REPORT OF FORENSIC PSYCHIATRY PLACEMENT AT EAST LONDON NHS
FOUNDATION TRUST
This report is prepared by Agnes Kyalingonza, a senior Psychiatry Nursing officer
practising in Butabika Hospital Uganda which is the National Referral Mental
Hospital of Uganda. It is found in the east of Kampala city at the shores of Lake
Victoria. Agnes had a three months experience with Forensic Psychiatry services of
East London.
BROADGATE PLACEMENT UNDER SUPERVISION AND MENTORSHIP OF
MODERN MATRON EMMANUEL
The placement was preceded by two weeks induction at East One (The Trust
Headquarters). I also underwent security induction at John Howard Centre. Both
inductions heighted the Trust’s important protocols and I also learnt about my
responsibilities. The fellow had several objectives to achieve and they included; to
acquaint with nursing routines of east London and city mental trust, share and gain
more experience in care as well as methods used to manage Forensic patients and
finally to strengthen leadership and management skills.
Through supervision and guidance by Practice Innovations Nurse (Celestina), I was
introduced to an admission ward of 16 patients. Each of these patients had a
separate bedroom, put on their own clothes and was allowed to have their own
property except for restricted items. The patients were encouraged to take care of
their own hygiene. A well organised room was used for administration of medications
and also had locked cupboards of restricted items. A medicines trolley contained a
week’s supply of medication for each patient. Each patient had a separate well
labelled box containing their medicine. Patients who had improved were allowed to
self medicate. A Pharmacist dispensed the medications by use of prescription charts.
Handing over meetings and nursing observations
During the shifts, each shift had a coordinator who made a duty allocation to other
staff in the shift. Each staff was allocated patients to nurse during that shift and at the
end of the shift such staff will have made clinical notes about those patients in their
files. After every shift, a handover was performed in a quiet room and all staff had to
attend the handover. All patients’ care plans and mental states are discussed in such
handovers. Shifts allowed to overlap hence smooth running of ward activities, e.g.
morning shifts started at 7am and 9am.
Every patient is allocated a primary nurse right from admission that is responsible for
coordinating that patient’s care. Such a nurse will have a deeper understanding of
that patient and allows for establishment of a deeper therapeutic relationship. Every
patient had a care plan and staff had to know where every patient was at any one
time. Patients were under different levels of nursing observation; 5 minutes, 10
minutes, 15 minutes, hourly depending on the specifications in the care plan. Holding
one to one session with each patient was part and parcel of nursing observations.
Occupational therapy, community meetings and leave
All staff and patients participated in the ward community meetings where patients
were encouraged to air out their problems relating to ward management and
interpersonal relationships. These were chaired by occupational therapist. Patients
meetings were held daily and were chaired by a patient and supervised by staff.
Patients were allocated leave as part of the Mental Health Act (1983). This was
implemented by the psychiatry team. Patients either had escorted leave or
unescorted leave. Patients sign out and in after the leave. They are also searched
for burned items on return from leave. Patients participated in several occupational
activities both in the ward and special group therapy rooms. These included indoor
games, cooking, reading magazines, and current affairs group.
Ward rounds and record keeping
I attended the weekly ward rounds and management meetings held before the ward
rounds. I observed the senior nurse present patients observation summaries to the
team. This was in form of typed out report between the two ward rounds, indicating
progress and actions performed as it was planned. The multidisplinary team also
presented their summaries and after review of the patient, a care plan was agreed
with. Ward records were well kept in clearly labelled files and easily accessible in the
file cabinets. A dairy contained all daily record of procedures.
Staff supervision and appraisal
Managers communicated the roles and goals for every new staff. Dates for appraisal
and supervision are set and one to one meetings were held to perform such
appraisals. I also attended staff meetings where staff was free to air out their
concerns. It was chaired by one of the junior staff. I went with the ward Matron to
lobby for staff welfare funds and observed the lobbying skills. The skill used was to
highly rationalise and contextualise the demand of funds to mean the best interest of
the organisation.
BAW WARD PLACEMENT (18th TO 29TH FEB 2008).
After a 4weeks placement on Broad gate ward, I reported to Baw ward. This is the
only female ward on John Howard centre for forensic services. The fellow’s
objectives were to acquaint with the modes of care and management offered to
women in forensic services in east London trust.
