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AUDIT OF THE IMPLEMENTATION OF THE MENTAL HEALTH (CARE AND TREATMENT) (SCOTLAND) ACT 2003

IN THE SCOTTISH PRISON SERVICE

October 2005-April 2006

Dr Lesley Graham Public Health Specialist Scottish Prison Service

January 2007

Contents Acknowledgements 3 Executive Summary 4 Background and Rationale 6 Aim and Objectives 6 Methods 7 Results 7 Key Findings, Discussion and Recommendations 17 Summary of Recommendations 23 Appendix One: SPS Mental Health Act Audit Tool 27

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Acknowledgements The remit for the audit was set by Dr. Andrew Fraser, Director of Health and Care and Kenny McGeachie, Mental Health Advisor. Peter Wilson and Kenny McGeachie both made major contributions to the initial study design. Thanks to Roisin Ash for commenting on the pro-forma design. In particular, thanks to the SPS Health Care Managers who co-ordinated the completion of the returns. Grateful thanks to Therese Ross for her help with data input and graphic production as well as to Brenda Beeby who contributed to preliminary data input. John Porter and Peter Wilson contributed helpful comments on the first draft. Peter Wilson has lent invaluable support throughout.

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Executive Summary

An audit was carried out of all prisoners in the charge of the Scottish Prison Service (SPS) managed under the Mental Health (Care and Treatment) (Scotland) Act 2003 for the period October 2005 to April 2006. During the audit period, 29 prisoners were sectioned under Mental Health (Care and Treatment) (Scotland) Act 2003. Audit returns were made by 8 establishments for 22 prisoners, representing 76% coverage. Limited data on the remaining 7 prisoners were drawn from HQ centrally held records.27 of the prisoners were men and 2 were women. 19 prisoners were on remand and 10 were convicted. The most frequent age category overall was aged 25-44 years old. There was a very short time interval from admission to first concern for almost all remand patients. For nearly all remand prisoners, concern was raised within 3 days of admission, with concern for almost half being raised on the day of admission. By contrast, less than half of convicted prisoners had concern raised within 3 days of admission. In most cases, a nurse first expressed concern. There was also evidence of good practice that prisoner officers were also expressing first concern. The commonest initial course of action was to refer for a multi-disciplinary mental health assessment. Most prisoners were seen by a doctor within a week after first concern was expressed, though for one case this period extended to 46 days. The audit was not able to determine whether this length of time was appropriate or not. Most doctors then referred to either a psychiatrist or to the multi-disciplinary mental health team. There was wide variation in the length of time from when a prisoner saw a doctor to when they saw a psychiatrist ranging from 0-37 days. Just over a third of prisoners were seen in less than three days. Psychiatrists most commonly carried out an assessment in the first instance. For just over half of cases, a diagnosis requiring sectioning under the Mental Health Act 2003 was made within three days. There was a wide range in timescales for the remaining cases with the longest being 199 days, with this likelihood more so for convicted prisoners. It is not possible to ascertain from the audit whether, for these cases, there was undue delay in making a diagnosis or, if so, for what reasons. Assessment of fitness to attend court, compliance with legal representation and informing of relevant people was being carried out.

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Although not all records were complete, these actions would appear to have been complied with for the majority of remand prisoners. Risk assessment for mental health nurse escort and vehicle type was carried out for most prisoners although again record keeping was incomplete. Risk assessment for vehicle type was not carried out in a quarter of cases. Provision of mental health nurse escort was not provided in nearly half of cases. There were delays from the time taken for records to be completed to admission to hospital, in particular for the remand population. Two cases waited more than 14 days (15 and 18 respectively). Preliminary findings were fed back to SPS health care managers and consulted on. Key critical care pathway indicators from the audit tool were agreed on. Additional areas for future audit to assess were identified. These included steps taken to ensure patient advocacy; reporting of whether the prisoner had been transferred from another establishment (including reason for transfer) and measurement of waiting times for those who have been sectioned. A series of recommendations are outlined both for consideration within SPS and for discussion with key partner agencies.

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Background and Rationale The Mental Health (Care and Treatment) (Scotland) Act 2003 (Mental Health Act 2003) came into force on 5th October 2005. Guidance for the Scottish Prison Service (SPS) on the transfer of prisoners into the mental health system for assessment and treatment was circulated on 28th September 2005. Further guidance was issued in December 2005 following a partnership meeting with SPS HQ; establishments; the Scottish Court Service; Scottish Executive and OSSE. [Guidance (revised) on the Transfer of Prisoners into the mental health system for assessment or treatment SPS Dec 2005]. Mental health governance brings a focus to accountability for mental health care, mental illness and mental health promotion in SPS. As a component of this governance, the Health and Care Directorate of SPS undertook an audit of prisoners who were managed under the Mental Health Act 2003 since the Act’s implementation. Aim

To undertake an audit of all prisoners managed under the Mental Health Act 2003 whilst in the charge of SPS. Objectives

1. To undertake a process mapping of the care pathway for every

prisoner who was managed under the Mental Health Act 2003 from October 2005 until April 2006 inclusive.

