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.
It has become apparent from events that we have studied in great detail that there are issues of general application that form a background to the specific treatment of XX. They arise from widely-accepted attitudes and practices which underlie many of the actions taken, and which shape quite fundamentally the individual decisions made. They therefore require careful analysis and consideration. They have each played a background role in contributing to the evolution of the events under review and in each case a modified approach, whilst not necessarily averting the tragedy, may well have contributed to maintaining XX in a state of health and at a level of control that would have lessened the danger. These matters are -
In looking at XX's treatment we had no doubt that, once Dr Yyyy had detected that XX had worries which appeared to embrace both physical and emotional problems, it was entirely appropriate to refer him first to a cardiologist and subsequently to counselling. The G.P. practice, and Dr Yyyy in particular, had made the use of counselling a feature of their care of patients. XX was just the sort of young man, finding it difficult to cope and with obvious social problems, who was likely to benefit from such a referral.
We are equally clear that it is right to assume that the work done with the counsellor, Mr AAA - whose notes were not formally disclosed to us, was of real potential benefit to XX. He clearly valued the help he was being given in this way. The question is raised as to why nothing happened with regard to his psychotic symptoms during the year of counselling. This was because they were not detected by Mr AAA. This suggests that the training of counsellors does not provide the necessary skills to allow them to recognise serious psychotic illness in their clients.
We feel it is most important to draw attention to the confidentiality of the information passing from patient to counsellor. Dr Yyyy had no set policy on this. She did not ask for routine 'reporting back' but appeared to expect that matters of concern to a counsellor would be referred back to her by the counsellors used in the practice. Mr AAA did not do this. However, he appears to have been of the opinion that his professional code prevented unilateral disclosure by him to anyone of anything but most serious matters. In general, it seems important that the guidance given to counsellors and, in particular, trainee counsellors should be reviewed to ensure that the position is clearly stated.
It is our impression, from what we have been able to discover in general enquiries and from documents kindly sent to us by the British Association for Counselling that the approach to problems that arise where mentally ill patients are being counselled are not yet fully developed. Their document on the Code of Ethics and Practice says -
B4.1 Confidentiality is a means of providing the client with safety and privacy. For that reason any limitation on the degree of confidentiality is likely to diminish the usefulness of counselling.It is difficult to find fault with those guidelines except the guardedness of 4.4. Clarity is lacking as to the action to be taken where a counsellor encounters circumstances leading to a belief that the client may well be mentally ill and even possibly dangerous. It should be made clear, without any doubt, that where such circumstances are encountered, the counsellor has a duty to disclose to an appropriate professional, skilled in the identification and treatment of mental illness, the worries that have arisen. Where a group of counsellors form part of a team serving the practice patients it would be reasonable to make clear at the outset that the counsellor would, in circumstances where he felt it important for the well-being of the client, be entitled to pass to his colleagues such information or worries as he thought essential to protect the client's health.4.2 Counsellors treat with confidence personal information about clients, whether obtained directly or indirectly or by inference...
4.3 Counsellors should work within the current agreement with their client about confidentiality.
4.4 Exceptional circumstance may arise which give the counsellor good grounds for believing that the client will cause serious physical harm to others or to themselves, or have harm caused to him/her. In such circumstances the client's consent to a change in the agreement about confidentiality should be sought whenever possible unless there are good grounds for believing the client is no longer able to take responsibility for his/her own actions. Wherever possible, the decision to break confidentiality should be made only after consultation with a counselling supervisor or an experienced counsellor.
Had the extent of professional powers and responsibilities been clearer to Mr AAA we have little doubt that he would have regarded it as within his professional duty to report any worries he may have had about XX's stability to Dr Yyyy, who had referred XX for counselling. Obviously the patient's agreement should be sought, but in the occasional case a decision could properly be taken to inform the G.P. We do not suggest that the counsellor's strict adherence to his concept of confidentiality is a matter for criticism - it is for that reason that we deal with the issue here as a matter for general clarification so that all counsellors are alerted to the importance of sharing such information - without necessarily having obtained the client's permission - with appropriate colleagues. Indeed it is arguable that Dr Yyyy, being herself bound by professional rules of confidentiality still maintained the shield of protection with which the counsellor was rightly concerned.
