Adam and his amazing support worker

As you know I am acting as an independent advocate for Adam as I know him well, having worked with him from 2012 onwards. I would like to preface this letter by complimenting the efforts made by staff at the unit in the weeks following his admission. As you know, Adam has been under section in the past and his family and staff tell me that his treatment and the respect he receives has been markedly better than any previous admission.

However, I am writing now to address some concerns, predominantly the use of seclusion, or at least the manner in which it is currently practiced, as a matter of urgency for Adam whilst he continues to reside at your MH unit. I have great concerns over both the efficacy of this room as a behaviour management strategy, of the potential trauma that Adam may suffer as a result, and of potential breaches of Adam’s rights under the Human Rights Act, Equality Act, and deviation from guidelines set out by the MHA Code of Practice and NICE NG10.

It has long been established that Adam does not have the mental capacity to understand punitive approaches to his behaviours, particularly during periods of crisis; additionally, when his mental health (mania, bipolar and possible anxiety disorders) has deteriorated to the extent to which he is no longer able to employ his many behaviour management strategies sufficiently, he will also experience intense fear and distress, resulting in high agitation and physical aggression.

This information is documented in his support plan along with detailed preventative, de-escalation and response strategies. These have been developed over many years with input from a multi-disciplinary team, working closely with family and support staff to ensure efficacy, safety, and positive, therapeutic engagement in the community. This document also details adaptive technologies that Adam requires to support him to manage his learning disability; Adam is highly reliant on a combination of systems and strategies that have been developed to enable him to function on both practical and communicative levels. Without these strategies Adam’s ability to function and cope with the challenges he faces is greatly compromised, and the impact this can have on his anxiety, stress, and overall mental health can be significant.

It is with this in mind that we must challenge the current application of seclusion in Adam’s case. I am very concerned that Adam’s lack of capacity to understand the purpose of seclusion, coupled with the deprivation of any and all of the resources that he relies upon, does in fact constitute treatment that is causing him intense mental suffering, fear and trauma, and is therefore a potential breach of his rights under section 3 of the Human Rights Act. Additionally, section 1.5 of the Act states: “Any restrictions should be the minimum necessary to safely provide the care or treatment required having regard to whether the purpose for the restriction can be achieved in a way that is less restrictive of the person’s rights and freedom of action.” The Act also states that any deviation from these guidelines should be clearly documented and justifiable as necessary and proportionate in the circumstances of the specific case.

The purpose of restricting his movements in this way for such a length of time need to be closely scrutinised here: if Adam was being secluded as a punishment then this is something that he would not have sufficient comprehension of and so would be inappropriate; if Adam was being secluded for the safety of himself and others then removal to a safe and secure space, such as his own room, for the least amount of time necessary should be the appropriate course of action. Whilst the risk Adam poses to himself and others is acknowledged and understood, the use of such restrictive practices for periods of up to 30 hours with no access to coping strategies or therapies represents significant deviation from his care-plan, a failure to demonstrate that less restrictive practices have been attempted, and as such is very troubling and potentially a safeguarding issue. If the use of any less extreme option, such as his room, contravenes policy on the ward then this needs to be challenged immediately as organisational policies do not supersede an individual’s human rights.

I believe that urgent action needs to be taken to resolve these issues and ensure that no further trauma is unnecessarily and unintentionally facilitated during his time in the unit. Some initial suggestions for achieving this are:

1. Adam should have access to his iPad at all times, including during seclusion. Time should be set aside for him to use it with staff to build meaningful two-way relationships that enable him to communicate more effectively and promote a holistic and therapeutic approach to his treatment.
2. Use of seclusion should be used only as a last resort once all other behaviour management strategies have been attempted.
3. If seclusion or removal to a ‘safe space’ becomes necessary it should be to a space with familiar items and resources that he can access to help him cope. This will ideally be his own room, with focused interactions from trusted individuals as part of a de-escalation strategy.
4. Adam should be involved in the creation of a meaningful timetable of activity that will give him access to a range of therapies and opportunities for interaction.
5. Adam’s family and support staff should be fully involved with decisions made around Adam’s care, as they are most qualified to coach staff and help him to communicate his needs.

Once again, I would like to recognise the efforts that staff have made prior to the incidents above and do not wish to imply that he has suffered intentional abuse. I also understand that there are complications when delivering bespoke care to individuals where one may seem to receive preferential treatment, however, Adam requires these adjustments not as a luxury but as a means for him to function and begin to overcome his mental health crisis; this means these adjustments are more akin to an interpreter for a non-English speaking patient, or a wheelchair for a patient unable to walk unaided. The current policy fails to take into account Adam’s substantial disadvantage compared with those who are not disabled, and must be urgently addressed.