2. To develop a pro-forma for use in the audit. 3. To assess the appropriateness and usefulness of the pro-forma

both as an audit tool and for potential use in future audit/routine monitoring.

4. To identify any examples of good practice or areas of concern. 5. To work in collaboration with the establishments and other

partners should any emerging issues need further investigation and/or resolution.

6. To produce a written report on findings and implications.

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Method A pro-forma (see appendix 1) was developed (by Lesley Graham, Peter Wilson and Kenny McGeachie) for use in the audit. This aimed to identify key steps and timelines in the care pathway for each prisoner sectioned under the Act from the time of admission to prison to the time of admission to hospital. The pro-forma was sent out to Health Care Managers in all establishments. This was to be completed for every prisoner managed under the Act since it came into force on 5th October 2005 until end April 2006. Returns were entered onto an Excel database for analysis. Data was assessed for completeness. An interim report was completed prior to a meeting with SPS health care managers to discuss and interpret the audit findings and to explore the audit process itself. A final report with recommendations was produced for dissemination and discussion with wider stakeholders. Results and Care Pathway

Replies were received from all directly managed SPS establishments (with one responder replying for three establishments) representing a 100% response rate. HMP Kilmarnock was not included in the audit due to separate management arrangements. 8/13 replies were received within

the requested timeframe. All but one establishment replied following a reminder. In one case, several reminders had to be issued. The final response was almost two months after the original deadline. During the period, a total of 29 prisoners were sectioned under the Mental Health Act 2003 [figure 1]. Returns were received from 8 establishments on 22 prisoners, representing 76% coverage. Only 1 form was fully completed.

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Fig 1 Prisoners sectioned under Mental Health ActOct 2005-April 2006 by establishment

0

2

4

6

8

10

12

14

Aberdeen

Barlin

nie

Cornton

Vale

Edinb

urgh

Inve

rnes

sPer

th

Peterhe

ad

Polmon

t

Convicted

Remand

27 of the prisoners were men and 2 were women. 19 were prisoners on remand and 10 were convicted [figure 1]. Ages ranged from 18-68 with the commonest age category being 25-44 years old [figure 2]. For remand prisoners, 8 were granted Treatment orders and 6 were granted Assessment orders. In one case the type of order was not known (pro-formas were not returned on the remaining four)

Fig 2 Prisoners by age and sex

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14

16-24

25-44

45-59

60+Male

Female

The following reports on the 22 prisoners for whom a pro-forma was completed.

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Care Pathway Each prisoner is seen on the day of his or her admission by a nurse who carries out a brief general health assessment. This will include an assessment of their immediate mental health status such as suicide ideation as well as the taking of any previous medical history. If the prisoner is thought to be at risk of suicide, they should be 'placed on ACT2Care', a system of care to manage risk of self harm. All prisoners are seen within 24 hours by a doctor with a further opportunity for assessment of current mental health status as well as taking of a medical history. However, concern that a prisoner may have a severe mental health problem can be raised at any time by all other staff members including Prison Officers.

The number of days between admission to prison and that of first concern being raised ranged from 0 days to 7 years 125 days. There was a marked contrast between those on remand and those convicted. For nearly all (14/15) remand prisoners, concern was raised within 3 days of admission, with concern for almost half (7/15) being raised on the actual day of admission. By contrast, less than half (3/7) of convicted prisoners had concern raised within 3 days of admission [table 1]

