dignity & respect ca ethical trea and lawful equality Annual report

Transcription

1 dignity & respect ca ethical trea and lawful equality Annual report

2 We aim to ensure that care, treatment and support are lawful and respect the rights and promote the welfare of individuals with mental illness, learning disability and related conditions. _ Laid before the Scottish Parliament by the Scottish Ministers under Section 18 (2) of the Mental Health (Care and Treatment) (Scotland) Act October 2013 SG/2013/211

3 Contents Who we are and what we do 02 Chair s statement 04 Key messages 06 Effective and efficient visiting Our focussed visits 10 Themed visits adult acute visit 11 Learning disability community care visits 12 Case study Jeremy s story 13 Monitoring and safeguarding care and treatment Overview of the use of mental health legislation in Scotland 15 Overview of the use of incapacity legislation in Scotland 18 Monitoring focus when parents are detained 20 Monitoring focus immediate redetention 22 Monitoring focus consent to treatment 23 Investigations Why we investigate 25 Anonymised investigations 25 Our published investigations 26 Ms AB 26 Ms CD 27 Our unpublished investigations 28 Carol s story 28 Ian s story 29 Providing information and advice Our advice line 31 Our website 32 newsletter 32 Case study whole service improvement 33 Good practice guidance 34 Case study Richard s story 35 Drug-induced psychosis guidance 36 Advance statement guidance 37 Influencing and challenging Excellence in Practice seminars 39 Principles into Practice Awards 40 National preventative mechanism 41 External stakeholder events 42 Improving our practice Involving people: advisory committee 46 Learning lessons 46 Our commitment to equality 47 Financial resources 47 Protecting the environment 47 01

4 Who we are and what we do principles leadershi dignity & human r 02 communi

5 p Our aim We aim to ensure that care, treatment and support are lawful and respect the rights and promote the welfare of individuals with mental illness, learning disability and related conditions. We do this by empowering individuals and their carers and influencing and challenging service providers and policy makers. Why we do this Individuals may be vulnerable because they are less able at times to safeguard their own interests. They can have restrictions placed on them in order to receive care and treatment. When this happens, we make sure it is legal and ethical. Who we are We are an independent organisation set up by Parliament with a range of duties under mental health and incapacity law. We draw on our experience as health and social care staff, service users and carers. Our values We believe individuals with mental illness, learning disability and related conditions should be treated with the same respect for their equality and human rights as all other citizens. They have the right to: ights c be treated with dignity and respect ethical and lawful treatment and to live free from abuse, neglect or discrimination care and treatment that best suit their needs recovery from mental illness lead as fulfilling a life as possible. What we do Much of our work is at the complex interface between the individual s rights, the law and ethics and the care the person is receiving. We work across the continuum of health and social care. We find out whether individual care and treatment is in line with the law and good practice We challenge service providers to deliver best practice in mental health and learning disability care We follow up on individual cases where we have concerns and may investigate further We provide information, advice and guidance to individuals, carers and service providers We have a strong and influential voice in service policy and development We promote best practice in applying mental health and incapacity law to individuals care and treatment 03

6 Chair s statement The publication of this Annual Report marks the end of my second year as Chair of the Mental Welfare Commission. This is an ideal time for me to look back on what we have achieved and look toward what we are planning. During we published some important reports, and I would encourage everyone involved in the care and treatment of people with mental illness, learning disability and related conditions to look at these reports for guidance. We remain focused on protecting the rights and welfare of individuals. Key achievements include: Two of our major investigations have important lessons for us all. Ms AB is a woman with dementia who was, in our view, unlawfully detained and excessively sedated in a remote Scottish hospital. We made recommendations on training and procedures to the NHS Board. I wrote to the Cabinet Secretary for Health about this case. Standards of care for people with dementia must apply in remote community hospitals as well as large general hospitals. Mrs CD is a woman in her 60s who was in serious distress but became aggressive and difficult to care for. We thought it was unacceptable that the offer of hospital care was withdrawn. As a result, she went to prison for a short spell. We believe that health, social care and criminal justice services must work together to provide better care for individuals such as her. 04