WARD ARRANGEMENT
The over roll manager is the modern matron. Who works hand in hand with the
practice innovation nurse and two practice nurse lead to run ward activities The
patients are divided in two groups the red and blue so each nurse lead takes over
one group and is responsible for all their well being and nursing care and one
psychiatrist manages the 16 patients although conducts rounds on different days to
see them
CARE PROGRAMME APROACH MEETINGS.(C.P.A)
This is a systematic arrangement for assessing the health and social needs of
people accepted into specialists mental services from variety of care providers and
they start three weeks before the patient has been admitted in hospital. The fellow
attended two meetings for different patients, one meeting the patient was not
improving so members of the multidisciplinary team first assessed a patient
individually and each presented a written report in that meeting and care plan
formulated which must be reviewed monthly. Another meeting was for the patient
who had improved ready to be discharged in the community. In this meeting the
primary nurse presented a written report to the team and community forensic nurses
were invited to receive the patient and handed over to hostel and this gradual
process is where by a patient is prepared before hand and in this meeting the patient
is allowed to invite members of the family or her solicitor if she wants.
MANAGERS HEARING.
Managers from another hospital are invited and they ask questions concerning
decisions taken by a team on a particular patient if they are convinced they are
given a go ahead.
DUTY NURSE. This is a nurse lead from any ward that takes over a hospital every
day and works hand in hand with the emergency nurse team to handle all
emergencies in the hospital and all admissions included. Checks radio calls and
makes sure the team is complete.
SECLUSION. Nursing care and management of patient in seclusion was observed
on this ward.
-Observations are continuous
- Patient remains on sight all the time
-Written observations recorded at a minimum of 15 minutes.
-A roster is designed by a shift in charge to ensure change over every after an hour.
-All meals served to the patient on time.
-A hard mattress is provided and tough linen which can’t tear easily.
The most common offences observed on the female ward were;
Women murdering their own children, husbands and assault
The fellow also observed that female patients in forensic were difficult to manage as
their relapses were frequent whenever there was a hint on the offences and most of
them never wanted to talk about them.
The fellow observed that apart from the social worker that time who was even
leaving for another job, there were only female staff working on that ward and when
tried to make enquiries was told it was a co incident, however when men visited the
ward many women would become excited. All the same the ward was well managed
but with a lot of work more than Broad gate ward.
PLACEMENT ON PENTONVILLE PRISON.
The fellow was placed to the above prison for a period of two weeks although she
missed two day which she used to attend the common wealth function and also one
day experience with adolescent and child community centre. I was introduced to the
team by Cerdic Hall on 4th march 2008 at Cal shot community care centre office
where meetings for the team are conducted routinely every Tuesday of the week. I
was welcomed to the meeting by Paton Len the manager and observed the team
meeting as they discussed mainly the way forward for patients. The day was tragedy
as I received news of the death of my sister Cissy however Cerdic and the team
were supportive. The manager gave me free air time from his office to call home and
this was a relief; may her soul rest in Eternal peace. After the meeting, we left for
prison with Stepheny, a social worker, who took me around the hospital of 16 beds
but that day was a lock down for all prisoners so didn’t see patients still could not go
to the prison chambers because was putting on address, next day had to put on
trousers to go round the prison. The two weeks worked with the mental health team
where my main objectives, were acquaint myself with the assessments and
management of mental patients in UK prisons, referral systems used to transfer
clients to mental hospital and how liaison system in police work.
Visited Camden and Islington health and social services in police station with a
community nurse and observed how a person suspected to be of an sound mind is
arrested, a quick mental assessment done if has risk factors is referred to a mental
health team for further management . However if this client has history of mental
illness can be followed up at home by the drug intervention team if he can take his
medication willingly. The fellow attended major ward rounds in prison where basically
the multidisciplinary team discuss patients who can be transferred to hospital and the
team from the identified forensic unit will come and assess the patient if can suit their
environment. Mental health clinic in the prison is conducted in such a way that
prisoners are escorted to the clinic by prison warders where a psychiatrist and
psychiatric nurse will do mental state examination if patient has pschopathology is
started on treatment and followed up letter. One member of mental health team
attends court every Tuesday and the fellow was given the opportunity to visit court
with Lucia one of the mental health nurse, in court the team do quick mental
assessments of a person suspected to have committed the offence due to un sound
mind and will do court diversion either to prison, high or medium secure unit for
continuity of care. Objectives of the fellow were achieved as when I go back home
will be able to sensitise nurses working in Luzira prison Uganda about the care and
referral system of patients to forensic services.
