FORENSIC PSYCHIATRY COMMONWEALTH PROFFESSIONAL
FELLOWSHIP PLACEMENT REPORT
INTRODUCTION
The partnership between the East London NHS Foundation Trust and Butabika Hospital
has been growing from strength to strength since its inception in 2003. In the year
2007, the training exchange with staff from Butabika coming to the UK was focused on
development of Forensic Psychiatry Services. Two senior staff; Dr. Julius Muron and Mrs
Agnes Kyaligonza have been here for six and three months respectively. Both
placements were funded by the Commonwealth Commission through the
Commonwealth Professional Fellowship Scheme.
The placement aimed to provide leaders involved in development of Forensic
Psychiatry Services in Uganda with relevant skills and knowledge. My experience is
based on observation of systems and practice of mental health services in HMP
Pentonville, Centre for Forensic Mental health (John Howard Centre), Community and
Forensic rehabilitation services. Right from the briefing at the British Council in Uganda,
it was clear to me that the British systems are of high standards. I struggled for a few
days to navigate through East London getting lost in two occasions and was even fined
once for use of an invalid ticket. It is quite different in Kampala where we use minibuses and motor bikes and one pays in cash for the journey. Hysterical and sweaty bus
conductors loudly call the destinations of the buses.
HMP PENTONVILLE PRISON PLACEMENT REPORT
DURATION
The placement was for six weeks from 15th Oct to 23rd Nov 2007. The fellow achieved
73% attendance rate. Attendance was affected by official meetings involving the
Commonwealth Scholarship Commission and General Medical Council as well as burn
out related to security protocols. Incidents of the unexpected also occurred e.g. strike by
Silver link transport network.
MANAGEMENT
The fellow was introduced to prison by Mr. Jonathan. He met the prison health care staff
and from there on, they were all very helpful to the fellow throughout his placement.
The Mental Heath Team in the prison was the main source of the training.
Administrative protocols were managed by Mrs Madhu assisted by Ms Ann. This was
demanding but was executed to the minor detail and the fellow is grateful to the
administrators. The fellow also met the Head of health care in the prison and received
his blessing.
The fellow closely worked with the Specialist Registrar in Psychiatry (Dr. Berg), Senior
House Officer (Dr. Ruchi Patel) and other Doctors. He held meetings with the Consultant
Psychiatrist (Dr. Mackenzie) and discussed issues concerning prison protocols as well
as management issues. During the placement, the fellow worked with social workers,
pharmacists, Nurses and other members of the mental health care. In the fifth week, the
fellow had experience with CARATS (Drug and Alcohol rehabilitation services in the
prison). While at CARATS, the fellow was supported by the CARATS lead administrator
(Mr. Daniel) and was given practice protocols and operational manuals.
ACTIVITIES
i)
ii)
iii)
iv)
v)
vi)
vii)
Joint assessments of prisoners; admitted to health care (with SpR, SHO),
referred to MHT from the prison wings (with social workers), and those who
need drug rehab (with CARATS social workers).
Responding to immediate needs of patients in the health care and regular
review of prisoners in a 16 bedded Health care (SpR, SHO, Nurses).
Management rounds (with Consultant Psychiatrist, SpR, SHO, Social workers,
nurses) were patients in health care and those seen in outpatients are
discussed one by one. Format used to write out management round list was
impressive and it contained; lists of patients, their needs, legal status,
planned interventions and persons responsible for those interventions.
Observation and learning use of Mental Health Act Sect 48, 47, 38, 37, 36 and
prison practice protocols.
Interacted with other prison services e.g. Chaplaincy, Independent
Monitoring Board, security, cleaners, recreation, sport, day care unit, use of
library, group therapy and observed how these contributed to rehabilitation
of sick prisoners.
Observed management of clinical records (EMIS data system, prescription
charts, and administrative documents), administration of medications and
methods of communication (Fax, telephone and face to face verbal).