Status Establishment Admission>first concern

first

concern>first seen by doctor Doc>psychiatrist

First concern>psych

First seen psych

>diagnosis under MHAct

MHAct

diagnosis >records completed

Records completed >admission

Convicted Edinburgh 113 6 0 5 22 35 1

Convicted Peterhead 7years 125 days 0 7 6 0 1 1

Convicted Barlinnie 9 NK NK 13 0 7 0

Convicted Barlinnie 140 NK NK 1 11 13 1

Convicted Cornton Vale 0 NK NK 3 NK 7

Convicted Perth 0 46 0 46 199 7 0

Convicted Perth 1 1 12 13 52 3 1

Remand Aberdeen 15 0 11 11 1 0 0

Remand Edinburgh 0 1 37 38 0 1 3

Remand Polmont 0 2 1 3 9 0 2

Remand Barlinnie 1 NK NK 6 7 0 3

Remand Barlinnie 3 NK NK 47 0 22 1

Remand Barlinnie 2 7 NK NK NK 0 6

Remand Inverness 0 1 3 4 14 0 15

Remand Cornton Vale 3 0 5 4 9 0 11

Remand Perth 0 1 1 1 1 0 2


Remand Perth 0 0 10 10 0 0 4




Remand Perth 3 NA 14 10 0 2 1

Table 1 Number of days between key events on care pathway

The member of staff who first expressed concern as to whether a prisoner had a mental health problem was known in 20/22 cases. Overall, concern was most likely to be expressed by a nurse (13) followed by a prison officer (5) then a doctor (2). [Table 2] Table 2 Member of staff expressing first concern

Status Nurse Officer Doctor Not Known

Remand 11 2 1 1

Convicted 2 3 1 1

Care Pathway Once concern is raised, the prisoner can be referred to the Multi-Disciplinary Mental Health Team for assessment. Members of the MDMHT vary and include mental health nurses; visiting psychiatrists, generic health care staff and a member of prison medical service. An assessment is carried out and a care plan agreed. This may include medication and review. Direct medical or psychiatric referral can also be made. In some instances, a psychiatrist will participate in the initial mental health assessment process. If a prisoner is thought to need psychiatric care that requires a transfer to a hospital setting and sectioning under the provisions of the Criminal Procedure (Scotland) Act 1995 and the Mental Health Act 2003, this must be carried out by a doctor. If an Assessment Order is required, this can be requested by a medical officer alone. If a Treatment Order is needed (remand prisoners only) or sectioning under Section 136 is to be carried out (convicted prisoners only) these must have two medical reports completed. One of these reports must be completed by an approved practitioner under section 22 of the Mental Health Act 2003, which is usually a psychiatrist. For remand prisoners, once medical reports are completed, an Assessment or Treatment Order is sought from the court. For convicted prisoners, once the two sets of medical reports are completed, a Transfer Treatment Directive is signed on behalf of the Scottish Ministers. No court hearing is required.

A range of subsequent actions following the first expression of concern were identified. These included a Nurse Assessment; a Mental Health referral; referral to a doctor; a Psychiatric referral; being placed on ACT2Care and being given a Health Care Marker on PR2 (the prison information system). For some prisoners, more than one action was taken. Overall the commonest action taken was a Mental Health referral (17) [Table 3].

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Table 3 Action following first concern

Status Nurse Assessment

Mental Health Referral Doctor Psychiatrist Act2Care

Health Centre Manager

Remand 2 13 3 1 2 1

Convicted 3 4 2 1 0 0

The date of the prisoner first seeing a doctor was reported for 17/21 cases. One prisoner was already under mental health care and the date was unknown for the remaining four. For those where the date was known, the number of days from concern first being expressed to seeing a doctor ranged from 0-46 days with the majority (12/17) being seen in under 3 days [table 1] The subsequent actions following been seen by a doctor were reported as Mental Health referral; Psychiatric referral; being placed on ACT2Care; given medication; given day care support; ‘assessment’; ‘sectioning under the Mental Health Act (136)’ and no action. For all cases only one action was reported. The subsequent action was not known in one case. The commonest action was a specialist Psychiatric referral (8/20) [Table 4]. Table 4 Action after seen by a doctor

Status

Mental Health

Referral

Psychiatric

Reports

Act 2

Care Medication Assessment

Day Care

Support

Not

Known

Section

Under Mental Health

Act

Remand 1 1 0 1 NA 1 1 1

Convicted 4 7 1 1 1 NA NA NA

The date when a prisoner saw a psychiatrist was known in all but one case. For those where both sets of dates were known (15), the number of days from seeing a doctor to seeing a psychiatrist ranged from 0-37 days with 6/15 being seen in less than 3 days [table 1]. For cases where both sets of dates were known (14/15), the number of days from first concern being raised to seeing a psychiatrist ranged from 1-47 days with only three being seen in under 3 days [table 1]. The subsequent actions having seen a psychiatrist were reported as assessment; review; medication; transfer to intensive psychiatric care unit (Barlinnie); request of assessment from the State Hospital, Carstairs; recommendation of an Assessment or Treatment order; and

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transfer to hospital. In one case, the prisoner had a planned appearance in court the day after having seen the psychiatrist and was admitted to hospital from there. The action in one was not known. For some cases more than one action was reported. The commonest action was an assessment (psychiatric) (12/21) [Table 5] Table 5 Action after seen by a psychiatrist

