Independent Forensic Mental Health Review: interim report

7 Populations of particular interest

7.1 Women

The Forensic Network's Inpatient Census reported 65 female inpatients receiving forensic services in November 2018. There was widespread agreement that current arrangements for women's forensic care in Scotland are inadequate and that there is a lack of 'joined-up thinking' and coordination at both national and local levels. The lack of high secure provision for women within Scotland is seen as unacceptable. Discharge planning for women is particularly challenging because of the lack of agreed pathways for access to low secure, rehabilitation and discharge into the community. There are also fewer opportunities for 'testing'. There was a broad consensus that this gender inequality is a human rights concern. People wanted parity of provision for men and women that ensures consistency in security but acknowledges differences in needs. Most people supported the provision of discrete services for women.

People felt there is need for a national strategy or nationally commissioned forensic services for women, with agreed pathways in and out of secure care and service-level agreements defining working relationships between NHS Boards. Working with NHS Board Executives, the Forensic Network review of the female pathway in 2019 made recommendations that included exploring the possibility of a co-located high secure development, the development of single sex accommodation in the Orchard Clinic and for NHS Boards to work regionally to determine the best solutions for low secure provision for women.^[12]

7.1.1 High secure provision

There is no high secure provision for women in Scotland. Women needing high security care and treatment are referred to Rampton Hospital in Nottinghamshire. That referral pathway is challenging. It includes different legislatures, delays in accessing placements and difficulties repatriating people moving back down security levels. All these challenges detract from delivery of care. Transfer to Rampton is not available to women who are on remand awaiting court proceedings as they are not allowed to be transferred outside Scotland. They are therefore unable to access high secure care.

Women in need of high secure care may inappropriately remain in – or be admitted to – medium security units. This places additional pressure on medium secure facilities because of the heightened risk of violence and aggression and the staffing levels required to support prolonged enhanced observations.

There was agreement that high security provision should be made available for women within Scotland. There is a lack of consensus around how this should be offered. Some people support the Forensic Network report's recommendation to co-locate of women's high secure facilities within existing medium secure units. Others voiced concerns about the time and costs that this would involve. An alternative suggestion proposed was re-opening female high secure beds at The State Hospital.

7.1.2 Access to medium and low security

There is a shortage of women's beds at medium and low security. Women's experiences of secure care in Scotland were characterised as involving frequent transfers between inpatient locations. Medium secure beds are available for women in NHS Lothian (in the Orchard Clinic) and NHS Greater Glasgow and Clyde (in Rowanbank). These can be purchased by other areas on a 'spot purchase' basis but these arrangements are dependent on a bed being available. All the medium secure female beds are within mixed wards: the Orchard Clinic ward is mixed-sex and Rowanbank's ward accommodates women with mental illness and learning disability.^[13]

7.1.3 Inappropriate, independent or out of area placements

Lack of local low secure forensic provision for women means that women are more likely to be placed in services which do not best meet their care needs or do not aid their recovery, such as IPCUs. It also prevents those other services from being used for their intended purpose. In addition, it increases the reliance of NHS Boards on independent or out of area provision. Out of area placements, especially in independent provision, are reported to be more common for women, placing them further away from their social networks. In one area, the development of a secure female ward has allowed women to be brought back into area from independent provision.

Women's accommodation in secure 'mixed wards' is a source of concern for some. There were requests for discrete services for women on a variety of grounds, including the different care needs of women.

7.2 People with learning disabilities

The Forensic Network's 2018 census of people accessing forensic services identified 78 people with a learning disability and seven with a learning disability and a mental illness. The Scottish Government recorded 55 people on a forensic learning disability ward in 2019.^[14]

People with learning disabilities are small in number within the forensic system but their needs are highly complex. They have different needs to the general forensic population including different presentations and co-morbidities. Meeting these needs requires significant coordination across health, social care and criminal justice professionals. Speech and language therapy and advocacy support is also important to ensure the voice of this population is heard, allowing their wishes and needs to be met.

It was reported that there is an 8% vacancy rate in Learning Disability psychiatric posts. Further concerns were raised about the low number of people taking up trainee places and the lack of a specific forensic learning disability curriculum.

There were calls for more consistent provision of forensic learning disability services in order to improve standards within inpatient and community services. It was also felt that forensic learning disability services would benefit from having closer links with forensic services in general.