PLACEMENT IN COMMUNITY FORENSIC SERVICES
(17th march-28 th 2008 UNDER SUPERVISION AND MENTORSHIS OF
GERTRUDE AND JULIA).
The fellow’s placement in the community forensic services started with one Gertrude
who is a senior forensic community Nurse. Met her at John Howard reception after
arrangements on phone call, gave me a warm welcome and gave me the day’s
programme which had to start with c.p.a meeting at Tower of Hamlets Berkentine
centre where the mental health team discussed clients and internal referrals made to
the specialist. Forensic team identifies high risk clients with serious offences’ like
murder, rape, attempted suicide and severe bodily harm and make care plan
according to their mental state. When the meeting ended at 11.30 am we went to the
Baw centre where Gertrude works with other mental health team members. Was
welcomed by the manager and introduced me to the team who were very excited
meeting a visitor from Uganda. Forensic community nurses follow their patients
before discharge from hospital and their community co-ordinators always invited to
C.p.a meetings before discharge and make care plans for the clients according to
patent’s mental health section. The fellow visited one of the hostels in hackney
where Gertrude was following up her client from john Howard where i had chance to
meet patient had met on the ward and she was remembering me very well this made
me feel good seeing real things happen. In hostels clients are visited by the team
and sometimes clients can visit the centre for appointment of Depot medication.
Thursday 21st march2008 met Julia Mukuzwa another forensic attached to Bethnal
green community mental health care where we met with the mental health team, at
the centre there is full day occupational department where clients come either from
home or hostels to be helped to regain their lost skills and start leaving independent
life. The fellow attended a C.p.a. meeting where there were internal transfers of
clients to the general psychiatric team because they were no longer high risk.
On Tuesday 25th march 2008 attended meeting with Julia at towerhamets where by
prisoners who had committed high risk offences are discussed and the victims
before there are released. The public protection unit (Mappa) meeting is attended by
the following members; Police representative, Probation officers, human rights
members, child protection unit, community forensic services to mention few.
Overall, the experience was excellent and the following can be used in Uganda;
observations procedure checklist, strengthen hand over meetings, storage and
administration of drugs, roles of primary nurse, record keeping, negotiation skills,
organisation and management of ward rounds, method of staff appraisal and
improving security protocols in Butabika.
RECOMMENDATIONS TO BUTABIKA HOSPITAL UGANDA MANAGEMENT
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As security is most paramount in forensic the following should be considered:
Training all staff in working in the unit security measures.
Improve communication system by providing alarms, radio calls and
adequate locking doors in forensic unit.
Training nurses in forensic about management of aggression and violence
and formulate a Butabika policy.
Improve on the structure of seclusion rooms and formulate a policy on
seclusion.
Provide locking medicine trolleys and plastic containers and dispense drugs
for the week for each patient.
Improve on the observation methods by providing check list forms per patient
and form observation policy depending on the number of patients.
Introduce care programme approach and allocate primary nurses to forensic
and very difficult patients.
Management of ward rounds should be by senior nurses and each patient
presented with well written notes.
Handing over meetings should be strengthened and care plans for difficult
patients reviewed and written down for everybody to see.
Emergency Nurse Team to be introduced to work hand in hand with duty
nurse to manage admissions and other psychiatric emergencies.
Encourage over lapping shifts to reduce burn out
Encourage patient participate in ward activities.
Work with the psychiatrist to sensitise staff in Luzira prisons proper referral
system of patients to forensic services.
Sensitise community nurses on resettling and follow up of forensic patients.
Rehabilitation of forensic patient strengthened.
Encourage the use of day area and in door games.
Strengthen professional and academic meetings weekly.
Set up modern library in the forensic unit.
APPRECIATION;
 Commonwealth fellowship,
 East London and city mental trust management,
 Butabika hospital management,
 All staff worked with during placement,
 Cerdic Hall co-ordinator and lastly my colleague Julius for all the
support rendered to me.
This experience is a turning point in my own professional practice as well as
Psychiatry practice in Butabika. New interventions will make care of our patients
better and the new management skills will raise the moral of our staff. I hope to keep
all of those interested in following up my progress informed. Do contact me on the
mail buthosp@infocom.co.uk