It is our hope that the bodies who at present are seeking to structure counselling as an important profession make sure that the point we have made is clearly set out in their Codes of Conduct. The sensitive handling of confidential information cannot be governed solely by a strict rule of confidentiality nor by the 'contract' between client and counsellor. Professional responsibility adds the additional burden, on rare occasions, of protecting the client by breach of confidentiality, certainly where the information is passed to other professionals with their own regard for confidentiality.
The situation also raises the question of the supervision of a counsellor, in this case on professional placement. It is not clear whether there is an adequate system in place. The question is one which should be considered by all G.P.s as a group, and by all those concerned with Community Mental Health.
The intervention of counselling was plainly of some benefit to XX. It was indicated to us that the organisation of counselling services required to be improved and this seems appropriate.
The priority to provide counselling services requires review with the purchasers of this service. The balance of resources allocated to meet a range of needs, from emotional distress to the most severe mental health conditions, needs to be evaluated.
The central feature of treatment in hospital is the accurate identification of the illness, the determination of the appropriate medication and assessment of its effectiveness. Once stability has been achieved, consideration has obviously to be given to return to the community. If, however, the patient does not give his co-operation, consideration has to be given to the availability of detention orders under the Mental Health Acts which enable those phases of diagnosis and treatment to be ensured for unwilling patients, in the interest of their own health and safety and the safety of others, by imposition initially of an Order under S.2 Mental Health Act 1983.
XX was regarded by Dr CCC, correctly we have no doubt, as liable to be placed under such an Order when she first examined him. He was plainly suffering from a serious illness - schizophrenia, which was affecting his behaviour and meant that he was at least a danger to himself unless treated.
XX appears to have been, his illness apart, a very pleasant young man and he agreed to enter hospital without the necessary imposition of an Order. He duly appeared as promised. His schizophrenia was easily recognisable and the standard medication in a normal dosage was administered. He made a rapid improvement and was soon returning to a state where he said that he was feeling much better and showing that he was keen to return home and restart work.
Dr CCC confirms his speedy improvement on medication. She did not indicate to us how long she would ideally have liked him to remain as an inpatient but in explaining why he was discharged quite quickly, said that she did not regard him as any longer 'sectionable'. That is to say his mental state had improved to such an extent that although he was by no means fully recovered he was no longer so ill as to be liable to the imposition of an Order. So she did not feel she was in a position to have resisted a refusal to stay and felt, in view of the apparent improvement, on balance it was better that he return home and continue to receive his medication as an out-patient. This did not appear to her to present any danger.
It is our impression that Dr CCC was expressing a generally-held view that, once there is a certain degree of improvement, an informal patient having been assessed and treated in hospital cannot at that stage be restrained by an Order so that treatment can be continued with certainty.
Assessment of the state of a patient with mental illness in terms of liability to be 'sectioned' involves a difficult judgement, since liberty has not lightly to be taken away. It is, however, one that psychiatrists are familiar with and used to making. An apparently difficult question arises, however, where the patient who could have been put on a section, such as XX, agrees to enter hospital voluntarily and medication speedily reduces the symptoms of the illness to a level which may well be thought to fall below what would normally be regarded as the threshold for sectioning.
It is surely part of the structure of the Mental Health Act that a patient, sectionable upon entry to hospital, must reach a level of improvement and of adequate insight that would warrant the discharge of a sectioned patient before the right to section lapses. It would be contrary to the structure of the statute, and against the wider interests of the patient and the public, to believe that once improvement has started and the patient's condition improved, the safeguard of detention is thereby lost even though improvement has not reached the level where the patient could be safely discharged if an Order had been imposed.