The Independent Review of Learning Disability and Autism in the Mental Health Act (IRMHA) recommended that existing low, medium and high secure forensic wards and units for people with a learning disability should become 'habilitation' units.^[15]

7.2.1 Hospital provision

Capacity issues across the wider forensic estate are replicated for learning disability hospital beds. It was reported that there are often no beds available to admit urgent cases. High and medium secure provision for men is provided on a national basis and is nearly always full. Lower secure care is variable across Scotland and can sit within either mental health or learning disability structures. Some areas operate regional or local low secure purpose built units. Others are working with locked wards that do not meet low secure standards.

There are significant gaps in forensic provision for women with learning disabilities. One staff member questioned the appropriateness of women with learning disabilities being in the forensic system at all.

There is no high secure provision for women with a learning disability and only four medium secure beds. There is no specialist forensic low secure service. As a result, women with a learning disability tend to be treated in IPCUs, general mental health wards or independent provision. If a woman does have high secure needs, specialist provision in England or bespoke arrangements have had to be made, both at a high cost to the Boards.

People expressed concern that people with learning disabilities spend longer in hospital. It can be harder for them to demonstrate that their risk has lowered and many experience severe delays while awaiting suitable accommodation in the community. The review was told of someone who has been waiting for eight years, and that one ward could be closed if everyone who was ready for discharge had a place to go to. One person who had been waiting on a place since 2016 said they 'just wanted out'. The IRMHA noted that delays in discharge for people with learning disabilities may amount to a breach of their human rights.^[16] Delays in discharge also mean that beds are not available for people with learning disabilities when they need to step-up from the community. The result is that they are placed in general wards. People said this population can be vulnerable when inappropriately placed in mental illness forensic wards and general wards.

7.2.2 Community provision

Community management for people with learning disabilities helps to widen people's social networks, minimises negative peer influence and offers opportunities to gradually reduce supervision levels. There was a feeling that there are insufficient forensically aware community services for people with learning disabilities. As in mental health, people with learning disabilities have difficulty moving from forensic community services back into general community care.

Forensic learning disability community services vary across Scotland. Community services, in the main, are part of learning disability services rather than forensic mental health. However, some do have separate specialist forensic teams. Staff highlighted that people with learning disabilities in the community were more likely to be provided with general services and interventions than specialised forensic ones. Co-located, dedicated multi-disciplinary community forensic learning disability teams were felt to improve the pathway between inpatient and community forensic services.

There is a lack of community accommodation and support packages to meet the needs of people with learning disabilities. In some areas, suitable accommodation simply does not exist.

A good relationship must be developed with the 'right' support worker in order to support successful and long-term community discharge. Staff spoke of support packages breaking down because a community support worker was not sufficiently skilled or empowered to manage difficulties that may only have been temporary, resulting in people being recalled back to hospital. It was also highlighted that people who receive 24 hour supervision can find it intrusive or experience increased loneliness. This happens because the constant presence of support staff reduces opportunities to make new connections, leading to greater dependence on care.^[17] There are calls for more creative solutions to meet people's needs.

7.2.3 Criminal justice

People with learning disabilities who spoke about police interviews said that the environment was intimidating. Having consulted with lawyers prior to the interview, they spoke of having trouble retaining the information during the actual interview. One person had been unclear what the role of their Appropriate Adult (AA) was in the interview and did not feel they had helped them. By contrast, another spoke positively of an AA who was engaged, took time to build rapport and supported them to advocate for their own needs. They felt that it was important that an AA was proactive. In most areas, AAs no longer support witnesses or the accused in court. The proposals to create a statutory AA service do not suggest that they should.

People with experience of court proceedings, and staff teams that work with them, said there are gaps in the support available for people in court. Support is needed to help people understanding the proceedings and the consequences of sentencing decisions. People recommended more staff training to address these gaps, as well as mechanisms to help courts identify people who need additional support. A number of people with a learning disability felt they could have stood trial if they had received more support. They also felt that this would have been a preferable option that would have seen them return to the community sooner. People raised concerns that the threshold for people with a learning disability being sent to hospital for offences is lower than that for the general population.

