Mr. Butler was essentially a law-abiding citizen, capable in the past of impressive personal achievement, notably being the first employee of Rolls Royce from his ethnic background and someone who retained demonstrable skills in engineering draftsmanship.
24.3 The team was unaware that neighbours were concerned at anti-social behaviour on the part of Mr. Butler.
The team did not make any contact with neighbours.
While there are difficulties with regard to disclosure of confidential sensitive personal and clinical information,
there is no reason why some form of contact with neighbours cannot be fostered, particularly in the case of a service user who is socially isolated.
25.4 The result was a focus on a medical model of care rather than a social one and a failure to devise exit strategies and targets for each service user.
They did not seek out new ways of tackling difficult cases such as Mr. Butler?s.
They failed to make sufficient time to discuss patients about whom they felt little cause for concern
and concentrated to their effective exclusion on the rest. Once a service user had fallen into the lowest category of case, it was unlikely that subtle signs of deterioration would be picked up.
25.5 The emphasis was on the delivery of medication as opposed to seeking out support measures which might have encouraged Mr. Butler to engage more with services and the community.
25.7.6 Mr. Butler?s desire to study and to return to work was never highlighted in a care plan.
26.3 The care plan did not contain any effective strategy for reducing Mr. Butler?s social isolation.
26.4 It is not clear that sufficient was done to support Mr. Butler in attempts to obtain training places or employment.
26.5 The team acquiesced in Mr. Butler?s desire for privacy without taking into account the possibility that this amounted to a wish to disengage and an indication of relapse.
26.6 There is no evidence that the needs of Mr. Butler?s brother were considered.
The team did not engage with Mr. Butler?s neighbours.
Such contact is possible without compromising confidentiality and provides opportunities for obtaining information which the community are often willing to offer
All these issues need to be addressed collectively rather than for individuals to be singled out. To do the latter would, we think, be unfair to such individuals and unlikely to be productive in terms of ensuring a better standard of service in the future
In the end, however, we have come to the conclusion that these are more to do with a problem with the culture and practice within the team as a whole, abetted by a failure in management at all levels, as well as team supervision and review.
There is a public interest in patients being able to confide freely in medical advisers and mental health workers without fear that their disclosures will be published.
In order for publication to be justified those factors have to be outweighed by pubic interest factors such as the protection of public health.
That interest can include the protection of public confidence in the management of the health service, and allowing the public to know sufficient of the facts to enable them to judge whether the conclusions reached by an Inquiry such as this are justified.
The court [ Stone appeal ] held that the public had a “true public interest” in knowing what treatment and care were provided and to be able to reach an informed assessment of the failures identified.
As the judge put it:
The existence of potentially dangerous persons at liberty in the community affects the entire community.
That community has a reasonable and justified expectation that an Inquiry undertaken after such a high profile case as the present will be publicised in full, so that the public is not left in the dark (or in the shade)
about how it happened or left to speculate about the lessons that have been or should be learned and about the recommendations made, with a view to implementation, to reduce the risk of such occurrences in the future.
Such objectives are not met merely by circulating the report among health professionals.
Where public agencies are criticised the public have a right to know about it and an expectation of being able to consider the details.
13.4 Unhappily we suspect that many of the problems we have identified in this Inquiry are not confined to one Assertive Outreach Team in Birmingham and that there may be a case for a review of practice elsewhere.
Unless the report is published in full this benefit may be prejudiced.
13.5 If things have gone wrong in the provision of mental health services by the State, the public are entitled to know what went wrong and why it did so.
Given the policy of having inquiries after events such as this, there is a legitimate expectation that their reports will be published.
It is not necessary to disclose confidential information about a service user to make and exploit opportunities to obtain information from neighbours about him.
These neighbours were obviously used to calls from frustrated would-be official visitors of Mr. Butler.
It should not be thought objectionable or a breach of confidence to seek information.
Of course not all neighbours will be willing to divulge information, but in a case where they are being disturbed it might be thought that they would be unlikely to withhold it.
5.4 There is, of course, something potentially disturbing about state officials,
even if well intentioned ones employed by the National Health Service,
effectively encouraging neighbours to report matters of concern about another neighbour,
particularly where this is without the consent or knowledge of the subject of the Inquiry.
There is also the anxiety that in seeking information, the team member may be implicitly, if not explicitly, disclosing that the subject of the inquiry is a service user and, hence, someone with a mental health history.
The unfortunate stigma attached to such a status, however unjustified should not be ignored.
In a case such as Mr. Butler?s the need, in his and the public?s interests,
for the outreach team to be able to seek information from neighbours and other contacts in the community
should be considered as part of the discharge planning.
The service user?s understanding of the need for information
and consent for approaches to be made should be sought as part of the planning process.
Should the need for such approaches be apparent to the team, but not recognised by the service user,
that should be taken into account in deciding whether it is appropriate to discharge the patient at all, and, if it is,
where the balance of the personal right to privacy and the public interest in protection from risk and safeguarding of mental health lies.
