Paper
Dr Kevin Murray, Clinical Director, Broadmoor Hospital, England
Mr Matthew Wilding, Security Liaison Nurse Manager, Broadmoor Hospital, England
Detective Constable Jayne Payne, Thames Valley Police, Hospital Liaison Officer, Broadmoor Hospital, England
Keywords: prosecution; violence; inpatient; staff safety
Introduction
Patients arrive at forensic services in the UK either from the Courts following the commission of a violent crime or from prison where they are serving a sentence typically for a violent offence. Our role is both to support recovery from the underlying disorder and to reduce risk of future similar incidents. We use a range of approaches including pharmacotherapy, psychotherapeutic approaches from a variety of backgrounds, and broader social therapies. However we have historically been reluctant to enforce the same legal consequences on our patients for violent behaviour in hospital as are applied in wider society.
In the high secure hospitals in the UK in recent years we have increasingly promoted the use of legal sanctions for non-trivial violent behaviour. This paper sets out the background to and the results from that initiative at one high secure hospital, Broadmoor.
In many ways the situation until recently in psychiatric services is analogous to that 20 years ago in respect of domestic violence, Police and prosecution attitudes were characterised by a hands off approach:
“It’s none of our business”
“What do you expect if you marry someone like him / work with people like that “
And from a judge a few years ago: “isn’t this behaviour exactly why he was sent to Broadmoor in the first place?”
But unlike other institutions such as prisons dealing with violent offenders we do not have a system of punishment or tariffs to apply when a patient assaults a member of staff or another patient. In prisons in the UK the Governor may adjudicate following an assault and add days to the sentence; in the hospital system we can move the aggressor to a more restricted treatment area but no more than that. Later the significance of the event may be challenged by lawyers representing the patient at tribunal hearings considering discharge: the record we make in the notes may be disputed and we may be accused of exaggerating. The absence of a formal independent record of violence in in–patient settings may contribute to incomplete assessment of risk, as was noted more that 20 years ago in the important case of Christopher Clunis.
In order to address the difficulties this situation presented we began some years ago to increase the number of assaults we reported to the local police and to press for prosecution in appropriate cases. We made this intention explicit in our local liaison meetings with the police, which had previously focussed on external security issues rather than internal safety issues. It is fair to say we met with some resistance and surprise initially, both from the usually rather junior officers sent to investigate the alleged offences and the local magistrates when such offences went forward to prosecution. However we made the most of every opportunity at police and court liaison meetings to explain our concerns and emphasise that we expected the same level of support for our staff at work as the staff in the local Hospital Emergency Department could expect: Emergency Departments being recognised to be high risk settings for staff dealing with intoxicated casualties and sometimes their intoxicated assailants.
It is acknowledged that this process was not designed as a planned experiment with data on levels of assault collected before and after a single well-designed intervention, but rather a continuing dialogue which requires consistent messages to be delivered as personnel change in the local police, prosecution and court services. However a number of important milestones have occurred along the way which should be highlighted alongside the data we have collected.
One of the unanticipated consequences of this approach was that this local relatively low – crime area of suburban Berkshire began to figure in police statistics as a higher crime area, which merited further
analysis and resource investment. This contributed to the case for the appointment of a liaison police officer based at Broadmoor in 2008. The role of this person is to support the hospital more generally in respect of the criminal justice system e.g. when there are trials forthcoming for our patients who have been admitted pre-trial, but also to investigate by taking statement and preparing a case for the prosecution authorities when there is a serious assault at the hospital: whether the victim is a member of staff or another patient.
