There has perhaps been a growing perception in recent years that the public is increasingly at risk of serious violence from people with mental health problems, a perception re-inforced by media coverage of a small number of tragic cases, such as the murder of Jonathan Zito (see other News item). In fact, only 5% of people convicted of homicide (which includes both murder and manslaughter) have symptoms of psychotic illness, such as delusions and hallucinations. Another 12% have other signs of mental illness, but 83% have none.
Also, where homicides are committed by people with mental health problems, the victim is more likely to be someone the person knows (in 82% of cases a family member), and only 10% are - as in the case of Jonathan Zito - complete strangers.
The government has used the report which produced these
figures"The National Confidential Inquiry into Suicide and
Homicide by People with Mental Illness" - to attempt to
re-assure the public, while also recognising that families of
people with mental health problems require improved support.
Paul Boateng, Health Minister, said:
I want to see explicit advice which spells out the need to consult families. They need to know what to do in a crisis. Who to contact and how. It should be standard practice. A patient's family may be the first people to realise that a patient needs urgent help.
With regard to suicides, the report covers people who had a mental illness and committed suicide. Of these, only a third were covered by the Care Programme Approach, and in most cases overall suicide risk was judged to be low when the person last had contact with the psychiatric services. 28% of cases studied were people who had been discharged from inpatient care within 3 months of death, while 13'% of cases were people who were actually still in hospital at the time of death.
The research behind this report operated from the University of Manchester, with the involvement/support of the Department of Health and the Royal College of Psychiatrists.
Jonathan Zito was stabbed and killed by Chistopher Clunis on the platform of a London Underground station five years ago. The incident had a very high profile in the media and contributed to a review of aftercare which led to the introduction of Supervision Registers. In Clunis's case, an inquiry found that various health and social services authorities had failed to communicate and co-operate, and no agency had an overall view of Mr. Clunis's needs nor the risk he posed to the public. He pleaded guilty to manslaughter on the grounds of diminished responsibility.
Christopher Clunis, who is now detained indefinitely at Rampton secure hospital, has been trying to establish a legal right to sue one of the health authorities which provided him with in-patient psychiatric care but which allegedly failed to provide proper aftercare. Such a right to sue, if successfully pursued, might have benefitted Mr. Clunis financially but it would also have meant that he could have paid damages to Jonathan Zito's widow, Jayne Zito, if she were to sue Clunis for killing her husband. [She is not legally able to sue the health authorities directly herself].
The Appeal Court decided that in formulating the Mental Health Act, parliament had not intended to create a wide-ranging responsibilty on health authorities, professional and other staff for actions carried out by people such as Christopher Clunis, who, although disturbed nevertheless must have known his actions were wrong.
Jayne Zito, who has been involved in campaigns for better mental health aftercare, is quoted, in The Daily Telegraph, as reacting to the decision with disgust:
That somebody like him could walk into the street with a knife, while highly vulnerable and dangerous, and kill someone, and yet nobody has a duty of care - well, they might as well have put the knife in his hands themselves. It is giving carte blanche to psychiatrists to discharge people into the community and when something goes terribly, terribly wrong there is no redress.
One mental health charity - SANE - has said it would support Mr. Clunis if he were to take his case to the House of Lords or the European Court of Human Rights, so the Appeal Court decision may not be the final word on this case.
The Department of Health has released statistics relating to Guardianship (under Section 7 or Section 37) for the 1996/7 year, ended 31 March 1997. At the year end, 705 cases were open in England, reflecting the fact that Guardianship is still not a widely-used provision of the Act. Over that year, 376 new cases were opened, while 305 were closed, resulting in an increase in total open cases of 11%. The new cases opened were fewer in number than in the previous 1995/6 year, so the overall increase in cases results from a considerable drop in the number of cases being closed during the 1996/7 year.
In 99% of cases in 1996/7, the Guardian was the local authorityonly in 1% of cases was it a named individual. Average duration of Guardianship at the time the case was closed during 1996/7 was 15 months, although 30% of these had been for 6 months or less.
The Appeal Court has decided that a man with autism - known in the Court proceedings as "H" - was unlawfully detained in a psychiatric hospital. His admission had been informal, not using the provisions of the Mental Health Act. He had been taken to the hospital when he became disturbed at a day care facility, and his usual carers could not be contacted. He remained in hospital on an informal basis and had been given treatment, which the NHS Trust concerned assumed was lawful as H had simply not decided to leave. This approach is common to most Trusts and hospitals. However, the Court ruled that where a person is not in a position to give proper consent to remain in hospital, then the person is being detained without consent and therefore the provisions of the Mental Health Act must apply. The Court felt that, in reality, if H had tried to leave hospital, he would have been prevented from doing so.
There are, arguably, many people in hospital deemed to consent to informal admission but whose ability to give fully informed consent may be in doubt - for example a large number of people with dementia. This Appeal Court ruling therefore has considerable implications and therefore a further appeal to the House of Lords is likely.
The government has announced its intention to ensure that a full range of mental health support services are available in the community before a local psychiatric hospital is closed. Health authorities are to review their closure programmes and an Independent Reference Group [IRG] has been established to consider the results of this review and advise government ministers accordingly. Specific criteria will be drawn up by the IRG against which to assess reprovision schemes (that is where a hospital closure is planned, with mental health services to be re-provided in the community rather than in the institutional setting).
Paul Boateng, a Health Minister, said:
The move away from institutional care to care in the community
has failed to deliver for many the necessary levels of support.
And it is no surprise that the public has never had confidence
in the system. We want to ensure that the full range of support
services are available in the community before local hospitals
for the mentally ill are closed. Mentally ill people should be
cared for in safety and security and we need to tackle everyday
concerns of the public.
Members of the IRG will be drawn from a variety of organisations, including the NHS Executive, MIND, SANE, the National Schizophrenia Fellowship, social work bodies and the Sainsbury Centre for Mental Health.
Every two years, the Mental Health Act Commission publishes a
report of its work. Its seventh Biennial Report, 1995-1997, was
published in July 1997. Main themes in the seventh report
include:
For more information, read the Review of the Report, at this site.
The Mental Health Act Commission has recently issued guidance on this topic, which has been the subject of considerable debate over the years. The note is reproduced in full at this site, as MHAC Guidance Note 3.
Developing Partnerships in Mental Health is the title of a government "Green Paper" - or consultation document issued in February 1997. In recent years, the need for all the agencies which contribute to mental healthcare to work closely together, has been emphasised in all aspects of mental health policy. While effective joint working has been created in some areas, it is not clear that the existing organisational arrangements will ever provide the "seamless" service which is being sought.
Details of this Green Paper consultation are now available at this site.
1997 has commenced with the launch of two important new Web
sites:
Many people working with the Mental Health Act will be familiar
with Richard Jones' Mental Health Act
Manual, an extremely detailed guide to the Act,
related Regulations and Guidance, and information on case law. A
new, 5th, Edition has recently been published. As a new service
for users of this HyperGUIDE, you
can order copies of this 684-page book at its published price of
£ 36.00 each, with FREE post and packing [UK only] from: