Forensic Inpatient Services Research Articles

Far from Home: Women’s Experiences of Being in Secure Forensic Inpatient Services

Specialist secure mental health inpatient service provision for women in England and Wales is limited, and beds are often commissioned in out-of-area services to meet their mental health and risk management needs. In North Wales, there are no NHS beds for women at any secure level, and most women are placed out-of-area in South Wales or England. The current study aimed to explore the experiences of women from North Wales who had resided in out-of-area secure inpatient services, using Interpretative Phenomenological Analysis (IPA) methodology. Participants described the challenges that they and their families experienced when in services at a great distance from their home areas. Services responded to women’s expressions of distress with restrictive interventions, including physical restraint and seclusion, exacerbating their sense of isolation. Participants voiced a desire to return home and viewed returning to Wales as indicative of progress they had made. This is thought to be the first study involving women from across the secure pathway, from high secure to the community. The findings are explored in relation to existing literature and study limitations are discussed.

Diabetes Care in the Psychiatric Inpatient Setting: A National Survey of Mental Health Professionals Knowledge, Attitudes and Skills

AimsPeople with Severe Mental Illness (SMI) are at increased risk of developing diabetes. There is currently a lack of monitoring and standardisation of diabetes care in the NHS psychiatric inpatient setting. This presents as a missed opportunity, as inpatient admission could be used to improve diabetes care for this population. We surveyed the multi-disciplinary teams in psychiatric inpatient units across England to develop understanding of current diabetes care in this setting.MethodsA 13-item questionnaire was designed to assess the knowledge, attitudes and skills relating to diabetes care. This was piloted via think out loud interviews with 5 staff at a Forensic unit. Amendments were then made to the questionnaire to improve the validity prior to national roll-out.Site coordinators working within General Adult, Old Age, Rehabilitation and Forensic inpatient services were recruited via medical education and academic links. This included 19 inpatient sites within 11 NHS Mental Health Trusts across England. Site coordinators circulated the questionnaire, primarily via electronic survey. A small number of paper responses were also collected.Results156 responses were collected via the national survey (electronic = 136, paper = 20). 6 responses were excluded due to missing professional role information or roles not involving physical healthcare. Respondents included within the analysis comprised 43 Doctors, 55 Nurses and 52 Allied Healthcare Professionals.93% of respondents agreed that addressing physical health needs was an important part of the mental health team's role, although only 28% had received physical healthcare training within the last 12 months.68% agreed that they had adequate skills and knowledge to manage diabetes safely on the ward. 69% agreed that the diabetic care on the ward was of an acceptable standard according to National Institute for Health and Care Excellent (NICE) guidelines. This reflects a need for appropriate training and guidance to help improve this aspect of care.Additionally, only 51% agreed that they felt able to refer a patient with diabetes to the most appropriate diabetes service based on type of diabetes and medication prescribed. This highlights an important issue, as cohesive shared-care and clear referral pathways are key when considering effective diabetes management.ConclusionPsychiatric inpatient admission could be used opportunistically to improve the healthcare disparities for people with comorbid diabetes and SMI. This national survey highlights key areas that would need to be addressed to standardise and optimise diabetes care in this setting. This includes appropriate training, clear guidelines and cohesive shared-care pathways.

The efficacy of offence-specific interventions in reducing risk and recidivism in women: a systematic review

ABSTRACT Almost a quarter of women released from prisons in England and Wales reoffend; this figure is three times higher for women serving less than 12-month sentences. Offender programmes used within prison, probation, and forensic inpatient services aim to reduce an individual’s risk of reoffending. Whilst offence-specific interventions are widely offered to men who offend, comparatively few are offered to women. The current systematic review aimed to evaluate the efficacy of offence-specific interventions in reducing women’s recidivism. Overall, recidivism in programme completers was low (m = 14.05%). However, the quality of studies included (n = 7) was low, limiting the conclusions drawn. Several studies yielded met the inclusion criteria, with the exception of reporting recidivism outcomes. A second review was conducted incorporating these studies, broadening the outcomes of interest to include incidents of violence in hospital or prison and self-report outcomes related to offending (n = 10). Incidents reduced following programme completion; however, self-reported outcomes were mixed. The review highlighted a lack of evidence for the efficacy of offence-specific interventions facilitated with women and limited use of recidivism as an outcome measure within the literature, despite often being a key aim of the interventions.