Status Psychiatric Assessment Review Rx

Psychiatric Unit Court

Rx Order

Assessment Order

Transfer to Hospital

External Assessment

Remand 11 1 4 1 1 1 1 NA NA

Convicted 1 2 2 NA NA NA NA 2 1

For those where both sets of dates were known (20/22), the number of days from first seeing a psychiatrist to when a diagnosis was made requiring sectioning under the Mental Health Act ranged from 0-199 days [table 1]. For 11/20 cases this was less than three days. For remand prisoners, the number of days from when a diagnosis requiring sectioning under the Mental Health Act was made to when medical records were completed was known in all cases. The number of days ranged from 0-22 days with 14/15 being within less than three days. For over two thirds (11/15) of patients, records were completed on the day of diagnosis. For convicted prisoners, the number of days from when a diagnosis requiring sectioning under the Mental Health Act was made to when medical records were completed (signing of a TTD) was known in 6/7 cases. The number of days ranged from 1-35 days with only one case having records completed in less than three days [Table 1]. Care Pathway For remand prisoners, an assessment should be made as to whether they are fit to attend court for the Assessment or Treatment Order to be granted. Under the Act, if not fit to attend, legal representation must be made. The Act also requires that ‘relevant people’ be informed.

For remand prisoners, assessment for fitness to attend court was known to have been carried out in 11/15 cases. In three cases this was not known and was not applicable in 1 case (where the prisoner attended court for a planned appearance and was transferred to hospital directly from there). Of these 11 cases, 9 were known to have attended, 1 did not and in 1 case it was not reported. For the one case reported as not having attended, legal representation was in place. Relevant people were informed that a request for an order had been made was carried out in 12 cases and not known for the remaining two. The relevant people

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informed were only known for 5 cases. These were reported as the prisoner (4); the solicitor (4) and the Procurator Fiscal (4). Care Pathway A risk assessment as to whether a nurse escort should be provided should be carried out by SPS staff for both remand and convicted prisoners (either to court or hospital). This risk assessment should be communicated to the escort service (at the time of the audit the escort service provider was Reliance) and acknowledged by them. The audit also investigated whether this escort was provided and, if so, whether the nurse was able to communicate with the prisoner throughout the transfer.

Risk assessment as to whether a nurse escort was required was carried out in 12/14 remand prisoners. In one case it was not and for the remaining case it was not known. A nurse escort was required for 4 of these cases. In all of these, this was communicated to Reliance and acknowledged in 3 cases (for the remaining one this was not known). For the four cases requiring a mental health nurse escort, this was provided for two. For these two, contact was maintained throughout for one case and not known for the other. For convicted prisoners, risk assessment was carried out in 6/7 cases. For the case where a risk assessment was not carried out, it was reported that there was ‘no mental health nurse to send’. A nurse escort was required for 4/6 cases where an assessment was carried out and in all of these, this was communicated to Reliance. It was acknowledged in three cases and for the remainder, the use of ‘own transport’ was reported. A mental health nurse escort was provided for 3 of these 4 cases and not known for the other. For these three, contact was maintained throughout. Care Pathway SPS staff should also undertake a risk assessment as to which type of vehicle should be provided for the transfer and this communicated and acknowledged by the carrier. The audit also enquired as to whether the preferred type of transport had been provided.

A risk assessment as to vehicle type was carried out for 10/14 remand prisoners. For two it was not and for the remaining two it was not known. For these 10 cases, the assessment was communicated to Reliance in only 5 cases. In one case this assessment was not communicated and for the remainder (4) this was not known. Acknowledgement of this communication was only reported in 3 cases. For the 5 cases where a type of vehicle was requested, this was provided in 3 cases and not provided for the remaining two.

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For convicted prisoners, a risk assessment as to vehicle type was carried out for 2 cases, not carried out in 3 cases and this was not known for the remaining two. For the two cases where a risk assessment had been carried out, this was communicated to and acknowledged by Reliance and the preferred vehicle type provided. Care Pathway For remand prisoners, the court grants an Assessment or Treatment order and transfer to hospital is carried out from there. For convicted prisoners, transfer to hospital is direct from prison.

