"Procedures to be initiated immediately ..... Patients will be identified as absent without leave when they cannot be accounted for by ward staff and/or at the time of prescribed observation checks. The nurse in charge of the ward must be informed immediately of patient's absence. The nurse in charge will be responsible for implementing the following procedures: • deploying staff to conduct a search of: • the ward • the entire unit, including courtyards • the immediate vicinity of the grounds surrounding Bede. If patient is not located the nurse in charge of the ward will inform: • nurse manager or designated deputy, who will offer advice and deploy additional staff, as appropriate. Out of hours the nurse co-ordinator for mental health directorate will be advised, who should ensure that the nurse manager is advised as soon as possible. Where the absconding patient is considered to be at significant risk the nurse manager on call should be informed and additional advice sought on action to be taken. • Nearest relative/carer informed immediately, advising them to contact staff if patient returns home if they have any relevant information regarding the patient's whereabouts. Where the patient remains absent daily contact should be maintained with the relatives and support/information provided where appropriate. • The Responsible Medical Officer (RMO) and seek advice on further management of situation. • Security via Ingham reception (Out of hours the hospital alert should be initiated). • The patient's general practitioner. • The key worker. Consideration should be given to: • The current risk assessment/management plan for the patient. • Any recent incidents/occurrences/ relationship problems which may be relevant. • Any known haunts frequented by patient. • Diagnosis (higher incidence of risk in patients with a predominant diagnosis of schizophrenia/affective disorder). • Gender. • Age. .... Legally detained patientsSection 18 Mental Health Act 1983 provides powers for the return of patients who are absent from leave. A patient who is liable to be detained in hospital may be taken into custody and returned to hospital by the following (section 18(2)) any Approved Social Worker any officer on the staff of the hospital any constable any person authorised in writing by the hospital managers. Otherwise the responsibility for the safe return of the patient rests with the detaining hospital. .... Police Involvement. Calls on the police should be kept to a minimum, but police should always be informed at once of the escape or absence without leave of a patient who is considered dangerous or who is subject to restriction on discharge under part III of the Mental Health Act. Police constables are among the people authorised to retake patients who are absent without leave from the hospital where they are liable to be detained, from the place where they are required under guardianship to reside (section MHA), who escape while being conveyed from one place to another or who escape from a place of safety or custody under the act (section 138). There may be cases where police assistance is required in the retaking of patients who are considered to be at risk of harming themselves or others."
"PROBLEM -- D. has been admitted to hospital under sec 3 MHA, there is a possibility that she may abscond. GOAL -- For Dawn to remain safe in the ward environment. INTERVENTIONS (1) D. states at present time has decided to remain on the unit therefore nominal observation only. (2) All staff to observe D.'s mood and behaviour and document changes. (3) Staff to encourage D. to accept prescribed medication. (4) Named associate nurse to explain rights under sec 3 MHA."
"There is no doubt that D. should have been in hospital, and had she been the chances of her injuring herself would have been much reduced. I therefore take the view that since the Defendants were responsible for the care of D., who was mentally ill and was supposed to be detained in the hospital, the fact that she was out doing injury to herself raises on the face of it, without other explanation, a case of negligence against the Defendants, and for that proposition I rely on the authority of Cassidy v The Ministry of Health[1951] QB 434 . Put another way, the burden of disproving negligence in a case of this sort lies on the Defendants."
"Dr Roy, the psychiatrist in charge of D.'s case, believed, as he put it, in negotiation not confrontation with patients such as D.. He took the view that if the patient is to be cured in the long term, or at least have their condition balanced, that that required the consent or the willingness of the patient to take his or her medication. Therefore he was against confronting such people, preferring to persuade them to take medication voluntarily."
"The claimant's case relies on the evidence of Dr Rix, a most distinguished psychiatrist, who has been a consultant forensic psychiatrist since 1997, and that of Peter McGuinness, a distinguished psychiatric nursing expert. Both those men conclude that, bearing in mind the history and presentation of D., she was subject to an observation regime which was inappropriately low. They believe that observations should have been at no more than fifteen minute intervals and that accordingly the hospital's care of D. was negligent. The defence case was supported by Dr Wood, another distinguished psychiatrist, albeit that he has not worked in the National Health Service for ten years and before that worked as a forensic psychiatrist; also by David Duffy, another distinguished psychiatric nursing expert, whose speciality is in the nursing of patients with suicidal tendencies. Mr Duffy was about as qualified as a nursing expert could be, in as much as he not only works hands on for six months of the year with mentally ill patients but he also has a number of publications on the subject of mental health and nursing to his name as well as a chapter in the standard nursing text book. Both those experts called by the Defence believe that there was nothing in D.'s history or presentation which necessitated any higher level of observation on September the 2nd 1996 than once an hour. So, those are the two rival contentions by the experts."