When cases are successfully prosecuted and the Hospital is asked for advice on sentencing we acknowledge our role in the continuing treatment of mentally disordered offenders and do not seek to simply dispose of such assailants back to the Criminal Justice System and to prison. We typically support the imposition of a restricted Hospital Order under UK mental health legislation which increases the scrutiny to which decisions on transfer and discharge are subject, for those patients who are not already subject to such an order. Alongside this, and for patients who are already subject to restricted hospital orders, we recommend fines and compensation orders. For patients who are subject to hospital orders, who are typically rather well off, given the very limited demands on their income benefits, thereby receive a significant financial sanction as well as the criminological sanction of the record of a further conviction. In one recent case of the prosecution of a repeatedly assaultative patient, who was already on a restricted hospital order, and who severely assaulted a psychologist at another hospital before transfer to Broadmoor, the sentencing Judge asked for details of the savings the patient had accumulated. On being advised these amounted to some £9,000 (€10.400) he ordered £8,500 compensation to the victim, £ 250 compensation to another member of staff more peripherally involved and £250 contribution to prosecution costs. The assailant later mentioned to his Consultant Psychiatrist “I’d better learn to keep my fists to myself”
In order to facilitate prosecution for non-trivial offences we have developed a template statement on behalf of the Hospital, available on request to the author, which provides evidence which the Court can include in considering sentence. This includes details of the financial and human impact of assaults on the running of the Hospital. We detail the number of days lost by ill health following assaults on staff. We detail the financial cost of employing additional staff to fill the vacancies resulting from staff sickness following assaults. We emphasise that the great majority of assaults which our patients commit are not the direct result of their mental disorder for which they should not be considered responsible, but are part of a more general pattern of disorganised or instrumental aggression which all treatment approaches have a role in extinguishing. We also emphasise that the support for prosecution is not the discretionary responsibility of an individual member of staff who has been assaulted, but a matter of agreed hospital policy which the senior management are committed to and can attend Court if necessary to explain. This is also emphasised in Community Meetings across the hospital, to minimise the likelihood of the repeated targeting of an individual member of staff who has been assaulted and whose assailant has been prosecuted. Equally we emphasise our commitment to the prosecution of patients who assault their fellow patients: the safer running of the hospital is in the best interests of both staff and patients.
The consequence of this approach is illustrated in the table below. This demonstrates a five fold increase in the rate of prosecutions for patients at Broadmoor over some four years, from about 10% reported assaults prosecuted to over 50% prosecuted. Perhaps most importantly, there is early non-significant evidence of a reduction in the number of assaults occurring.
Year ending Assaults reported to police Successful prosecutions % prosecuted
March 2010 95 9 10
March 2011 79 14 18
March 2012 93 42 45
March 2013 62 36 58
In addition we are now seeing significant compensation awards being paid as a matter of routine. In 21 cases of assault on members of staff for which we have full details, the mean compensation awarded was
£193; range £75 – 1000: (mean €222 range €86 – 1150). Additional court costs averaging £85 (€100) were imposed in 6 cases.
For assaults on patients we have details in four cases: in three of these compensation awards averaging
£90 (€105) were made. In the fourth the aggressor, who was transferred from prison for treatment, was sentenced to return to prison for a further period of time at his request, and against our advice that he be made subject to a restricted hospital order.
Conclusions
It is our considered view that the routine approach of holding patients accountable for their actions unless their clinical team judge them to be exceptionally unwell is one which promotes responsibility and recovery. We believe it contributes to a safer hospital and a clearer focus on the reality of rehabilitation which is increasing self determination.
We will continue data collection which we anticipate will demonstrate a gradual downward trend in the number of incidents of assault in the hospital and the benefits of continued partnership work with the Criminal Justice System in the robust management of such incidents. We expect this will promote the shared understanding across the hospital that actions have consequences and detention in a high secure hospital does not provide an automatic excuse for instrumental violence. We are committed to promoting the efficiency of our services particularly in respect of reducing expensive in-patient detention and the earlier in a period of care a patient understands that assaults on staff or fellow patients have significant consequences, the sooner we can begin to work together on alternative strategies to deal with the underlying conflicts more appropriately.
It is our view that along with physical security, our walls and locks, and relational security, our sensitivity to the mental states of our patients, this aspect of procedural security – the robust formal multiagency response to violence in hospital - is an important limb in our security and therapy strategies.
Acknowledgements
We acknowledge the support of the security liaison staff at Broadmoor Hospital, of our partners in Thames Valley Police and in the Crown Prosecution Service. We also acknowledge the support of all our clinical staff who have contributed to this initiative. Finally we acknowledge the contribution of Dr Simon Wilson, Consultant Forensic Psychiatrist, Oxleas Foundation trust; Dr Mike Harris, Accountable Officer at Rampton High Secure Hospital, Notts Healthcare, and Inspector Michael Brown, West Midlands Police, who collaborated on the article referenced below which describes the policy background to this initiative in greater detail
References
Wilson, S., Murray K., Harris, M. and Brown, M. Psychiatric in – patients, violence and the criminal justice system. The Psychiatrist, 36, 41-44, 2012.
Ritchie, J. and Dick, D. The report of the Inquiry into the care and treatment of Christopher Clunis. London: HMSO. 1994
Correspondence
Dr K Murray
kevin.murray@wlmht.nhs.uk