Skip to main content

Patient Security (Mental Health System)

Volume 535: debated on Monday 7 November 2011

Motion made, and Question proposed, That this House do now adjourn.—(James Duddridge.)

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.

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.

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.”

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.

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.

I congratulate my hon. Friend the Member for Loughborough (Nicky Morgan) on securing the debate, and on the thoughtful way in which she set out her case. Let me begin my speech where she ended hers. The coalition Government are totally committed to securing parity of esteem between mental and physical health. Quite simply, that is the right thing to do, and it is long overdue. We are determined for it to happen as part of the strategy that we are currently delivering and the changes currently taking place.

I am well aware of the tragic incident to which the hon. Lady referred, and which was undoubtedly the spur for the debate. I also thank her for sharing the coroner’s report with me. I am keenly aware of the fact that the trust involved in this sad case fully accepts the coroner’s verdict and has undertaken an overhaul of its patient security arrangements. It is important for public confidence in the system that lessons are learned and actions are taken to improve patient safety and service quality.

The coalition Government are committed to patient safety. It is a high priority in our strategies and in the outcomes on which we are judging the NHS. Our cross-Government mental health strategy, “No health without mental health”, includes two core objectives to which I wish to draw attention: ensuring that people who are acutely ill receive safe, high-quality care in an appropriate environment, and thereby ensuring that fewer people suffer avoidable harm. The NHS outcomes framework also prioritises patient safety and emphasises treating and caring for people in a safe environment and protecting them from avoidable harm.

My hon. Friend rightly referred to the invaluable work done by the national confidential inquiry into suicide and homicide by people with mental illness. Although the suicides rates in England have been at a historical low and are much lower than those of most of our European neighbours, the most recent figures, dating back to 2009, show that there are still about 4,400 suicides in England; that is one suicide every two hours.

Over the past decade, good progress has been made in reducing the suicide rate in England. However, there has been a slight rise in the last couple of years. It is therefore important that we maintain vigilance. We know from experience that suicide rates can be volatile as new risks emerge. That is why we recently completed a national consultation on our suicide prevention strategy. We are considering the responses received, and intend to publish the final strategy next year.

The draft strategy aimed to set out a broad and coherent approach to suicide prevention and to helping us sustain, and reduce further, the relatively low rates of suicide in England. In particular, it sets out to reduce the suicide rate in the general population and to provide better support and information to those bereaved or otherwise affected by a suicide.

Substantial improvements have already been made in in-patient services. The most recent national confidential inquiry into suicide and homicide was published in July 2011. It shows that the long-term downward trend in in-patient suicides continues. In 1997 there were 214 in-patient suicides, falling to 94 by 2008. That is still 94 too many, so there is still more to be done.

I applaud my hon. Friend on her initiative in gathering the statistics she has presented to the House. However, she is right to sound a note of caution about how the figures might be interpreted, and what they reveal to us. For example, information about the length of time for which patients are missing or the level of risk that they pose either to themselves or to other people is relevant to gauging the true scale of the problem on which she seeks to persuade the Government to take action.

There are a wide variety of reasons for recorded unauthorised absences. These include situations that pose minimum risk to the patient or the public, such as a delay in return to hospital from authorised leave because of a missed or delayed bus. We could be talking about a delay of no more than a couple of hours before some patients return safely to their unit. However, that return has to be recorded, even if it is for just a matter of a couple of hours.

Recent statistics from the confidential inquiry show that between 2004 and 2008 the number of suicides per year by patients who have absconded from mental health services has dropped by more than 50%, from 50 cases to 21 cases per year. That is a substantial improvement, but it is still 21 cases too many.

That is why we are not complacent. We know that a significant number of suicides still occur during a period of in-patient care in spite of the improvements. Managing risk effectively is therefore essential, and the confidential inquiry collects and analyses the detailed clinical information on all suicides and homicides committed by someone with mental illness, and more latterly also on sudden and unexplained deaths of psychiatric in-patients. It also makes recommendations for improvements, which goes to the heart of my hon. Friend’s representations tonight. Its December 2006 report sets out some compelling statistics—for example, that 27% of in-patient suicides occurred after the patient left the ward without permission. Those deaths were clustered in the first seven days after an admission.

