Risk and defensive practice in psychiatry l.jpg
This presentation is the property of its rightful owner.
Sponsored Links
1 / 84

Risk and defensive practice in psychiatry PowerPoint PPT Presentation


Risk and defensive practice in psychiatry. D B Double. David Clark, 1995.

Related searches for Risk and defensive practice in psychiatry

Download Presentation

Risk and defensive practice in psychiatry

An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -

Presentation Transcript


Risk and defensive practice in psychiatry l.jpg

Risk and defensive practice in psychiatry

D B Double


David clark 1995 l.jpg

David Clark, 1995

  • “Much has happened since 1983. The number of people in mental hospitals over Britain has continued to decline. The attitudes … of denigrating public service, of running down public hospitals, building up private enterprise, and of mean-minded economising have filtered down through the NHS bureaucracy. ... Battered by public enquiries and outcries, pressured by harassed Ministers, [the administrators and managers] have reverted to the kind of administrative behaviour that marked the worst of the asylum days - issuing memoranda forbidding activities, putting up warning notices, setting up disciplinary enquiries and penalising staff who take risks or show initiative. Staff have learned to be cautious, to get everything in writing, to avoid initiative.”


Origins of community care l.jpg

Origins of community care

  • Numbers of people in psychiatric hospitals increased until a peak in the 1950s in the UK and USA and later in other countries


Origins of community care4 l.jpg

Origins of community care

  • Numbers of people in psychiatric hospitals increased until a peak in the 1950s in the UK and USA and later in other countries

  • Motivation was to make the traditional mental hospital more therapeutic


Origins of community care5 l.jpg

Origins of community care

  • "Dismay and disgust with the old asylum system"


Origins of community care6 l.jpg

Origins of community care

  • "Dismay and disgust with the old asylum system"

  • David Clark’s description of back ward at Fulbourn hospital in 1953


Origins of community care7 l.jpg

Origins of community care

  • Opening the doors of the psychiatric hospital


Origins of community care8 l.jpg

Origins of community care

  • Opening the doors of the psychiatric hospital

  • “Return to moral treatment”


Origins of community care9 l.jpg

Origins of community care

  • Opening the doors of the psychiatric hospital

  • “Return to moral treatment”

  • Hospital as a therapeutic community


Negative process of institutionalisation l.jpg

Negative process of institutionalisation

  • “Institutional neurosis” (Russell Barton)


Negative process of institutionalisation11 l.jpg

Negative process of institutionalisation

  • “Institutional neurosis” (Russell Barton)

  • Apathy, lack of initiative, loss of interest and submissiveness


Negative process of institutionalisation12 l.jpg

Negative process of institutionalisation

  • “Institutional neurosis” (Russell Barton)

  • Apathy, lack of initiative, loss of interest and submissiveness

  • “Total institution” (Irving Goffman)


Dehospitalisation of mental health services l.jpg

Dehospitalisation of mental health services

  • Traditional hospitals went into decline


Dehospitalisation of mental health services14 l.jpg

Dehospitalisation of mental health services

  • Traditional hospitals went into decline

  • Alternative services developed (including psychiatric units in general hospitals, residential homes and day centres).


Dehospitalisation of mental health services15 l.jpg

Dehospitalisation of mental health services

  • Many old long-stay patients grew old and died in hospital


Dehospitalisation of mental health services16 l.jpg

Dehospitalisation of mental health services

  • Many old long-stay patients grew old and died in hospital

  • Bed numbers overall have steadily continued to decrease


Politics of community care l.jpg

Politics of community care

  • Many psychiatrists felt threatened by their perceived loss of power due to the rundown of the traditional psychiatric hospital


Politics of community care18 l.jpg

Politics of community care

  • Many psychiatrists felt threatened by their perceived loss of power due to the rundown of the traditional psychiatric hospital

  • Campaigning organisations, such as SANE, deliberately exploited public anxieties


Politics of community care19 l.jpg

Politics of community care

  • Initial concern was that homelessness was being increased among the mentally ill


Politics of community care20 l.jpg

Politics of community care

  • Initial concern was that homelessness was being increased among the mentally ill

  • Tack changed when evidence accumulated against this view to concern about public safety due to homicides by psychiatric patients.