For the 14 remand patients who appeared in court, an order was granted in 13 cases. For the case where an order was not granted, the reason given was that bed availability could not be confirmed. The number of days from when medical records were completed to admission to hospital ranged from 0-18 with only six being less than 3 days. Two cases waited more than 14 days (15 and 18 respectively). For the 7 convicted prisoners, the number of days from completion of records to hospital admission ranged from 0-7 with all but one being less than 3 days. For the prisoners on whom a return was not completed, the number of days from admission to date of completion of records was ascertained from records held at SPS headquarters. The number of days ranged from 1-58. Table 6 shows this by establishment. Table 6 Number of days from admission to completion of records for non-returns

Establishment Remand/Convicted Number of

days

Barlinnie Remand 22

Barlinnie Remand 58

Barlinnie Convicted 9

Perth Convicted 7

Perth Convicted 10

Perth Convicted 12

Polmont Remand 1

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Discussion with Health Care Managers An interim report with key findings and recommendations from the audit was discussed with all health care managers in October 2006. The audit was welcomed and thought to be a useful step in quantifying the care of prisoners managed under the Mental Health Act. It was also thought to be of use in promoting the agenda for wider mental health issues both within and out with SPS. Examples of good practice were fed back and areas of concern addressed. Key critical care pathway indicators from the audit tool were agreed on. Additional areas for future audit to assess were identified. These included steps taken to ensure patient advocacy; reporting of whether the prisoner had been transferred from another establishment (including reason for transfer) and measurement of waiting times for those who have been sectioned. On the whole, the pro-forma was thought to have been easy to understand and the audit process had been made clear. Incompleteness of returns was primarily due to incomplete record keeping. These views have been incorporated into the recommendations below.

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Key Findings, Discussion and Recommendations There is a very short time interval from admission to first concern

for almost all remand patients

There is convincing evidence to support the view that prisoners are being sent to prison when they should be being diverted to health care from either police custody or court. Recommendation 1: The indicator ‘date of admission to first concern’ is critical and should be built in to future audit/routine monitoring. Consider setting tolerance levels which would trigger incidence review. Recommendation 2: This issue should be urgently raised with external stakeholders, in particular, NHS court diversion services, the police and courts. In most cases, the nurse first expresses concern

Given that the first point of care contact is a nurse, this is reassuring that detection is good. There is also evidence of good practice that prisoner officers are expressing first concern. Recommendation 3: Review what assessment is made of both immediate mental health status and previous psychiatric history both by nurses and doctors during admission assessments. Consider ensuring previous psychiatric history is taken within 24 hours for all prisoners. A range of actions following expression of first concern were

identified

Whereas this might be both practical and expedient, variable actions also might reflect a lack of a coherent care pathway and/or mental health capacity issues. The commonest initial course of action was to refer for a multi-disciplinary mental health assessment, which does follow recommended care protocol [Positive Mental Health SPS 2002]. Recommendation 4: Consider clarification/development and distribution of mental health care pathway protocol. Only three prisoners were placed on 'ACT2Care' procedures

It is not possible to ascertain from the audit whether this reflected true clinical/care needs or not. Recommendation 5: Consider in future audit/care management protocol whether placing on ACT2Care has been actively considered in each case and reasons given if not.

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Most prisoners were seen by a doctor within a short time after first concern was expressed

This would suggest that input from a doctor is sought at an early stage in most cases, which could include input into the assessment process by the multi-disciplinary mental health team; for an independent medical opinion; for medication and for statutory reasons (such as completion of records). In one case there were a considerable number of days between first concern and being seen by a doctor (46). It is not possible to ascertain from this audit whether this length of time was appropriate or not (the prisoner may have been under adequate care and treatment from the multi-disciplinary mental health team). While a short time interval until first doctor's input suggests good practice, the number of days from first concern to being seen by a doctor was not thought to be a critical care pathway indicator for future audit. Not all prisoners were referred to a doctor. The time taken from first concern being raised to being seen by a psychiatrist should be a critical care path indicator. Recommendation 6: A key critical care pathway indicator is the number of days from first concern to being seen by a psychiatrist and this should be included in future audit.

Doctors most commonly referred prisoners to either a psychiatrist

or for a multi-disciplinary mental health referral

This would suggest that an integrated approach is being taken by the medical staff, with recognition of the multidisciplinary nature of mental health provision. There was a wide variation in the length of time from when a prisoner saw a doctor to when they saw a psychiatrist. Just over a third of prisoners were seen in less than three days. Although it is not possible to be definitive in this audit whether this has been appropriate or not, it does raise an area of potential concern, particularly since the evidence suggests that the most common course of action for a doctor is a specialist psychiatric referral. These findings could suggest delays and difficulties in obtaining a psychiatric consultation. It is not possible to tell whether this is delay in referral by SPS staff or delay in provision by NHS staff. Recommendation 7: The number of days from being seen by a doctor to being seen by a psychiatrist was thought to be a critical care pathway indicator. If prolonged, investigate whether these are delays and if so why, including discussion with external NHS providers.

Psychiatrists most commonly carried out a psychiatric assessment in the first instance.

