Do psychiatric inpatients know their rights? A re-audit on information given to inpatients at a London mental health trust about their rights and admission to hospital

Introduction

The experience of being an inpatient is intended to be fundamentally supportive and therapeutic. However, certain aspects of the psychiatric inpatient experience can be highly stressful, for example, sharing facilities, attending ward rounds and restrictions on movement. In the 1970s psychiatric care moved towards unlocked wards and community care ¹ and article 5(1) of the European Convention on Human Rights states ‘No one shall be deprived of his liberty save in … the lawful detention … of persons of unsound mind … ’. ² However, services have a duty of care to protect against harm to self or others, so ward staff often face difficulties balancing right to freedom versus safety. The practice of locking ‘open wards’ has been increasing across the UK, including at South West London St George's Mental Health Trust (SWLSTG). This appears a reversal in the ethos of psychiatric care over the past three decades. The Mental Health Act Commission ³ noted that ‘Nurses spend much of their time engaged in intensive observation of a few patients, but a quarter of wards had no nurse interacting with patients at the time of the visit.’ There is an anecdotal perspective that locked doors increase the time nursing staff spend with patients rather than ‘guarding the door’, supported by an audit in York. ⁴

The majority of psychiatric patients are admitted informally (the MHA Commission found 70% informal patients, 30% detained in a 1998 survey). ³ Section 131 of the Mental Health Act 1983, revised 2007 (MHA) emphasizes the right of patients to be admitted without legal restrictions, and Section 132 details hospital managers’ duty to inform detained patients of their rights. There is no legal duty to inform informal patients of their rights but it seems good practice to do so. Rogers et al. found that of 516 informal inpatients, 80% felt they had not received enough information about what to expect of treatment. ⁵ Sugarman and Ross found only half (67/117) of informal psychiatric patients believed they were legally allowed to leave hospital and only 55/117 believed they had the right to refuse treatment. ⁶

At SWLSTG the ‘locked door’ policy is in place ostensibly to protect individuals within from malign external influences (such as the sale of illicit drugs). The authors were concerned that not all inpatients were aware of their legal rights in relation to the locked door, so in 2009 Lomax and Raphael audited three general adult wards at Springfield hospital, finding worrying deficiencies in the information either given to (or absorbed by) patients in relation to their status on the ward. Only 54.1% believed they were allowed ‘short time away’ from the ward, 33.3% believed they were ‘allowed to go home’ and 37.5% of informal patients believed they could refuse treatment. ⁷ No informal patient was actually detained illegally, in that all who had asked to leave had not then tried to do so; however, some informal patients’ explanations of why they had not asked to leave included obvious references to fear of reprisals. Actively or passively allowing a culture of letting informal patients remain under misapprehensions about their rights concerning time away from the ward is clearly poor practice, which needs challenging. The audit was presented at the academic programme and the authors planned to re-audit at one year and after wide discussion included other wards within SWLSTG.

Audit standards

100% patients should know whether they are informal or detained under a section of the MHA, and if detained, they should know which section;

Methods

The sample population was all current inpatients on 28 March 2010 on the four general adult wards at Springfield Hospital, two at Tolworth Hospital and inpatients in the national adult deaf service, the national obsessive compulsive disorder (OCD) service, the addictions service and the national eating disorders service. All inpatients who verbally consented and were available were interviewed. Individuals lacking capacity to consent to the interview (e.g. those suffering dementia, a lowered level of consciousness or learning disability) were excluded. It was not feasible to include patients who were on leave during that period, and a small number of patients were discharged before the authors were able to interview. Deaf service patients were interviewed with a British sign language interpreter. Questions were asked using an interview proforma based on the standards above. Results were analysed using ‘Graphpad’ software, using χ ², or if any value was 5 or less, Fisher's exact test.

Results

The sample comprised 91 women and 96 men. Fifty women, 55 men were available, suitable for and consented to interview. Reasons for not interviewing are displayed in Figure 1. Sixty-one informal patients (of 100, 61% response) and 44 detained patients (of 87, 50.6% response) were interviewed. The mean age was 41.4 years. OPEN IN VIEWER

Discussion

This audit showed clinically significant improvement in patients’ understanding of their rights and hence the information given to them, although the relatively small numbers of patients involved in the 2009 audit means many results are non-statistically significant. The strengths of this audit are that it was a brief snapshot of all inpatients on a particular date, meaning no time over which patients could learn from other participants, inflating or deflating results. Staff were not warned exactly when the audit would take place, so they could not alter practice specifically around the audit period. In terms of limitations, the study was small compared with studies by Rogers et al. ⁵ and Sugarman and Moss, ⁶ and achieved only a 61% response rate among informal patients and 50.6% response rate among detained patients. The two audits are not directly comparable given the inclusion of highly specialist tertiary wards in 2010. These wards include more planned admissions and a more structured ward routine. Due to the nature of the illnesses, patients with OCD or eating disorder may be more likely to ask more questions, and absorb more information than patients with other psychiatric illnesses.

The differences between 2009 and 2010 are unlikely due to the information leaflet designed during the 2009 audit because the leaflet has not been widely distributed (due to cost implications). However, the 2009 audit influenced other practical changes such as signs by ward doors indicating informal patients were allowed to leave. The differences may reflect the wider variety of illnesses and patients in this audit, and difference in ward practice; however, it also may reflect greater understanding and awareness in staff due to presentation of audit locally. This audit highlights the need to improve awareness of patient rights. It does show modest improvements, demonstrating how presentation of audit improves practice. However, patient experience of informal admission or detention in hospital still sometimes crossed legal boundaries, with significant numbers of informal patients believing they were not allowed to leave hospital or refuse treatment. This audit led to a SWLSTG multidisciplinary staff survey of mental health law, and the results will be used to influence the content of induction and training programmes. Future research is needed on the most effective methods of verbal and written communication to improve patient knowledge about rights.

DECLARATIONS

Competing interests: At the time of the audit, Dr Frances Raphael was a general adult inpatient consultant at Springfield Hospital, and the other authors were working as trainees on inpatient wards around South West London and St George's Mental Health Trust (SWLSTG).

Funding: The original audit in 2009 won the SWLSTG Audit Prize in 2009, totalling £75.00. This money was used for administration during the audit in 2010. No other funding for this project was received by any author.

Guarantor and contributorship statement: GAL and FR had the idea for the audit, based on experiences while GAL was a core trainee working for FR, on an inpatient ward. GAL will act as guarantor, has access to all the original data and wrote a significant proportion of this article. GAL, JP and RP all data collected. Data collection was also done by fellow trainees at the time, Dr Jessica Harris, Dr Sophie Sacks and Dr Jessica Radley but they have not contributed to writing the article. JP, RP and FR all revised and contributed to the final version.

Ethical considerations: This audit was discussed with the South West London and St George's research and development department. As an audit, it was judged not to require full ethical approval. All inpatients involved had a full explanation of their rights after the interview, and were directed towards their ward health-care team if they had questions in future.

Acknowledgements: Data collection for this audit was also done by Dr Jessica Harris (ST3, SWLSTG), Dr Jessica Radley (F2), Dr Sophie Sacks (ST2, SWLSTG). Thanks to them for their help.