Politics of community care21 l.jpg

Politics of community care

  • New Labour government decided ‘community care had failed’


Politics of community care22 l.jpg

Politics of community care

  • New Labour government decided ‘community care had failed’

  • Debates about community care are no longer as polarised as they were in the past


Inquiries into mental health services l.jpg

Inquiries into mental health services

  • Scandals that uncovered mistreatment of patients in hospital


Inquiries into mental health services24 l.jpg

Inquiries into mental health services

  • Scandals that uncovered mistreatment of patients in hospital

  • eg. Ely Hospital inquiry


Inquiries into mental health services25 l.jpg

Inquiries into mental health services

  • Scandals that uncovered mistreatment of patients in hospital

  • eg. Ely Hospital inquiry

  • eg. Whittingham Hospital inquiry


Inquiries into mental health services26 l.jpg

Inquiries into mental health services

Political response

  • (i) setting up of Health Advisory Service (HAS)


Inquiries into mental health services27 l.jpg

Inquiries into mental health services

Political response

  • (i) setting up of Health Advisory Service (HAS)

  • (ii) renewal of promotion of policy of community care


Inquiries into mental health services28 l.jpg

Inquiries into mental health services

  • Shift from focusing on abuses and over-restrictive practices within institutions to anxiety about the lack of control in the community


Inquiries into mental health services29 l.jpg

Inquiries into mental health services

  • Shift from focusing on abuses and over-restrictive practices within institutions to anxiety about the lack of control in the community

  • Since 1994 health authorities obliged to hold an independent inquiry in cases of homicide committed by those who have been in contact with psychiatric services


Inquiries into mental health services30 l.jpg

Inquiries into mental health services

  • Tragic killing of Jonathan Zito by Christopher Clunis on London Underground led to the formation of the Zito Trust


Inquiries into mental health services31 l.jpg

Inquiries into mental health services

  • Tragic killing of Jonathan Zito by Christopher Clunis on London Underground led to the formation of the Zito Trust

  • Zito Trust closed following implementation of Mental Health Act 2007


Homicide inquiries l.jpg

Homicide inquiries

  • Can have devastating consequences for mental health services


Homicide inquiries33 l.jpg

Homicide inquiries

  • Can have devastating consequences for mental health services

  • Reinforces stereotype of the ‘dangerous lunatic’


Homicide inquiries34 l.jpg

Homicide inquiries

  • Can have devastating consequences for mental health services

  • Reinforces stereotype of the ‘dangerous lunatic’

  • Public fears of the mentally ill are fuelled


Luke warm luke inquiry scotland et al 1998 l.jpg

Luke Warm Luke inquiry (Scotland et al, 1998)

  • Two volumes cost £750,000


Luke warm luke inquiry scotland et al 199836 l.jpg

Luke Warm Luke inquiry (Scotland et al, 1998)

  • Two volumes cost £750,000

  • Luke Warm Luke (formerly Michael Folkes) stabbed to death Susan Milner in 1994.


Luke warm luke inquiry scotland et al 199837 l.jpg

Luke Warm Luke inquiry (Scotland et al, 1998)

  • Two volumes cost £750,000

  • Luke Warm Luke (formerly Michael Folkes) stabbed to death Susan Milner in 1994.

  • Diagnosed as suffering from paranoid schizophrenia, in and out of mental health facilities since 1983.


Luke warm luke inquiry scotland et al 199838 l.jpg

Luke Warm Luke inquiry (Scotland et al, 1998)

  • Criticised the lack of communication in the community care team


Luke warm luke inquiry scotland et al 199839 l.jpg

Luke Warm Luke inquiry (Scotland et al, 1998)

  • Criticised the lack of communication in the community care team

  • Also criticised the decision to discontinue depot medication.


Luke warm luke inquiry scotland et al 199840 l.jpg

Luke Warm Luke inquiry (Scotland et al, 1998)

  • Criticised the lack of communication in the community care team

  • Also criticised the decision to discontinue depot medication.

  • Should have been discharged into a staffed hostel


Luke warm luke inquiry scotland et al 199841 l.jpg

Luke Warm Luke inquiry (Scotland et al, 1998)

  • Criticised the lack of communication in the community care team

  • Also criticised the decision to discontinue depot medication.

  • Should have been discharged into a staffed hostel

  • Attacks could have been prevented if admitted to hospital.


Luke warm luke inquiry scotland et al 199842 l.jpg

Luke Warm Luke inquiry (Scotland et al, 1998)

  • Unclear why Luke Warm Luke killed Susan Milner.


Luke warm luke inquiry scotland et al 199843 l.jpg

Luke Warm Luke inquiry (Scotland et al, 1998)

  • Unclear why Luke Warm Luke killed Susan Milner.

