ORIGINAL PAPERS
Galappathie et al Civil and forensic patients in secure settings
Civil and forensic patients in secure psychiatric
settings: a comparison
Nuwan Galappathie,1 Sobia Tamim Khan,1 Amina Hussain1
BJPsych Bulletin (2017) 41, 156-159, doi: 10.1192/pb.bp.115.052910
1
St Andrew’s Healthcare,
Birmingham, UK
Correspondence to
Nuwan Galappathie
(ngalappathie@standrew.co.uk)
First received 15 Oct 2015, final
revision 26 Jun 2016, accepted
4 Aug 2016
B 2017 The Authors. This is an openaccess article published by the Royal
College of Psychiatrists and distributed
under the terms of the Creative
Commons Attribution License (http://
creativecommons.org/licenses/by/
4.0), which permits unrestricted use,
distribution, and reproduction in any
medium, provided the original work
is properly cited.
Aims and method To evaluate differences between male patients in secure
psychiatric settings in the UK based on whether they are detained under civil or
forensic sections of the Mental Health Act 1983. A cohort of patients discharged
from a secure psychiatric hospital were evaluated for length of stay and frequency of
risk-related incidents.
Results Overall, 84 patients were included in the study: 52 in the forensic group and
32 in the civil group. Civil patients had more frequent incidents of aggression, sex
offending, fire-setting and vulnerability, whereas forensic patients had more frequent
episodes of self-harm.
Clinical implications Secure hospitals should ensure treatment programmes are
tailored to each patient’s needs. Civil patients require greater emphasis on treatment
of their mental illness, whereas forensic patients have additional offence-related
treatment needs. Regular liaison between forensic and general adult services is
essential to help ensure patients can return to appropriate settings at the earliest
opportunity in their recovery.
Declaration of interest
Further to the closure of the asylums and subsequent rare
but high-profile failures in community care, forensic
psychiatry in the UK has rapidly expanded, with the
development of high, medium and low secure in-patient
services across the country as well as specialist forensic
mental health teams in the community.1 Alongside its
expansion, an ongoing debate related to its interface with
general psychiatry has persisted.2 In England and Wales, the
forensic v. general psychiatry divide extends to the
subdivision of in-patients detained under the Mental
Health Act 1983 into those affected by civil and forensic
sections. Patients detained under Part II of the Act are
termed ‘civil patients’. They can be detained under Section 2
for assessment and treatment for up to 28 days where there
is suspicion of a mental disorder. Section 2 can be converted
to Section 3 for further treatment. Alternatively, patients
can be admitted directly under Section 3 when there is a
known mental disorder. Patients detained under Part III of
the Act are termed ‘forensic patients’, given their involvement
in the criminal justice system through the courts and prisons.
While forensic units have expanded, there has been an
overall reduction of in-patient bed numbers in the UK,
which have fallen from 155 000 in 1954 to just 18 166 as of 31
March 2014. The number of patients detained in all settings
under civil sections during 2013/2014 was 32 781, of which
25 300 were under Section 2 and 7481 were under Section 3.
During 2013/2014 there were 1847 detentions under
forensic sections: 99 under Section 35 or 36, which is
156
None.
admission for assessment or treatment via the courts; 763
under Section 37 hospital orders, allowing detention in
hospital instead of a prison sentence; and 457 under Section
47, which allows transfer of a serving prisoner to hospital.2,3
Secure psychiatric hospitals are generally geared
towards providing assessment, treatment and rehabilitation
for forensic patients, since they are the majority group in
such hospitals. In particular, Coid et al found that 69% of
patients in medium security were detained under forensic
sections.4 Despite this discrepancy in distribution, research
into whether there are differences between these groups is
limited. The only study we could identify was that by Reed
(2004),5 who evaluated the differences between civil and
forensic in-patients in a low secure intellectual disability
setting and found, surprisingly, that the forensic patients
were less likely to be aggressive or use weapons but more
likely to harm themselves.5 It is not known whether these
findings are isolated to intellectual disability settings.