7 We place great emphasis on our visiting work. During the year, we visited almost 500 individuals receiving care and treatment in acute adult wards. Most of them praised their care and treatment, even when they had been detained against their will. We used the report to highlight best practice, while taking action if we thought services or facilities were not respecting individuals rights or doing enough to help them recover from serious mental illness. Our other major theme was the care of people with learning disability in the community. We visited individuals who needed a lot of care and support. We were very pleased to find good attention to the principles of benefit and least restriction of freedom. Individuals had a major say in how they spent their time. It is important that they have well-trained and supported staff and that care packages are reviewed regularly to make sure that they provide maximum benefit. Scottish Ministers asked us to host a National Confidential Forum on the experiences of individuals who had been in residential care during childhood. We were honoured to be asked to do this and are working with the Scottish Government and stakeholder groups to develop this important project. We know that our stakeholders value our advice and guidance. We revised and updated some of our existing guidance documents and produced new guidance on advance statements and drug-induced psychosis. We continue to audit our advice for accuracy and have exceeded our target for this. Our website attracts around 34,000 visitors each year. We welcome feedback on the structure and content of the website. Looking ahead we consulted stakeholders over priorities for the coming year. As a result, we are concentrating on people with dementia in mental health care, women with mental health care needs who have committed offences and young people in secure care who need mental health services. My thanks go to all stakeholders who have helped us, especially those who come to our advisory committee. Their views are essential in helping us prioritise our work. The next two years will see changes in our executive team. We were delighted to welcome Mrs Alison Thomson in her new role as Chief Nursing Officer for the Commission. There will be opportunities for other experienced practitioners to join us as we further develop our important and unique safeguarding duties.. 05

8 Key messages We want parents who are detained to have better contact with their children. We made 491 recommendations following 133 focussed visits conducted during this period. We found that 40% of all long-term civil compulsory treatment now takes place in the community. There has been a very small increase in the number of people on long-term orders. There have been more emergency compulsory admissions this year. In one large NHS area, most emergency detentions did not have the safeguard of mental health officer consent. 06

9 Too many individuals under the age of 18 are being admitted to adult wards. But some NHS Boards have managed to avoid this by providing intensive home treatment. We welcomed another large fall in the number of welfare guardianships granted for an indefinite period of time. Indefinite orders may not be compatible with human rights law. Our unannounced visits found that over 20% of people who cannot consent are being given medical treatment without proper lawful documentation. 07

10 Effective and efficient visiting principles leadershi dignity & human r 08 communi

11 p - We reviewed the care and treatment of 3,429 service users and met 1,924 in person - 25% of our focussed visits were unannounced - We carried out a national themed visit to all adult acute services in Scotland One of the ways we monitor care and treatment is through our visits programme. We visit people in a range of settings throughout Scotland: at home, in hospital or in any other setting where they are being cared for. Visiting helps us to look at the care and treatment people are getting, to see the kind of places where care and treatment is provided and to hear how they feel about their care and treatment. Themed and focussed visits At the Commission we undertake many different types of visits throughout the year. When we visit a service or individual we may refer to this visit as being part of a themed or focussed visit. Each year we have two or three big themed visits this year s being the Adult acute visit and the Intensive learning disability community care visit. These visits mean we visit all services or individuals who meet the criteria covered by the theme of the visit. We undertake a focussed visit to individuals receiving care and treatment in a particular service. There are several reasons for these visits: following up on previous recommendations by examining concerns ights received by telephone or mail, or simply to check how people are being treated if we have not visited recently. c 09

12 Our focussed visits We visit individuals in hospitals, care homes, prisons and other places where they receive care and treatment. We want to hear what they think of their care, and find out if their needs are being met and their rights respected. If not, we make recommendations to staff and managers, and we check if they have done what we asked. This year, we undertook 133 focussed visits. We reviewed the care and treatment of 948 individuals, 675 of whom we were able to interview in person. We made 491 recommendations. We committed to follow up 90% of the recommendations we made. We followed up 97% of our recommendations. We can report that 93% of our recommendations have been fully implemented or resulted in significant service improvement. We believe this demonstrates our effectiveness in influencing service improvements through a targeted, risk-based programme of focussed visits. Of all the visits we carried out, 33% of recommendations we made related to NHS mental health services for older people, however we did carry out significantly more visits to this type of service. In the full report we give a detailed description of where we visited and the main themes that arose from all our recommendations. Many of the recommendations we made related to the provision of therapeutic activity and the majority of these related to services for older people both in NHS and private care home settings. We found that too often, activities were provided in a one-size-fits-all way and the personal preferences and abilities of individuals taking part in them were not always recognised. Other themes that emerged were: Lack of compliance with the provisions of the Adults with Incapacity (Scotland) Act 2000 Lack of compliance with the Mental Health (Care and Treatment) (Scotland) Act 2003 The physical care environment Inefficient care planning and review Restrictions on individuals freedom of movement Lack of person-centred care Involvement of carers Assessment of capacity Training needs for staff Read the full focussed visit report on our website. 93% of our recommendations have been fully implemented or resulted in significant service improvement. _ 10

