Improving care, treatment and community access for the forensic learning disabled patient by the use of multi-agency pub

1. Improving care, treatment and community access for the forensic learning disabled patient by the use of multi-agency public protection arrangementsDel Warden, Senior Forensic Social Worker

2. INTRODUCTION The Tarentfort Centre is a relatively new development within the Kent Forensic Psychiatry service. It offers 20 places for male learning disabled offenders into two wards of 10 within a low secure setting. The Unit opened in August 2007 and in the service development stage early in 2007 I was keen for us to grasp the nettle of how to include MAPPA into our general practice. I found the local North Kent Joint Chair from Police and Probation were open to include our service, given new guidance for MAPPA also instigated in 2007.

3. The MAPPA guidance document is very lengthy, running to some 129 pages, but under that document offenders detained under Mental Health Act are clearly included in the MAPPA process. Local north Kent MAPPA accepted their responsibility to include the Tarentfort patient group and reviews by MAPPA began as patients were admitted.

4. STATUS OF THE GUIDANCE This guidance is issued by the Secretary of State under Section 325(8) Criminal Justice Act, 2003. This guidance is therefore statutory. All responsible authorities and �co-operating bodies�, being public bodies, have a duty imposed by public law to have regard to this guidance in exercising their functions under the Multi-Agency Public Protection Arrangements (MAPPA). MAPPA are the statutory arrangements for managing sexual and violent offenders. MAPPA is not a statutory body in itself but is a mechanism through which agencies can better discharge their statutory responsibilities and protect the public in a co-ordinated manner. Agencies at all times retain their full statutory responsibilities and obligations.

5.  DUTY OF CO-OPERATION The Responsible Authority (RA) consists of the Police, Prison and Probation Services. They are charged with the duty and responsibility to ensure that MAPPA is established in their area and for the assessment and management of risk of all identified MAPPA offenders. Other agencies under Section 325(3) of the Criminal Justice Act 2003 have a �duty to co-operate� with the RA. They are:

6. Local Authority Social Care Services. Primary Care Trusts, other NHS Trusts and Strategic Health Authorities. Jobcentre Plus. Youth Offending Teams. Registered social landlords which accommodate MAPPA offenders. Local Housing Authorities. Local Education Authorities. Electronic Monitoring Providers.

7. MAPPA FOR KENT FORENSIC PSYCHIATRIC SERVICE Facilities for the service are split between the Regional Secure Unit � Trevor Gibbens � in Maidstone and Tarentfort in Dartford, therefore two different MAPPA areas. The main service in Maidstone is much larger and presents a greater challenge in terms of scale having in excess of 60 places. However given the economy of scale, 20 was a manageable number and the specific nature of our learning disabled patient group added to the necessity of MAPPA review.

8. High proportion of offenders detained under Section 3 and 37 who could be discharged by either MHRT or Managers� Hearing against the team�s recommendations. High incidence of impulsive behaviour both as an inpatient and potentially on leave under Section 17. High numbers of repeat offences and high number of offence behaviours which have had direct affect of the public, e.g., sexual offences and arson.

9. MAPPA FOR SECTION 3 AND 37 There is regular ongoing 6 monthly MAPPA review for this group. Dependant on MAPPA�s assessment of risk posed to the public. Of the 18 current inpatients, 17 pose high risk for public protection purposes. Of those 18, four are restricted patients and not subject to regular review (as previously explained) 13 of the remaining 14 are regularly reviewed by MAPPA. 1 patient has been assessed as being of no risk to the public and takes no part in the MAPPA process.

10. RESTRICTION ORDERS AT TARENTFORT We have instigated slightly different arrangements to cover restriction orders. Provided that we are certain that all aspects of historical offending behaviour has been properly researched and recorded, plus assessment of risk to the public has been completed, the following action is taken. Regular review is not required and MAPPA sign-off responsibility to me in order to re-assess under the following circumstances. The patient should move to another service. Unescorted leave is to be granted. There are active plans to set up conditional discharge. This helps to keep the number of reviews down to manageable levels without risking public safety but it does place the responsibility squarely with the link person to notify MAPPA of significant changes.

