A rotten culture

Where were the watchdogs?  Where were the safeguards?  These questions have been bothering me ever since I read about Lisa in a report by the CQC and the death of Stephanie Bincliffe, which was reported over the weekend.  Both women had learning disabilities, both appear to have been detained under the Mental Health Act 1983 (MHA) in assessment and treatment units, and both appear to have been subjected to seclusion for several years.  This is Lisa’s story as it appears in the CQC report:

During the two-day inspection of the assessment and treatment unit, no one set eyes on Lisa – the [Challenging Behaviour Foundation] Expert by Experience was concerned because she was told that Lisa lived in a locked area at the end of a male ward. She did not come out and no one went in. The CBF raised concerns through the usual channels and was “reassured” that Lisa was “well-known”, had an advocate, that there were regular review meetings, and that she was very complex and challenging. CBF insisted on pursuing her case and discovered that she was kept in a locked area, slept on a beanbag, never went out and staff interacted with her through a small letterbox style “hatch”. For example, her food was passed to her through this hatch, and her hair was brushed through this hatch. She lived like this for nine years detained under the Mental Health Act. There was no therapeutic input – it was containment, and it cost an average of £1,800 per day, over £12,600 per week. No one raised concerns about this arrangement until CBF did. Lisa has now moved to a new service and is doing well, but there is considerable work to do to undo the damage caused by living in solitary confinement for so long.’

As Sara Ryan comments, Stephanie Bincliffe is said to have been secluded for a period of seven years.  During this time she put on ten stone in weight, and she died of sleep apnoea.  An inquest into her death is underway.

I find these cases so harrowing and appalling that I have been struggling to know what to write about it here.  What keeps going through my mind is how could this happen, how could the professionals working with these women have thought it was an appropriate way to treat a fellow human being?  What beliefs must they have held about these women, about people with learning disabilities, to think that this was remotely acceptable?

In conversation with lawyers about these cases, inevitably, we pick apart the safeguards that should have been available to them, and wonder whether we need more law, more safeguards, to prevent this type of thing.  I would not want to conclude that there are no legal changes that we should be looking at, but I just keep thinking: these women were detained under the MHA, the ‘gold standard’ of procedural safeguards, and yet this still happened.  They would have had multiple professional assessments – including psychiatric assessments and assessments by Approved Mental Health Professionals.  Lisa is said to have had an advocate.  There should, if the MHA Code of Practice guidance on seclusion and ‘longer term segregation’ were followed, have been regular multi-disciplinary meetings (although, we don’t know if this actually happened). They would have had reviews by the hospital managers.  Because these women were detained for so long under the MHA, they would almost certainly have had tribunals, because they would have been automatically referred to them (even if they did not exercise rights of ‘appeal’).  This means that they would almost certainly have had solicitors, who presumably must have known that they were being secluded in these conditions.  This means that tribunal members – including a medical member, a legal member and a lay member – must have considered their detention and may have had at least some awareness of the conditions of their detention.  It is true that the Tribunal do not have powers to consider the conditions of detention or make requirements therein (unlike, interestingly, the powers of BIA’s and the Court of Protection under the Mental Capacity Act 2005 deprivation of liberty safeguards).  But the point is, a very large number of professionals – medical, social work, and legal –  must have known about this, and either endorsed it or else failed to take sufficient action to bring this treatment to an end.

What about the monitoring bodies?  Until 2009 the Mental Health Act Commission (MHAC) carried out independent monitoring and visitation of patients detained under the MHA to ensure their rights are being protected.  These functions are now carried out by the Care Quality Commission (CQC).  As well as having a long history in England and Wales, this is part of our international treaty obligations under the United Nations Optional Protocol on the Convention Against Torture (OPCAT).  The very point of such visitation is to ensure that those who are detained are not subject to torture or inhuman and degrading treatment.  If locking a person in a room for many years, leaving them with only a beanbag to sleep on, and feeding them through a hatch does not amount to ‘inhuman and degrading treatment’, if it does not arouse ‘feelings of fear, anguish and inferiority capable of humiliating and debasing them and possibly breaking their physical or moral resistance’ (Ireland v UK, 1978), then I do not know what does.  And yet, the monitoring bodies appear not to have brought to an end the treatment of Stephanie Bincliffe, and only brought to an end Lisa’s treatment after several years.  There are so many unanswered questions here: did they know about this – and if not, how was it missed?  Did they endorse it at any point?  Did they raise any concerns?

These women had ‘safeguards’ coming out of their ears, and none of them worked, or they worked far too late.  ‘Legalism’ (procedural safeguards) is based on the idea that if we inject enough additional layers of independent scrutiny, of review and appeals, then those responsible for these safeguards will restrain any abuses of power.  The idea is that a fresh set of eyes will help to ensure that any problems are picked up on and addressed.  But here, this did not happen until an expert by experience discovered Lisa, and it appears that nobody picked up on what was happening to Stephanie Bincliffe until it was too late.  All those eyes on those women, all those watchdogs, and none of them barked.

When we encounter horrendous abuses of this nature, we typically have two prescriptions: we need more money, or we need more law.  What is so troubling about these cases is that there was certainly no want of money – Lisa’s detention is said to have cost an astronomical £12,600 a week.  As Sara Ryan points out, you could rent a luxury suite at the Ritz for that much.  And as I’ve already pointed out, there were numerous legal safeguards that were theoretically in place here. The idea that creating additional layers of scrutiny will fix this seems to miss the essential point here, which is that numerous professionals (including legal professionals and advocates) must have been complit with this. This is not a case of a few rotten apples being missed because they hid their abusive actions from view.  This was happening in plain sight.  It is hard to avoid agreeing with Norman Lamb that these cases are indicative of ‘a deeply embedded and rotten culture where people with learning disabilities are treated as second class citizens’.  How do you fix a rotten culture?