13 Themed visits Adult acute visit This year we visited all adult acute wards and intensive psychiatric care units in Scotland. As well as meeting with anyone who wanted to talk to us, we were particularly interested to meet with people who: had been admitted three or more times in the last two years were from an ethnic minority had problems with drug or alcohol use as well as mental illness were detained under the 2003 Act and had parental responsibilities for a child/children under 18 years of age were homeless or in unsettled accommodation prior to admission were deaf or deafened. On our visits we found some excellent examples of recovery-based care. We heard about how much people felt they benefit from having lots of activities, having positive staff and having support from their peers. However, some people told us that they were not given enough information or that they were not involved in planning their care. We also raised serious concerns about the poor physical environments in some of the wards. The majority of parents we spoke to said they were concerned about their children while they were in hospital. We feel staff should do more for parents to identify and address these concerns when they are admitted. The full report is available on our website. 11

14 Due to the complexity of people s needs there must be close attention to their rights and the legal basis of any restrictions. _ Learning disability community care visits We wanted to look at the quality of life, the opportunities and the choices being experienced by people who have been traditionally labelled as having high or complex support needs. We contacted local authorities across Scotland for details of the most expensive care packages they provide to people with complex needs in the community. We visited 202 individuals across the 32 Scottish local authorities. We looked at various aspects of the arrangements in place to provide care and support. We were impressed overall with the support being provided to most of the people we saw. Particularly for those who had previously been in institutional care, the move to their own home had been literally life-changing. We saw people with very complex needs receiving support. We felt there was invaluable input from many of the providers, specialist health teams and local authority care managers. However, in some cases we felt that local authorities should be more regularly reviewing the individual s care plan and how this is being delivered by the provider and their involvement of the service user. Due to the complexity of people s needs there must be close attention to their rights and the legal basis of any restrictions. Our full report will be available later in the year on our website. 12

15 Case study Jeremy s story We visited Jeremy during our visits to people with intensive support in the community. Jeremy had severe physical and learning disabilities. He had been receiving a large package of care from the council. Jeremy had been bought a Jacuzzi bath for therapeutic reasons. He was not getting to use this very much because staff were not being scheduled for long enough to help him to use it. We were concerned to see that Jeremy was spending most of his day in his wheelchair. A special chair had been bought for him out of his own money but this was not suitable for him. Jeremy was being put to bed very early in the evening so that he could change positions after being in his wheelchair all day. We did not think this was fair to him. There was no evidence that the care provider was reviewing Jeremy s care needs. We contacted the social work department to inform them about our concerns and ask them to make some changes to how they managed Jeremy s care package. Following our intervention we heard from Jeremy s care team who said he was now getting extra time to have baths, a new chair was being organised and that reviews were carried out as they should be. The care team were grateful for the changes that had been made following our intervention and said that, whilst small, they had a big impact on Jeremy s life. 13

16 Monitoring and safeguarding care and treatment principles leadershi dignity & human r 14 communi

17 Overview of KPIs p - We processed 28,797 Mental Health Act and 2,096 Adults with Incapacity Act forms - We monitored the support parents received when they are detained - We monitored cases where patients were detained on back-to-back short-term detention certificates - We monitored the use of section 47 certificates under the Adults with Incapacity Act in homes, acute hospitals and mental health wards for the care of the elderly Both our annual monitoring reports are available in full from our website. Overview of the use of mental health legislation in Scotland We receive notifications of most interventions under the 2003 Act. We use these to report on how the Act is used. We also continue to report geographical variations in the use of the Act. ights This year, we have three major concerns: emergency detention, social circumstance reports and admission of children to adult wards. Emergency detention This year, we found a 3% rise in all new episodes of compulsory treatment. c We were concerned that the number of emergency detention certificates (EDCs) rose by 7%. We would expect short-term detention to be used instead. Short-term detention involves an assessment by an experienced psychiatrist and social worker before the individual is deprived of liberty and given treatment without consent. NHS Highland and NHS Dumfries and Galloway had the highest rates of emergency detention. 15