Intensive Use of Forensic Inpatient Services by People with Intellectual and Developmental Disabilities in Ontario, Canada: Prevalence and Associated Characteristics

People with intellectual/developmental disabilities (IDD) are reportedly intensive users of forensic inpatient services. Using administrative data, we identified people with and without IDD in forensic inpatient settings in Ontario, Canada over a ten-year period. We compared them on sociodemographic, clinical, and admission characteristics and post-discharge healthcare use to explore factors that could account for differences in forensic inpatient resource use. The prevalence of IDD in forensic inpatient settings was 16.7% (vs. 0.8% population prevalence). Those with IDD did use forensic inpatient services more intensively (more historical forensic admissions, longer lengths of stay, greater staff frustration). There were, however, few differences between forensic inpatients with and with IDD in their baseline sociodemographics, upon admission, during their index forensic episode, or in accessing post-discharge healthcare services. The only differences were that those with IDD had higher percentages of forensic inpatient episodes under review board (ORB) supervision and of delayed discharge from hospital in the year post-forensic-discharge. These findings are more consistent with system-level than individual-level explanations and suggest that increasing forensic inpatient and community-based resources for individuals with IDD may be critical for reducing the intensity of their forensic inpatient use and increasing the likelihood of successful transition to the community.

“My Kids Will Always Be around Me, if Not Physically, Spiritually They Will Always Be around Me”: Fathers in Forensic Inpatient Care

ABSTRACT The current study aimed to increase understanding of men’s experiences of fatherhood in forensic inpatient care; a population overlooked in research and at risk of neglect in clinical practice. Eight participants recruited from forensic inpatient services were interviewed. Data was analyzed via social constructivist Grounded Theory. The central psychological concept developed was that of paternal connection, reflecting a transient sense of connection to the father-child relationship. Core categories included 1) Psychological Processes, 2) Interpersonal Relationships, and 3) Institutional Organization. Fathers in forensic inpatient care experience dynamic psychological connectivity to their paternal relationship, regardless of child contact. This multi-layered experience requires responsive intervention to support fathers in this context. Recommendations for research, practice, and policy are outlined.

Annual physical health checks within a forensic inpatient service

AimsPatients prescribed antipsychotics are at risk of ill effects to their physical health. Our aims were to assess whether inpatients within a forensic service, on antipsychotic medications, were receiving annual physical health monitoring in accordance with current NICE and SIGN Guidelines. Based on these Guidelines the following objectives were identified: 1: Physical examination, BMI and blood pressure recorded within the past year2: FBC recorded within the past year3: U&Es recorded within past year4: LFTs recorded within the past year5: HbA1C / random glucose / fasting glucose recorded within the past year6: Random lipids / fasting lipids recorded within the past yearMethodInclusion Criteria: Patients admitted for longer than a year currently prescribed an antipsychotic.Data were collected cross-sectionally on 24/7/20 for all inpatients meeting the inclusion criteria. Medical notes and the blood results system were reviewed for results of any annual physical examinations and blood monitoring over the past year.Anonymized data were analysed using Excel.Result13 out of 17 inpatients fulfilled the inclusion criteria. Of these 13 inpatients, 9 (69.2%) were prescribed clozapine, 1 (7.7%) zuclopenthixol, 1 (7.7%) paliperidone and 1 (7.7%) amisulpride.All patients had BMI and blood pressures recorded within the preceding month. Only 1 patient (7.7%) had an annual physical health examination within the past year.Findings for bloods taken within the past year were as follows:12 patients (92.3%) had an FBC recorded9 patients (69.2%) had U + Es recorded9 patients (69.2%) had LFTs recorded11 patients (84.6%) had HBA1c recorded7 patients (53.8%) had lipids recordedConclusionThere is scope for improvement with both annual physical examinations and blood monitoring.All patients had regular BMIs and blood pressure recorded which is largely attributable to nursing staff protocols. Low compliance with full annual physical examination could be explained by there being no local system in place for annual physical health checks and also frequent changes in junior doctor ward cover.Blood monitoring showed variable compliance with established standards. FBC monitoring had the best compliance, likely because the vast majority of our patients are prescribed clozapine, which necessitates minimal monthly FBC monitoring.This audit was presented to the Forensic Team and thereafter it was agreed for a local system to be put in place for annual physical health checks in the summer each year. This will improve oportunities to optimise our patients health. We plan to re-audit at this time.

