Nigel Eastman

Public health psychiatry or crime prevention

In the wake of the recommendations of the Fallon inquiry into the personality disorder unit at Ashworth Hospital 1 2 the government has now announced its own solution to the problems presented by people with antisocial3 or dissocial4 personality disorder.5 After a joint Home Office and Department of Health review which ran in parallel with the Fallon inquiry it has proposed for consultation new services and law. Although not prescriptive about the detail of its solution, both the governments philosophy and its resolve are clear. In pursuing, above all, public protection, it intends services which essentially hybridise punishment and health care, with law that allows preventive detention of even the unconvicted. The uncertain treatability of antisocial personality disorder,6 consequent professional therapeutic ambivalence,7 and inherent uncertainty about the moral status of the condition (whether individuals “suffering” from it are mad or bad)8 combine sensibly to imply a hybrid service solution which is far more radical than that which emerged from the last governments attempt at a similar review.9 Reflecting its close look at various European service models, the present government seems to intend a “third way,” involving establishing new specialist institutions which would be hybrids of prison and hospital and would house only people with severe personality disorder. This contrasts with the solution proposed by Fallon …

Who should take responsibility for antisocial personality disorder?: Fallon suggests emphasising custody, but psychiatrists' future role remains unclear

News p 211 and Personal view p 271 The diagnostic boundaries and treatability of personality disorders have always been medically controversial. Whether offenders with antisocial1 or dissocial2 personality disorder—“a most elusive category [with] wavering confines”3—should be treated in hospital or punished in prison is profoundly controversial. Now, because of highly publicised cases of paedophilic violent offenders released from prison and the case of Michael Stone, a convicted psychopathic murderer, the medical response to personality disorder has become a subject of national political debate. The dispute between the home secretary4 and the president of the Royal College of Psychiatrists5 about whether psychiatrists should be preventively detaining untreatable psychopaths under the Mental Health Act illustrates well the field of political conflict. Into this debate comes the Fallon inquiry into the personality disorder unit at Ashworth high security hospital.6 This will soon be followed by the announcement of government policy on future services and legal provisions for personality disordered offenders, arising out of a Home Office-Department of Health working party that has been running in parallel with the inquiry. Fallon investigated and largely confirmed complaints of patients trading in …

Security needs of South West Thames Special Hospital patients: 1992 and 1993. No way out?

Abstract Two audit surveys were carried out, one in 1992 and the other in 1993, to examine the security needs of South West Thames Region (SWTR) Special Hospital patients. Special Hospital responsible medical officers (RMOs) were surveyed regarding need for security, appropriate placement and reasons for transfer delay for South West Thames patients. Results from both audits were strikingly similar and were also consistent with previous studies based on RMO surveys. They suggest that there are large numbers of Special Hospital patients who do not require maximum security. Assessed need for medium- and long-stay (greater than 2 years) medium secure care in the region highlighted current deficiencies in medium secure provision within South West Thames, which falls short of both Department of Health and Home Office specifications. The most frequently cited reason for postponement of transfer was Home Office delays. The consistent findings of this and previous studies emphasize the ongoing problem of overcont...

Psychiatric, psychological, and legal models of man

Models of man are rarely defined in such practical disciplines as law and medicine, but are implicit and frequently covert. They gain their character and variation, one with another, through the pursuit of specific purposes and through the methods of thought and procedure applied to those purposes. Hence, the very different general traditions of law and medicine (specifically here psychiatry) combine with their varying purposes to determine essential disjunctions when the two disciplines are drawn into an apparently common purpose. Such disjunctions are commonly misperceived according to their superficial and case-specific appearance rather than correctly viewed as deriving ultimately from incongruous models of man variously implied by each discipline and coincidentally applied one “discipline type” against the other. This paper attempts to explore the characteristics both of the variety of implied models originating in both law and psychiatry and of the potential and real model disjunctions. It will argue that the degree of disjunction operating will vary according to the model characteristics arising from law and from psychiatry in any particular case. Finally, it will suggest that incongruence will be minimised both by encouraging legal rules which put the two disciplines into inherently “least disjunctive” model interactions and by encouraging law and psychiatry (and their practitioners) coincidentally to recognise the implicit varying purposes and models which they apply and the character of casespecific “model boundaries” and incongruities. The argument is presented in terms of English law but has applicability to other common law traditions and jusidictions and perhaps even beyond.

Research on the supervision registers: Inconsistencies in local research ethics committee responses

Abstract This article examines the responses of twelve local research ethics committees to a proposal to carry out a study on the supervision registers using case-note material, and does so in the context of the controversies surrounding the supervision registers and the most recent Department of Health and professional guidelines on the ethics of using case-note material for research purposes. Local research ethics committee responses to the proposal varied starkly, and ranged from approval through chairmans action to outright refusal. The main stated reasons for refusing permission for the study were failure to obtain patient consent to use case-notes, although all guidelines recommended that case-note studies do not require patient consent. Possible reasons for refusal to approve the study are examined in the context of published ethical guidelines and specific concerns about the supervision registers themselves. It is recommended that guidelines be issued to local research ethics committees, provider...

A survey of the use of supervision registers in South Thames (West) Region

Abstract A telephone survey of South Thames (West) Region (STWR) providers established the number of cases on the supervision registers broken down by risk categories. There were 374 cases held on 13 registers. Risk categories were used mutually exclusively by only 2 providers. The most frequently used were ‘violence’ alone (34%), ‘self-neglect’ alone (22%) and ‘suicide’ alone (20%). The percentage of each district population on the registers ranged from 0.005% to 0.024%. There was no significant correlation between the percentage of cases on the registers and Jarman Underprivileged Area scores (rho = 0.12, p = 0.75) or between rates of suicide in the district health authorities and the number of cases in the ‘risk of suicide’ category (r = -0.07, p = 0.86). The estimated cost of the registers, based on an estimate by the Royal College of Psychiatrists, was & 187,000. The registers are operating highly inconsistently across providers and district health authorities in STWR. This has ethical, clinical and ...

Minimum secure services in South West Thames: A description of operational policies and patient characteristics

Abstract South West Thames Regional Health Authority adopted a unique approach to the development of forensic psychiatry services. Part of the money ring-fenced for the development of medium secure units following the Butler and Glancy reports was diverted to establish district-based close supervision units (CSUs) backed up by a small medium secure unit. CSUs were located within general psychiatry services and were intended to bridge the gap between Special Hospitals and general psychiatry, albeit with specialist forensic psychiatry links. Little is known about how CSUs operate and to what extent they serve mentally disordered offenders (MDOs). This study addressed these questions by surveying the operational and admission policies of CSUs and by carrying out a 1-day census on all CSU patients. Admission and operational policies differed considerably across CSUs, as did patient characteristics. CSUs differed in the extent to which they could be described as ‘true’ MDO services, and the application of a si...

The Pool judgment has not changed the law of expert evidence

We are concerned that the editorial by Series & Herring[1][1] is likely falsely to give readers the impression that the Pool judgment represents a change in the law of expert evidence. The judgment has not changed the law in any way. And we would advise doctors who work, or wish to work, as experts