18 We found a high number of older people admitted from the community via an EDC. We are looking into the reasons for this. If emergency detention is used, a mental health officer (MHO) must consent unless this is impracticable. This year, we found that the proportion of EDCs with MHO consent was much higher in Ayrshire than in previous years. Most EDCs are granted outside office hours. The Ayrshire councils withdrew from the West of Scotland standby service and set up their own out-of-hours MHO service. In contrast, we found that most EDCs granted in Greater Glasgow and Clyde did not have MHO consent. This NHS Board and its local authority partners must examine out-of-hours MHO services as a matter of urgency. Social circumstances reports We remain concerned that MHOs are not providing social circumstances reports (SCRs). We find these reports extremely valuable when we are asked to look into an individual s care and treatment. There are many events that should trigger an SCR, too many, in our view. However, it is unacceptable for there to be no SCR at all for individuals detained under short-term certificates or criminal procedure orders. We are concerned that the lack of provision of SCRs shows that MHO services are struggling to cope with the duties imposed by mental health, incapacity and adult protection legislation. Admission of children to adult wards The Scottish Government s previous mental health strategy included a commitment to reduce admissions of children to adult wards. Many NHS Boards have failed to achieve this. This year, the number of admissions reported to us rose to 177. Nearly three-quarters were in four NHS Boards: Greater Glasgow and Clyde, Forth Valley, Grampian and, in particular, Lanarkshire, where there was a large increase. In contrast, Lothian and Fife had very few admissions to adult wards. The largest increase in admission was for girls. Many of these were in response to actual or threatened self-harm. This is a challenge to the implementation of the Scottish Government s latest mental health strategy. We found that admission to adult wards is least likely in areas where intensive home treatment is available. We also found a rise in the treatment of girls under compulsory powers, especially short-term detention and safeguarded treatment with artificial nutrition. We had raised concerns that parents had been asked to give consent where girls under 16 were treated for eating disorders. The Act gives greater safeguards and we think it is probably good that it is being used more. 16

19 Other findings Some other interesting points we found were that: Short-term detention was highest in inner city areas Detention by nurses has risen, but we still think this is not reported as often as it should be The total number of compulsory treatment orders (CTOs) in existence fell slightly. Looking back to when the Act came into force, CTOs have risen by only 7% but over 40% are now community orders. This is a huge shift to community compulsory treatment without a major rise in the total use of long-term orders. Greater Glasgow and Clyde has the highest numbers of people on long-term orders of all types. Highland has a very high use of community orders. Dumfries and Galloway still has comparatively few people on long-term orders Criminal Procedure (Scotland) Act 1995 (CPSA) Orders It is difficult to interpret trends in CPSA orders on a yearly basis. This is due to variations in length of court cases and not necessarily rises and falls in offending. The figures we quote are for order incidence, i.e. the number of orders granted in the period. This year, 236 individuals were subject to CPSA orders, the total number of orders amounting to 474. This compares to 212 individuals the previous year, with a total number of orders at 371. Last year we noted an increase in the use of Treatment Orders which has continued this year. Treatment Orders are imposed either at a post conviction, pre-sentence stage or pre-trial, where an individual has been charged but the proceedings are not yet underway or no decision about whether to proceed has been taken. We will continue to monitor aspects of CPSA legislation as they apply to people with mental disorder. 17

20 ...the percentage of orders granted on an indefinite basis has fallen by more than half over the past four years. _ Overview of the use of incapacity legislation in Scotland Our monitoring of the use of the welfare provisions of the Adults with Incapacity (Scotland) Act 2000 is a result of our functions under the Act. We receive all statutory forms relating to use of welfare provisions, visit some people on guardianship, provide advice and good practice guidance on the operation of the Act and also investigate circumstances where an adult with incapacity may be at risk. We are part of the framework of legal safeguards that are in place to protect the rights of people on welfare guardianship, intervention orders, and powers of attorney. We also monitor the use of Part 5 of the Act relating to consent to medical treatment and research. Here you can review our findings from these monitoring activities. The main messages are: We looked into the use of welfare guardianship under incapacity legislation. The number of new orders continues to rise. The most striking development in this past year has been the increase in approved local authority applications up 12% in the past year following a 5% rise the previous year. This followed years where there was no increase in the number of local authority applications. This represents a significant challenge for local authorities in managing the workload of mental health officer services. Dundee, Glasgow and East Lothian all had a very high increase in the rates of approved orders in 2011/12 and these rates (per hundred thousand) increased even further in these areas in the past year. While the Scottish average for approved welfare guardianship applications stood at 44 per 100,000, these areas showed rates of 79, 77 and 76 respectively. There was a further significant reduction in the granting of orders on an indefinite basis down from 45% in 2011/12 to 35% in the past year. This means that the percentage of orders granted on an indefinite basis has fallen by more than half over the past four years. The granting of orders on an indefinite basis has fallen for both private (from 50% to 39%) as well as local authority (from 31% to 25%) approved applications. 18

21 The percentage of orders granted where the cause of the adult s incapacity was dementia fell to 46%, down from 51% the previous year. Conversely, there was an increase from 37% to 41% of orders where the incapacity was caused by a learning disability. The rise in the number of approved orders in the past year was solely down to the increased use for adults with a learning disability. This is the first year we have seen this. Courts dealt with 82% of applications within two months. In 18% of those 560 adults we visited, Commission staff had to undertake further casework because of issues picked up in carrying out the visits. These issues were primarily related to the welfare guardian not specifically delegating their powers to carers, the lack of evidence that the local authority had carried out their statutory duty to visit the adult, the lack of authority to administer medication and no evidence that the continued need for the placement was reviewed by social work. Generally, however, we were satisfied with the care and treatment being provided. In 18% of those 560 adults we visited, Commission staff had to undertake further casework because of issues picked up in carrying out the visits. _ 19