Families, carers and friends support group in a forensic inpatient mental health service: A new format of carer support

The benefits of involving carers who support those with a severe mental illness have long been recognised in improving patients’ outcomes and reducing the cost of care. Despite various mental health standards requiring services to offer support to carers and involve them in patients’ care and treatment, not much guidance is offered on how this support and involvement can be implemented, especially in forensic inpatient services, where carers are reported to experience elevated stress levels compared to non-forensic carers. This paper outlines a new format for delivering carer-centred, co-produced support groups, based on an integrated approach. In addition, the authors present a focus group evaluation of the family, carers and friends support group for forensic inpatients with severe mental illness.

Predicting time to recall in patients conditionally released from a secure forensic hospital: A survival analysis

BackgroundThe recall of conditionally discharged forensic patients in England is a formal order from the Ministry of Justice under the Mental Health Act (1983) which has the power to revoke conditional release and direct readmission to hospital. Recall has significant implications for the individual and for hospital services, but despite this, little is known about predictors of recall for forensic patients. MethodsWe examined the rate of recall for 101 patients conditionally discharged from medium secure forensic inpatient services between 2007 and 2013. Demographic, clinical, and forensic factors were examined as possible predictors of time to recall using Cox regression survival techniques. ResultsConditionally discharged patients were followed for an average of 811 days, during which 45 (44.5%) were recalled to hospital. Younger age (HR 1.89; 95% CI 1.02–3.49; p = 0.04), non-white ethnicity (HR 3.44; 95% CI 1.45–8.13), substance abuse history (HR 2.52; 95% CI 1.17–5.43), early violence (HR 1.90; 95% CI 1.03–3.50), early childhood maladjustment (HR 1.92; 95% CI 1.01–3.68), treatment with a depot medication (HR 2.17; 95% CI 1.14–4.11), being known to mental health services (HR 3.44; 95% CI 1.06–11.16), and a psychiatric admission prior to the index admission (HR 2.44; 95% CI 1.08–5.52) were significantly associated with a shorter time to recall. Treatment with clozapine reduced the risk of recall to hospital (HR 0.40; 95% CI 0.20–0.79). ConclusionsTime to recall can be predicted by a range of factors that are readily available to clinical teams. Further research is required to determine if targeted interventions can modify the likelihood or time to recall for conditionally released forensic patients.

In search of a family: The contribution of art psychotherapy to a collaborative approach with a man residing in a forensic learning disability setting

Accessible Summary Some clients in learning disability services have problems in their relationships with people. Some clients with learning disability have broken the law and live in hospital. For clients in hospital, treatment can be learning about managing behaviour, feelings and relationships. This treatment is given by different professionals. This treatment is important to help stop these clients getting into trouble with the police again. An important part of treatment is to help clients understand their experiences in relationships. This case study is about Oliver, and how psychologists and an art therapist worked together to help him.​ AbstractBackgroundClients with attachment issues are over‐represented in learning disability services. Forensic inpatient services are no exception. Treatment pathways comprise multidisciplinary interventions, and skills‐based treatments are considered vital to recovery and maintenance of prosocial and adaptive behaviour and reduction in risk. An important aspect of treatment is the psychological intervention to enable clients to understand their early experiences and the way this may have impacted on later relationships and behaviour. Without exploring the difficult early lives that many clients in forensic inpatient services have experienced, skills‐based treatments and attempts to facilitate discharge may not be effective.Materials and methodsThis case study presents the theoretical background of attachment, autism, learning disability and sexual offending that informed the collaborative multidisciplinary psychological treatment offered to one man with learning disabilities and autism in a secure forensic setting.ResultsThe introduction of Art Psychotherapy enabled the client to explore his history and the potential internal barriers to his therapeutic progress. Issues of safety and belonging, previously unexplored with this man, were uncovered and these themes were incorporated into his risk formulation and treatment plan.ConclusionsThe paper reflects on the specific contribution of Art Psychotherapy in specialist services, and the importance of the collaborative relationship between the Art Psychotherapist and the ward Multi‐Disciplinary Team.