Attended two SHO teachings; conference on case of sexual abuse in childhood
and adult borderline personality focussing on management challenges and a
case of ‘mentalisation’ as means of group therapy for patients with
personality disorders in an inpatient personality unit (North London).
ACHIEVEMENT OF EXPECTED OBJECTIVES
The following objectives were comprehensively achieved;
1.
2.
3.
4.
Experience with 16 bedded health care -based on daily activities.
Observation of assessment of new prisoners –based on daily activities.
Health promotion in the prison.
Observed Psychiatry in-reach team and consultations provided by Forensic
Psychiatrists from medium secure units. It was through this mechanism that
prisoners get admitted to hospital; either to a Medium Secure unit or general
Psychiatry unit. During this period, only one prisoner was admitted to a high
security hospital.
Management of disturbed behaviour and engagement with disturbed prisoners was
observed. De-escalation and close nursing observation of prisoners at risk were central
to the care of disturbed prisoners. Deliberate self harm and risk of suicide were the
common disturbed behaviours with very minor cases of violence at the health centre.
Cases were brought from the prison wings with history of physical violence after
management at segregation. ACCT was the protocol used for observation and recording
disturbed behaviour. There was no use of physical restraint and rapid tranquilisation
used as their need was limited. I did not have a chance to witness incident review and
debriefing as none occurred during this period.
The fellow learnt use of UK MHA 1983 and common law applicable prison psychiatry
practice. Upon review of the Uganda Mental Health Treatment Act (MHA) 1964, I
sighted sections 3, sect 5 and sect 21 to be equivalence of sections 35-38, 47-48 used in
the UK. The fellow experienced use of atypical antipsychotics and Zopiclon. There was
often uncommon to respond to medication side effects as these occurred only rarely.
The medication dosages were often at the lower end of BNF recommendations.
Whenever patients with perceived capacity to refuse medications refused to take any
medication, they would not be forced to take medication in prison instead they waited
for admission to hospital for any medication to be started.
Use of occupational assessment was not structured in prison and often relied on verbal
reports of how one interacted and performed during an activity.
PLACEMENT WITH NORTH EAST LONDON FORENSIC
SERICES (Dr, G. Waldron’s team)
PSYCHIATRY
Objectives of this placement were to observe the assessment, and management of mentally
disordered offenders both in inpatient and community settings.
The placement was for four weeks and it was the first placement in a Medium Secure Unit
(John Howard Centre).
ACHIEVED
A four hour security induction was conducted to highlight the structural and procedural
security measures applicable at a medium secure unit. I was introduced to the staff of the
team and was given a weekly program.
I participated in ward rounds which provided the opportunity to appreciate the use of Mental
Health Act 1983, understanding issues about leave, evaluation of patients for medication side
effects and efficacy of medications used. I observed the use of atypical antipsychotics and
Clozapine, participated in providing information to patients about drugs used and consenting
to treatment. I also witnessed management of patients under seclusion and use of behavioral
methods to manage violence in the PICU. The use of alarms, radio calls and function of the
rapid response team was appreciated. Talking down patients and close observation limited the
use of physical restraint. Violent patients were often reviewed in the presence of the physical
restraint team even when talking down was successful in the previous review until when such
a patient becomes stable in behavior.
The liaison between Forensic Psychiatry and General Psychiatry services were observed. This
provided a link for referrals to be made, allowed for the Forensic Psychiatry team to work
with CMHT and AOT in the community. The Forensic Psychiatry team was involved in
assessment and management planning (CPA) for community treated patients with Forensic
Psychiatry needs; i.e. high risk of violence and patients on part III MHA 1983 restrictions. I
attended a CPA meeting at Camlet lodge on a case of transfer from acute ward of Medium
secure unit to low security rehabilitation setting.
During this placement, I held discussions with the consultant on matters such as; use of MHA
1983 in Forensic setting including Sect 136 and 17, forensic aspects of fire setting, stalking
and fitness to stand trial. I had access to journals of forensic psychiatry to supplement the
discussions.