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10 thoughts on “A rotten culture

  1. Dear Ms. Series,

    Thank you for the post. Your comments are always refreshingly clear.

    I was looking at the Courtel website this morning and found the above case. I am not sure what to say about the judgement at this stage. I hoped I had left John Stuart Mill behind in the depths of my first year at university. I will read it again.

    Steve Brett

    Date: Wed, 19 Nov 2014 10:08:37 +0000 To: communitycare@hotmail.co.uk

    • Thanks Steve. The passage from JS Mill cited in the judgment has dated somewhat; here it is in full:

      “It is, perhaps, hardly necessary to say that this doctrine is meant to apply only to human beings in the maturity of their faculties. We are not speaking of children, or of young persons below the age which the law may fix as that of manhood or womanhood. Those who are still in a state to require being taken care of by others, must be protected against their own actions as well as against external injury. For the same reason, we may leave out of consideration those backward states of society in which the race itself may be considered as in its nonage. The early difficulties in the way of spontaneous progress are so great, that there is seldom any choice of means for overcoming them; and a ruler full of the spirit of improvement is warranted in the use of any expedients that will attain an end, perhaps otherwise unattainable. Despotism is a legitimate mode of government in dealing with barbarians, provided the end be their improvement, and the means justified by actually effecting that end.”

  2. Lets start with prosecuting Psychiatrists. Maybe just maybe with the knowledge of knowing their actions is a crime against humanity. After all they do this in America, so why not here?
    Re educating professionals is not enough, though this is a good starting point but I think we need the Law.

    Question remains, how many more are there out there like Lisa and Stephanie?

  3. This story breaks my heart. Many, many years ago I worked with an individual who, whilst complex, was a great character. He was very difficult to integrate into his community due to his behaviours and how others would percieve him, and indeed the risk he posed to his fellow citizens. I’m going back 20 odd years and look now at how we could have served him so much better. But at the time it felt as though we really were being progressive and making a differece. Reading these stories of the lives of people, who are just as much a person as you or I, is still happening in this day and age and this society makes me genuinely weep. The social model of disability has long been accepted, yet is still to be applied in cases where the square peg does not fit into the round hole.

  4. This is beyond appalling. Yes, we have a rotten culture. A culture where staff put newspaper down on chairs which have been used by patients with mental illness on the ward, & still use words such as “retarded” to describe a person with learning disabilities. Where many services are involved, but argue over who is responsible for what – often in front of their service-users – leaving the person with none in particular. This is the least. What is horrific is that there are likely to be other people imprisoned & suffering in the same way as Lisa & Stephanie had been, in “care” settings where time has stood still. How to fix this rotten culture? I believe this falls to many things including ignorance around the use of the MHA, lack of compassion from staff, fractured & overstretched services, stigma within society.

  5. Compassion for Lisa and Stephanie

    The act of compassion is costly. it makes us consciously aware of the agony around us, the spiritual and moral poverty. Georges Bernanos

    Compassion constitutes a radical form of criticism, for it announces that the hurt is to be taken seriously, that the hurt is not to be accepted as normal and natural, but it is an abnormal and unacceptable condition for humanness. Thus, Compassion that might be seen as generous good will is, in fact, criticism of the system, forces, and ideologies that produce the hurt. Walter Brueggemann

    Compassion is not a mere sentimental emotion, nor is it an attempt to pity another…however empathy might lead one to become compassionate. The compassionate act becomes a living basis for assisting those who are suffering. The complimentary ethics of compassion and advocacy may well be the most powerful rewarding and necessary acts in healthcare. Compassion encompasses all those involved – physician, nurse, psychologist, psychiatrist, social worker, administrator in the care of the person, and no one exists above or beneath its power to make understanding possible and to heal.

    According to the reports this particular ‘healthcare’ system has treated these two women as though they were dangerous criminals, depriving them entirely of their personal liberty, keeping them in solitary confinement for years. It is heartbreaking to think of them day after day, night after night for months, for years, exiled by those who profess to care. It is possible that not one professional in the institution saw these women as human beings in need of comfort and care? History has shown the consequences of the actions of a world whose institutions are considered more important than the human soul. There is an inability to act or actions are devoid of compassion. The passivity and fatalism is profound. Those in power may feel some stirring of remorse about this state of affairs and assuage their consciences with more dissertations, new continuing education courses for professional personnel, more safeguards, more lawyers, new laws, more expert consultants and, of course, spend more money. Institutions foster the dehumanization of man by promoting the principle of institutionalism before the principle of mankind. What can heal the spiritual anemia of this healthcare institution?

  6. Pingback: The difference between institutionalisation and independent living is the difference between abusing human rights and respecting them. | Making rights make sense

  7. Like many of the respondents on this and similar blogs, I’ve struggled at work against uncaring systems and obstructive jobsworths of individuals, (only sometimes successfully.)

    In my experience it’s worse today because there are so many regulations, directives, procedures and so much paperwork to, all of which are used to block attempts at change or consideration of any alternative approach. This has created an environment where overstretched staff or those lacking in compassion can cite cast iron reasons for not meeting the actual needs, or considering the feelings of those they “care” for.

    At worst it’s cruelty and sadism, at best it’s exhaustion, burn-out and self preservation. In the middle it’s a mix of idleness, lack of imagination, ability, decent training, decent pay, decent leadership and/or commitment to the job.

    Compassion is spiritually and politically costly as Jeanine so rightly quotes above.

  8. Pingback: How could they have thought it was an appropriate way to treat a fellow human being? - La déficience intellectuelle dans le monde

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