Essential elements of treatment and care in high secure forensic inpatient services: an expert consensus study

Purpose – The evidence base for what works with forensic patients in high-security inpatient settings has typically focused on outcome research and not included clinical expertise from practice-based experience, which is an important facet of evidence-based practice. The purpose of this paper is to establish whether experts with clinical and/or research experience in this setting could reach consensus on elements of high-security hospital services that would be essential to the rehabilitation of forensic patients. Design/methodology/approach – A three-round Delphi survey was conducted to achieve this aim. Experts were invited to rate agreement with elements of practice and interventions derived from existing research evidence and patient perspectives on what worked. Experts were also invited to propose elements of hospital treatment based on their individual knowledge and experience. Findings – In the first round 54 experts reached consensus on 27 (out of 39) elements that included physical (e.g. use of CCTV), procedural (e.g. managing restricted items) and relational practices (e.g. promoting therapeutic alliances), and to a lesser extent-specific medical, psychological and social interventions. In total, 16 additional elements were also proposed by experts. In round 2 experts (n=45) were unable to reach a consensus on how essential each of the described practices were. In round 3 (n=35), where group consensus feedback from round 2 was provided, consensus was still not reached. Research limitations/implications – Patient case complexity, interventions with overlapping outcomes and a chequered evidence base history for this population are offered as explanations for this finding alongside limitations with the Delphi method. Practical implications – Based on the consensus for essential elements derived from research evidence and patient experience, high-secure hospital services might consider those practices and interventions that experts agreed were therapeutic options for reducing risk of offending, improving interpersonal skills and therapeutic interactions with patients, and mental health restoration. Originality/value – The study triangulates what works research evidence from this type of forensic setting and is the first to use a Delphi survey in an attempt to collate this information.

Coping with stress: the experiences of service-users with intellectual disabilities in forensic services

Purpose – It is now widely acknowledged that stress negatively impacts holistic and well-being and has been identified as a major global concern. The purpose of this paper is to report on a qualitative research study which sought to explore the experiences of stress and the use of coping strategies from the perspective of people with intellectual disabilities (ID) currently residing within the forensic in-patient services of one National Health Service Trust. Design/methodology/approach – Data were gathered via focus group discussions involving 20 service-users with an ID. The data were subject to thematic analysis. Findings – Data analysis produced three key themes: experiencing stress; sources of stress and coping with stress. Practical implications – The findings of the research study have implications for practice. These include the need to utilise appropriate stress assessment measures and implement effective stress reduction and management programmes to address the holistic needs of people with ID, to ensure forensic services are truly high quality, person-centred and recovery focused. Originality/value – Whilst stress experienced by people with ID residing in community settings has been explored, no studies have focused on how stress is experienced by people with ID residing in forensic services. This paper seeks to address this gap in the literature.

Improving the detection of detainees with suspected intellectual disability in police custody

Purpose – The purpose of this paper is twofold. First to ascertain the efficacy of current police reception screening to detect detainees with intellectual disability (ID). Second to assess the validity of a short targeted screen for ID among police custody detainees. Design/methodology/approach – The study comprised three stages. First, 248 police custody detainees were assessed for a range of health morbidities, including a pragmatic clinical evaluation of ID. For those with suspected ID, the police custody screens were scrutinised for evidence that this had been detected. Second, a new police health screen, incorporating a short screen for ID, was piloted. Totally, 351 detainees were assessed in the same way as in part 1 with the new screens being scrutinised for evidence that ID had been detected where relevant. Third, the new police screen for ID was validated among a sample of 64 inpatients, some with ID and some without, from forensic inpatient services. Parts 1 and 2 were carried out in the Metropolitan Police Service, London. Part 3 took place in one NHS Trust. Findings – In parts 1 and 2, the rate of detainees with suspected ID was 2-3 per cent. The standard police screen detected 25 per cent of these detainees in part 1. When the new screen was introduced in part 2, the sensitivity for ID increased to 83 per cent. However, there was no requisite improvement in the proportion of detainees with ID receiving an Appropriate Adult. In the inpatient study, the new screen showed a good level of sensitivity (91 per cent) and reasonable specificity (63 per cent). Practical implications – It is possible to improve the detection rate of detainees with suspected ID by introducing a short ID screen into the police custody officers’ reception health screen. Originality/value – The Health Screening of People in Police Custody (HELP-PC) study is a project evaluating screening for health morbidity among police custody detainees. Other data from this study have been reported elsewhere, but this is the first time the data pertaining to ID screening has been reported in detail.

Characteristics of female patients admitted to an adolescent secure forensic psychiatric hospital

Bluebird House is the only mixed gender NHS secure forensic psychiatric hospital for adolescents in the South of England. It has admitted more than 30 female patients since the service opened in 2008. The admission criteria are that patients must be detained under the Mental Health Act and present evidence of being a risk of harm to others. This article describes the clinical characteristics of 30 consecutive female patients admitted to a highly specialised adolescent forensic inpatient service. Key results include a very high rate of incidents of risk behaviours exhibited by female patients within the unit but good clinical outcomes. The majority of patients had severe symptoms of mental disorder, especially emotional instability, self-harm behaviours and aggressive behaviours. Few had diagnoses of mental illness. Assessment findings from the Millon Adolescent Clinical Inventory and the Structured Assessment of Violence Risk are discussed, as are parallel with studies from other female secure services.

