Case study 6: South London and Maudsley NHS Foundation Trust (Forensic Service)

Background

case6This person has had a number of experiences within mental health services. Having had a few previous admissions to the acute service, he eventually found himself in the forensic service.  He had had varied experiences in the community before admission to the forensic service, and during this time he had also had admissions back to the acute service.

During his acute admissions, he was treated for a two week period, given medication and when he went on leave and did not return on time he was discharged. For a second time he again tried to seek help and was given medication which he took during the admission and for a while after, but he got forlorn and stopped taking it because it did not appear to be doing anything and there was very little follow-up care.

He is a young man with a number of issues which he feels need to be addressed. The main one is his mood and this has been the main area which needed to be addressed on each of the preceding admissions. During his initial admissions, he explained he was asking for help but again as soon as he appeared well enough or it was possible to send him on leave he was discharged.

His most recent admission to the forensic service has been under the Mental Health Act  which initially he was upset about and still felt that if he was given the care and attention he had asked for in the past, it would have avoided a criminal history appearing on his file. This he felt would restrict his plans for the future.

In terms of his experiences, he spoke of the variations in communication in different wards. He has also found that even in the forensic service, there are variations in staff approaches, from those staff members who focus on obeying rules to those who are encouraging and have a positive influence on him. He explained that there were differing styles of interaction with him, and he experienced various responses and attitudes by both staff members and other patients.

Personalised interventions

He previously found that the acute service was very busy, he was very much ‘in the shadows’, staff had done plans for him and the doctors told him what they thought he needed. He did not feel listened to by many members of staff. However, there were a few who spoke to him and made him feel comfortable on the ward, although he thought that they were nursing assistants, as the qualified nurses seemed to be very busy. He felt that the people who helped him most were those who treated him as a human being, not as a patient, and were not necessarily being nice to him all of the time but who treated him with respect.

One approach he found particularly useful in the forensic service was the Primary Patient Pathway Meeting where all staff and the patient are responsible for setting and achieving targets and all are accountable for things not being done, including the primary and associate nurse.  This meeting also had the benefit of giving him direction and some idea of what he had to achieve and what this would mean for him.

  • Spending time with me
  • Smiling when they meet me
  • Listening when I need to talk to someone
  • Showing they are trying to help
  • Getting information for me
  • Telling me the truth
  • Helping me get accommodation
  • Talking in the day area
  • Coming to see me when they see I am quiet
  • Working with me to do illness work to help get leave
  • Telling me what pathway I would benefit from
  • Helping me through problems
  • Giving me ideas on what to do
  • Motivating me to help myself
  • Helping me to understand things
  • Treating me like a person
  • Getting leave and moving on.
  • Not having time
  • Listening to what I am saying but not hearing what I say
  • Strict with rules but no explanation
  • Being too busy
  • Not explaining things
  • Being rude
  • Being abrupt
  • Saying you are here because you are not well
  • Diverting me to the doctor for answers
  • When I think they are judging me
  • When I feel alone and no one cares
  • When I pass each day without knowing when I will get released or get some help or my mood will improve
  • Stopping medication because they think it is in my best interests
  • Being treated differently when rules are bent for others and I am picked on
  • Not getting help but feeling I was in the way, just a number and the bed needed.

These are some of the statements made by X, which often show poor reflection on the part of the nurses. In some cases a move away from controlling the patient towards exploring and accepting decisions made by him appears essential in facilitating greater engagement.

It is noticeable that the Primary Patient Pathway is of great benefit because without meaningful engagement we have nothing.

Source: Jim Tighe, Team Leader, Cane Hill, South London and Maudsley Hospital