It seems important to stress that the test to be applied to a patient, sectionable at the beginning of treatment but admitted informally, who seeks to leave hospital at a stage that is premature, is not that which is used on initial sectioning in the community. It is rather - 'would that patient, if an Order had been in place, have been discharged from it at the current stage of improvement'. If not, it is surely both reasonable and responsible to make an Order, no doubt explaining the reasons and indicating that if improvement continues it is likely to be removed before it has run its four weeks' course.
We would add here that it appears to have been reasonable to decide that XX had improved to such an extent that his wish to leave could be accepted. It was a matter for judgement by Dr CCC and she clearly took into account that he was going home where he would not be alone and that his job was available to him. It was her indication that she felt the alternative of the imposition of an order detaining XX, had she felt it necessary, was not available to her that has prompted these comments.
The short period that XX spent in hospital - XX slept there for 11 nights between his admission and discharge - and the way he appears to have occupied himself whilst in hospital raises the very wide question of the purpose of treatment in hospital.
Plainly the central purpose is to diagnose and to begin treatment of the psychiatric illness. It is clear in the circumstances being reviewed that neither of these tasks were particularly difficult since XX was plainly suffering from schizophrenia, as indicated by the GP on referral, and he responded quickly and well to the usual medication. Indeed, in one sense the problem had been rapidly identified and potentially solved, for had he continued with his medication we have little doubt that there would have been no relapse and the tragedy would have been avoided. It was other pressures which led to non-compliance with medication and XX's relapse.
We feel it necessary, however, to raise wider aspects of XX's period in hospital. He appears to have been offered attendance at a workshop in the hospital, but declined this and no particular persuasion was used. It is, moreover, difficult to discover accurately what he did whilst in the hospital. It was suggested to us by the staff that he took part in some ward activities, which we do not doubt, but he himself indicated that he quite often went home and to town, we must assume without this being noticed. We were unable to verify this but must comment that, no doubt because his illness presented no problems of diagnosis or control, there appears to have been a failure to observe him closely, assess him generally and to ensure he had something to occupy himself with.
There may have been special reasons for what happened, it is difficult for us to be certain. We did, however, gain the impression that the focus was on treating the illness rather than the patient in the round. This is not uncommon in psychiatric practice, in cases such as XX, where the effect of the drug treatment is good and there is apparently a reasonably stable background.
It should have been very clear that there were some serious social problems and that XX had never been able to develop his potential nor to find an appropriate job which interested him for long. It is unlikely that a return to such a lifestyle would itself have precipitated a return of his illness, but it would undoubtedly have increased the chances of a relapse. A routine investigation of the social background would have disclosed that he needed some urgent assistance and support with these aspects of his life.
It followed from the narrow medical and scientific approach that no social work assessment of XX's social background was sought and, therefore, the situation to which XX was discharged was not fully assessed. It is worthwhile noting that had he been under section, and he had made application to a Mental Health Review Tribunal, a full, specially-prepared, home and social circumstances report would have been available to the Tribunal. The preparation of the report would have entailed an interview with XX and with his family by a social worker assessing matters such as his home circumstances, job prospects and need for further training. The question of his setting up independently, which was a possibility mentioned for XX, would also have been considered. Such a report for XX would undoubtedly have shown that he was likely to meet a range of problems and that he might well find it exceptionally hard to cope.
One of the important conclusions that can be drawn, and it forms an important part of our recommendations, is that no patient with a major mental illness should be discharged from hospital without there being available for consideration a full, up-to-date social work report covering matters such as the home circumstances and work prospects. We strongly recommend that such a report should be prepared in all such cases prior to discharge. For many patients the information will be well-known and readily available and merely need collecting together and perhaps up-dating. XX's discharge is an illustration where, despite indication of tensions, there was a lack of social investigation which can now be seen to be an important omission.
Where a patient has suffered a psychiatric illness and been admitted to hospital, there will almost certainly be very many carers involved; consultant, hospital psychiatric department, community nurse - the list is very long indeed. There is bound to be considerable difficulty in ensuring, at the various stages, adequate communication between those immediately involved.
