My name is Lauren Smith and I am a Solicitor who works in a specialised area of Mental Health / Human Rights Law with Peter Edwards. A large portion of my clients are detained under the Mental Health Act 1983 and today I write about those who are detained in High Security. Within High security there are 3 levels of dependency, high, medium and low. Today when I visit I will be seeing a range of men who have a range of different diagnoses and who are detained in difference levels of dependency within Ashworth High security.
There is a safeguard under the Mental Health Act that allows patients detained to make an application to a First Tier Tribunal to consider their case. Each tribunal is comprised of an experienced lawyer, often a judge, a psychiatrist and a lay member who in effect represents the views of society. The tribunal criteria must consider whether a person has a mental disorder and whether they need to be detained in a hospital environment for treatment of their mental disorder. The Tribunal will look at a patient’s ongoing risk to themselves, their health and to others.
Today I’m seeing four men with personality disorders and four with paranoid schizophrenia. I’m going to three different wards in the morning and visiting two wards in the afternoon. I am representing all of the men in respect of a Tribunal or helping them decide on the timing of making an application. I pack up my trolley and load the car. Ashworth here I come.
Within the walls, the wards are in three semi circles and it is a very long walk from Arnold Ward at one end to Tennyson ward at the other. There is a pervading stillness that takes some getting used to. The media coverage of Ashworth often does not accurately describe the place I have come to know.
When I arrive at the security gate I often have to wait a long time before I can be escorted into the hospital. Sometimes it is because there has been ‘an incident’ in the hospital and it goes into ‘lock down’. It’s just accepted that waiting goes with the job. I get to my first appointment at 10.30 and my client is frustrated about having had to wait for me.
I need to discuss complex medical, nursing and social work reports with him in advance of his Tribunal. It is important that I build a rapport and ask questions to get the information I need. I am with a man who has schizophrenia and he is quite well at present so the interview goes well. Unfortunately the question, ‘what do your doctors think of your progress?’ prompts a strong response. ‘Why what have you heard’, ‘what have they been saying?’ I realise we have been discussing his reports for some 40 minutes and he is understandably getting tired. It is time for a strategic change of direction. We start talking about the tribunal and what might happen. He decides he would like to give his evidence first and he would like an’ informal recommendation’ for transfer to a less secure hospital. This demonstrates to me that he has a degree of understanding of his condition as he realises that for the time being, he needs to remain in hospital but he feels he is ready to move to medium security.
I explain to him the details of a case called EC v Birmingham and Solihull Mental Health NHS Trust (2013) EWCA Civ 701, (2013) MHLO 47. Very few patients are discharged directly from hospitals like Ashworth directly into the community. Most are transferred to conditions of lesser security on their road to rehabilitation. The case states that the tribunal do not have to consider arguments about transfer or leave in restricted cases because these are outside the power given to them by the Mental Health Act. This case is disappointing for patients as often their progress through high security to medium is recommended by the independent tribunal. I’ve found that newer judges are less willing to listen to arguments about transfer to medium security. Judges that do agree to the submissions, however, are happy to make such recommendations. There has been a period of caution after the ruling but in general the pendulum is swinging back. I hope therefore that they will listen to the arguments for an informal recommendation for transfer at the hearing.
This client is on a ‘low dependency’ ward and has been having leave of absence. This is a very carefully considered process and for restricted patients that requires the permission of the Ministry of Justice. There have been no ‘incidents’ in the past six months and his future looks positive. He is due another trip out tomorrow and his spirits are high. He is a trusted patient and I am hopeful for him as reports are positive but I have to manage expectations. This is difficult. Yes it is true that a tribunal has the power to discharge the hospital order and it is the patient’s right to request this, however there are so many factors to consider. Patients are assessed and a list of recommendations agreed. Often this includes future therapies within Ashworth before a ‘gatekeeping assessment’ could be considered that could lead to a move. Managing client’s expectations is one of the most challenging aspects of my role.
My client is fortunate, his progress has been good and his gatekeepers attended his last meeting. They’re satisfied he has been settled and rehabilitated enough to be managed in conditions of lesser security. I know these are good signs and should be a good indicator however there is the real world and then there is Ashworth.
My second client has a diagnosis of a Personality Disorder. When I arrive on his ward I am told, ‘He’s having a difficult morning’. He is on a high dependency ward in seclusion in Ashworth. He is not in long term segregation. To find him in seclusion now it means there must have been a serious incident or he has requested voluntary seclusion. I am allowed to see him through his seclusion hatch (in his bedroom). He has previously instructed me to ask for his discharge and I am here to go through his reports. When I approach the hatch he is responding to unseen stimuli. He smiles as soon as he sees me and declares, ‘my personal Jesus here to free me’. He settles on the end of his bed to talk to me. I ask him how he is. I have to adopt a completely different approach to my last client. I don’t ask any direct questions in this meeting I only see how he responds and then decide how I proceed.
He explains that he is back in seclusion because he had a fight with a member of staff about not being able to smoke. This is a familiar story since the smoking ban has been introduced. He tells me he isn’t a risk and really it was the staff that were at fault because they had been trying to ‘wind him up’. He tells me that he wants to be discharged from Ashworth. I find the positive points in his report, unfortunately they are few. He doesn’t accept he has a Personality Disorder. He feels every person could be diagnosed with a Personality Disorder to one degree or otherwise. We discuss the notion that all people have Personality ‘Traits’ that are stronger in some than others. He feels that because he led a criminal lifestyle he was just stuck in the system and most people who have similar personalities to him are living in the community without any interference. I agree to question his clinical team at the Tribunal about this. He then asks me to go as he’s ‘had enough’. I say thank you and move to my next client.
I arrive at my next appointment and he refuses to see me. Staff tell he has been changeable and up all night. They ask if I can re arrange, I check my file and agree. I move on to my next ward.
I reach my next appointment is to discuss a written decision from a Tribunal with a client who has schizophrenia. He did not attend the Tribunal because he has been in long term segregation for the past two years due to unpredictable violent outbursts fuelled by derogatory auditory hallucinations. I am expecting to see him through his hatch in this room. Today staff ask me and my client to agree for four men from the ‘Positive Intervention Programme’ team (PIP) to be in the meeting with my client. He has already agreed because it means he will be ‘tried’ out of his room. I understand the importance of my agreement to this in terms of his progression and the clinical team taking a positive risk to facilitate it. Part of me wishes they had picked a different meeting, one with a Social Worker perhaps or even one with me where I wasn’t discussing the outcome of a Tribunal he had great expectations from. I know I have to give him disappointing news. Before I make a decision about the PIP team I ask to speak to my client privately about the meeting being confidential. He doesn’t mind he just wants to come out of his room. He is happy for the PIP team to hear what I have to say. I agree to the PIP team in the meeting because I know it means everything to my client to make steps towards his future and this is a big one. If this goes well then in the long term these kind of steps will be the evidence I put forward at a Tribunal to demonstrate his risk to others is reduced.
The rest of my visit goes well but as I go to leave my finial ward at 17.15 an alarm rings, there’s a security alert on another ward and all movement in the hospital is stopped. Eventually I make it to the gate. I’ll be back tomorrow for a tribunal hearing. I wonder how it will go.
I really enjoy the diversity and challenge of working in a high security hospital.