Patient Security (Mental Health System)

Baroness Morgan of Cotes Excerpts

Monday 7th November 2011 Commons Chamber

[Nicky Morgan (Loughborough) (Con)]

I am extremely pleased to have the opportunity to raise this important topic in the Chamber tonight. I should declare at the outset my position as a vice-chairman of the all-party parliamentary group on mental health.

The Government’s recent mental health strategy stated that mental ill health represented up to 23% of the total burden of ill health in the UK, and that it was the largest single cause of disability. At least one in four adults will, at some point in their life, experience a period of mental ill health. For some, it may be a relatively mild, one-off episode. For others, the first episode will herald the start of a long-term relationship with the mental health services in all their guises. Such episodes, whether short term or long term, have a profound effect not only on the person suffering with a mental health condition but on their families and friends, many of whom will never have come into contact with these conditions or this part of the NHS before.

In the most serious cases, a patient might spend a period of time in an acute care setting, either voluntarily or while being detained under the Mental Health Act for their own welfare and the welfare of those around them. At such times, the patient and their families and loved ones will expect the patient to be kept safe and secure while they are given the appropriate therapy and treatment to enable them to resume their place in our communities. That expectation, and the fact that it is sometimes not fulfilled, are the focus of this short debate tonight.

In June 2010, shortly after I was elected as the Member of Parliament for Loughborough, I was approached by a constituent, Glyn Brookes, who told me about the tragic death of his daughter, Kirsty. I appreciate that the Minister is unlikely to be able to respond to this particular case, although I have sent his office a copy of the coroner’s report into Kirsty’s death. However, it is because of this case that I have ended up leading this debate tonight.

Kirsty was a patient at the Bradgate unit at University Hospitals of Leicester. She was able to escape from the unit using the frame of an external door to help her. Her escape was not dealt with as it should have been, and she was able to commit suicide before either the hospital authorities or the police found her. This has clearly been devastating for the Brookes family, and I would like to pay tribute to them, and particularly to Mr Brookes who contacted me to tell me their story. I would also like to pay tribute to the excellent coroner whose report helped, I think, to answer the Brookes family’s questions about the tragedy. I should say that I have spoken to the former and current chairmen of Leicestershire Partnership NHS Trust, which administers the unit, and I understand that work is ongoing to learn and act on the lessons of this case.

As a result of the case being raised with me, I began to wonder how many other patients absconded each year from units run by our mental health trusts. I submitted Freedom of Information Act requests to all 58 of the mental health trusts in England, 57 of which have replied. The figures make grim reading. Before I go into them, however, I should say that this exercise has shown me that there is a real variety in the quality of record keeping at the trusts. There also seems to be a real difference in the way in which the term “abscond” is used by the trusts as a basis for recording the relevant information. I hope that the Minister and the Department will be able to help with this matter.

The Mental Health Act 1983 defines “abscond” as when a patient who is liable to be detained under the Act

(a) absents himself from the hospital without leave granted under section 17 above; or

(b) fails to return to the hospital on any occasion on which, or at the expiration of any period for which, leave of absence was granted to him…; or

(c) absents himself without permission from any place where he is required to reside in accordance with conditions imposed on the grant of leave of absence”.

In responding to my request for information, some trusts used this definition, while others made the distinction between a patient who was “absent without leave”, “absent without explanation”, “missing” or escaped. In addition, some trusts use the terms “AWOL” and “abscond” interchangeably without definition or explanation. Other trusts used only “abscond”, but did not define what they meant by the term. Finally, some trusts provided the number of “incidents” of absconding, rather than the number of patients. Others did not make that distinction. For simplicity, however, the figures that I will now mention refer to the total number given for the five-year period that I asked about, and therefore do not differentiate the different types of absconding incident.

My research showed that in the past five years about 40,500 incidents of absconding occurred, ranging from a total of three reported incidents for Barnet, Enfield and Haringey Mental Health Partnership Trust to 3,891 for Lancashire Care NHS Foundation Trust. There is significant variation across the country, so clearly some trusts are doing things very differently from others. In the case of Leicestershire Partnership NHS Trust, the total figure for the past five years is 386. I must stress caution in comparing those numbers. We could, in many cases, be comparing different things—although the overall effect of patients absconding is the same—simply because the trusts use their own definitions, despite the fact that the Department of Health has published its definitions of absconding and escaping.

[Dr Julian Lewis (New Forest East) (Con)]

I do not know where on my hon. Friend's list the Hampshire Partnership NHS Trust figures, but did she find any correlation between the quality of the infrastructure of the units and the numbers of people absconding? Did she find, for example, that a brand-new unit, such as Woodhaven in my constituency, tended to have a lower rate of such problems? This is of particular interest to me, as that eight-year-old hospital is threatened with closure, and I have a debate on it later this week.

[Nicky Morgan]

I am grateful to my hon. Friend. I have seen the subject of his Adjournment debate later this week. Unfortunately, I did not have the opportunity to go into that level of detail, but I shall come to the quality of care and to demonstrate that it has a huge impact on the absconding rate for patients. As I shall come on to mention, this is an issue on which the Department of Health and the trusts could work together. Interested Members or other interested parties should see the link between absconding and the quality of care given. There is no doubt that there are innovative ways of ensuring that patients do not feel the need to abscond, and that if they are outside the environment, of ensuring that they will come back because they know that they will receive therapeutic treatment.

As I was saying, despite all the caveats, the numbers are simply too high for organisations that owe their patients a duty of care. The fifth agreed objective in the Government’s mental health strategy launched earlier this year stated:

“Fewer people will suffer avoidable harm—people receiving care and support should have confidence that the services they use are of the highest quality and at least as safe as any other public service.”