Therefore, we present findings from our evaluation of
male patients discharged from a secure psychiatric hospital
(excluding intellectual disability - the hospital does not
cater for such patients) and suggest recommendations on how
to meet the differing clinical needs identified in each group.
Method
The study was conducted as part of a service evaluation into
length of stay at St Andrew’s Healthcare, Birmingham, and
ORIGINAL PAPERS
Galappathie et al Civil and forensic patients in secure settings
registered with the St Andrew’s Clinical Audit Team. In
keeping with previous similar evaluations, ethical approval
was not required as the study evaluated retrospective,
non-patient-identifiable data from health records as part of
service evaluation.5 Data were retrospectively collected for
all discharges from the two medium and three low secure
wards since the opening of the hospital in March 2009 to
the study end point of 30 December 2014. The source of
data were patients’ electronic health records, including
medical reports, Historical Clinical Risk Management-20
(HCR-20) assessments, Care Programme Approach records,
electronically recorded risk incident logs and discharge
summaries.
Summary statistics were calculated for all patients
evaluated. Patients were then grouped by whether they were
initially detained under a civil or forensic section at the
start of their admission to St Andrew’s Birmingham. In order
to evaluate illness severity between the two groups, Health of
the Nation Outcome Scales for Users of Secure and Forensic
Services (HoNOS-secure) assessment scores taken at admission and discharge were noted.6 A power calculation was not
performed but all available data were used in the analysis.
The average length of stay was calculated for each group.
SPSS version 16 for Windows was then used to calculate
independent t-test statistics to examine any between-group
associations and frequency of various types of incidents.
Results
In total, 93 male patients were discharged from the hospital
during the data collection period; 9 patients were excluded
from the study: 7 were excluded as their admission was less
than 3 months and unlikely to be representative of the
treatment phase being evaluated, and discharge would also
have occurred prior to the standard Care Programme
Approach meeting held 3 months after admission, where a
formal diagnosis would have been made. One patient was
excluded as they were informal during the course of their
admission and one was excluded due to death from natural
causes. Therefore, 84 patients were included in the study,
with 32 in the civil group and 52 in the forensic group. In
the civil group, 16 patients were admitted from general adult
services, 1 from a police station, 7 from low secure services
and 8 from medium secure services. The legal status of
patients in the civil group remained unchanged during the
course of their admission, apart from one patient who
became informal in the days prior to discharge. None of the
patients in the civil group switched to being forensic
patients following convictions in court. Regarding the
forensic group, 4 patients were admitted from general
adult services, 3 from low secure services, 16 from medium
secure services, 28 from prison and 1 from a high secure
hospital. In this group, 14 patients changed their legal status
prior to discharge; 11 changed from being sentenced
prisoners under Section 47/49 to being detained under a
notional Section 37, as they had gone past what would have
been their automatic release date from prison. Two patients
switched from being remanded prisoners under Section 48/49
to being sentenced under a Section 37 hospital order at court
and one patient switched from Section 48/49 to a Section 37/41
hospital order with restrictions after sentencing at court.
Table 1 outlines the baseline characteristics of each
group, including diagnosis, age, ethnicity and Mental Health
Act status on admission. All patients were male, with a
mean age of 37 years (range 20 to 63 years). Table 2 shows
the mean length of stay, HoNOS-secure scores on admission
and discharge, and frequency of risk-related incidents.
Discussion
The study found no significant difference in length of stay
or severity of illness based on HoNOS-secure scores at the
Table 1 Patient characteristics
Civil groupa
n (%)
Forensic groupb
n (%)
Primary diagnosis
Psychosis (schizophrenia, schizoaffective disorder, delusional disorder)
Personality disorder
Affective disorder (depression, bipolar affective disorder)
30 (94)
2 (6)
0 (0)
46 (88)
3 (6)
3 (6)
Secondary diagnosis
Personality disorder
Substance misuse
Alcohol misuse
5 (16)
18 (56)
1 (3)
11 (21)
33 (63)
7 (13)
Ethnicity
Black
White
Other
10 (31)
18 (56)
4 (13)
13 (25)
27 (52)
12 (23)
Legal status
Section 2
Section 3
Section 37
Section 47 (notional 37)
Section 37/41
Section 48/49
Section 47/49
1 (3)
31 (97)
8
5
12
7
20
(15)
(10)
(23)
(13)
(39)
a. n=32.
b. n=52.