Academic seminars provided for opportunity to discuss management of challenging cases as
well as service development issues. An opinion journal article in Psychiatric Bulletin 2008
discussing the limitations of Medium Secure Unit services was reviewed. It highlighted need
for continued innovations to respond to the limitations of the services set up.
Also case discussions on ; (i) sexual offending, i.e. incest, domestic violence, zoophile and
child protection issues and (ii) a case of challenging behavior with changing paranoid
personality and polydypsia associated with severe hyponatreamia (27 mmol/L) were the other
top of the list challenging cases discussed..
PLACEMENT WITH FORENSIC PSYCHIATRY SERVICES OF EAST LONDON
(Dr. J. Berman’s team at London Borough of Newham)
The objectives of the placement were to observe the assessment and management of mentally
disordered offenders in the inpatient and community setting. Major ward rounds and
assessment of referrals were the major learning activities. This placement was for four weeks.
ACHIEVED
I observed weekly ward rounds in acute ward (Ludgate) and long stay (Lime house). The
ward rounds involved presentation of multi-disciplinary team reports, review of issues about
escorted and unescorted leave, medication review and monitoring medication side effects,
discussion of plans for discharge including legal procedures, accommodation, education,
employment and finances.
I attended multiple Care Program Approach meetings demonstrating; team work,
involvement of patients in care planning, working with patients legal representatives and
working with community mental health teams in planning discharge. Regular weekly
community forensic psychiatry team meetings were held to promote team work, validation of
decisions by the team members and role allocation.
I attended a tribunal hearing and appreciated the constitution of the tribunal, its role,
documentation involved, patient representation and tribunal process. The Tribunal aimed to
promote patients dignity and rights. It balanced legal and moral judgment based on presence
of mental disorder of the nature and severity, patient’s needs, treat ability and prognosis of
mental health problem.
Court diversion involved police or GP making referrals of offenders suspected to have mental
problems to a mental health worker. The mental health worker then makes a brief assessment
and makes a report to court indicating issues about fitness to stand trial, the need for
admission of the offender for assessment (Sect 35 or 3 MHA 1983), or treatment to hospital
and coordination of such an admission. I participated in court assessment and admission
process of elderly offender to a old adult ward. The decision about the level of security
needed to assess or treat the offender determined the hospital were the offender would be
admitted. If the offender is known to mental health services, his community mental health
team would be contacted to plan his care.
I attended the monthly Multiagency Public Protection Panel (MAPPA) meetings and
experienced team work involved in MAPPA care planning. I appreciated the role of a mental
health representative in the MAPPA meetings. These included; reporting on mental health
issues that may negate safety, Identifying needs for Psychiatry assessment and making
referrals. Other members of this team were; housing managers, child protection officers, and
probation and prison officers.
PLACEMENT IN FORENSIC REHABILITATION SERVICES
Forensic rehabilitation services provided opportunity to experience the contribution of
Psychiatry interventions to recovery and advancement of skills, knowledge and
attitudes of patients. These interventions were in relation to the mental health needs,
offending behaviour and planning reintegration of patients to the community. The
rehabilitation services observed were organised around a low secure unit within a
hospital setting (Tuke Ward), low secure unit in the community (Tariro house) and
various levels of supported accommodations (Hostels).
Patients in the rehabilitation units (Tuke Ward) typically had minimal psychotic
disturbance, the environment was homely and patients had responsibility to manage
the environment. The patients had a say on how the ward was managed and addressed
the managers directly during the ward community meetings. These provided a high
level of accountability from staff as well as patients behaviour. Most of the patients also
had unescorted leave; they used it to go to study, shop, leisure, work or visit relatives.
Some patients had weekend leave to stay in the community based hostels as part of
their progress to discharge. Most clients had a time table of activities to be carried out
during the course of the week. These activities also included attending therapeutic
groups; either within Centre for Forensic Health or in the day care centres in the
community. Use of standardised tools for assessment of level of function such as CASIG,
were witnessed. Monitoring medication side effects and treatment of physical
conditions were integral part of rehabilitation care. Patients were given all necessary
information to promote their mental health.