In mental health services, respect for the patient’s wishes must at all times be balanced with the concern for the individual’s safety and well-being. There is no doubt that that balancing act can, and does at times, present significant challenges for services. However, the solution to the problem does not have to be heavy-handed or coercive in its approach. A significant body of research, guidance and best practice has demonstrated practical strategies that can be implemented and can help to reduce significantly the number of people going missing. Such strategies include: early assessment; ensuring that staff begin to form a meaningful, therapeutic and collaborative relationship with patients straight away; understanding the factors that trigger a decision to leave the ward, such as a disturbed environment or an incident affecting the patient; recognising that patients will have social responsibilities such as paying bills or ensuring that their property is secure—staff need to identify these issues early to prevent anxiety and stress that may lead to the patient choosing to leave—and making greater use of technology, such as CCTV or swipe cards, to observe and control ward entry and exit.

Key to the successful delivery of those approaches will be the ongoing development of an acute specialist work force with the right skills and attitudes, and a culture of inquiry and service improvement based on evidence and regular service user and carer feedback. The law is clear in the obligations it places on services. The Mental Health Act 1983, to which my hon. Friend referred, sets out the legal provisions relating to keeping patients in legal custody and bringing them back if they abscond. The Mental Health Act code of practice is equally explicit in the guidance it gives to services about the systems and processes that should be in place to safeguard detained patients. Hospital managers should ensure that there is a clear written policy about the action to be taken when a detained patient, or a patient on a supervised community treatment order, goes missing. These policies should, in turn, be agreed with other agencies, such as the police and ambulance services, which have significant roles to play in safeguarding patients who are absent without leave.

Just last year, it was confirmed for the first time that the detaining authorities would be required by statutory regulation to notify the Care Quality Commission, without delay, of any absence without leave of any person detained or liable to be detained under the Mental Health Act. A failure to take adequate measures to keep a detained patient safe from fatal harm is potentially a breach of article 2 of the European convention on human rights. The CQC asks services that are designated as low, medium or high security, and psychiatric intensive care units, to notify it of all incidences of absence without leave. There are different reporting requirements depending on the security level of the service. I can tell my hon. Friend and others who are listening to this evening’s debate that the CQC will be reporting its first round of these statistics next month. The CQC monitors trends in absence without leave and has followed up with the particular providers in relation to specific incidents or patterns of absences. The CQC recommends that providers monitor and review absences without leave to understand why patients go absent and to help develop strategies to address these identified issues.

My hon. Friend identified concerns about what she described as the variation that she encountered in the definitions that appeared to be being used by different trusts when she undertook her freedom of information requests. I can, however, assure her that the definitions of “escape”, “attempted escape”, “abscond”, “failure to return” and “absent without leave” are applied consistently in mental health services. Indeed, most of those definitions relate to the three-part description that she listed. I suspect that the differences in the returns she received are due to the mixture in the type and size of mental health services within one trust, and therefore the mixture of type and number of absences reported. For instance, a trust may include a high-secure hospital, two medium-secure units and also low-secure and non-secure mental health services. The numbers from that trust may give us no understanding of the type of risk of the absences recorded. That is why my hon. Friend is right to say that we need good data collection in this area, and that is why we have asked the CQC to collect those data in such a way that we can meaningfully segment them to understand what is going on. I shall write to her about the statistics that she has collected.

The Government believe that people with acute mental health needs have a right to receive the care and support they need in a safe and comfortable environment in which they are treated with the dignity and respect they deserve. As my hon. Friend has said, there is a cross-Government mental health programme in place to drive whole system and cultural change in mental health services. However, this cannot and should not be seen as solely the Government’s responsibility. The essential building blocks are in place but, as always, the responsibility for the quality and safety of front-line care crucially depends on three things. First, providers have a duty of care to each individual for whom they are responsible—ensuring that services meet individual needs and that there are systems in place to make sure that services are effective, efficient and deliver high-quality care. Secondly, the regulator is responsible for assuring the quality of the system itself. Thirdly, the commissioners are responsible for securing the care that meets people’s needs.

My hon. Friend was absolutely right to bring this important debate before the House, and she was also right to point out that we often debate issues of physical health in the House but rarely debate mental health issues except in extremis. I assure her that the Government are determined to invest in mental health services to ensure that more therapies and therapeutic services are available. Indeed, that is why we are investing in talking therapy services. It is important that with mental health we look at the whole-life course, intervene earlier to provide more preventive services, and invest in services that deliver dignified outcomes. I am grateful to my hon. Friend for securing the debate and allowing us to shed some light on those important issues.

Question put and agreed to.

House adjourned.