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ORIGINAL PAPERS
Galappathie et al Civil and forensic patients in secure settings
Table 2 Length of stay in secure care and frequency of risk-related incidents
Length of stay, days: mean (range)
Mean HoNOS-secure score:
admission
discharge
Risk incidents per 30 days, mean
Violence (includes assaults against staff or peers)
Self-harm (threats or acts)
Unauthorised leave (attempts or episodes of absconding or escape)
Substance misuse (intentions or incidents of illicit drug misuse)
Self-neglect (poor self-care/diet)
Fire-setting (threats or acts)
Sex offending (sexual comments or contact offences)
Vulnerability (being intimidated, bullied or assaulted)
Verbal aggression (abusive comments)
Other unspecified risk incidents
Civil groupa
Forensic groupb
Independent t-testc
587 (95-1396)
523 (105-1407)
t = 0.75, P = 0.96
25.31
20.16
24.62
18.77
t = 70.39, P = 0.07
t = 70.81, P = 0.94
0.92
0.06
0.22
0.06
0.41
0.08
0.06
2.10
2.10
1.85
0.34
0.21
0.05
0.12
0.25
0.02
0.03
0.29
1.62
1.99
t = 2.01, P = 0.02
t = 72.09, P = 0.02
t = 1.17, P = 0.44
t = 71.14, P = 0.15
t = 1.39, P = 0.17
t = 1.76, P = 0.002
t = 1.09, P = 0.04
t = 4.88, P = 0.00
t = 0.87, P = 0.36
t = -0.33, P = 0.36
a. n=32.
b. n=52.
c. d.f=82.
start or end of admission between the civil and forensic
groups. However, it should be noted that HoNOS-secure is
not a specific measure of mental state, since it also evaluates
behavioural functioning and a range of security measures.
This study identified that civil patients in secure settings
have more frequent incidents of aggression, sex offending,
fire-setting and vulnerability, whereas forensic patients have
more frequent episodes of self-harm. This finding challenges
the preconception that forensic patients are more
‘dangerous’ and difficult to manage.2 One explanation for
this may be that the civil patients in this study represent a
cohort of general adult patients that have been placed in
forensic services due to their frequency of aggressive and
difficult to manage behaviours, whereas the more stable
forensic patients have been admitted due to severe but more
isolated offences.
The higher frequency of incidents in the civil group
may make engaging with specialist treatment programmes
practically more difficult for this group, which may in turn
become a factor that limits their motivation to engage.
Secure hospitals should be aware that civil patients, due to
higher frequency of risk incidents, may have differing needs
to forensic patients. Therefore, we suggest that civil patients
who present with a high frequency of incidents will benefit
from a greater emphasis on treatment of their mental illness
combined with behavioural interventions, with less of a
requirement to engage in specialist treatment programmes
or to complete formal psychological therapy programmes
that are often required in forensic settings. Further research
is needed to explore whether the higher frequency of
incidents among civil patients affects the therapeutic milieu
on the ward and has an adverse impact on outcomes for
forensic patients engaging in specialist treatment interventions. The higher frequency of vulnerability incidents
among civil patients highlights the difficulty they experience
in forensic settings and suggests a greater need for vigilance
and robust safeguarding for this patient group, who may be at
risk of reprisal assaults by their forensic peers. The findings
of our study must also be considered in light of the
Schizophrenia Commission report,7 which comments that
158
patients stay too long in secure services, and highlights
funding cuts and acute bed closures in general adult services
as part of the problem.
We conclude that our study supports the need to focus
more on preventive interventions, such as avoiding delays in
assessment, ensuring early treatment and supporting
alternatives to admission such as crisis and home-based
treatment teams, to help avoid admissions. Regular liaison
between forensic and general adult services is essential to
help ensure patients can return to appropriate settings at
the earliest opportunity in their recovery. This may only be
possible with careful consideration when commissioning
services at all levels of care.