Tariro house was a 16 bedded low secure unit in the community and it provided for 24
hour nursing care to all patients on daily basis. The unit demonstrated a partnership
between private and NHS service delivery. It had a complete Psychiatry team, all of
whom were from the NHS except the nursing staff and occupational therapist who were
directly employed by the private health provider. Most of the clients had unescorted
leave and the daily duration of leave depended on the patient’s needs. Several
therapeutic groups were available, and I participated in sharing solutions and current
affairs groups. This unit functioned more or less like a ward. The patients applied to the
Tribunal for discharge and were given either absolute discharge or more commonly
conditional discharge. The conditions included restriction orders (Section 41/49 of
MHA 1983), no go zones, appropriate housing, Random Urine checks and extra.
After the low secure units, patients who progressed in care, moved on to live in
supported accommodation. There were various types of supported accommodation
(hostels); hostels were clients lived completely independent of other clients in the
hostel and those hostels were clients had common meals, recreation and support from
wardens to meet activities of daily living. Wardens help the clients to manage
medications, monitor client’s ability to perform activities of daily leaving and help them
to access rehabilitation services in the community. The wardens reported issues of
concern to the Psychiatry team and the Multiagency Public Protection Panel meetings.
The Forensic Psychiatry Team supported the Community Mental Health teams (CMHT)
for the first six months after discharge of Forensic cases. A joint CPA would be held
during that period before the care is handed over to the CMHT. Forensic Community
Psychiatry Nurse provided daily psychiatry care in the community and coordinated the
CPA.
During this period, I witnessed the relapse of self harming behaviour of a patient who
over the last 20 years had progressed from high security hospital (Broadmoore) to low
secure rehabilitation unit.
This patient had schizoaffective disorder but predominantly with antisocial personality
disorder. He had poor compliance with medication, limited engagement with
rehabilitation services and was actively erotomanic towards female nurses who had
previously nursed him. After this patient attempted suicide by over dose of
chlorpromazine, he was readmitted in the Psychiatry Intensive Care Unit.
The Consultant Rehabilitation Psychiatrist of Tuke ward provided the fellow with
learning materials as well as Library materials for Butabika Forensic Psychiatry Library.
The placement achieved its overall aim of exposing the fellow to a range of Forensic
Psychiatry Rehabilitation Services.
PLACEMENT IN COMMUNITY FORENSIC PSYCHIATRY SERVICES
The objectives of the placement were; to observe mental health assessments at the
police stations, and during court diversions, to participate in ward rounds, care
planning and visiting of clients in their homes. I visited a range of Community Forensic
Psychiatry Services (CMHT) and the services were organised with Community Mental
Health teams playing a central role in continued care of Forensic cases. Forensic
Psychiatry teams liaised with CMHT at the time of planning patients discharge and
during the first six months to one year after discharge. Continued participation of
Forensic teams was particularly needed in care of patients discharged with restriction
orders and those managed under Multiagency Public Protection Panel. A Forensic
Psychiatry Community Psychiatry Nurse (CPN) provided care to clients in their homes,
reported to the Forensic team and coordinated the Care Programme Approach (CPA)
meetings. Each CPN had a client load of 15-20 patients at any one time. Other members
of the team visited patients in their homes depending on their needs. Primary health
care trust team members provided the treatment for physical conditions.
Special housing arrangements exist between local councils and NHS trusts to
accommodate discharged Forensic patients. Patients moved from acute wards of a
Medium Secure Unit (JHC) to a highly supported accommodation and finally to
independent living in hostels or flats. It was exciting to be hosted to a cup of tea
prepared by clients in their hostel and witnessed how those clients worked as a team in
the residence. The wardens in the hostels helped the clients with activities of daily living
whenever they needed such help and also supervised medications.
