Just over two years ago Geoffrey Hodgkins died after being restrained in the ‘family room’ of the Cheriton psychiatric ward in St James’s Hospital in Portsmouth.
The 105 page independent report, commissioned by Hampshire and Isle of Wight Strategic Health Authority, into the death of the 37-year-old schizophrenia patient frequently reports “concern” about Hodgkin’s standard of care. To Joanna Bennett, sister of David Bennett who also died while being restrained, in 1999 in a Norwich clinic, this is a gross understatement. She describes Hodgkins’ care as “unbelievably bad”.
For starters, Hodgkins was not violent, aggressive or threatening anyone immediately prior to being restrained, the report details. Secondly, staff made no efforts to talk to Hodgkins before restraining him. Thirdly, four security guards without basic life support training were primarily involved in restraining Hodgkins. Fourthly, tranquillisation drugs were injected into Hodgkins despite staff knowing he did not respond to them. Fifthly, Hodgkins had been restrained many times before his death on the evening of November 19, 2004. On occasions he was restrained for up to six hours. Moreover, he died after being held face down (the ‘prone’ position) for 25 minutes. This was despite hospital guidelines stating patients should not be held in the prone position for more than three minutes. Plus, despite being obese and a heavy smoker (making prone restraint additionally risky) no assessment of Hodgkin’s physical health was ever made. As a final wretched humiliation, staff restraining Hodgkins were reported to have passed round a communal cigarette to each other.
In a cruel twist of irony, Hodgkin’s “template” care plan actually had a “brief mention” of the widely-publicised inquiry 11 months previously into the death of Bennett, also diagnosed with schizophrenia. Like Hodgkins, Bennett had died after being restrained face down for just short of half an hour.
Portsmouth City Teaching Primary Care Trust has admitted the treatment of Hodgkins was “inexcusable”. It said it is examining the raft of recommendations included in the report.
Yet, while there are no central national figures on the number of deaths of psychiatric patients held under restraint in mental health units, the report into Hodgkins’ death has stepped up pressure for measures to both ensure restraint is carried out safely and that the need for it is decreased.
Last year Nice issued wards with guidelines on the short-term management of violent behaviour in psychiatric in-patient settings. One key recommendation is that rapid tranquillisation of patients only be used if de-escalation and other non-physical strategies have failed to calm a patient. This was not applied in Hodgkins’ case.
It is the NHS Security Management Service (NHS SMS) which has responsibility for encouraging wards to take up the Nice guidelines. Training representatives, usually nurses, from NHS trusts and private employers are participating in seminars to recognise, understand, de-escalate and safely manage violent incidents on mental health and learning disability settings. The training, entitled Promoting Safer and Therapeutic Services, is said to be the first time such a course has been developed to a national standard. To date more than 500 trainers have participated. Their job is to return to their employers and, in turn, deliver the training to their colleagues. NHS SMS pledges that, by March 2008, the training will be delivered to all frontline mental health [as well as learning disability] NHS staff.
“The report on Geoffrey Hodgkin’s death makes grim reading, and is dispiriting” admits Rick Tucker, NHS SMS’s head of security management in mental health services. “But actions have been since taken,” he says. Significantly, he claims the training is obligatory. “It is a legal requirement – in terms of a trust’s health and safety and healthcare commitments,” he says.
When discussing restraint, the debate around how long someone should be held in a prone position is perhaps the most highly-charged. The Bennett inquiry recommended patients not be held longer than three minutes. But, in February last year the government rejected this.
And Tucker, a nurse, believes a time limit is not all-important. “The three minute recommendation is impractical,” he says. “The main issue is to always be checking the physical well being of the patient. When involved in high risk physical intervention, as a clinician you have to be constantly assessing the physical well being of a person. Plus, you should not lie across the back of the legs, you should allow breathing to take place, and you should put a patient being restrained into another position as soon as possible. It’s a distraction to have a time limit.”
Yet, it is the bigger and bleaker picture of ward environments that is the main focus for people working to de-escalate violent incidents and physical restraint.
Nice’s guidelines were on the heels of a 2005 Healthcare Commission audit exposing a violent ward culture which service user groups have long complained about. Such a culture leads to confrontations, so precipitating restraint. The audit found 78% of nurses, 41% of clinical staff and 36% of service users have either been personally attacked, threatened or made to feel unsafe. And 35% of service users said staff ‘winded them up’. This year’s Mental Health Act Commission biannual report stated more than half of mental health wards were understaffed and untherapeutic. “On some wards you could cut the atmosphere of danger with a knife,” is how Tucker, whose work takes into him into different wards around the country, puts it.
