Low security is a poorly understood concept, particularly in relation to people with an intellectual disability. Characteristics of patients offered an admission to low…
Low security is a poorly understood concept, particularly in relation to people with an intellectual disability. Characteristics of patients offered an admission to low secure intellectual disability settings have not been robustly demonstrated. The same applies to staff perceptions of low security. The aims of the study were to ascertain the characteristics of patients referred to a low secure intellectual disability unit which lead to an offer of admission, identify the views of staff working on the unit on the concept of low security, and use both sets of data to discuss low secure provision for people with intellectual disability. A case‐controlled study was carried out for 33 patients referred to the unit over 42 months. The characteristics of 18 patients offered an admission were compared with those of 15 patients not offered an admission, and five of the staff working on the unit were interviewed about the concept of low security. Patients offered an admission were more able than those not offered an admission, posed more risks and were more complex diagnostically. Staff working on the unit agreed that their patients were complex, but felt that they were appropriately placed overall. The challenges of low secure provision were discussed by staff. Patients sampled were complex and heterogeneous, but not necessarily ‘forensic’. Their complexity requires sophisticated care plans and management strategies. This study has implications for referrers, staff, patients and managers, and highlights areas for future research.
There is substantial evidence that young people moving from child and adolescent mental health services to adult services are more likely to experience poor transitions…
There is substantial evidence that young people moving from child and adolescent mental health services to adult services are more likely to experience poor transitions. However, little is known about the care pathways of young people transitioning from forensic services. This retrospective case note review sought to examine the clinical characteristics, transition pathways and psychosocial indicators of transition outcomes amongst young people in forensic medium secure services discharged to adult services.
The electronic records of 32 young people, who transitioned from six adolescent medium secure units in England to adult services between May 2015 and June 2016, were examined.
Approximately 65% of young people were between 18 and 19 years at the time of transition and the average waiting time from referral to discharge was six months. A total of 63% young people transitioned to community placements and adult medium secure services. Four pathways describing the journey into and out of adolescent medium secure services were identified in a subsample of 12 young people. A total of 25% young people with neurodevelopmental problems moved to specialist services.
The results suggest that diagnosis, severity of offence and clinical background are associated with transition pathway. Promoting a person-centred approach and gradual independence of the young person may improve current practice.
These results inform existing policy and clinical practice in an effort to reform transition guidelines around young people’s needs during transition times. Further studies in adolescent forensic services are needed to understand complex neurodevelopmental problems and comorbidities.
Medium secure units were designed to treat patients for up to three years, but some patients spend longer in acute medium secure settings which in general do not have a 'longer term focus'. The aim of this investigation was to assess and describe the needs of these patients. A survey questionnaire was designed and sent to responsible clinicians who had patients admitted at least five years previously to the Three Bridges Medium Secure Unit (males) in West London. Carer ratings using the Camberwell Assessment of Need: forensic version (CAN‐FOR) were completed by the primary nurse for each patient, complementing the survey questionnaire. Of 122 medium secure male patients 25 (21%) had been admitted at least five years before. We found high levels of co‐morbidity and treatment resistance. The CAN‐FOR revealed two groups, one with chronic challenging behaviour, treatment‐resistant mental illness and need for a high level of support, and another more able group not needing as much support but with a dependency on the hospital. It is considered here whether certain groups would benefit from a different approach or setting.
Individuals being treated in medium secure hospitals have typically engaged in some form of offending in other service settings or while in the community. Although…
Individuals being treated in medium secure hospitals have typically engaged in some form of offending in other service settings or while in the community. Although psychological treatment for addressing such behaviour in medium secure hospitals is beginning to be developed, at present there is a lack of evidence of ‘what works’. This paper reports a review of the type and level of offending behaviour engaged in by those in a single medium secure service, including the conviction histories for such behaviours and the psychological approaches to risk reduction and offending behaviour taken in medium secure hospitals in England and Wales. The need to develop an evidence base for psychological treatment in medium secure services including at the individual level is clearly indicated.
The aim of the project was to evaluate the short‐term treatment outcomes of patients treated in a medium secure service for people with intellectual disability. A total of…
The aim of the project was to evaluate the short‐term treatment outcomes of patients treated in a medium secure service for people with intellectual disability. A total of 138 patients, 77 discharged and 61 current inpatients, treated over a six‐year period were included in the audit. Information on demographic and clinical variables was collected on a pre‐designed data collection tool and analysed using appropriate statistical methods. The median length of stay for the discharged group was 2.8 years. About 90% of this group were discharged to lower levels of security and about a third went directly to community placements. None of the clinical and forensic factors examined was significantly associated with length of stay for this group. There was a ‘difficult to discharge long‐stay’ group which had more patients with criminal sections, restriction orders, history of abuse, fire setting, personality disorders and substance misuse. However, when regression analysis was done, most of these factors were not predictive of the length of stay. Clinical diagnosis or offending behaviour categories are poor predictors of length of hospital stay, and there is a need to identify empirically derived patient clusters using a variety of clinical and forensic variables. Common datasets and multi‐centre audits are needed to drive this.