This is, of course, an objective that anyone who has an interest in any health service, but particularly mental health services, would want to see met. The fact is that guidance is already in place for mental health trusts and for those working within them to follow, although it would be fair to say that a lot of that guidance deals with how to react to an incident of absconding rather than offering concrete guidance on prevention. In the case of my constituent, the coroner expressly found that

“it would appear that the hospital had a system and policies in place to protect and supervise Kirsty from harm but at all material times those caring for her did not follow those policies.”

That is just not acceptable.

The Minister will remember the long sessions earlier this year discussing the Health and Social Care Bill in Committee Room 10 upstairs—how could we forget them? One of the recurring themes was not just that we all want to see high-quality services but how we ensure our health and social care services are of high quality and that everyone is focused on the primary objectives of the health system. Do we do so through inspections? Do we hope that everyone working within the health system works to their own high standards, as many thousands of employees surely do? Do we ensure that guidance is not only available but followed? And do we ensure that when things go wrong, as in the case of my constituent, thorough investigations follow and lessons are learned? Surely it must be a combination of all those things.

As I mentioned, hospital wards are meant to be places of therapy, but too often, especially in the case of mental health wards, they are anything but. In a recent report, the Centre for Social Justice said:

“Hospitals tend to be untherapeutic and dangerous places”.

In helping me to prepare for this debate, Mind sent me a note saying:

“The quality of care quite clearly has an impact on a patient’s decision to abscond. Unfortunately, as Mind’s forthcoming acute and crisis care campaign will show, people in inpatient settings often experience substandard quality, with no meaningful activities, little or no interaction with staff or each other, and at worst, lack of safety, abuse and coercive treatment.”

[Dr Daniel Poulter (Central Suffolk and North Ipswich) (Con)]

Does my hon. Friend agree that one problem—she has done well in bringing this debate before us this evening—is the fact that people often become labelled when they are in a mental health care setting, whereas what we need to do if we are to deal with the issue properly is to break down and challenge those labels, so that the patient is not seen just as a mental health patient but as a person? All the therapies and preventive measures she is talking about relate to that issue. If we can get that right, we will be able to look at people and treat them in the way that they deserve—with respect, which will help to prevent the episodes of absconding or escape that my hon. Friend mentions.

[Nicky Morgan]

I entirely agree with my hon. Friend, who is a qualified NHS practitioner and knows far more about these matters than I do. Everything that he has said confirms the fact that we must not forget that people are at the heart of all cases of this kind—not just patients, but their families. The sooner patients receive good therapeutic treatments and can resume their place in society, the better. My hon. Friend made another important point: for too long a stigma has been attached to mental ill-health conditions, and people do not talk about them. I hope that tonight’s debate will mark the beginning of more open discussion of such conditions, in the House and beyond.

Kirsty's father told me that he believed that there was nothing to do at the unit where she was being treated. He said that there were no constructive therapies.

Rethink Mental Illness and the Royal College of Psychiatrists drew my attention to a 2010 report that had been prepared as part of the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness. According to the report, between 1997 and 2006 absconders accounted for 25% of all in-patient suicides and 38% of suicides that occurred off the wards. Absconding patients were also significantly more likely to have been under high levels of observation, but clinicians reported more problems in the observation of those who had absconded owing to ward design or other patients in the ward. The report made three recommendations for improvement: that staff need to pay better attention, not just to patients but to ward exits; that observation methods should improve, as there was little evidence regarding the protective effect of close observation, and high levels of observation may be ineffective for people who are intent on leaving the ward; and that there should be an increased focus on engagement and support by staff when patients are admitted.

However, as Mind pointed out to me, there is evidence that when wards take a more innovative approach to in-patient care, there are fewer incidences of both aggression and absconding. There is already an incentive for our mental health trusts to do better in terms of the treatment and care that they offer to in-patients.

Let me end by drawing all those thoughts together. First, we need more research in order to understand the scale of the problem. The information that I have obtained is, I hope, a good start, but I think that the Department could insist that trusts use one set of definitions so that numbers can be properly compared, and that trusts with low incidences of absconding could share their experiences with those whose absconding rate is very much higher. The Department could also insist on publication of the information that I had to obtain under the Freedom of Information Act.

Secondly, trusts should not only follow existing guidance, but work out how they do their best to prevent patients, when they are at their most vulnerable, from absconding and causing harm to themselves. My office did not have to look very far to find seven newspaper reports about patients who had absconded this year. Six of those cases tragically ended with the patients taking their own lives, and in one case the patient killed someone else. I believe that only by encouraging trusts to take those steps will the Department stand a chance of fulfilling the fifth objective in its laudable mental health strategy.

Finally, I should like us all to remember that at the heart of this are usually very ill people and their families. Mr Brookes said to me in July this year, “We trusted the system. We paid our taxes, and we expected the best care for those who are at their most vulnerable.”

We talk a lot in the House of Commons about physical health outcomes, but the time has come for mental health to get a proper look in. As someone speaking at one of the all-party meetings on mental health said, “We all have mental health; it is just that some people’s is better than that of others.”

We are talking about people, so there are no absolutes, and there will always be those who are determined to take their own lives, but I hope that tonight, by focusing on one part of the mental health system—the security of patients being treated in hospital settings—the House can begin to make clear its desire to see real parity between physical and mental health conditions in the context of funding and treatment. I believe that if we do not do that, we will be storing up huge trouble for the country, and there will be more tragic deaths of patients like Kirsty which could perhaps be prevented.