22 Monitoring focus when parents are detained We looked at the support that parents receive when they are detained. Under section 278 of the Mental Health Act, there is a duty for service providers to mitigate the effects of compulsory measures on parental relations. When we did our visits to adult acute wards we spoke to patients about the support they received as a parent and this helped us with this report. We found that, although there are areas of good practice, these duties are generally unknown and neglected. Staff were often unaware of their obligations and struggled to meet them because of inconsistent systems and a lack of resources. We spoke to nursing staff and mental health officers as well as looking at Mental Health Act documentation. We identified common themes, including challenges with inter-agency working and poor awareness of s278. We also found a lack of resources to support families: from simple things like age-appropriate information on mental illness, to child-friendly spaces in hospitals and access to community support. This initial exploration allowed us to make recommendations, but it leaves many questions unanswered. The most important is how parents and children who have been through the experience of compulsory procedures feel. We hope to explore this in future. In the meantime, we will be mindful of the needs of parents when we visit patients in psychiatric facilities throughout Scotland. We spoke to Alison, who was diagnosed with post-natal depression after having her first child ten years ago. She has spent time in and out of hospital, but it was only two years ago she began receiving specific support as a parent. Under section 278 of the Mental Health Act, there is a duty for service providers to mitigate the effects of compulsory measures on parental relations. _ 20

23 Alison says: We have a family therapist; she s made a real difference. She sees me as a mother, not just a patient. In the past, the only question I was asked about my children was if I was a danger to them. Alison s children now live with their father, but the family therapist has helped her to maintain contact. When I couldn t see my children, I felt obsessed with that. I don t see how I was expected to get better in those circumstances. Now I have access to my children, it s made a difference to our relationship, and it s helped me recover. I feel much better. You can download When parents are detained from our website. She sees me as a mother, not just a patient. _ 21

24 Monitoring focus immediate redetention We were asked by the Equality and Human Rights Commission to look into cases where individuals had been detained in hospital after a failed application to the Tribunal. We also looked at other circumstances where an individual had been further detained after the expiry of a short-term detention certificate (STDC). The 2003 Act forbids immediate re-detention after an STDC expires. Immediate is not defined in the Act, but it is important that the Tribunal looks into the grounds for detention as soon as possible. The Act intended that this should happen within 28 days (with a possible extension of five working days to arrange a hearing). We found that in some cases individuals were detained under a further short-term detention certificate, but only because the application failed for technical reasons, not because the Tribunal rejected it on the basis of the grounds for compulsion. If the risk to the patient is felt to be serious, doctors may need to re-detain the individual so that another application can be made to the Tribunal. Sometimes, we found it took too long to do this. We came across a case where the individual was, in effect, detained for 66 days before the Tribunal tested the grounds. We think this is unacceptable and recommended strongly that the application should be made much sooner. We have asked the Scottish Government to look at changing the law to make sure this happens. Our report Immediate redetention is available on our website. If the risk to the patient is felt to be serious, doctors may need to re-detain the individual so that another application can be made to the Tribunal. _ 22

25 Monitoring focus consent to treatment From July 2011 to November 2012 we conducted a series of unannounced visits to hospitals and care homes to look at compliance with Part 5 of the Adults with Incapacity Act. We identified wards (in psychiatric and general hospitals) and care homes where we were likely to find people who were not able to consent to their treatment. We spoke with staff to ask them to identify how many people they thought lacked capacity to consent and then looked at how many of those residents had Section 47 certificates in place. Treatment was being given under the authority of a Section 47 certificate to 79% of people who lacked capacity to consent to treatment. We found better compliance with the legislation for individuals in hospital compared with residents in care homes. Where we found there were discrepancies, we immediately made recommendations to care managers to ensure that these were corrected. Our report Adults with Incapacity part 5 is available on our website. We found better compliance with the legislation for individuals in hospital compared with residents in care homes. _ 23

26 Investigations principles leadershi dignity & human r 24 communi

27 p - We completed four major investigations - We remitted four cases back to local services after initial investigation. In these cases, we expressed concerns and made recommendations to service managers for further internal investigation - We are continuing to investigate a further seven cases Why we investigate We investigate when we believe that something has gone wrong in the care and treatment of an individual. Of course, we cannot investigate every case of poor treatment, so we aim to choose cases where we think there may be wider lessons. Through our visits and monitoring, we develop a general picture of care and treatment across Scotland. Our investigations allow us to drill down into a single case and make recommendations that can improve practice across Scotland. ights Our investigations focus on one person, but the recommendations will have an impact for lots of people. Anonymised investigations All of our investigation reports are anonymised. We don t name people and we don t name the area, the health board or the local authority. All of our investigation reports aren t about naming and shaming; they re about making things better across Scotland. By keeping our investigations anonymous, we can protect the individuals who our reports focus on. It c also makes the professionals we talk to more likely to speak openly. It also makes our reports relevant to everyone. Our recommendations aren t just for the health board area where that investigation took place. We want professionals across Scotland to read them and think about the lessons that they can learn. 25

