"Excellent" Trust Gets a Good Kicking From the Mental Health Act Commission

"When I tell the truth, it is not for the sake of convincing those who do not know it, but for the sake of defending those that do"
William Blake


Don't look directly at Mr Sunshine by Baggelboy

The Mental Health Act Commission's (MHAC) job is to safeguard the interests of all people detained under the Mental Health Act 1983 (MHA). As an organisation it has the task of protecting of the human rights of detained patients.

It visits hospitals, meets with patients in private, and examines records relating to their detention or treatment. It also inspects the general living conditions of the wards, staff attitudes and the general hospital environment.

The MHAC report on the Cambridgeshire and Peterborough NHS Foundation Trust (the Trust) for 2008 has been delivered to the Trust, but for unknown reasons is not publicly available, although the Trust's response to this mysterious report, is available on the MHAC website.

Foundation Trust Watch has written to the MHAC asking to be provided with a copy of the report and we are awaiting their response.

Until we have the 2008 report, we will have to make do with the MHAC 2007 report. This document was compiled after 15 separate visits to various in-patient units, between December 2006 and September 2007. A total of 35 patients were interviewed in private.

The report makes horrific reading

It's difficult to know where to begin, so many and so serious are the MHAC's findings.

Section 58 of the MHA deals with treatment requiring consent or a second opinion.

The Mental Health Act requires written certification of the patient's understanding of the treatment being offered, and their consent to it. This is recorded on a "Form 38". If the patient is unable or unwilling to consent to treatment, a Second Opinion Appointed Doctor (SOAD) must be consulted. If the two doctors agree the treatment is in the patient's best interest, then this is recorded on a "Form 39"; the medication can then be given to the patient against their will and if necessary, by using force. A typical example of 'good practice' for the completion of these forms is here.

A copy of the form is then added to the patient's case notes, one is sent to the hospital's MHA Administrator (an officer appointed to oversee the application of the MHA), and one is attached to the patient's medicine card, kept on the ward. This is so staff can check the legality of their provision of medication.

Patients given medication unlawfully

In regard to two in-patient wards, the MHAC reported the following:

David Clarke House and Burnet House

The Commission has particular concerns about the administration of Section 58 on these wards.

Some of the Forms 38 examined were not completed in accordance with the Code of Practice guidelines.

One patient being treated at David Clark House under a Form 38 was not aware of the medication or what it was for. There appeared to be no indication that the doctor had assessed the patient’s capacity or consent as required.

Two patients were being treated under a Form 38 and had been prescribed and given up to three drugs which were not indicated on their Form 38 and were therefore being given without legal authorisation.

Several medicine cards did not have the corresponding Form 38/39 attached to them and it was difficult to see how nursing staff could check the legal authorisation of the medicine they were administering.

Both wards received a follow up visit six months a later... ...disappointingly, the evidence did not suggest [] much progress in David Clark House.

So it seems patients have been given psychotropic medication illegally. It also seems some staff, saw fit to ignore the law and continued to ignore the law, even when told they're acting illegally. Who are these doctors and nurses that have such a contemptuous attitude to the law? Why weren't they subject to disciplinary proceedings?

staff unaware of the law

Section 132 of the Mental Health Act is designed to ensure that the patients are aware of, and regularly reminded of their legal rights.

The Commission states that although patients were informed of their rights on admission, no further reminders were given and it seems to imply that documents were sent to the MHA Administrator indicating that reminders had been given to patients, when in fact, no such advice was offered.

The Commission goes on to say:

On Edith Cavell ward, Hawthorn ward and David Clark House, the Section 132 documents for a total of six patients indicated that they had understood their rights but on interview by the Commissioner it was clear that they lacked understanding.

At David Clark House staff appeared to be unaware of the requirements of Section 132.

How can it be that staff are unaware of the one of the fundamental parts of mental health legislation? At a Trust, who's Chief Executive claimed:

2007/08 has been no different to other years, in that we have continued to provide excellent care for service users and carers, evidenced by external reviews and assessments.

CPA reviews did not take place

Section 117 of the MHA and the Care Programme Approach (CPA)

Section 117 of the MHA sets out how each patients needs and wishes are to be met via the CPA. This is documented in their "Care Plans".