This article reports on a study designed to review the media coverage of patients in a medium secure unit and to demonstrate the value to such units of having a media…
This article reports on a study designed to review the media coverage of patients in a medium secure unit and to demonstrate the value to such units of having a media strategy. Most of the patients in the study had a history of sexually motivated offending, a significant proportion against children. The pattern of a typical media report and the organisational response is discussed, while broader political developments over the study period are noted.
There are high levels of psychiatric morbidity amongst people in prisons. In England and Wales, prisoners who present with the most acute mental health needs can be…
There are high levels of psychiatric morbidity amongst people in prisons. In England and Wales, prisoners who present with the most acute mental health needs can be transferred to hospital urgently under part III of the Mental Health Act 1983. This project reviewed all such transfers within one region of England, with an emphasis on differences across levels of security.
Over a six-year period (2010–2016) within one region of England, 930 psychiatric referrals were received from seven male prisons. From these referrals, 173 (18.5%) secure hospital transfers were required. Diagnostic and basic demographic information were analysed, along with hospital security categorisation (high secure, medium secure, low secure, psychiatric intensive care unit and other) and total time to transfer in days.
There were substantial delays to urgent hospital transfer across all levels of hospital security. Prisoners were transferred to the following units: medium security (n = 98, 56.9%); psychiatric intensive care units (PICUs) (n = 34, 19.7%); low secure conditions (n = 20, 11.6%); high secure conditions (n = 12, 6.9%); other (n = 9, 5.2%). Mean transfer times were as follows: high secure = 159.6 days; other = 68.8 days; medium secure = 58.6 days; low secure = 54.8 days; and psychiatric intensive care = 16.1 days.
In keeping with the wider literature in this area, transfers of prisoners to hospital were very delayed across all levels of secure psychiatric hospital care. Mean transfer times were in breach of the national 14-day timescale, although transfers to PICUs were quicker than to other units. National work, including research and service pilots, is required to understand whether and how these transfer times might be improved.
This paper extends the available literature on the topic of transferring prisoners with mental illness who require compulsory treatment. There is a small but developing literature in this area, and this paper largely confirms that delays to hospital transfer remain a serious problem in England and Wales. National work, including research and service pilots, is required to understand whether and how these transfer times might be improved. This could include different referral and transfer models as a component of service-based and pathways research or combining referral pathways across units to improve their efficacy.
Secure inpatient services for people with intellectual disability are provided in a piecemeal way, often without strategic commissioning. We describe how we conducted a…
Secure inpatient services for people with intellectual disability are provided in a piecemeal way, often without strategic commissioning. We describe how we conducted a needs assessment that enabled us to develop a new service for men with intellectual disability who often had substantial additional mental health needs. Consulting with all stakeholders was essential, and we found the service user and family perspectives particularly helpful. We had to make special arguments for some aspects of the treatment programme. We found that foundation trusts that are able to develop services at financial risk, before contracts are signed, enabled development to take place at a faster pace. Good relationships with community teams have been essential, as has true integration with mainstream forensic services. Maintaining a relationship with commissioners was a particularly challenging aspect, perhaps because the development was provider‐led. Despite these challenges, many people with intellectual disability with very high needs are being supported much nearer to home.
Records of violent incidents were retrospectively analysed to identify trends associated with violent incidents within an NHS medium secure psychiatric unit. Over a…
Records of violent incidents were retrospectively analysed to identify trends associated with violent incidents within an NHS medium secure psychiatric unit. Over a 12‐month period, 116 incident forms related to 112 incidents. These incidents were compared with a study from the previous 12 months within the same unit. Both studies were based upon work from within a high‐security setting (Caldwell and Naismith, 1989). There was a significant reduction in the overall number of violent incidents.The majority of incidents continued to occur within the intensive care admission unit. There continued to be a higher incidence of assaultive behaviour throughout the afternoon and evening. Seasonal variations demonstrates a reduction of incidents throughout the autumn and winter months compared with the previous year, and a significant change in the number of incidents that occurred during the summer.There remain opportunities for comparison with other secure units and further refinement of the methodology.
This article outlines conventional dual diagnosis outcome measures and the challenges of using these measures to evaluate interventions in medium secure units. It suggests…
This article outlines conventional dual diagnosis outcome measures and the challenges of using these measures to evaluate interventions in medium secure units. It suggests how these challenges can be overcome by using alternative outcome measures such as measures of motivation, stages of change, beliefs, knowledge, group satisfaction, therapeutic alliance or coping strategies.