28 Our published investigations Ms AB Ms AB has dementia and lives in a rural setting. She was supported at home until she was admitted to hospital in October 2011 following a couple of falls. Ms AB was unwilling to remain in hospital following her first fall, or to go to hospital the next day. A doctor arrived and gave Ms AB a sedative; she was then admitted to hospital informally. Ms AB did not want to be in hospital and was sedated several times to ease her agitation and aggression and to stop her from asking to leave. This sedation was not always recorded on her prescription sheet. She was transferred to another hospital and, eventually, a nursing home. The doctors involved felt that incapacity legislation allowed them to treat and move Ms AB. We think that Ms AB was unlawfully detained during her time in hospital. We were concerned by how often she was given sedatives and the poor recording of this in her notes. It is important that hospitals which serve remote communities have proper policies and procedures to meet the extra challenges of treating people in rural areas. We made recommendations to the Scottish Government, the NHS Board and its local authority partners. It is important that hospitals which serve remote communities have proper policies and procedures to meet the extra challenges of treating people in rural areas. _ The full investigation is available from our website 26

29 Mrs CD Mrs CD had problems with anxiety and depression for many years. She became even more unhappy and was constantly thinking of suicide and attempting to harm herself. Mrs CD had a lot of contact with emergency services, including the police, when she threatened or attempted to harm herself in public. She spent long periods in hospital and in the community under compulsory care. She was treated with medication, electroconvulsive therapy and psychological treatment but it did not work. Mrs CD could be violent towards staff and, at times, other patients. Her psychiatrist decided that the problem was Mrs CD s personality, so a decision was made to discharge her and not to readmit her when she became distressed and difficult to care for. She ended up in prison for a short time before being transferred back to mental health care. We thought that it was unlikely any specific treatment would have helped, but that it was wrong that Mrs CD ended up in prison when what she needed was care. We want service providers and policy makers to think about this case. It is an example of what can go wrong when an individual with serious mental distress becomes too difficult to provide with care and treatment. We thought that it was unlikely any specific treatment would have helped, but that it was wrong that Mrs CD ended up in prison when what she needed was care. _ This investigation will soon be available from our website 27

30 Our unpublished investigations We also investigated two other cases in depth during In both cases, we decided that there had been no deficiency of care and treatment. There were some learning points from both cases. We did not publish the investigations, but we used the learning points in other ways. Carol s story We heard about Carol from Healthcare Improvement Scotland. She was receiving electro-convulsive therapy (ECT) as an outpatient. Sadly, Carol took her own life. The NHS Board reviewed her care and treatment. They sent the review to Healthcare Improvement Scotland, who thought that it was incomplete and suggested that we should investigate further. We reviewed Carol s care and treatment and met the consultant psychiatrist responsible for her care. We were concerned that, during her treatment with ECT as an outpatient, the consultant undertook most of the reviews by telephone. This was unusual but, when we reviewed her care, we understood and accepted the reasons. Her decision to take her own life was sudden and unpredictable and related to family circumstances. We thought her care was good during this time but the consultant did not record the reasons for his decisions well enough. We highlighted this in our Chief Executive s advice notes. We also thought that the internal review should have picked this up. The NHS Board is revising the way it carries out internal reviews....when we reviewed her care, we understood and accepted the reasons. _ 28

31 We used Ian s case as part of the consultation that produced our guidance on the use of mental health legislation for drug-induced psychosis. _ Ian s story Officials in the Scottish Government asked us to look into Ian s care and treatment. He killed a close family member while suffering psychotic symptoms brought on by using street drugs shortly after discharge from hospital. Ian was known to mental health services. He had been prescribed medication but he may not have taken it regularly. He coped well with his illness for most of the time. He used street drugs at times. This led to him becoming acutely mentally ill. These episodes did not last long, even without treatment. He was admitted to hospital for short periods but was always keen to leave. A few days before the homicide, he was taken to hospital by the police. He was behaving strangely and had been carrying a weapon for self-defence. Again, he had been taking drugs. He seemed better the next day and medical staff agreed to let him home. Unfortunately he took drugs again, heard voices telling him to kill a family member and he obeyed the voices. Ian had no history of violent behaviour and we did not think the homicide could have been predicted. But this case, and others we heard about, made us wonder about the use of mental health legislation for people who become psychotic after taking drugs. We used Ian s case as part of the consultation that produced our guidance on the use of mental health legislation for drug-induced psychosis. The Drug-induced psychosis guidance is on our website. 29