The Commission said:

The Trust has received feedback over the past year from both staff and service users that the CPA is not working well and this is reflected by the Commission’s findings at ward level.

On most wards visited the process appeared muddled; care plans were focused primarily on in-patient management rather then the total spectrum of care. There is little evidence to suggest that service users were involved in the planning of their care or that it was recorded in the documentation.

On one ward, CPA reviews did not appear to take place.

On another ward, the Commission visited in April the CPA documents examined appeared to be out of date or incomplete and detained patients had no care and risk management plans relating to their current status under the Mental Heath Act.

The Commission returned to this ward six months later and were:

Disappointed that there was no evidence patients had been involved in the planning of their care and the ample space in the documents to provide for this was blank.

At David Clark House, at the time of the Commission visit in April the CPA process was described as “somewhat chaotic”; detained patients appeared not to have received a thorough assessment of their needs and care plans were primarily focused very specific needs such as not smoking or getting out of bed.

It was not clear which care plans were current and there was little evidence that care plans were regularly reviewed or that risk assessments had been undertaken.

malodorous and not very clean

We will quickly skate over the Commission's findings that at Burnet House:

There were particular concerns about the male toilet/bathroom area which was malodorous and not very clean.

misuse of MHA for staff's convenience

Section 4 of the MHA dealing with emergency admissions to hospital of people under section 2 of the Act for assessment.

Section 4 of the MHA deals with emergency admission to hospital

The MHAC says:

There has been a small but significant increase in Section 4 admissions in the past year (especially from the Fenland area) and one ASW report examined by the Commissioner indicated that this was because of non-availability of an approved doctor.

The Commission draws the Trust's attention to the Code of Practice and in particular that Section 4 should be used for a genuine emergency, not for administrative convenience.

The Department of Health's Mental Health Act Code of Practice states:

Urgent necessity: Section 4 should be used only in a genuine emergency, where the patient's need for urgent assessment outweighs the desirability of waiting for a second doctor. Section 4 should never be used for administrative convenience.

The MHAC recommends:

The precise reason for a Section 4 admission should be recorded in detail on the ASW's report and its use closely monitored.

Trust Watch would like to know the name of the Approved Social Worker who saw fit to ignore the code of practice and it seems, broke the law.

distress caused to patients

Section 136 of the MHA - place of safety.

Section 136 of the MHA allows police to detain people they believe to be mentally disordered and convey them to a "place of safety". Many people maintain that a police station is not a "place of safety", and the use of police cells as such, is frowned upon generally: "Police custody is an unsuitable environment for someone with mental illness and may make their condition worse, particularly if they are not dealt with quickly, appropriately and don’t receive the care they need".

The Commission was informed that some patients were detained for 12/15 hours in a police cell whilst arrangements were made for a full Mental Health Assessment and/or a bed was located in an appropriate mental health ward. The Area Commissioner was given examples of the distress caused to patients in this situation and occasional lack of police sensitivity to patients in their temporary care.

One can only speculate as to the true nature and degree of the patient's "distress" and "occasional lack of police sensitivity to patients".

Trust's response "uncoordinated and unsatisfactory"

So, to summarize the findings of the Commission:

However, as last year (2006) there are continued concerns about the Consent to Treatment.

The Commission interviewed a number of patients who were unsure of their rights even though it was recorded that they understood them.

In many wards the Care Programme Approach did not appear to be working effectively.

In the first six months of the year (2007) the Trust's response to Commission visits appeared uncoordinated and unsatisfactory.

For four visits, the Commission did not receive the Trust's feedback response, despite reminders, until three to four months after the visit.

unfettered power

Perhaps the reason patients' rights and the Commission's findings were repeatedly ignored was because the Trust at the time was expending most of it's energies in a desperate, grasping bid for Foundation status and implementing the new LEAN management techniques, imported wholesale from a Japanese car maker.

The needs and rights of the patients, and the requirements of the law had simply dropped of the Trust's radar, to be replaced by the sea-clutter of corporate onanism and the prospect of the unfettered power that Foundation status would bring.

Excellent!