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TX: 05.09.03 – COURT RULES THAT HOSPITAL BREACHED SECLUSION GUIDELINES
PRESENTER: LIZ BARCLAY


BARCLAY
Thousands of psychiatric patients could be affected by a court ruling on when mental health patients can be kept locked up on their own in seclusion. In a landmark ruling the Court of Appeal upheld a claim by a patient of AshworthHospital on Merseyside that staff should not have kept him alone in a room, in one case for 20 days. The court decided that that was a breach of government guidelines. AshworthHospital is now seeking leave to appeal.

Lucy has spent time in seclusion and her words are spoken by one of our reporters because she doesn't want her voice to be recognised. She told us how she felt about how she was treated.

LUCY
Well I feel like what they could have maybe done is just gently talk to me because when you're in a panic it makes everything far more fearful and nobody ever tried to talk to me. Not even after to explain why. Very little dialogue takes place in any ward actually - the nurses have very little contact with the patients. There was no kind of reassurance, nothing.

BARCLAY
So is Lucy at all reassured by the court ruling that AshworthHospital has breached the guidelines on seclusion?

LUCY
It is a step forward and that's brilliant but no, not me. Because of my past experience I'm so terrified that I just don't trust them at all.

BARCLAY
Dr Andrew Johns is a consultant forensic psychiatrist in charge of the medium secure unit at BethlemHospital in Kent. And Sophie Corlett is head of policy at the mental health charity MIND. Sophie welcomes the court's decision that AshworthHospital breached the guidelines.

CORLETT
Well it's a big relief to us that at last the court has come round to thinking that the government guidelines are things that you shouldn't be in breach of because the first two times this has gone through the courts the judgement has fallen the other way - in other words, the court has agreed that government guidelines needn't be kept to. And in fact we even had information that some lawyers were beginning to circulate to hospital trusts to say look you don't need to worry about the Code of Practice, you can treat patients as you see fit. So we're at last relieved that the Code of Practice, which is a very thorough document, does now hold some legal status again.

BARCLAY
You say it's very thorough but presumably it isn't always terribly clear. I mean we've heard that in this test case it involved someone being locked up for 20 days.

CORLETT
Well the guidelines are very clear on some points that clearly weren't followed in this respect and the examples here would be that although the guidelines don't say what should happen after certain periods, it's very clear that seclusion should be reviewed regularly and this wasn't occurring even in the early stages of this seclusion, that there should be a policy and in one of these two cases there was no policy, that seclusion should only be used for the minimum amount of time in extreme cases after all other options have been looked at and there's no evidence that those three things were taking place in these instances. So on some aspects it's true the Code of Practice isn't clear but even where it is clear in these two cases it wasn't being followed.

BARCLAY
And is this a typical case or is this a one off?

CORLETT
Well we don't actually have up-to-date figures, they've not been collected centrally for some time, but the last figures that we did have for 1998 [BREAKTHROUGH] …both the number of hospitals using seclusion and the number of patients being affected was gradually on the increase, there were 119 hospitals that were using seclusion and in that year 1,993 patients were secluded. And so potentially yes seclusion is being increasingly used as a method of restraint as opposed to as an unusual method.

BARCLAY
Dr Andrew Johns from the Maudsley Hospital in London you deal with severely disturbed patients every day in your job, what do you make of this ruling?

JOHNS
Well I think the important starting point is that the ruling confirms the legality of seclusion as an appropriate intervention when everything else has failed. And I can give data from a unit that I'm concerned with in that out of 2,200 violent incidents less than 3% have led to episodes of seclusion. So certainly in the unit that I'm responsible for we spend a lot of time training the nurses and other members of the team and also making sure that if a potentially difficult or threatening incident arises that the team have really a range of interventions before seclusion.

BARCLAY
So when in your view then can and should seclusion be that last option?

JOHNS
Well it might be helpful if I just said what other interventions are possible first and we heard from Lucy on the tape that no one talked to her, now that doesn't sound very good at all, if someone is anxious, paranoid or frightened they need to be with a nurse and other members of a team who know them, who know about their problems, who can talk to them sympathetically. Medication can often be used to reduce anxiety and fear. The ward environment is important. If despite all that you have a patient who's getting aroused and perhaps posing a threat to self or to others then often more secure units are used to look after such people. And at a level above that we make use of, for example, de-escalation suites - this is the notion of a room where you'd have that particular patient of concern with one or two nurses, not too much pressure on the patient but talking the patient down from their anxious state. If all that fails, and the risk to other people is imminent, that is when seclusion is to be used.

BARCLAY
Sophie Corlett in situations like that, where this is a last resort, it would seem that there's very little option other than seclusion.

CORLETT
I think yes, if it's an absolutely last resort, if other things have been tried and if it's about potential harm to other people and for the minimum necessary amount of time. But I think there isn't really the evidence at the moment to suggest that across the board all other options are being pursued. And I think our concern is and again it was the thing that Lucy said - nobody talked to her - and it's something that people tell us time and time again about being an inpatient, that nobody talks to them, that they get 15 minutes a day maximum talking to anybody. In an environment like that we don't really have great faith that there is the possible staffing to ensure that all other things are pursued, particularly if the thing that somebody most needs is assurance and time and there's somebody just to talk through why they're there, what's happening to them, their anxieties.

BARCLAY
So Dr Johns there's a lot at stake here, both for the secure hospitals and for the patients, do you think that Ashworth could win an appeal against this decision?

JOHNS
I would be surprised because my reading of the ruling is that their monitoring of the patient in seclusion was less stringent than the Code of Practice. A problem does arise in a literal reading of the code because it's silent on what to do for more than short periods - if a person is in seclusion for more than say 18 or 24 hours then the Code of Practice doesn't suggest that anyone should do anything different. But however the legal ruling said that hospitals may identify a good reason for departing from the code.

BARCLAY
So Sophie, despite what you said earlier, the guidelines do need to be tightened up.

CORLETT
Well I think there are some issues about the guidelines but I think the main thing is about the status of the guidelines, the guidelines that we have may not cover everything but they cover a great deal about the regulation of professional practice for some of the most vulnerable people in society, this will become increasingly important as the Mental Health Act is changed in coming months to potentially mean that there are very many more people who are possibly going to be compulsorily treated.

BARCLAY
Sophie Corlett from MIND and Dr Andrew Johns and I apologise for the interruption to that interview.




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