It is likely that most if not all prisoners would undergo psychiatric assessment with or without input from the multi-disciplinary mental health team and doctor. A range of possible actions would then ensue

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with either care being provided in SPS or a transfer sought. For just over half of cases, the fact that a diagnosis requiring sectioning under the Mental Health Act was made within three days would suggest there were no undue delays in the psychiatric assessment process. However, there was a wide range in timescales for the remaining cases with the longest being 199 days, with this more likely to occur for convicted prisoners. It is not possible to ascertain from the audit whether, for these cases, there was undue delay in making a diagnosis or, if so, for what reasons. Recommendation 8: Consider further in depth case review for cases where there was a long period between first seeing a psychiatrist and a diagnosis being made. Recommendation 9: Time from first seeing a psychiatrist to a diagnosis requiring sectioning should be a critical care pathway indicator for ongoing audit/routine monitoring with setting of tolerance levels. Recommendation 10: Discuss reports on the length of time between seeing a psychiatrist and diagnosis requiring sectioning being made with external stakeholders such as NHS boards and the Forensic Network. Assessment of fitness to attend court, compliance with legal

representation and informing of relevant people is being carried out. Although not all records were complete, these actions would appear to have been complied with for the majority of remand prisoners. It should be noted that the audit was carried out retrospectively. Recommendation 11: This good practice should be fed back to establishments. Recommendation 12: These actions could be developed into a checklist for routine monitoring as well as for audit use. Recommendation 13: Completeness of record keeping should be ensured. Risk assessment for mental health nurse escort and vehicle type was carried out for most prisoners

In general, there was good practice in this area but there were several instances when this was not so. Communication with the provider was good. Data in these categories were also missing, suggesting record keeping was insufficient. Recommendation 14: This good practice should be fed back to establishments. Recommendation 15: These actions could be developed into a checklist for routine monitoring as well as for audit use.

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Recommendation 16: Completeness of record keeping should be ensured. Provision of mental health nurse escort was not provided in nearly

half of cases.

Contact would appear to have been maintained throughout for cases where an escort was provided. Data was incomplete in this area. It should be noted that the audit was carried out retrospectively. Recommendation 17: Clarification should be sought with the escort service provider as to the responsibility for provision of mental health nurse escorts. Recommendation 18: Provision of escort should be recorded as part of routine monitoring/audit. Recommendation 19: Completeness of record keeping should be ensured. Risk assessment for vehicle type was not carried out in a quarter of cases

Where this was carried out, it was in most cases communicated to and acknowledged by Reliance. For the most, the preferred vehicle type was provided. Data was incomplete in this area. It should be noted that the audit was carried out retrospectively. Recommendation 20: This issue should also be raised and addressed through the contract with Reliance. Recommendation 21: Risk assessment and provision of vehicle type should become part of routine monitoring/audit. Recommendation 22: Completeness of records should be ensured. There were delays from the time taken for records to be completed

to admission to hospital

There is convincing evidence that there are delays in transfer to hospital, in particular in the remand population. In one case this was explicitly stated. Recommendation 23: This issue should be raised urgently with key stakeholders such as the NHS, State Hospital and Forensic Network. Recommendation 24: Develop an indicator ‘waiting for hospital bed’ and monitor with tolerance levels. Returns were not received for one quarter of prisoners who had been sectioned

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Although the audit was retrospective, this does raise concern as to record keeping. Recommendation 25: Ensure records are complete and accessible. Two thirds of establishments replied within the deadline but only one record was fully complete

Data were missing in all sections of the pro-forma but in particular with regard to risk assessment and escort/vehicle provision. This would suggest that record keeping this area is not good, or that feedback from the Escort Provider on these services is not being received. It could also be as a result of lack of understanding of the pro-forma and/or audit process. Recommendation 26: Ensure future audit/monitoring is built into clinical governance framework. Recommendation 27: Steps taken to ensure patient advocacy; reporting of whether the prisoner had been transferred from another establishment (including reason for transfer) and measurement of waiting times for those who have been sectioned should be included in future audit/monitoring.

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Summary of recommendations by topic with priority status

Number Recommendation Priority Status

Critical path indicators

1

The indicator ‘admission to first concern’ is critical and should included in future audit/routine monitoring. Consider setting tolerance levels which would trigger incidence review.

High

6 A key critical care pathway indicator is ‘the number of days from first concern to being seen by a psychiatrist’ and this should be included in future audit/monitoring.

High

7 The ‘number of days from being seen by a doctor to being seen by a psychiatrist’ is a critical care pathway indicator and this should be included in future audit/monitoring . Delays should be investigated including with external providers.

High

9 ‘Time from first seeing a psychiatrist to a diagnosis requiring sectioning’ should be a critical care pathway indicator for ongoing audit/routine monitoring with setting of tolerance levels.

