How NHS Mental Health Care was failing, as patient Nicola Edgington killed again
Dr Raj Persaud and Dr David James
Edgington walked out of hospital in the early hours of October 10th, where she had gone seeking help, apparently explaining that she was hearing voices. Later that day she slit the throat of Sally Hodkin with a meat cleaver and nearly decapitated her, after earlier pinning Kerry Clark down with a knife.
Oddly enough, because cases such as these grab headlines – which is understandable given the scale of the tragedy – the suffering of those who are not a danger to others, gets ignored. But in neglecting the mental health care of the vast majority, the conditions are created where rare fatalities become more likely.
A recent report and survey by MIND the mental health charity found four in ten mental health trusts have staffing levels well below established benchmarks and only a third (33%) of respondents who came into contact with NHS services when in crisis were assessed within four hours, as recommended by the National Institute for Health and Clinical Excellence (NICE) . Only 14% of people said that, overall, they felt they had all the support they needed when in crisis
Because the media only become interested in mental health care when fatalities grab the headlines, this drives Government policy. As a result of over-emphasising the link between mental illness and dangerousness, there is a concentration on treating a small number of oﬀenders in secure hospitals. This costs £1 billion per year – 15% of the total NHS investment in the mental health of working-age adults.
The number of NHS psychiatric beds has gone down by 60% in the last two decades, while the number of involuntary admissions has gone up by 60%. In other words, it is increasingly difficult to gain access to psychiatric care when acutely unwell.
There is hushed talk in the corridors of NHS power that certain psychiatric hospitals in our inner cities will shortly become ‘sectioned only’ institutions – in other words soon no one in them will be voluntary.
Psychiatrists Patrick Keown, Scott Weich, Kamaldeep Bhui and Jan Scott found in a study entitled ‘Association between provision of mental illness beds and rate of involuntary admissions in the NHS in England 1988-2008: ecological study’ that any reduction in NHS psychiatric bed numbers was strongly correlated with a parallel increase in involuntary or ‘sectioned’ patients the following year.
The terrible irony at the heart of the Nicola Edgington case is that she was in fact a voluntary patient – she apparently wanted to be admitted. This may explain why she found it so easy to walk out of the unit during the admission process.
As psychiatrists with experience of this kind of case in the NHS we believe the opportunity to treat someone early in their illness is no longer there, and they have to become a risk to themselves or someone else, before they can now get a psychiatric bed.
As psychiatrists used to dealing with similar patients, we wonder if Nicola Edgington had had the same symptoms, but if their digitised records were not that she had previously killed her mother – even if she was equivalently dangerous and with the same psychotic symptoms – we wonder if the system would have the capacity to admit her. The lack of NHS mental health care provision means it’s often impossible to get proper attention if you are merely suffering – but not an immediate danger to anyone.
The search for psychiatric beds, in our experience of trying to admit patients in London, may extend across the whole of the South East of England. Even when a bed is eventually located – because someone will have to be discharged (or sent on emergency leave) in order to liberate that bed – usually you are merely bringing someone in who is a danger to themselves or others and sending someone else out who has only marginally recovered from that self-same predicament.
Community Psychiatrist Professor Peter Tyer from Imperial College London, quoted data in an article in the British Medical Journal in 2011, that the suicide rate in the first 28 days after discharge from psychiatric hospitals is over 200 times greater for men and over 100 times greater for women than that for the general population. Suicide rates are meant to be declining in the general population but the rate after discharge from a psychiatric unit still remains too high. Precipitate discharging from NHS units probably contributes to this, Professor Tyer argues.
Doctors are also marginalised in care of patients – occupational therapists, nurses, social workers – there are any number of different ‘case workers’ you will be allocated to in your hazardous expedition into NHS mental health care, but encountering someone who went to medical school gaining scientific expertise in psychological problems, is becoming impossible.
The media seems to believe that doctors hold all the power in the NHS, and therefore hunt for a physician to blame when tragedies such as the Edgington case hit the headlines.
A large team of psychiatrists recently wrote an article entitled ‘Wake-up call for British psychiatry’ in the British Journal of Psychiatry, where they referred to the ‘downgrading of medical aspects of care’ in the NHS.
We believe they are agreeing with us; even if you are becoming severely unwell, you get at best in the modern NHS what is referred to as ‘non-specific’ psychological support (ie tea and sympathy) rather than proper medical care.
Doctors have not been in charge of NHS psychiatric care for some time now. Bureaucrats and managers, who never seem to be in the firing line despite scandal after scandal in NHS care, need to be held more accountable.
Because in terms of the poor management we witness, the lunatics have taken over the asylum.
David James is a Consultant Forensic Psychiatrist and partner in Theseus Partners LLP, and specialises in stalking and the assessment and management of threat to prominent individuals. He has worked as a consultant in the National Health Service since 1992 and was formerly a Senior Lecturer in Forensic Psychiatry at University College, London. He is the co-ordinator of the first joint police and NHS unit, which assesses and manages risk to politicians and senior members of the Royal Family from isolated loners. He was written more than fifty articles in peer-reviewed journals and 14 book chapters. He has given more than 100 presentations to international conferences, in three languages.