Patient safety or patient risk? The case of people who are mentally ill

2. Patient safety or patient risk?The case of people who are mentally ill Penny Rhodes Bradford Institute for Health Research

5. Crisis Resolution and Home Treatment teams • offer an alternative to hospital care • provide intensive, time-limited, home-based treatment • act as a “gatekeeper” to mental health services whereby individuals are referred to the most appropriate service • provide a 24 hours a day, 7 days a week multi-disciplinary, community-based treatment service • be actively involved in discharge planning • provide intensive care at home to enable early discharge • ensure that individuals are treated in the least restrictive environment and as close to home as possible • Department of Health 2001

6. We found: • When asked about safety, workers spoke about staff safety. • Workers seemed not to understand what we meant by ‘patient safety’. • Instead, they talked about ‘risk’

7. The discourse of safety related almost entirely to staff safety.  The discourse of patient risk superseded that of patient safety.

8. Patients at risk • they may be disoriented or confused as a consequence of their illness and/or medication • their views may be discounted on grounds of mental incapacity • physical symptoms may be missed or wrongly attributed to mental illness

9. Patients at risk • increasing administration of medication in community, as opposed to more controlled environment of hospital • increasing treatment against patients’ wishes (compulsory treatment orders) • antipsychotic drugs among those most frequently associated with severe harm

10. National Patient Safety Agency (2006) report on incidents in mental health services • Majority of incidents from inpatient services • Most incidents concerned: patient accidents; disruptive / aggressive behaviour; self-harming behaviour; absconding or missing patients. • MH trusts report lowest average number of medication incidents, except for ambulance trusts and PCTs.

11. National Patient Safety Agency (2006) report on incidents in mental health services • Antipsychotics among the medicines most frequently associated with severe harm. • Likely to be significant under-reporting. • Reports about medication, clinical assessment and treatment may be particularly under-reported. • Bias towards reporting more serious incidents

12. MIND (2008) submission to the House of Commons Health Select Committee on Patient Safety • general safety: assault, threats and feeling unsafe on mental health wards • sexual safety on mental health wards • reporting crimes (in hospitals)

13. MIND (2008) submission to the House of Commons Health Select Committee on Patient Safety • protection from abuse (from staff) • complaints poorly handled • need for third-party reporting schemes • need for training for staff • prescribing practices - serious adverse effects

14. " excessive anxiety around the risks posed by people experiencing mental distress, and insufficient concern as to the risks posed to them by poor services".

15. Safety from staff Safety from the general public Safety from poor services

16. Risk management for whom? • to protect patients from harming others or themselves • to protect the service’s back e.g. from liability claims • to protect the service from adverse publicity • to satisfy politicians responding to media and public pressure • national policy drivers e.g. suicide reduction

17. What are the ways forward?

18. Ways forward? See safety as a wider issue More research about how MH practitioners practice safe care Better reporting of safety incidents and better feedback and learning

19. Ways forward? Less punitive approach to error Refocus debate onto independent living and support in the community Litigation a double-edged sword? Public protection should not over-shadow patient safety

20. Why was he on the streets? The ‘prophet of God’ who decapitated British woman in Tenerife Mail Online 14 may 2011 ‘Schizophrenic kills brother, 9, with a kitchen knife’ Sun 20 Feb 2010

21. Public Health Perspective • Data from a representative sample of 1,151 remanded • offenders whounderwent a full structured diagnostic interview • RESULTS • About 3% of violent offenses could be attributedto individuals • with a principal diagnosis not related to substanceuse. • An additional 7% of violent offensescould be attributed to • individuals with a primary diagnosisof a substance use disorder. • CONCLUSION • ‘Public perceptions of mentally ill personsas criminally • dangerous appear to be greatly exaggerated.’ • Stuart & Arboleda-Flórez, 2001

22. Murder risk 'higher for mentally ill' • The mentally ill are: • frequently victims of violent crime • six times more likely to be murdered than the general population • have higher death rates from suicide and accidental causes. • http://www.suite101.com Friday, 21 December, 2001