High

12 The actions of ‘assessment of fitness to attend court’, ‘compliance with legal representation’ and ‘informing of relevant people’ could be developed into a checklist for routine monitoring as well as for audit use.

Medium

15 The actions of ‘risk assessment for mental health nurse escort and vehicle type’ could be developed into a checklist for routine monitoring as well as for audit use.

Medium

18 Provision of escort should be recorded as part of routine monitoring/audit.

Medium

21 Risk assessment and provision of vehicle type should become part of routine monitoring/audit.

Medium

24 Develop indicator ‘waiting for hospital bed’ and monitor with tolerance levels.

High

26 Ensure future audit/monitoring is built Medium

23

into clinical governance framework.

27 Steps taken to ensure patient advocacy; reporting of whether the prisoner had been transferred from another establishment (including reason for transfer) and measurement of waiting times for those who have been sectioned should be included in future audit/monitoring.

High

External stakeholder discussions

2

The issue of the high numbers of prisoners with mental health problems being identified shortly after admission which subsequently require sectioning under the Mental Health Act should be urgently raised with external stakeholders, in particular, the police, the Scottish Court Service and the NHS providers.

High

7 Investigate whether long periods between ‘being seen by a doctor and being seen by a psychiatrist are delays and why’, including discussion with external NHS providers.

High

10 Discuss reports on ‘length of time between seeing a psychiatrist and diagnosis requiring sectioning being made’ with external stakeholders such as NHS and forensic network.

High

23 The issue of delays from the ‘time taken for records to be completed to admission to hospital’ should be raised urgently with key stakeholders such as the NHS and the Forensic Network.

High

Care protocol

3

Review what assessment is made of both immediate mental health status and previous psychiatric history both by nurses and doctors during admission assessments. Consider ensuring previous psychiatric history is taken within 24 hours.

High

4

Consider clarification/development and distribution of mental health care pathway protocol.

Medium

5 Consider in future audit/care Medium

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management protocol whether placing on ACT2Care has been actively considered in each case and reasons given if not.

8 Consider further in depth case review for cases where there was a long period between ‘first seeing a psychiatrist and a diagnosis being made’.

Medium

Feedback of good practice

11 The good practice of assessment of fitness to attend court, compliance with legal representation and informing of relevant people should be fed back to establishments.

Medium

14 The good practice of risk assessment for mental health nurse escort and vehicle type should be fed back to establishments.

Medium

Record keeping

13 Completeness of record keeping for assessment of fitness to attend court, compliance with legal representation and informing of relevant people should be ensured.

High

16 Completeness of record keeping for risk assessment for mental health nurse escort and vehicle type should be ensured.

High

19 Completeness of record keeping of provision of mental health nurse escort by escort services should be ensured.

High

22 Completeness of records for risk assessment and provision of vehicle type should be ensured.

High

25 Ensure records of prisoners who have been sectioned are complete and accessible.

High

Contract monitoring

17 Clarification should be sought with the escort service provider as to the responsibility for provision of mental health nurse escorts.

Medium

20 The issue of provision of requested vehicle type should also be raised and addressed through the contract with Reliance.

Medium

Appendix One

SPS Mental Health Act Audit Tool

ASSESSMENT or TREATMENT

ORDER (REMAND)

To be completed for every prisoner ON

REMAND within the terms of the Mental

Health (Care and Treatment) Act 2003 from 5th October 2005 until 30th April

2006 inclusive

Prisoner Spin Number:

1. Date admitted into prison Dd/mm/yy

Please give date in format shown

2a. Date first concern that prisoner could be mentally ill

Dd/mm/yy Unknown


2b. Who first expressed this concern?

Nurse/Officer/Prisoner/Family Member/Not Known/Other __________________

Please circle relevant category. If Other, please state in words

2c. What action was then taken? Nurse assessment/Mental Health

Referral/Doctor referral/Psychiatric referral/Act2Care/No action/Not Known/Other ___________________

Please circle relevant

category/categories If Other, please state in words

3a. Date first seen by doctor regarding mental health problem

Dd/mm/yy Please give date in format shown

3b. What action was then taken? Mental Health Referral/Psychiatric referral/Act2Care/No Action/Not

Known/Other ___________________________

Please circle relevant category/categories

If Other, please state in words

4a. Date first seen by psychiatrist Dd/mm/yy Please give date in format shown

4b. What action was then taken? Medication/Assessment/No Action/Not

Known/Other ______________________



27

5. Date psychiatrist diagnoses

mental illness requiring sectioning

under Mental Health Act 2003


6. Date medical reports(s)

completed


7. What application was sought? Assessment Order/Treatment Order Please circle relevant category

8a. Did physician assess prisoner as being fit to attend court?