Rehabilitation of Forensic cases in the community occurred in any Psychiatry
rehabilitation services in the locality. These services included; day care centres, leisure
centres, education facilities and employment. Other specialised teams in the community
such as drug and alcohol team treated discharged patients and those referred from the
court diversion scheme. Both the CMHT and the wardens reported to the probation
officers on matters concerning patients on restriction orders and those released on
parole. Such issues could include; use of illicit drugs, random urine checks, breach of no
go zones, violence, compliance with medications, and any other worrying behaviour.
Such reports would be discussed during Multiagency Public Protection Panel. Breach of
restrictions and relapse of Psychiatry morbidity were common reasons for recall of
patients released on licence.
After this placement, I had a chance to visit general Psychiatry services at Mile End
Hospital (Global Ward) and Homerton Hospital (Bavern, Joshua wards). The patients in
those wards were more acutely disturbed than the Forensic cases seen at JHC. The
teams were stretched by the patients’ diverse needs, there was increased use of PRN
medication (haloperidol and benzodiazepines) and the dosages were higher than those
used at JHC. At Mile End Hospital, it was nice to see how female and male patients
shared a common room of the ward. Patients in both Forensic and General Psychiatry
were of diverse origin, mostly African and Asian origin. The commonest diagnosis was
schizophrenia (Probably 70% and over).
During this period, I made a presentation to JHC audience on nature of Forensic
Psychiatry Services available in Uganda and interventions we have planned to start
when we return back to Uganda. The presentation was well attended and it stimulated a
discussion and some staff indicated that they would be interested in coming over to
Uganda to support the development of new interventions.
CONCLUSION
The HMP Pentonville prison experience provided the fellow with a foundation of skills
and knowledge upon which he will be able to model the prison mental health services in
Uganda. Some of the practices observed here are directly transferable while the labour
intensive and expensive strategies may need to be modified. Other reforms will need
preliminary work with the Ministry of Health, Ministry of Internal Affairs and
Directorate of Prison Health Services of Uganda. The experience attained from the JHC
placement will provide knowledge and skills to make realistic changes in our care of
Forensic cases in Uganda. Details of the developments are as contained in the power
point presentation here attached.
ADMINSTRATION OF THE FELLOWSHIP
The candidate selection and travel arrangements were smoothly organized. For this the
Commonwealth Commission, British Council and East London NHS Foundation Trust
deserve an excellent score. The predeparture briefing and the flash disc organized by
the British Council were very helpful. Meeting the Commonwealth Alumni in Uganda
was not only lovely but also inspiring. I was particularly thrilled and challenged by the
achievements and the profile of the Commonwealth Commissioners I met during the
events in the UK. The host organization arrangement to receive the Fellow at the airport
provided a kind and calming reception. The first dinner in the UK is memorable and it
straight away took some convincing for me to accept that tap water was safe to drink
right away. The host organization had also arranged for hostel accommodation and I
initially did not like it for its shared amenities. It took two weeks to adjust and things
then started operating smoothly. The payment of stipend was timely and convenient.
Solitary life, discovering opportunity to network and making new friends took some
time. Commonwealth events were the first real place I met people both from Uganda
and other parts of the world who liked charting out. Mail networking then started and
to date I have contact to friends in Malawi, Bangladesh, Guyana. Later, I was able to
make friends in a pub where I used to go to watch football. Friends of Butabika link
were also important networks through which I went out to their homes for Sunday
Dinners and also went to watch Arsenal Football at Emirates Stadium. Going to church
was the most refreshing way to start a new week. Christmas (2007) found me here and
it provided opportunity to learn something different and enjoy while far away from my
family. Tuning to BBC radio channels provided both entertainment and current affairs.
Listening to talk shows has enabled me to appreciate level of public opinion and know
commonly used English words.
I am looking forward to my last few days in the UK and hopefully a fascinating enjoyable
flight back to Uganda without any bad memories about Heathrow. My experience will
begin to influence formal and informal interactions as soon as I return to Uganda. I will
keep you up dated if you flag up your interest on juliusmuron@yahoo.co.uk