If the balance is in favour of the team being free to seek information and, if necessary for that purpose to share information,
then they should document their reasons, and thereafter be free to seek information.
Should such action be included in a care plan without the service user?s informed consent, he should be told what is to happen, and of his rights in respect of the decision.
The team saw itself as being very experienced but thought that there were no formal opportunities for the team to have discussions about policies or procedures,
and although in principle there was supposed to be a weekly business meeting in practice it did not happen.
This This was mainly because of time over-running in the discussion about patients.
We knew that he tolerated, quite often reluctantly, our intrusion into his life and that, if we were too assertive, we would lose contact.”
“We can?t get a snapshot. There is not even a kind of summary statement about the patient… because all our patients have more than a 10 year history, and at least have five or six folders, so it is not easy to go through all these files. There is no summary statement anywhere.”
Mr. Butler?s brother was mentioned with some regularity during this time in the records.
Could a carer?s assessment have been appropriate? In relation to the Carer?s Act 1995 criteria, he may not have offered a ”substantial amount of care” but he may have had the “intention” of offering more had this been possible or accepted by Mr. Butler.
At any rate, his needs were not acknowledged and it is probable he would have found more information and support helpful.
The point is that this was not explored.
Working in the community can bring rare opportunities that are not predominantly available in other spheres of care delivery in mental health services, i.e. contact with the general public.
Such contacts cannot be under-estimated for the value they can contribute to the understanding of circumstances and can give a clear picture of the person cared for. Community care workers meet and greet neighbours with regularity, while maintaining confidentiality as to the nature of their identity and business. Nevertheless, these encounters can be critical to gleaning information which may be of benefit in the overall understanding of current circumstances.
In Mr. Butler?s case his neighbours were concerned about his activity at night as he could be heard walking around his flat and playing music into the early hours. In addition his previous history of aggression towards his neighbours should have given rise to anxiety and concern for their welfare.
The Assertive Outreach Team did not engage with Mr. Butler?s neighbours and so were not aware of their experiences of him as a neighbour. This was a missed opportunity for a more detailed understanding of his day to day living circumstances as well an opportunity to assess his mental health and to detect signs of deterioration/relapse.
CPN (C) told the panel:
…..if Mr. Butler had seen me talking to neighbours it would have increased his paranoia and probably have diminished the slight relationship that we had with him.
14. In view of these circumstances there is a need for staff to re-visit the area of confidentiality
and sharing information as set out in the draft Mental Health Act, Code of Practice
to ensure that confidentiality is not used as a means which prohibits gaining knowledge
therefore impacting on providing a comprehensive assessment and care package.
Professional care and treatment does go wrong.
These patient tragedies get an offical external Inquiry - into the standards in actual practice and the quality in delivery of service that was there - in the particular local Mental health Service and they issue a final public Report from their examination, as " Inquiry into the Care and Treatment of ...." that is the kind of service delivered to the patient who subsequently perpetrated a tragedy.
*** !!!212 Inquiry CP - wife killed -comment
They are the only national accounting of what went on within actual working practices in secondary mental health services [ not the what shpould be going on - we say that - but what was done ] in the public domain.
Not attributing blame - but what was going on at the time, not what was presumed by management to be going on.
They did not know .
There is no prominent, easiiy accessible way to examine these Inquiry Reports as a whole.
They are just not put out for the public to know
They take so long to be published that the impetus of the initial shock at what is revealed, dissipates. The newspaper headlines reverberate, the facts of delivery of care failure do not.
*** !!! The National Patient Safety Agency has a duty - unfulfilled [ odd for a public body given the job of examining 'safety' ] to obtain and hold them and they should make sure access is available [ odd again for a public body - they don't ] - they are easily placed on the internet - but getting hold of them is made difficult.
The Inquiry Reports are mandatory - that is a measure of their importance to the public interest.
Yet the SHA.s act as though the interest should be kept to themselves.
One common feature; those who observe the expression of care in the community 'in between' professional interviews, are not asked for what they have seen.
British Journal of Psychiatry(1990),157-671 - 674; C. R. Brewin, J. K. Wing, B. Macarthy and T. S. Brughabr
The Assessment of Psychiatric Disability in the Community
A Comparison of Clinical, Staff, and Family Interviews
*** In general, interviews with residential staff and family members revealed much higher
levels of symptoms and behaviour problems than either of the other two interviews.
[ that is the core explanation of many failures in care delivery. My sufferer comes acroos well at interview - hours later at at home he is shouting grimacing and negative to appraoch - visted by a Home Treament call, he holds up well for the brief encounter "
These findings have implications for research and clinical practice including the fact that adequate assessments should include the testimony of family or residential staff "
see one extreme example ... page143 para 6 from the Blom Cooper; Robinson Inquiry
*** !!!What are the lessons - that are not learnt
A general mental disorder website
..Sainsbury Centre Inquiry and Report June 2006 .. Sainsbury Centre inquiry
" More than half of England's mental health trusts have seen money diverted away from them to pay for deficits in other local health services "