32 Providing information and advice principles leadershi dignity & human r 30 communi

33 p - We said the advice given by our phone line would be at least 97.5% accurate. Our advice was 98% accurate - Almost 4,000 people phoned us for advice - We introduced our new website in July Between August 2012 and March 2013 we recorded 34,792 visits to our website ights A vital part of our work is providing information to service users, carers and professionals about the effect that mental health and incapacity legislation has on their lives and work. Our advice line Our advice line offers guidance on rights and best practice in relation to mental health and incapacity legislation. We offer a free phone number for service users and carers, as well as a standard number for professionals. c In , almost 4,000 people called us to ask for advice. We audited the accuracy of the advice given and found 98% of it was accurate, this exceeds our target of 97.5% accuracy. Almost two-thirds of callers were looking for advice on the Mental Health Act and over a quarter were for advice about the Adults with Incapacity Act. 31

34 There are more than 2,600 people signed up to receive our newsletter. _ Our website We launched our new website in July We have had lots of positive feedback and we hope it is easier to use than the old site. We use Google analytics to measure the use of our website. Between mid August 2012 and the end of March: 21,337 people visited the site 34,792 times They viewed 131,859 pages They downloaded 25,583 publications We are aiming to increase engagement with service users and carers on our website. We can see that most people visited during working hours, with just 10.5% of visits at the weekend. We think this means that most visitors are professionals. However, we were encouraged to see the weekend visitor figure increase from 7.8% in September to 12.8% in March. This is a 40% increase. We think more of these visitors are service users or carers. We are keen to receive feedback on our website. Please get in touch if you have any comments. newsletter This year, we have set up an newsletter to provide information about our latest activities and publications. There are more than 2,600 people signed up to receive the newsletter. You can sign up at our website, or enquiries@mwcscot.org.uk to have your name added to our mailing list. 32

35 Case study whole service improvement We helped to improve the care of individuals in a care home by directly intervening and by working with other agencies. We were contacted by an adult support and protection committee raising concerns about the high number of alerts they had received over a year from a care home. They also contacted the Care Inspectorate. We were aware of the home due to an incident from last year where we got involved. In response to the new concerns, we carried out an unannounced visit to the care home. Our visit highlighted a number of issues. These were mainly about care plans, medication and understanding of the Adults with Incapacity Act. We told the new management of the home about changes that could be made. We shared our findings with the Care Inspectorate to help inform their work. We encouraged them to use ourselves and the Care Inspectorate as well as local services as resources. After the input from ourselves and the Care Inspectorate there were many changes at the home. They made several staff changes, established links with the local NHS services and changed the pharmacy and GP provision. Since then they have continued to improve training for staff. They are more robust in auditing their practice. The home now has better links to local authorities who have placed residents on guardianship within the home. The home s grades with the Care Inspectorate have gone up and they regularly contact us regarding any care issues they are struggling with. Thanks to our work, the residents are receiving an improved standard of care. Social work guardians and supervisors are encouraged to regularly visit residents and carry out reviews. We will provide information and support to the service so they can continue to provide a better care environment and experience for all their residents. 33

36 Good practice guidance This year we amended and updated two of our good practice guides; Risks, rights and limits to freedom and Carers and confidentiality. The main change we made to Risks, rights and limits to freedom was to amend it to apply to a variety of care settings. Our previous version referred to care home settings only. We expanded our discussion of human rights issues involved in restraint and limits to freedom. We felt it should be clear that it is unlawful for any public body to act in a way which is incompatible with the European Convention on Human Rights. We laid out changes to the composition of scrutiny and regulation organisations in Scotland in recent years. We also reviewed the appendices to focus on issues of law of direct relevance when freedom is restricted. We restructured Carers and confidentiality to make it clear to carers and professionals which parts were most relevant for them. We also included an expanded section on adults with incapacity. We highlighted a number of issues that have arisen, including those around young people and named persons. We also discussed capacity and consent. We gave case examples to illustrate how to proceed in different situations, depending on capacity and consent. In particular, we highlighted the value of professionals listening to carers, and of negotiating limited sharing of information. You can get both our guides from our website. This year we amended and updated two of our good practice guides; Risks, rights and limits to freedom and Carers and confidentiality. _ 34