11. OVERALL MAPPA INVOLVEMENT IN KENT FORENSIC PSYCHIATRIC SERVICE With multi-agency public protection arrangements running for the Tarentfort Centre, Trevor Gibbens relies on the security of detention by restriction order to reduce the necessity of regular MAPPA review though it is still used prior to instigating conditional discharge and also for the very small minority of patients detained under Section 3 or 37. KFPS (Kent Forensic Psychiatric Service) maintain a role in providing specialist input into Level 3 County MAPPA by having a regular input on that panel with the attendance of a senior clinician. The role and function of all input into MAPPA is also discussed quarterly at a meeting attended by all KFPS staff involved (such as myself), along with representatives from police, probation and the Crown Prosecution Service (CPS).

12. MAPPA TRUST POLICY Trust Policy has now been drawn up following the new guidance for MAPPA in 2007. That policy document is extensive and is in fact as large a document as the guidance document itself, running to some 112 pages, however in very brief summary, my role in MAPPA is governed by. Must be a senior member of staff. That I have been trained under the Data Protection Act. That I maintain any MAPPA documentation completely separately from the patient�s clinical files given that MAPPA documentation is the property of police and probation and that should a patient�s legal representative, or any independent clinician, require access, they must apply to police and probation for that information. They cannot gain access via the usual route of the Responsible Clinician.

13. REPORTING OF MAPPA REVIEWS FOR THE PURPOSE OF MHRTs OR MANAGERS� HEARINGS IS DONE IN THE FOLLOWING WAY. Example: MAPPA involvement. Given the nature of Mr. XXX offending history he is subject to regular review by the local level 2 MAPPA panel for North Kent. His last review took place on xxx where he was assessed as being high risk to the public, even whilst detained at the Tarentfort Centre. He is due for review again in (xxx approximately 6 months). Unless there is any radical change in his circumstances, e.g., a move to another hospital, instigation of unescorted leave or plans for discharge. Should a MHRT or Managers� Hearing wish to consider him for discharge against the recommendations of his multi-disciplinary team, this will then trigger an urgent referral for a level 3 County MAPPA, given then that his would be regarded as being at the highest risk in terms of public protection.

14. PATIENTS� UNDERSTANDING OF THEIR INCLUSION IN THE MAPPA PROCESS At every stage, even to pre-admission, the patient is informed that the service works closely with MAPPA. MAPPA appears as a heading under the patient�s care plans and we will refer to this and the MAPPA review process at every CPA meeting. The patient�s status with MAPPA is referred to in every MHRT or Hospital Managers� report.

15. Assessment of risk may seem stacked against the patient however we should all agree that prevention particularly for crimes of a sexual nature and arson are in the best interests of the patient, let alone the interests of the general public. WHAT ARE THE OTHER ADVANTAGES FOR THE PATIENT? Accurate assessment of risk given full account of historical records. Links to family members, friends and contacts. Local risk areas, other possible offender contacts within the operational area. Risks involved around general facilities used by the service, e.g., day facilities, colleges and amenities. Hot spots frequented by known offenders. Links to local police knowledge for a patient�s home area rather in the Unit�s local patch. Kent is a very big County.

16. SPECIFIC EXAMPLES Patient D During regular escorted home leave there was a mysterious visitor who seemed intensively involved in the life of the patient�s mother (she lives alone). MAPPA confirmed that this man had a history of multiple sexual offences against children and was on police bail whilst under investigation for further sexual offences again against children. The same man accompanied mother during visits to our patient, although not attempting to enter the unit; this individual was seen in public areas of the hospital waiting for mother where other vulnerable learning disabled patients had access. Given the above knowledge access to home leave was suspended. Ultimately MAPPA confirmed this man�s conviction for the above sexual offences previously under investigation, he is now serving a life sentence for his crimes.