The finding that forensic patients have a greater
frequency of self-harm incidents should be treated with
caution as the numbers in this study are small and selfharm is a rare outcome. One possibility is that forensic
patients may find the criminal justice system and their
conviction distressing, leading to a greater risk of self-harm
and potentially suicide. We suggest that clinical teams
should be aware of this risk in these patients and ensure
careful monitoring, risk management and support for
patients during criminal proceedings.
Limitations
This study has a number of limitations. Most significantly, it
is a comparison of forensic and civil patients conducted in a
secure mental health hospital and the findings cannot be
used to compare differences between forensic and general
adult patients in non-secure settings. In addition, the civil
patients in the study are likely to represent patients with
greater treatment resistance whose aggressive behaviours
have led to them being transferred to secure settings. It
remains possible that the section status assigned to the
patient on admission may be misleading, as quite often
patients who commit offences when unwell are not
prosecuted.8 The study is reliant on accurate recording of
risk incidents in patients’ records. Although some degree of
inaccuracy in recording of incidents may have occurred, it is
anticipated that this would have occurred evenly between
ORIGINAL PAPERS
Galappathie et al Civil and forensic patients in secure settings
both groups and thus not affected the validity of the results.
This study, in line with previous work, evaluates data for
a cohort of discharged patients in order to evaluate
comparable groups. It is possible that the study may
underestimate the severity of risk incidents, since the
most challenging patients would not have been included in
the analysis as they have not yet been discharged from
hospital. It is anticipated that the impact of this factor
would be evenly distributed between each group.
Practice recommendations
Secure hospitals should ensure all treatment plans are based
around the individual. There should be an emphasis on
managing the mental illness of civil patients and tailoring
treatments based on this goal, which will help reduce risks
and hopefully shorten length of admission. Forensic
patients are more likely to have additional offence-related
treatment needs which would require specific interventions.
Regular liaison between forensic and general adult services
is essential to help ensure patients can return to
appropriate settings at the earliest opportunity in their
recovery. This can only be possible with careful consideration
when commissioning services at all levels of care.
About the authors
Nuwan Galappathie is a consultant forensic psychiatrist, St Andrew’s
Healthcare, Birmingham, and Visiting Researcher, Institute of Psychiatry,
Psychology & Neuroscience, King’s College, London; Sobia Tamim Khan is a
consultant forensic psychiatrist, St Andrew’s Healthcare, Birmingham, and
honorary senior lecturer, University of Birmingham; Amina Hussain is a
trainee forensic and clinical psychologist, St Andrew’s Healthcare,
Birmingham, and University of Birmingham.
Acknowledgement
We thank Catherine Clarke, Psychology student at the University of
Birmingham, for her help in the study.
References
1
Goldberg D. The state of British psychiatry. Prog Neurol Psychiatry 2006;
10: 12-16.
2 Turner T, Salter M. Forensic psychiatry and general psychiatry:
re-examining the relationship. Psychiatric Bull 2008; 32: 2-6.
3
Information Centre. Inpatients Formally Detained in Hospitals under the
Mental Health Act 1983, and Patients Subject to Supervised Community
Treatment: Annual Report, England, 2013/14. Health and Social Care
Information Centre, UK Government Statistical Service, 2014.
4 Coid J, Kahtan N, Gault S, Cook A, Jarman B. Medium secure forensic
psychiatry services: comparison of seven English health regions. Br J
Psychiatry 2001; 178: 55-61.
5 Reed S. People with learning disabilities in a low secure in-patient unit:
comparison of offenders and non-offenders. Br J Psychiatry 2004; 185:
499-504.
6 Dickens G, Sugarman P, Walker L. HoNOS-secure: a reliable outcome
measure for users of secure and forensic mental health services. J
Forens Psychiatry Psychol 2007; 18: 507-14.
7
Schizophrenia Commission. The Abandoned Illness: A Report by the
Schizophrenia Commission. Rethink Mental Illness, 2012.
8 Tuddenham L, Hunter R. Prosecution of violent patients. Psychiatric Bull
2005; 29: 275.
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