37 Case study Richard s story We were contacted by Richard s mother because she was very concerned about her son. Richard has schizophrenia and was not coping well in his flat. Richard had told staff not to give information to his mother so she felt that they were not listening to her. Richard was admitted to hospital. When plans were being made for him to leave, Richard s mother was concerned that he did not have enough support. She told us she was worried because no one would listen to her. We gave advice to her and to Richard s doctor about how they could listen to her without sharing any information about Richard. Unfortunately, Richard s mother was still largely excluded from discharge planning. Richard relied heavily on his mother rather than the limited support package provided. He did not take medication or eat properly and soon had to return to hospital. Richard s mother contacted us again and told us there was a plan to discharge him again quickly. She was still not being given any information that might help her to care for her son. We visited Richard and found that staff were taking a very literal interpretation of his instruction about not speaking to his mother. However, they were relying on her to support him when he left hospital. We were concerned that the different views on Richard s ability to make decisions about looking after himself had not been properly addressed in planning for discharge. We raised our concerns with the service, and a further opinion was sought from the rehabilitation service. The service then offered Richard a place on the rehab ward. Our guidance on Carers and confidentiality is available from our website. 35

38 Drug-induced psychosis guidance When is it appropriate to use mental health legislation for drug-induced psychosis? We put this question to a range of experts, including professionals, service users and carers and, after extensive discussion of the law, practice and case studies, we came up with our latest good practice guide: Drug-induced psychosis and the law. Based on all the evidence, we consider that drug-induced psychosis is a mental illness and that the use of mental health law can be appropriate to protect the individuals and others from harm, especially in times of crisis. The publication offers guidance on when to use the law, how to minimise restriction of freedom and provide ongoing care and treatment. We repeat the recommendation, initially made in our Hard to help investigation, that a care-programme approach can be particularly helpful for service users who have problems with drugs. You can download the guide, along with all of our other publications at our website....the use of mental health law can be appropriate to protect the individuals and others from harm... _ 36

39 Advance statement guidance We produced a good practice guide, in consultation with professionals, service users and carers, in the hope that it may increase the number of advance statements that are made. The Mental Health Act includes a right for an individual to make a written statement, when well, which sets out how they would prefer to be treated if they become unwell in future. This is known as an advance statement. We do not know how many people have made advance statements. Some people have found them to be very helpful. They can promote good relationships between service users and staff and can aid recovery. However, fewer people than expected have made advance statements. There may be a number of reasons for this. Anecdotally, we know some individuals think it is not worth it as the statement will be overridden anyway; others say they do not like thinking about the possibility of becoming unwell. Some professionals and service users have found the rules for advance statements difficult to understand. We want people to understand what makes a good advance statement and reduce the numbers that are overridden. We heard about Chris who had been admitted to hospital several times with psychotic episodes. Chris found being admitted very distressing, particularly because he had to receive injections when he refused his medication. When he was well, Chris understood the need for medication and was happy to take it orally. Along with his named person, he spoke to advocacy services about making an advance statement. He wanted staff to show him his advance statement if he became unwell again. The next time he was admitted, the staff showed him his advance statement, which had been approved by his named person and witnessed by his social worker. For the first time, he agreed to take the medication orally. Chris recovered more quickly than usual. He didn t need time in the intensive psychiatric care unit, he didn t suffer the side effects of the injection and his relationship with staff on the ward got off to a much better start than when he d had an injection. You can download the Advance statement guidance from our website. 37

40 Influencing and challenging principles leadershi dignity & human r 38 communi

41 Influencing and challenging - We facilitated the third Principles into Practice (PiP) awards to promote outstanding services - We continued to run our popular Excellence in Practice seminars - We organised a session at Holyrood to give MSPs advice about mental health p We aim to constantly help professionals to improve the care and treatment they provide. Our work improves individuals care and treatment. Sometimes this means a change in the law or policy. Often it means a change in the way these are applied. Our visits and monitoring give us a general picture of what is happening. Our investigations allow us to drill down and make recommendations that will apply across the board. Our good practice guides support professionals to put this learning into practice. Excellence in Practice seminars This year we continued to run our Excellence in Practice seminars. The seminars focussed on areas of mental health and incapacity legislation where legal and ethical issues have an impact on individual care and treatment. The topics cover areas that people raised with us during our visits, investigations and through the telephone advice line. The aim is to improve the care and treatment that individuals receive and ensure it is lawful. ights c We ran seven individual seminars this year. The topics for these were: Medical treatment for people who lack capacity rights, duties and the law Professional challenges welfare guardianship and powers of attorney Restrictive management of individuals rights, risks and legislative frameworks Mental Health Act and consent to treatment What people said about our seminars: Our seminars have been very popular and we received lots of positive feedback. 98% of the people who attended said they would recommend the seminar to their colleagues. The day was absolutely excellent. The input will change my practice in relation to Adults with Incapacity (Scotland) Act. You can t say better than that. Very informative. Good to meet practitioners from other parts of the country and discuss the variations in practice across health boards and local authorities. 39