The Quality in Psychiatric Care-Forensic In-Patient Staff (QPC-FIPS) instrument: Psychometric properties and staff views of the quality of forensic psychiatric services in Sweden

The aim of the present study was to evaluate the psychometric properties and dimensionality of the instrument Quality in Psychiatric Care-Forensic In-Patient Staff (QPC-FIPS) and to describe the perceived quality of psychiatric care among forensic inpatient service staff. A sample of 348 forensic inpatient staff from 18 forensic wards in Sweden participated in the study. A confirmatory factor analysis revealed a seven-factor structure with item loadings > 0.50 on expected factors, indicating adequate psychometric properties. The staff’s ratings of quality of care were high, 94% being positive. The highest ratings were found for the secluded-environment dimension and the lowest for the secure-environment dimension. Several factors influenced the ratings of quality of care, for instance, staff’s time to perform their duties and staff’s age. It is concluded that the QPC-FIPS can give valuable information about staff’s perceptions of the quality of care provided at inpatient forensic psychiatric care services, which can be used to identify areas for quality improvement. Use of the QPC-FIPS is an easy and inexpensive way to evaluate quality in forensic inpatient care, preferably in conjunction with the QPC-FIP instrument developed for forensic inpatients and covering the same items and dimensions.

A Critical Analysis of Clinical Evidence from High Secure Forensic Inpatient Services

High-secure forensic inpatient hospitals serve important functions in the detention and rehabilitation of people with serious mental health needs who present as a risk to society. Establishing whether services are effective in restoring mental health and reducing risk is an important task, but one that has not been systematically undertaken. A systematic review of outcome evidence from this setting was therefore conducted to establish its scope and quality. Evidence was found from 22 studies for nine different interventions targeting multiple and overlapping outcomes, which included recidivism, mental health, aggression, social functioning and quality of life. Studies were commonly assessed as being at a potentially high risk of bias from validity threats. The ‘best’ available evidence was for medication, psychoeducation and third-wave cognitive-behavioral interventions. Clinical implications are tentatively offered given the narrow focus of the review on high security. Directions for the high-secure services research agenda are more definitively proposed.

Mentoring within a high secure forensic inpatient service: Service user perspectives on developing a mentor service

Bettina was supervised by Dr Emily Glorney (University of Surrey), Dr Estelle Moore (Broadmoor Hospital), and James Tapp (Broadmoor Hospital).

Cultural sensitivity in forensic services: findings from an audit of South London forensic inpatient services

This paper summarises the key findings from an audit using the Cultural Sensitivity Audit Tool for Mental Health Services (The Sainsbury Centre for Mental Health, 2001) to evaluate the views of service-users and staff in a South London Forensic Inpatient Service. Forty-one service-users and 47 members of staff working in the service took part in the audit. Staff completed the tool as a questionnaire, and service-users were interviewed. The majority of staff believed that black and minority ethnic patient groups were over-represented in the service, and many attributed this to misunderstandings of culture. Staff identified gaps in their training on race and culture; none of the staff believed they had received all the training required. Nevertheless, service-users highlighted culturally sensitive and effective aspects of the service, and many believed their cultural needs were understood. Given this disparity, the authors question whether the large emphasis on the cultural sensitivity of services is something service-providers are more concerned about than our service-users; and whether a greater focus on service quality, of which cultural sensitivity is one aspect, would be more helpful.

Staffing of Forensic Inpatient Services in the United States

Data on patient census, bed capacity, and staffing levels in state-operated forensic psychiatric inpatient programs in 1986 were collected from forensic mental health directors of the 50 states and the District of Columbia. Of the 75 programs identified, 54 were based in units within larger psychiatric hospitals and 21 in freestanding hospitals. For all programs, direct-care staff-patient ratios ranged from .35 to 4, with a mean of 1.3. The ratio of filled beds to bed capacity ranged from .5 to 1.54, with a mean of .95. Nearly a fourth of the programs were over capacity. A negative relationship between filled-bed ratios and direct-care staff-patient ratios was found.