Yes/No/Not Known Please circle relevant category

8b.If Yes, did prisoner attend court? Yes/No/Not Known Please circle relevant category

8c. If No, was s/he legally

represented?


9. Date request made by prison for

Assessment or Treatment Order hearing in Court


10a. Were the relevant people notified that request for Order is

being made?


10b. If Yes, who were these? Prisoner/Prisoner’s Solicitor/Local Prosecutor

/Not Known/Other__________________



11a.Was a risk assessment undertaken by Health centre staff regarding need for mental health

nursing escort ?

Yes/No/Not Known Please circle relevant category/categories

11b. If Yes, what date was

assessment done?


11c. If Yes, was a mental health

nursing escort required?


11fd. If Yes, was the risk

assessment outcome for a mental health nursing escort communicated


28

to the escort provider?

11e. If Yes, give date Dd/mm/yy Please give date in format shown

11f. If Yes, was this communication acknowledged by the escort

provider?


11g. If Yes, give date Dd/mm/yy Please give date in format shown

11h. If Yes, was a mental health nursing escort provided for the court

hearing and subsequent transfer to hospital / return to prison?


11i. If Yes, was the mental health nursing escort able to remain in

direct contact with the prisoner throughout the escort?


12a.Was a risk assessment undertaken by Health centre staff regarding need for particular vehicle

type?



assessment done?


12c.. If Yes, was the risk

assessment outcome for a particular vehicle type communicated to the

escort provider?


12d. If Yes, give date Dd/mm/yy Please give date in format shown

12e. If Yes, was this communication acknowledged by the escort

provider?


12f. If Yes, was a particular vehicle

type provided for the court hearing and subsequent transfer to hospital

Yes/No/Not Known Please circle relevant

category/categories

29

/ return to prison?

13 Date Assessment or Treatment

Order hearing occurred in court


14a. Was Assessment or Treatment

Order made by the Court


category/categories

14b. If No, why? Please give reason if known

15. Date of admission into hospital Dd/mm/yy Please give date in format shown

TRANSFER FOR TREATMENT

DIRECTION (TTD) (CONVICTED) To be completed for every prisoner

WHILST CONVICTED within the terms of the Mental Health (Care and

Treatment) Act 2003 from 5th October 2005 until 30th April 2006 inclusive

Prisoner Spin Number:

1. Date admitted into prison Dd/mm/yy


2a. Date first concern that prisoner

could be mentally ill

Dd/mm/yy

Unknown


2b. Who first expressed this

concern?

Nurse/Officer/Prisoner/Family Member/Not

Known/Other __________________

Please circle relevant category.


2c. What action was then taken? Nurse assessment/Mental Health

Referral/Doctor referral/Psychiatric referral/Act2Care/No action/Not

Known/Other ___________________



3a. Date first seen by doctor

regarding mental health problem


3b. What action was then taken? Mental Health Referral/Psychiatric

referral/Act2Care/No Action/Not Known/Other



30

___________________________

4a. Date first seen by psychiatrist Dd/mm/yy Please give date in format shown

4b. What action was then taken? Medication/Assessment/No Action/Not Known/Other ______________________

Please circle relevant category/categories


5. Date psychiatrist diagnoses

mental illness requiring sectioning under Mental Health Act 2003


6. Date 1st medical report completed


7. Date second medical report completed


8. Date TTD signed on behalf of Scottish Ministers


9a.Was a risk assessment undertaken by Health centre staff

regarding need for mental health nursing escort ?


9b. If Yes, what date was assessment done?


9c. If Yes, was a mental health nursing escort required?


9d.. If Yes, was the risk assessment outcome for a mental health nursing escort communicated to the escort

provider?


9e. If Yes, give date Dd/mm/yy Please give date in format shown

9f. If Yes, was this communication acknowledged by the escort

provider?


9g. If Yes, give date Dd/mm/yy Please give date in format shown

31

9h. If Yes, was a mental health

nursing escort provided for the court

hearing and subsequent transfer to hospital / return to prison?


9i. If Yes, was the mental health

nursing escort able to remain in

direct contact with the prisoner throughout the escort?


12a.Was a risk assessment

undertaken by Health centre staff regarding need for particular vehicle

type?


category/categories


assessment done?


12c. If Yes, was the risk assessment

outcome for a particular vehicle

type communicated to the escort provider?


12d. If Yes, give date Dd/mm/yy Please give date in format shown

12e. If Yes, was this communication acknowledged by the escort provider?


12f. If Yes, was a particular vehicle type provided for the court hearing

and subsequent transfer to hospital / return to prison?


13. Date of transfer to hospital Dd/mm/yy Please give date in format shown

audit of the implementation of the mental ......4 executive summary an audit was carried out of all...

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