Facilities and Treatments Facilities and Treatments in Forensic Servicesin Forensic Services

Dr Wallace BrinkDr Wallace BrinkConsultant Forensic PsychiatristConsultant Forensic Psychiatrist

Langdon HospitalLangdon HospitalDevon Partnership NHS TrustDevon Partnership NHS Trust

ServicesServices

The need to know where to treat- The need to know where to treat- Clinical/Political decision ?Clinical/Political decision ?

• High Secure (Special Hospitals)High Secure (Special Hospitals)

• Medium Secure (Regional Units)Medium Secure (Regional Units)

• Low SecureLow Secure

• Independent SectorIndependent Sector

ServicesServices

• High Secure – e.g. Broadmoor – average length High Secure – e.g. Broadmoor – average length of admission ~ 8-10 years.of admission ~ 8-10 years.

• Medium Secure – e.g. Butler Clinic – usually Medium Secure – e.g. Butler Clinic – usually less than 2 years.less than 2 years.

• Low Secure – Variable interest; variable length. Low Secure – Variable interest; variable length.

Now: National Standards - DoHNow: National Standards - DoH

Security as therapy ?Security as therapy ?

• Security plays a positive and supportive role to the care and therapy provided.

• It should not be seen as negative or as preventing things from happening but rather as positive, providing the structure within which the clinical agenda can be safely carried out and privacy of patients maintained.

SECURITYSECURITY

Security is a threefold concept where each element must be developed in relation to and with the other two

• Physical • Procedural • Relational

Physical SecurityPhysical Security

• Physical security is the provision, maintenance and correct application of appropriate equipment and technology.

• The security provided should protect the privacy and dignity of patients, prevent others passing contraband items into the unit and make escape difficult.

• There are a range of differing unit designs with physical security provided in differing ways, the principle being a secure/protective envelope to the care facility.

Physical Security Physical Security

• Perimeter (present, inspected and Perimeter (present, inspected and maintained)maintained)

• Fencing enhancementsFencing enhancements

• Gates and perimeter roofsGates and perimeter roofs

• Keys, locking systems, alarmsKeys, locking systems, alarms

• Reception, CCTV, windows ceilings Reception, CCTV, windows ceilings courtyardscourtyards

• Etc…………………..Etc…………………..

Procedural SecurityProcedural Security

• Procedural security is the proper application of set procedures, routines and checking.

• Serves a dual purpose in that staff are able to quickly and efficiently establish clear boundaries across the service but, more importantly, procedures reinforce in patients and staff the requirement to balance the needs of the individual against the needs of others.

• Staff will be trained to not only recognise these

procedures but to understand their application and purpose for the individual

Procedural SecurityProcedural Security

• Searching, including patient searching, bedroom searching, ward and off-ward areas and visitors.

• Management of violence and aggression, seclusion, control and restraint, use of forced medication including rapid tranquilisation, observation, anti-bullying policy –meet the needs of those who are bullying and those who are bullied.

• Prevention of suicide and management of self-harm, transportation of patients, e.g. to court, escort procedures, control of illegal substances.

Procedural SecurityProcedural Security

• Prosecution of offences within the unit – this should be agreed with the police and the Crown Prosecution Service

• Possessions, smoking; monies; censorship of material, including pornography; control of mail and use of telephones; control of tools used in therapy or education or ward areas;control of mobile phones, including camera phones, computers

• visiting procedures, child safety, patient confidentiality.

• Critical incident review and patient roll checks.

Relational SecurityRelational Security

• Relational security is the formation of a therapeutic alliance between staff and patients centred in continuing risk assessment and detailed knowledge of the patient and the use of personal and professional skills by each member of staff to ensure that they support and offer appropriate treatment for patients.

• Relational security is the key provider of security within a healthcare setting. It is not always helpful to set a definitive staff/patient ratio but it is more useful to recognise that there is a need to provide a high ratio of experienced staff to allow for optimal intervention with patients, provide a high quality of treatment, and maintain policies related to security and patient confidentiality.

Relational SecurityRelational Security

• At the centre of relational security is the individual patient care treatment plan. Within the plan there is a collation of information, an assessment of what has occurred and what is occurring.

• Regular, usually weekly, reviews provide the opportunity to set and monitor treatment, activity programmes and to monitor and reset objectives as necessary. Security input into these plans can be helpful. Security should be seen as facilitating treatment safely, enabling therapeutic gains for patients by judicious and planned risk taking within a controlled environment.

• Good security can therefore provide the opportunities to test out patient care plans

Relational SecurityRelational Security

• Observation and assessment needs to take place in a variety of settings and it is therefore essential that treatment programmes, occupational therapy, work, education, activity and leisure are structured into the day over a seven-day week.

• Each offers the opportunity to assess and support the patient’s recovery.

Liaising with other servicesLiaising with other services

• Court Diversion Schemes• Courts• Prisons/ In-reach Teams• MoJ• MAPPA• Probation/ VLO• Acute Services• GP• Others including community forensic

services

MAPPAMAPPA

• Multi-Agency Public Protection Arrangements Multi-Agency Public Protection Arrangements (MAPPA) support the assessment and (MAPPA) support the assessment and management of the most serious sexual and management of the most serious sexual and violent offenders.violent offenders.

• The aim of MAPPA is to ensure that a risk The aim of MAPPA is to ensure that a risk management plan drawn up for the most serious management plan drawn up for the most serious offenders benefits from the information, skills offenders benefits from the information, skills and resources provided by the individual and resources provided by the individual agencies being coordinated through MAPPA.agencies being coordinated through MAPPA.

Identifying offenders to be Identifying offenders to be supervised under MAPPAsupervised under MAPPA

This is generally determined by the offender's offence and This is generally determined by the offender's offence and sentence, but is also by assessed risk.sentence, but is also by assessed risk.

There are three formal categories:There are three formal categories:

• Category One: Registered Sex Offenders (around 30,000 Category One: Registered Sex Offenders (around 30,000 offenders in 2004/05)offenders in 2004/05)

• Category Two: Violent or other sex offenders (around 12,600 Category Two: Violent or other sex offenders (around 12,600 offenders in 2004/05)offenders in 2004/05)

• Category Three: Other offenders (around 3,000 offenders in Category Three: Other offenders (around 3,000 offenders in 2004/05)2004/05)

Managing the risk posed by Managing the risk posed by individual offendersindividual offenders

MAPPA offenders should be managed at one of MAPPA offenders should be managed at one of three levels. While the assessed level of risk is three levels. While the assessed level of risk is an important factor, it is the degree of an important factor, it is the degree of management intervention required which management intervention required which determines the level.determines the level.

Managing the risk posed by Managing the risk posed by individual offendersindividual offenders

• Level One: involves normal agency managementLevel One: involves normal agency managementGenerally offenders managed at this level will be assessed Generally offenders managed at this level will be assessed as presenting a low or medium risk of serious harm to others. as presenting a low or medium risk of serious harm to others.

• Level Two: often called local inter-risk agency Level Two: often called local inter-risk agency management - management - Most offenders assessed as high or very Most offenders assessed as high or very high risk of harm. high risk of harm.

• Level Three: Level Three: Appropriate for those offenders who pose the Appropriate for those offenders who pose the highest risk of causing serious harm or whose management highest risk of causing serious harm or whose management is so problematic that multi-agency co-operation and is so problematic that multi-agency co-operation and oversight at a senior level is required. oversight at a senior level is required.