17. Patient B Patient B is not convicted of any crime, he is detained under Section 3, having mild learning disability and autistic traits, he is aged 19. Whilst living at home with his mother, who was a lone carer, he had knocked her downstairs rendering her unconscious. Held a knife to her throat whilst she called police to her home for assistance, he attacked the police on arrival and was sprayed in order to detain him and take him to the police station. He was later released without charge, given his learning disability. He took a hand gun to school and threatened a teacher with the weapon � police were involved at the time but again he was released without charge. He threatened to slit the throats of two young girls in his road � at the time he was carrying four knives, two in each hand. Police took him to local acute mental health unit under Section 136 � after mental health assessment he was sent back to mother in a taxi because he was not acutely mentally ill but learning disabled. There are other accounts of his various misdemeanours however none of this behaviour attracted any prosecution due to his learning disability.

18. His MAPPA review caused great consternation for police and probation about the lack of formal prosecution into this high risk behaviour, however my suggestions regarding his management into his care could also be construed as difficult to comprehend from a public protection perspective. The issue of home leave to visit mother. Although mother was very supportive and a regular visitor to the unit, patient B needed to see his home and his friends in order to be settled and to feel he was progressing in his treatment. Mother confirmed she would be powerless to stop friends being in the house and that a party atmosphere would be an inevitability for B�s first homecoming. The risks: Mother had previously been the primary victim to B�s violent assaults. The friends were also known high risk offenders, drug users and dealers. B�s closest friend had supplied the gun B had used to threaten the teacher.

19. Having assessed the situation myself, first hand and with the absolute assurety that there would be no problems from all concerned, the Responsible Clinician was still left with a difficult decision to grant escorted leave. The dilemma was discussed at MAPPA review, the risks being quite obvious. Police offered one further option. Via MAPPA the police could notify the local force to our impending visit, should a problem develop local police would know we were in trouble if we called; they could then respond accordingly. The risk would have to be born by the team but backup could be available, subject to local demand. Patient B supported by myself, a senior nurse and a care worker, has completed several of these visits without undue difficulty, police assistance has never been needed and the visits have become much more mundane and family centred. B has progressed well and his visits home have been a positive focus for his engagement in therapeutic treatment.

20. Patient L This patient has a long history of violent sexual assaults against women and children but he had been detained under the Mental Health Act following a diversion from a prison sentence. His initial MAPPA review police had no knowledge of him on the police national computer. It is only after taking our known list of convictions that he was then included on PNC.

21. Patient M Patient M is currently detained under Section 37 at Tarentfort for an index offence of arson. As part of his social history, his brother was previously living with him in the same residential care home when without any warning the brother left with the intention of absconding from the area. The brother approached a lone female and attacked her with a blade. Patient M was under the impression that his brother had killed her and was now in prison serving a life sentence, contacts by me with other family members also confirmed this impression. Via MAPPA review

22. Patient M�s brother had indeed attacked the woman with a Stanley knife � this he had drawn across her throat but barely penetrating the skin. This crime had attracted a life sentence as the motive was murder. Probation was also able to confirm which prison to find M�s brother. We have at least been able to re-address this crime with patient M and have put M in touch by letter with his brother. They continue to correspond and have also talked together on the telephone. As part of two-way information to the police, patient M has been identified by two other names which has helped with investigation into his accurate PNC record.

23. Patient R He is the only patient I have referred to MAPPA prior to admission. The Responsible Clinician had assessed him whilst on remand and was definitely prepared to admit him. His index offence was a very violent assault on his grandmother with a cricket bat. There had been a previous assault on her by him with a table leg. Having MAPPA review prior to admission revealed a history of sex offences, none of which were known to the Responsible Clinician at the time of her initial assessment and none of that information was known to his representatives. We were able to include this into the RC�s court report which resulted in a restriction order.

24. The MAPPA process has served as an ongoing tool to the assessment and treatment process at the Tarentfort Centre. It can support and inform the patient�s development, moving with the patient, from a secure setting back into the community. Having practised in the days prior to the instigation of MAPPA, supervising many restricted patients and working in community teams, particularly in the field of learning disability. Working without MAPPA would feel to me now like working in the dark, probably with one hand tied behind my back.

25. MAPPA can help the individual stay safe and away from potential crime. It can also help and inform the development of a secure service providing the statutory agencies with a clear appreciation of its roles and respective responsibilities.

26. Acknowledgments: Joint Chair of MAPPA, North Kent:- Detective Inspector Kaye Braybrook and Ruth Hardy, Senior Probation Officer