  • Simple view that schizophrenia is a biological illness that determines how a person behaves, especially if they are violent


Luke warm luke inquiry scotland et al 199844 l.jpg

Luke Warm Luke inquiry (Scotland et al, 1998)

  • History of serious violence, which antedated the illness, passed over without comment


Luke warm luke inquiry scotland et al 199845 l.jpg

Luke Warm Luke inquiry (Scotland et al, 1998)

  • History of serious violence, which antedated the illness, passed over without comment

  • Focus on mental health services tends to exclude the role of other actors in the drama.


Luke warm luke inquiry scotland et al 199846 l.jpg

Luke Warm Luke inquiry (Scotland et al, 1998)

  • History of serious violence, which antedated the illness, passed over without comment

  • Focus on mental health services tends to exclude the role of other actors in the drama.

  • Understanding complex cases requires an approach that goes beyond blaming.


Richard king inquiry norfolk waveney mental health 2005 l.jpg

Richard King Inquiry (Norfolk & Waveney Mental Health, 2005)

  • Convicted of the manslaughter of his mother-in-law’s partner on 6 August 2004


Richard king inquiry norfolk waveney mental health 200548 l.jpg

Richard King Inquiry (Norfolk & Waveney Mental Health, 2005)

  • Convicted of the manslaughter of his mother-in-law’s partner on 6 August 2004

  • Known to mental health services in Norfolk since 1991

    .


Richard king inquiry norfolk waveney mental health 200549 l.jpg

Richard King Inquiry (Norfolk & Waveney Mental Health, 2005)

  • Convicted of the manslaughter of his mother-in-law’s partner on 6 August 2004

  • Known to mental health services in Norfolk since 1991

  • Panel concluded the homicide occurred because of mental illness and that although it was not predictable, it was preventable because he should have been detained under the Mental Health Act.


Richard king inquiry norfolk waveney mental health 200550 l.jpg

Richard King Inquiry (Norfolk & Waveney Mental Health, 2005)

  • Trust panel understood public expectation that mental health services should exert some control


Richard king inquiry norfolk waveney mental health 200551 l.jpg

Richard King Inquiry (Norfolk & Waveney Mental Health, 2005)

  • Trust panel understood public expectation that mental health services should exert some control

  • Report was written to maintain this public confidence by identifying mistakes and errors of judgement.


Richard king inquiry norfolk waveney mental health 200552 l.jpg

Richard King Inquiry (Norfolk & Waveney Mental Health, 2005)

  • Trust panel understood public expectation that mental health services should exert some control

  • Report was written to maintain this public confidence by identifying mistakes and errors of judgement.

  • Homicide inquiries are being used to achieve political aims?


Richard king inquiry norfolk waveney mental health 200553 l.jpg

Richard King Inquiry (Norfolk & Waveney Mental Health, 2005)

  • The report did not demonstrate that staff acted in bad faith, nor without reasonable care.


Richard king inquiry norfolk waveney mental health 200554 l.jpg

Richard King Inquiry (Norfolk & Waveney Mental Health, 2005)

  • The report did not demonstrate that staff acted in bad faith, nor without reasonable care.

  • Written with the benefit of hindsight bias


Richard king inquiry norfolk waveney mental health 200555 l.jpg

Richard King Inquiry (Norfolk & Waveney Mental Health, 2005)

  • The report did not demonstrate that staff acted in bad faith, nor without reasonable care.

  • Written with the benefit of hindsight bias

  • Nor is it as clear that detention under the Mental Health Act was indicated.


Richard king inquiry nhs east of england 2008 l.jpg

Richard King Inquiry (NHS East of England, 2008)

  • “Looking through the reeds” - inherent difficulty of reconstructing past events


Richard king inquiry nhs east of england 200857 l.jpg

Richard King Inquiry (NHS East of England, 2008)

  • “Looking through the reeds” - inherent difficulty of reconstructing past events

  • Professional consequences for Trust staff


Richard king inquiry nhs east of england 200858 l.jpg

Richard King Inquiry (NHS East of England, 2008)

  • “Looking through the reeds” - inherent difficulty of reconstructing past events

  • Professional consequences for Trust staff

  • Six points in time which were missed opportunities for professionals to take an overview of the deterioration in mental state


Richard king inquiry nhs east of england 200859 l.jpg

Richard King Inquiry (NHS East of England, 2008)

  • No individual and no single act or omission led directly to the killing


Richard king inquiry nhs east of england 200860 l.jpg

Richard King Inquiry (NHS East of England, 2008)

  • No individual and no single act or omission led directly to the killing

  • On the balance of probabilities better quality care and treatment would have substantially reduced the increasing risk of a violent act.


