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

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david clark 1995
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
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
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
Origins of community care
  • "Dismay and disgust with the old asylum system"
origins of community care6
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
Origins of community care
  • Opening the doors of the psychiatric hospital
origins of community care8
Origins of community care
  • Opening the doors of the psychiatric hospital
  • “Return to moral treatment”
origins of community care9
Origins of community care
  • Opening the doors of the psychiatric hospital
  • “Return to moral treatment”
  • Hospital as a therapeutic community
negative process of institutionalisation
Negative process of institutionalisation
  • “Institutional neurosis” (Russell Barton)
negative process of institutionalisation11
Negative process of institutionalisation
  • “Institutional neurosis” (Russell Barton)
  • Apathy, lack of initiative, loss of interest and submissiveness
negative process of institutionalisation12
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
Dehospitalisation of mental health services
  • Traditional hospitals went into decline
dehospitalisation of mental health services14
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
Dehospitalisation of mental health services
  • Many old long-stay patients grew old and died in hospital
dehospitalisation of mental health services16
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
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
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
Politics of community care
  • Initial concern was that homelessness was being increased among the mentally ill
politics of community care20
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
Politics of community care
  • New Labour government decided ‘community care had failed’
politics of community care22
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
Inquiries into mental health services
  • Scandals that uncovered mistreatment of patients in hospital
inquiries into mental health services24
Inquiries into mental health services
  • Scandals that uncovered mistreatment of patients in hospital
  • eg. Ely Hospital inquiry
inquiries into mental health services25
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
Inquiries into mental health services

Political response

  • (i) setting up of Health Advisory Service (HAS)
inquiries into mental health services27
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
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
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
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
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
Homicide inquiries
  • Can have devastating consequences for mental health services
homicide inquiries33
Homicide inquiries
  • Can have devastating consequences for mental health services
  • Reinforces stereotype of the ‘dangerous lunatic’
homicide inquiries34
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 199836
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
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
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
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
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
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
Luke Warm Luke inquiry (Scotland et al, 1998)
  • Unclear why Luke Warm Luke killed Susan Milner.
luke warm luke inquiry scotland et al 199843
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
Risk and mental health
  • Homicide inquiries have made modern mental health services defensive
risk and mental health66
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
Risk and blame
  • Someone has to be blamed for misfortune
risk and blame68
Risk and blame
  • Someone has to be blamed for misfortune
  • Increasingly technological society switches blame onto services
risk and blame69
Risk and blame
  • Always a political question about what is acceptable risk
risk and blame70
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
Complexity of healthcare
  • Uncertainty in clinical practice
complexity of healthcare72
Complexity of healthcare
  • Uncertainty in clinical practice
  • Guidelines and procedures cannot eliminate clinical judgement
complexity of healthcare73
Complexity of healthcare
  • Greater consistency and invariance cannot cope with the unexpected
complexity of healthcare74
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
Defensive practice
  • Fear that things may go wrong distracts from the task of how to make things better
defensive practice76
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
Examples of defensive practice
  • Admitting patients overcautiously
examples of defensive practice78
Examples of defensive practice
  • Admitting patients overcautiously
  • Placing patients on higher levels of observation than necessary
sensible accountability
Sensible accountability
  • Accountability needs to be applied sensibly
sensible accountability80
Sensible accountability
  • Accountability needs to be applied sensibly
  • Improvement needs to be authentic and not façade for placating society’s fear
sensible accountability81
Sensible accountability
  • Fear of being criticised and unfairly judged does not lead to creativity
sensible accountability82
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
Conclusion
  • Possibility of rational risk governance in fact an elaborate technocratic fantasy and a bureaucratic defence against anxiety of disorder
conclusion84
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
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