Similarly a great deal of information about a patient, the illness and progress is recorded in many different places. For example, initially there are the notes of the G.P., detailed daily ward notes and any number of specialist assessments. It is, therefore, a problem to ensure that relevant information is always promptly passed to those who are taking over responsibility for the next phase of care. In practice, of course, much of the information is disseminated and generally known. Transmission takes the form of passing on significant information as new phases of care arise.
It is clear, however, from our investigation that further thought needs to be given to the timing and form of the information given. Two random, but important, examples concerning XX will serve to illustrate this.
It does not appear that all the information sent from the hospital to his G.P., when XX was discharged, came to her notice, as quickly as is desirable. The precise reason for this was difficult to determine. Similarly, it was also apparent that, once the patient was being cared for in the community, the accepted methods of communication were not as efficient as they should have been. The most notable instance related to procedure rather than what actually happened. It was indicated to us that had the CSN or CPN decided to terminate efforts to persuade XX to accept Depot medication, this decision may have been taken without prior discussion with his consultant psychiatrist and may not even have been speedily communicated.
We did look in great detail at these matters and saw clear indications that a review of the network and methods of communication would be of benefit. The existing system of communication of routine matters will probably merely require reconsideration and up-dating. Where there are major matters arising, discharge and refusal to take the prescribed Depot injection are the two clear examples here, there should be consideration of more immediate forms of communication - telephone, fax and E-mail for example.
There is no doubt that a multi-disciplinary, multi-agency review of communications would be beneficial. Admission, discharge and other transfers of information should be considered within this review by all those involved. These matters are now of particular importance and relevance prior to the disaggregation of services between Derbyshire County Council and the newly-created unitary authority for Derby City.
It should be noted that XX's father, who clearly had worries about his son's health and welfare, felt that he had been unable to ensure that his feelings were fully understood and taken into consideration whilst XX was in hospital. The impression he got was that, no doubt because XX was an adult, his views were not given great weight, whereas what XX said was more readily accepted.
He also felt that where there is a serious psychiatric illness, families should be involved as early as possible. Although the legal concept of 'adulthood' is of great importance, where a patient is suffering from a severe psychiatric illness, proper weight has to be given to the experience and views of those who have been close to him.
There needs to be information and advice on the nature of the illness and the effects of medication.
The description given by XX's father of his own experiences immediately following the tragedy also gave us considerable concern. He does not feel that he was treated with consideration.
On returning to his home, where the tragedy had occurred, he was, understandably, refused entry by the police. He was provided with necessary clothing and taken to a relative's home. Since then he has received continuous support from the "Family Officer" of the Derbyshire Constabulary.
For the reason indicated at the outset of this section, we did not look into the matter in detail but had noted the apparent lack of contact from the hospital and the primary health care team.
Their use depends upon the initiative of general practitioners and there is very wide variation.
29. The current training should be offered to all counsellors with the purpose of clarifying their role in the care of patients/clients and of ensuring their ability to recognise when there is the need for reference to other specialists. They need to have an understanding of the early symptoms of mental illness.
30. Bearing in mind the current variations of counselling practice that currently exist, guidance should be made available to G.P.s as to the most effective use of the differing forms of counselling.
31. Building on the varying rules and practice of the various professional bodies in counselling, clear rules should be promulgated by the Health Authority, setting out for counsellors the basic standards expected. Clarity of the rules as to the sharing of information is crucially important.
32. Standard requirements, also set out in the Job Specification, including the duty to attend training and discussion sessions, should also be included in contracts offered to Counsellors. The current support for counsellors should be extended to include trainees and qualified counsellors on professional placement.
33. More collaboration would be appropriate between mental health services and primary care counsellors. Counsellors should have a periodic opportunity to discuss their work generally with Psychiatrists, G.Ps., and social workers. This might be achieved by an annual study session.
34. Attendance at joint training sessions for general practitioners and practice staff on the use of counsellors should be encouraged.
35. The limits of confidentiality between the various professionals concerned with a patient's care should be carefully defined, indicating the circumstances in which others must be informed.
36. As comprehensive a register of counsellors as possible should be available, setting out the type of counselling they are prepared to offer.