Psychiatrists are, it seems, equally concerned. And the Royal College of Psychiatrists (RCP) has identified key factors necessary to build therapeutic psychiatric ward environments. These include that wards are clean, well-furnished and well lit, patients have privacy and therapy if required, and the trust is not reliant on agency staff. Plus there is strong leadership.
In a bid to promote therapeutic wards, the RCP has launched an accreditation scheme for acute inpatient psychiatric wards. Trusts are being asked to check themselves against more than 100 measures, covering everything from staff support and training, to patient advocacy provision, to making sure that on the day a patient is admitted and well enough they are notified who their primary nurse is, and how to arrange to meet with them. A three-tiered accreditation scheme means wards will be, at best, “excellent” and, at worse, “a significant threat to patient safety, rights or dignity and/or would breach the law.”
Up to now around 20 wards have participated in a pilot of the scheme, which is run in partnership with the British Psychological Society, the College of Occupational Therapists and the Royal College of Nursing.
“Staff on the wards are being very explicit [about what they are experiencing],” says Paul Lelliott, director of the college’s research and training unit. “Yes, there is a point at which you feel despondent. But the challenge is to do something about that. There are excellent staff in these wards. But too often they do not feel they can improve their wards. The responsibility lies with managers to back them.”
Dr Lelliott adds: “Nice guidelines are necessary but they are not sufficient.”
But questions remain as to whether the RCP ward accreditation scheme – which is voluntary – like the Nice anti-violence guidelines and Healthcare Commission ratings system – have the teeth to bring about change.
Joanna Bennett, a senior research fellow at the Sainsbury Centre for Mental Health, says: “A ward can get a particular accreditation one week, but the situation can quickly change, like the staffing levels. Having policies alone is quite useless. There is a lot of paperwork saying what people should do. But when it comes to applying it, it does not seem to happen.”
In her brother’s case, no one was prosecuted in connection with his death. Although Hodgkins’ family lawyers are examining the report, it is likely the same will apply. The report into his death stated no individuals were responsible.
But some in mental health wish the services for which they work were – in cases of violence management and restraint – accountable to law. Lelliot, for example, questions why trade unions have not been proactive in pursuing cases under health and safety laws when poorly trained, under-resourced staff are caught up in violent incidents. “I am surprised there have not been more prosecutions,” he says. “Trusts do have employees at risk, and trusts should take this more seriously.”
Likewise Bennett believes that unless something akin to corporate manslaughter in brought to the statue books, mental health services have no obligation to change. She says: “There’s never been anybody legally held responsible for these deaths. Therefore, things will never change.”
Hodgkin’s last minutes
Evening of November 19, 2004, around 8pm at Cheriton Ward, St James’s Hospital, Portsmouth
• Geoffrey Hodgkins threw glass cup at another patient. Carrying fork and glass cup he went into ward’s family room.
• Decision made to restrain Hodgkins. Discussion between four security guards, three nurses, and two healthcare support workers about which restraint process to follow, who should enter family room first and which positions individuals should take.
• Staff enter the room with Geoffrey Hodgkins standing with back to door
• Security guard brings Hodgkins to floor. Hodgkins held in prone position on his front. Three security guards, two nurses and two healthcare support workers restrain Hodgkins.
• Nurse injects Hodgkins with Haloperidol and Lorazepam. Hodgkins kicking, swearing and struggling.
• After about 25 minutes, Hodgkins stops breathing. Mouth to
mouth given. Hodgkins starts breathing and is placed into recovery position. Hodgkins stops breathing again, mouth to mouth resuscitation continues.
• Hodgkins taken by ambulance at 8.58pm to Queen Alexandra Hospital, accident and emergency department. Arrives at 9.23pm. Hodgkins’ life support turned off on 20th November, at 8.25am.
What Nice says mental health wards should implement for short-term management of violent behaviour
• Staff training to include anticipating, de-escalating or coping with disturbed/violent behaviour.
• All staff involved in administering or prescribing rapid tranquillisation, should receive ongoing competency training to a minimum of Immediate Life Support issued by the Resuscitation Council UK
• Staff employing restraint be trained to Basic Life Support (BLS), issue by Resuscitation Council UK.
• Patients have access to information about what may happen if they become disturbed/violent.
• Patients at risk of violent behaviour should have opportunity to have wishes recorded in advance directive.
• Rapid tranquillisation, physical intervention and seclusion should only be considered once de-escalation and other strategies have failed.
• During restraint one team member is responsible for protecting and supporting head and neck.
• Level of force applied justifiable, appropriate, reasonable and
proportionate to situation. Applied for minimum amount of time.
* A shortened version of this article appeared in Mental Health Today magazine