mr Man from “scoring” 4 in the risk assessment was that he hadn’t decided on a location yet.


Inspector Gadget said...

The quality and quantity of mental health provision depends very much upon where you live. This is another 'post code' lottery. I have personal experience of two Health Authorities, one good and one not, the boundary between them only being the river which runs through the village. It's unfair that the quality of care is so different just because you happen to live one side of a river - if you see my meaning.

Mr Mans Wife said...

Yes I do. Thank you for your comment Inspector Gadget.

As far as quality goes I saw a huge difference in the attitudes of staff between two different hospitals in the same town.

Actually, the day Mr Man attempted suicide the nurse who took my call was one who usually worked in the other hospital. After expressing my concerns she wasted no time in checking on Mr Man to see if he was safe, but had one of the usual staff answered I doubt that they would have bothered. (I'll write more about this in detail another time.)

I don't understand why some people bother doing the job to be honest. Having nurses that don't care is like having police officers with no sense of justice. What's the point?

As for quantity of provisions, I suppose it depends on how each area spends their funds.

slurry from surrey said...

I have just stumbled across your blog, and think its great, as a schizophrenic myself its very intresting to see things from a carers point of veiw, I am very well controlled on medication, but alot of my friends arent, but yet are still let out on section 17 leave and quite a number have ended up comitting suicide, or severly self harming and in some cases harming other people. I find it sad thst hospitals dont take in to account or sometimes even do risk assesments, how is it i can see they shouldnt be out on leave but all these staff with many yrs in the job think they are safe and allways get it so wrong??

Mr Mans Wife said...

Hi there Slurry, thank you for posting.

Firstly I want to say how sorry I am that you have had the awful experience of losing friends through suicide.

I agree with you that it is beyond belief that hospital staff often can’t see what is so glaringly obvious to everyone else – particularly other patients who are supposed to be so “unaware”. As for staff always getting things so wrong – I stopped listening to them a long time ago because I found that every time I took on board a piece of their advice it would back fire badly. Now I look at things this way: they know more than me about mental health generally, but I know more than them about Mr Mans mental health because I live with it.

Do you agree that the level of risk increases once a patient leaves the ward?

slurry from surrey said...

Yes I feel strongly that people are at a much greater risk in the first few weeks after discharge, and if let out on section 17 leave unsupervised. Down here in the depths of surrey,one of the most afulent areas of the country, we have one of the poorest mental health systems in the country,half the cmht are in need of medication more than half their clients, and when released from hospital it takes them about 6 weeks or till something goes wrong to realise that that person is out of hospital!
Some times the hosoitals are not much safer than the community, often there are violent paitents on acute wards, and self harm is rife, in some cases people who have commited suicide not in found for hours. It makes me angry that at the age of 24 i have lost a few friends and know of many others who have been failed by the system, and things arent set to get any better, but we stay strong for each other. Ps just read all your posts, really great reads!

Mr Mans Wife said...

Slurry, your experiences are truly shocking. Have you thought about writing a blog of your own?

For other readers not familiar with mental health services: CMHT - Community Mental Health Team. Section 17 - patients who are detained in hospital under a section of the Mental Health Act can be granted leave from the ward under section 17

Anonymous said...

I think it is very much a post code lottery like with pretty much everything else in the NHS. There are some good staff and the bad ones, just like in any other job.

Mr Mans Wife said...

Thank you Anonymous, I'm sure you're right. Obviously I only have experience of where I live though, and so far I have found that bad staff outweigh good staff.

The thing is, experiences such as my own or that of Slurry shouldn't happen anywhere. And obviously when there are news items such as the one in my original post then these problems are perhaps more common than people think.

I know through my own experience that when people try to complain about such services it gets swept very neatly under the carpet. When families and patients are already feeling vulnerable, they are treated as if they are making a fuss over nothing. I would have pursued with my complaint, but I just couldn't cope anymore. In the NHS the higher up you go the more like a brick wall they become.

Sorry, I'm going on and on a bit now! Thank you for your comment.

Anonymous said...

I wanted to say hello and thanks for having me as a follower on your blog. I also wanted to add that I used to work in the Psychiatry setting both inpatient and outpatient and I have to say that stays were determined according to diagnosis and insurance type as well as hospital beds availability and turn overs...

So sad but true. The worst part is that whenever patients were labeled as "difficult" they got dumped to other hospitals.

Regarding discharges, they've patients were placed on a voluntary out patient "Day Hospital" that was Monday-Friday which focused on after-care steps towards regaining mental stability and focusing on triggers and coping skills.

Patients that required 24 hour 'round the clock care were typically were admitted to nursing homes unfortunately, so, I was wondering if you ever dealt with hospitals pushing nursing home care? and What are your thoughts on that?