They have been adopted by the Southern Derbyshire Health Commission and the Southern Derbyshire Mental Health Trust and in documents drawn up jointly with Derbyshire County Council Social Services Department - evidenced by the publication 'People and the Care Programme Approach'. These publications were commended by John Bowis, Parliamentary Under-Secretary of State.
We have, however, identified several weaknesses in the application of the procedures.
38. Steps should be taken to ensure that at appropriate times patients and their carers are included in discussions concerning discharge and after-care.
39. A discharge letter by, or on behalf of, the consultant should deal with social aspects in addition to the strictly medical. It should always be approved by the consultant.
41. In the case of all patients, a social worker and wherever possible relatives should be involved in this screening.
42. Schizophrenia, a severe mental illness, should warrant level 2 or level 3 of the Care Programme Approach, thus receiving a multi-disciplinary review of need or a co-ordinated care package.
The central role of the Consultant and her Senior House Officer is clear. This is supported by the input at Multi-Disciplinary Meetings (MDM's), held regularly. The role of the "named nurse", in the case we examined, appears to have been underplayed. During the short stay of XX his "named nurse" was on leave for several days, but also, within the regular structure, the nurse was not expected to attend the Clinical Ward Round or the MDM when patients were being reviewed. The designation as "named nurse" did not take place within 72 hours as laid down and so XX's nurse was not involved in the initial planning of care.
The "named nurse's" absence from MDMs is most surprising and wrong. As is the failure to nominate a 'stand-in' to cover absences.
The initial phase of care was non-specific and lacked clear identification of individual need. Although some occupation was offered, it does not appear to have been regarded as part of the assessment and a refusal was quickly accepted.
The nursing documentation prior to week-end leave and thereafter was found to be inadequate. There was no identification of the goals set, nor assessment of the leave on return, as laid down in the model of nursing used on Ward 34.
In the absence of adequate notes of various discussions on the Ward, we have had to assume that communication to the community team was largely oral and most probably inadequate because it did not include concerns about the family background and the existence of weapons.
The only communication with the family, whilst XX was an in-patient, was initiated by Mr X, XX's father. It does not appear that the serious concerns he was expressing were given sufficient weight. In addition, Mr X was not made aware of the difficulties which were likely to arise following discharge, nor given information about the possible consequences of a schizophrenic illness.
44. The nursing handover should explicitly involve the passing on of relevant patient information, which should be documented.
45. There should be early identification of the particular needs of the patient as an individual, as well as in terms of his illness.
46. The information passed to those undertaking community care on discharge should be full, as set out in the development model of nursing used in Ward 34.
47. Firm efforts should be made to devise and supervise an inpatient programme to occupy and assist in the rehabilitation of a patient.
48. Ward staff should ensure that they are aware of a patient's location at all times during their inpatient stay.
49. Prior to discharge it is essential to have a co-ordination meeting to assess needs and nominate, as appropriate, a care co-ordinator.
50. The assessment of the home circumstances of patients, particularly those with behavioural problems such as with schizophrenia, should be regarded as essential.
The consideration of XX by the Community Mental Health Team failed to recognise any special difficulties. It appears to deal with a considerable number of cases in a relatively short time - 40 to 60 in about 2 hours - and cannot be sure to identify and deal adequately with cases of difficulty. Allocation of patients to individual nurses should not be purely administrative but should be based on the patient's needs and the experience and expertise of the nurse allocated.
52. The Community Mental Health Service should receive full professional information from those with medical responsibility for the patient.
53. Allocation of individual patients should take full note of the difficulty of the case and the level of experience of the nurse.
54. Initial home assessment of those diagnosed as suffering from schizophrenia should be made by a Community Psychiatric Nurse.
55. A Community Nurse should be designated, for a period of a year or so, in each of the relevant areas, as a formal link with Ward 34.
56. After a year has elapsed from the implementation of these recommendations, a review should be undertaken to assess their impact and to give an opportunity to consider any necessary reinforcements of their objectives.