Richard king inquiry nhs east of england 200861 l.jpg

Richard King Inquiry (NHS East of England, 2008)

  • No individual and no single act or omission led directly to the killing

  • On the balance of probabilities better quality care and treatment would have substantially reduced the increasing risk of a violent act.

  • But the frenzied killing could not have been reasonably foreseen.


Richard king inquiry nhs east of england 200862 l.jpg

Richard King Inquiry (NHS East of England, 2008)

  • Cannot agree with conclusion, that had Richard King been detained under s.3 he would probably have spent longer in hospital and would not have been given early home leave….The report gives the impression that the homicide could have been avoided if Richard King had been detained and not discharged in July 2004. We take the view that the shortcomings so evident in his care and treatment were longstanding and deeply rooted.


Richard king inquiry nhs east of england 200863 l.jpg

Richard King Inquiry (NHS East of England, 2008)

  • Recommendations may appear to replicate the rather imprecise recommendations and exhortations of the first inquiry, but they do not. All are addressed to the Trust or to specific individuals in order to bring about changes in practice.


Richard king inquiry nhs east of england 200864 l.jpg

Richard King Inquiry (NHS East of England, 2008)

  • Recommendations may appear to replicate the rather imprecise recommendations and exhortations of the first inquiry, but they do not. All are addressed to the Trust or to specific individuals in order to bring about changes in practice.

  • Relationship between the factors described in the report and the homicide was cumulative and complex: no simple direct causative link. No single individual can be held responsible.


Risk and mental health l.jpg

Risk and mental health

  • Homicide inquiries have made modern mental health services defensive


Risk and mental health66 l.jpg

Risk and mental health

  • Homicide inquiries have made modern mental health services defensive

  • Ever more rigid and bureaucratic interpretation of Care Programme Approach and risk assessment


Risk and blame l.jpg

Risk and blame

  • Someone has to be blamed for misfortune


Risk and blame68 l.jpg

Risk and blame

  • Someone has to be blamed for misfortune

  • Increasingly technological society switches blame onto services


Risk and blame69 l.jpg

Risk and blame

  • Always a political question about what is acceptable risk


Risk and blame70 l.jpg

Risk and blame

  • Always a political question about what is acceptable risk

  • Taking risks may be an opportunity for growth not just something to be avoided


Complexity of healthcare l.jpg

Complexity of healthcare

  • Uncertainty in clinical practice


Complexity of healthcare72 l.jpg

Complexity of healthcare

  • Uncertainty in clinical practice

  • Guidelines and procedures cannot eliminate clinical judgement


Complexity of healthcare73 l.jpg

Complexity of healthcare

  • Greater consistency and invariance cannot cope with the unexpected


Complexity of healthcare74 l.jpg

Complexity of healthcare

  • Greater consistency and invariance cannot cope with the unexpected

  • Illusion created that can be effective in preventing individual tragic outcomes


Defensive practice l.jpg

Defensive practice

  • Fear that things may go wrong distracts from the task of how to make things better


Defensive practice76 l.jpg

Defensive practice

  • Fear that things may go wrong distracts from the task of how to make things better

  • Follow procedures more for the purpose of protecting staff than helping patients


Examples of defensive practice l.jpg

Examples of defensive practice

  • Admitting patients overcautiously


Examples of defensive practice78 l.jpg

Examples of defensive practice

  • Admitting patients overcautiously

  • Placing patients on higher levels of observation than necessary


Sensible accountability l.jpg

Sensible accountability

  • Accountability needs to be applied sensibly


Sensible accountability80 l.jpg

Sensible accountability

  • Accountability needs to be applied sensibly

  • Improvement needs to be authentic and not façade for placating society’s fear


Sensible accountability81 l.jpg

Sensible accountability

  • Fear of being criticised and unfairly judged does not lead to creativity


Sensible accountability82 l.jpg

Sensible accountability

  • Fear of being criticised and unfairly judged does not lead to creativity

  • Excellent leadership provides ethos where staff are valued and supported


Conclusion l.jpg

Conclusion

  • Possibility of rational risk governance in fact an elaborate technocratic fantasy and a bureaucratic defence against anxiety of disorder


Conclusion84 l.jpg

Conclusion

  • Possibility of rational risk governance in fact an elaborate technocratic fantasy and a bureaucratic defence against anxiety of disorder

  • Psychiatry should know because of its history in the asylum


  • Login