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Psychiatric in-patients, violence and the criminal justice system

  • Simon Wilson (a1), Kevin Murray (a2), Mike Harris (a3) and Michael Brown (a4)
Summary

There is ambivalence about prosecuting psychiatric in-patients for violent offences. This ambivalence is reflected in the Memorandum of Understanding that exists between the Crown Prosecution Service and the NHS Security Management Service. This has led to an unwelcome change in practice when the police ask for information from an individual's consultant psychiatrist, the police requesting information about the individual's cognitive abilities at the time of the alleged offence and using this to make decisions about prosecution. However, there is also guidance on this area from other sources. We describe this and make further suggestions for dealing with these requests.

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Copyright
This is an Open Access article, distributed under the terms of the Creative Commons Attribution (CC-BY) license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution, and reproduction in any medium, provided the original work is properly cited.
Corresponding author
Simon Wilson (simon.wilson@kcl.ac.uk)
Footnotes
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Declaration of interest

None

Footnotes
References
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1 Health Policy and Economic Research Unit. Violence at Work: The Experience of UK Doctors. British Medical Association, 2003.
2 Health and Safety Executive. Violence at Work: New Findings from the British Crime Survey 2000. Home Office & HSE, 2001.
3 Young, C, Brady, J, Iqbal, N, Brown, F. Prosecution of physical assaults by psychiatric in-patients in Northern Ireland. Psychiatr Bull 2009; 33: 416–9.
4 Wexler, DB. Therapeutic jurisprudence and the criminal courts. William Mary Law Rev 1993; 35: 279–99.
5 Ritchie, JH, Dick, D, Lingham, R. The Report of the Inquiry into the Care and Treatment of Christopher Clunis. HMSO, 1994.
6 Eastman, N, Mullins, M. Prosecuting the mentally disordered. J Forens Psychiatry 1999; 10: 497501.
7 Crown Prosecution Service. The Code for Crown Prosecutors. CPS Policy Directorate, 2010.
8 Crown Prosecution Service. Mentally Disordered Offenders. CPS, 2010 (http://www.cps.gov.uk/legal/l_to_o/mentally_disordered_offenders).
9 Crown Prosecution Service, NHS Security Management Service (CPS & SMS). Memorandum of Understanding between the NHS Counter Fraud and Security Management Service and the Crown Prosecution Service. CPS & SMS, 2008 (http://www.cps.gov.uk/publications/agencies/mounhs.html).
10 National Policing Improvement Agency. Guidance on Responding to People with Mental Ill Health or Learning Disabilities. ACPO NPIA, 2010 (http://www.npia.police.uk/en/docs/Mental_ill_Health.pdf).
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BJPsych Bulletin
  • ISSN: 1758-3209
  • EISSN: 1758-3217
  • URL: /core/journals/bjpsych-bulletin
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Psychiatric in-patients, violence and the criminal justice system

  • Simon Wilson (a1), Kevin Murray (a2), Mike Harris (a3) and Michael Brown (a4)
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eLetters

Prosecuting violent in-patients: the importance of staff attitudes

Pratish B. Thakkar, Consultant Forensic Psychiatrist
09 March 2012

The editorial by Wilson et al highlights important dilemmas faced by mental health professionals in relation to reporting violence perpetrated by mentally disordered patients. Whilst we welcome the proposals made in the editorial, we suggest that unless there is a significant change in staff attitudes to reporting non-trivial violence perpetrated by psychiatric patients, progress in this area is unlikely to occur.

Our observation is underpinned by the results of two surveys which wecarried out in a Medium Secure Unit (MSU) Middlesbrough in 2006 and 2008. There were 80 incidents of assaults on staff by in-patients, the majority of incidents having been perpetrated by a minority. Despite being a MSU, the majority of assaults were perpetrated by patients detained under Part 2 of the Mental Health Act and by female patients. Only 10 incidents (12.5%) were reported to the police, despite 70% of nursing staff being aware of the memorandum of understanding . We explored the attitudes of nursing staff using self report attitude questionnaires (each of the 13 attitude statements measured on a 5 point Likert scale) to identify enablers or barriers to reporting incidents. In the latter survey, 66 out of 100 staff responded.

In both surveys, approximately a third of respondents feared that reporting incidents would result in breakdown of therapeutic relationshipswith patients and half feared reprisal from patients following reporting. In 2006, half of respondents considered being assaulted as an 'occupational hazard', but encouragingly this attitude was reflected only in a quarter of respondents in 2008. Although 84% nursing staff perceived that they had a 'right to report', one fifth of respondents perceived thatreporting incidents was a bureaucratic exercise without benefits and 60% of staff perceived the required reporting forms and procedures difficult to complete. Staff were more likely to report incidents perpetrated by patients with personality disorder than those having mental illness. 20% of staff stated that they would only report incidents which resulted in physical injury. Only 40% of staff believed that reporting incidents wouldstrongly deter patients from re-assaulting staff. Some of these free text comments capture the ambivalence in this area. 'I came to the nursing profession to help patients, not to be a punch bag.' 'I would report only if the assaults were due to badness than madness.' 'Disillusioned towards police dealing with incidents.' 'Waste of time.' 'Zero tolerance should mean zero tolerance.'

In summary, whilst we acknowledge and endorse the value in developingrobust policies, procedures and systems to address this important issue; significant progress in this area is unlikely to occur unless considerableefforts are made to shift attitudes of mental health professionals. Campaigns and systems to report and reduce violence are akin to taking a horse to the water. Making the horse drink will require change of attitudes in relation to reporting violent incidents to the police. We propose that this can be done in a number of ways such as inclusion in staff induction training, appraisal, supervision sessions and Trust audits.

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Conflict of interest: None declared

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Psychiatric inpatients and the criminal justice system: benefits but any downsides?

Lin Sun Choong, consultant psychiatrist
21 February 2012

Sir, the paper by Wilson et al highlights the serious issue of in-patient violence. The potential benefits of involving the criminal justice system (CJS) are well laid out. The suggested approach is likely to be useful in practice. Unfortunately the paper fails to look at the possible downsides of such practice.

Potential adverse outcomes include short and long term stigma for theindividual patient and loss of therapeutic relationship between patient and clinicians. These are likely to result in poorer services and longer periods of detention.

The critical step in deciding to refer to the CJS will be based on the clinician's judgement of non-trivial violence. Good training can reduce lack of consistency but long term follow up and critical examination of such practice will ensure the adverse outcomes are kept to a minimum as we juggle to find the ethical balance here.

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Conflict of interest: I work in a Psychiatric Intensive Care Unit

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