7.3 People with neurodevelopmental disorders

The only neurodevelopmental disorder people spoke about was autism spectrum disorder. There were reports of increased numbers of people with autism coming into contact with criminal justice. Identifying autism during police and court processes can be difficult, which can result in failures to provide an AA. The review was told that for a person with autism to receive just outcomes, people interviewing them need to be aware that they could have verbal fluency exceeding comprehension; speed of processing and working memory deficits; a desire to please and conform to authority; and poor emotional control when under stress. False confessions are also among the dangers of failing to identify autism when someone is in police custody.

There are no central reports currently available to say how many people with autism are receiving care and treatment in the forensic system. There is, however, a known lack of specific provision and forensic pathways for people with autism. Forensic services are mainly set up for those with a mental illness or learning disability.

Most staff groups acknowledged a lack of expertise about autism. Psychologists do have the necessary skills and use these to assist with risk assessments and treatment plans in inpatient, community and criminal justice settings.

The family members of one person with autism within the forensic system said that their relative received good medium secure care but that the 'staff had to learn fast' about autism. They highlighted the particular importance of involving family in discussions about care and treatment of people with autism as they can be the person's 'emotional voice'. The same family members expressed disappointment in the level of care provided in the community as it has not delivered what was promised. One parent spoke of her decade-long struggle to get her son appropriately diagnosed prior to his subsequent decline into drug addiction, leading to a custodial sentence.

7.4 Children and young people

There is a lack of access to general or forensic mental health services for children and young people in conflict with the law. In the community, NHS Greater Glasgow and Clyde is the only Health Board with a Forensic Child and Adolescent Mental Health Service. Young adults and their family members feel that some of the problems that they are experiencing now are the result of not getting appropriate help when they were younger.

Specific concerns were raised about the unmet mental health needs of young people in secure care. The in-reach of general Child and Adolescent Mental Health Services to secure care was reported to be variable. There can also be tensions and disputes across Health Board and local authority boundaries in relation to the funding and provision of secure care.

Mental Welfare guidelines on the admission of people under 18 to general adult wards are applied to forensic mental health services.^[18] In general, no one under 16 should be admitted and the admission of young people aged between 16-18 should be exceptional. Consideration of admitting anyone under 18 to higher secure settings requires particular scrutiny and national oversight. The lack of low secure inpatient care can result in young people being placed in adult IPCUs. Young people requiring medium secure care, including those with learning disabilities, are currently placed in specialist provision in England. There are concerns that out of area provision can lead to a breakdown in young adults' support networks.

Plans for a secure National Adolescent Secure Inpatient Service for Scotland have been approved. It will be located within NHS Ayrshire and Arran and provide care and treatment for male and females up to the age of 19. However, one person suggested no one under 25 should be placed in an adult medium secure unit. People also questioned whether the planned 12 bed facility will be sufficient to meet current needs.

Difficulties were highlighted around provision of court reports when a child is remanded in secure care outwith their home area. The review of mental health services in HMP YOI Polmont indicated that greater inter-agency communication and information exchange is needed around young people in the criminal justice system, including those transitioning into and out of secure services.^[19]

7.5 Older adults

The Scottish Government's Inpatient Census found 9% of people receiving forensic services in NHS Scotland facilities in March 2019 were 65 or older.^[20] The forensic population is ageing and there is an increase in older adults entering the system as a result of historic offences. There is no upper-age limit for admission to forensic services, nor is there a distinct older adult forensic services or an older person's forensic pathway. Decisions on whether to admit people over 65 to forensic wards are made by adult and forensic services on a case by case basis.

The forensic population faces difficulties associated with old age comparatively early. Staff have a desire to 'get ahead of the game' to prepare for age-related needs. Forensic units are not currently set up for an ageing population and people felt that consideration should be given to creating special wards or units for this group. It was suggested that the needs of this population may overlap with those of some elderly prisoners and that a national or regional approach may be required.

Staff in the forensic system acknowledged their lack of expertise in recognising and dealing with issues associated with old age such as dementia, frailty, and hearing loss. They identified a growing need to understand how these issues relate to effective risk management strategies. The lack of expertise leaves a gap in information available to MAPPA, which affects its ability to plan for this population and their needs in the community. People also raised concerns that dementia is not picked up early enough by police or social work in the community and that, even if it was, there would be no healthcare pathway to address it.

Older adults can remain inappropriately placed in secure settings due to a lack of alternative provision. The risk or stigma associated with forensic services makes it difficult or inappropriate to return this population to general services or nursing homes in the community. In some cases, people have been placed in specialist provision in England.