"Dr Rix and Mr McGuinness point out that D. was obviously extremely ill on August 29; that that is followed by the crisis on August 30 which led to her forcible injection; on the following day she walks out of hospital, having been told not to; then on September 1 she rows with her mother. The picture, they say, is of an unpredictable woman in the grip of an episode of schizoid disorder and a woman who is liable to be a danger to others as well as to herself. Accordingly, they say, she required close observation, among other reasons to prevent absconding. In the light of her past history of absconding, they say, that she would abscond at lunchtime on September 2, having been refused leave at that moment, was entirely predictable."
"Dr Wood and Mr Duffy, on the other hand, take the view that in the four days following her admission on August 29 D. had made progress in taking at least some of her medication. They approve of Dr Roy's policy of negotiation rather than confrontation for the long-term good of the patient and her taking at least some medication was a considerable improvement on her previous admission when, as I have said, she took no medication. On the morning of September 2, D. again did accept some of her medication. She was described as being pleasant and co-operative all morning, and so Dr Wood described her condition as being a mild hypomanic illness. There was no specific indication of suicide nor any specific indication that she might do harm to others. He and Mr Duffy both point out that in their view the only way to prevent D. absconding would have been by constant or one-to-one observation which was not justified by the risk D. presented, and in any event close observation had antagonised D. in the past and so would undermine the policy of getting D. to willingly take her medication and willingly stay in hospital. Another matter those experts say has to be factored into the risk assessment was that D. had been absent from the unit on no less than thirteen occasions between July 29 and September 2 and had come to no harm. Finally, Mr Duffy made the point that there is in fact no professional consensus about the length of intervals between observations to be used in different circumstances with mentally ill patients, and he said that in different hospitals many different approaches were used."
"I listened to both those experts being cross-examined by Mr Wilby. Neither expert yielded in his view, and that was a view which seemed to me to be logically defensible. .... I am therefore satisfied on the evidence of Dr Wood and Mr Duffy, that there is a responsible body of medical men who would have done as Dr Roy did, and in those circumstances I cannot find that the hospital were negligent."
"Confrontation will first of all lead to mistrust, she will not trust, she will become angry, and compliance will be even worse. On the other hand, negotiation and discussion will help to ensure that she will get some medication, and she is likely to continue with it if you do it with negotiation, rather than challenging all the time. It is a matter of building the trust."
"It strikes me as a perfectly reasonable approach, in that the long-term goal is very much to engage the patient in her own treatment in a cooperative fashion for her own welfare, and a policy of pure confrontation would overcome the immediate acute symptoms but not achieve the sort of drug treatment plan that you would be looking for."
"First of all, I don't think leaving the observations where they were is unreasonable. I think a reasonable body of opinion would have left them at that level. And secondly, I don't think instituting 15 minute observations would have prevented D.D. from absconding, the choice was clearly that of one-to-one nursing, or removal to a secure environment, which was likely to undermine any benefit of the softly-softly negotiated approach that Dr Roy was trying to achieve."
"As we have heard from the nursing staff and others, the way to try to achieve compliance in the case of this patient, was to negotiate with her and was to try to build a therapeutic relationship with her to persuade her to take her medication, and all I can imagine is regular 15 minute checks around the clock for several days would have had the exact opposite effect, and intended to make her less willing to comply."
"The priority for this patient was to get her to comply with medication. I will come back to that point. I mean something happened that has cast a long shadow of hindsight over things, I appreciate that, but the priority was getting this patient to take some medication, and to be imaginative in trying to find ways of getting her to do so."
"The natural history of bipolar affective disorder is of severe mood disturbance, sometimes depression, sometimes hypomania or mania, with the type of depression associated carries a particular raised risk of suicide, and often when a patient is profoundly depressed they preempt contact with doctors by completing suicide. Because it is a lifelong condition, and it continues to recur in many cases, despite treatment, the risk of suicide continues over many years. Which is why the end result for this percentage of patients, and it used to be said about 10 per cent, but I accept 5 to 10 per cent occurs, where that is the end result, despite all our treatment."