The Tragic Case of the Teenager on the Number 9 Bus (Or “Do less better, rather than more badly”)

DASH, MARAC, CJTTAG, CAMHS, LSCB, PICU, BSMHFT, IDVA, BCPFT, PCLT, PAPPU, ACCT, BASS, SIG, HTT, BMT, P-NOMIS, CPA CAT, IMR, CSRA

 

These are a sample of the acronyms which crop up in the recent report into the random killing by Phillip Simelane of a 14 year-old girl on the top deck of a number 9 bus in Birmingham in March 2013. The investigation was chaired by a forensic consultant psychiatrist, supported by four senior non-clinical or ex-clinical managers, who rounded off their work with 51 recommendations for 6 different organisations. Along the way, they document a number of what they call “overarching lessons”; namely, people with mental illness are not always able to look for and make use of help, staff don’t listen to relatives enough, information is scattered not shared, and it is important that treatment is guided by a full history of the patient’s disorder – not so much lessons as elementary tenets of good practice.

 

Here, neatly encapsulated, are the flaws both in the structure of mental health services and in the approach to investigations when things go wrong.  Phillip was an ordinary patient, familiar to every inner-city mental health team. This will come as a surprise to outsiders but his background, the symptoms of emerging mental illness interleaved with intermittent drug use, and even his criminal record and history of aggression, mainly towards his family, would not have stood out to the average psychiatrist, nurse or social worker in Birmingham or London.

 

He had 17 mental health reviews or assessments in the three years or so before the incident, provided by 4 different organisations. This may seem excessive or exceptional but, again, it is par for the course which sufferers of serious mental illness must navigate.  By the time the average patient is, say, three years into what sadly often turns into a career, with maybe a couple of admissions, he or she may have seen well over a hundred different mental health staff, if you include ward and home treatment nurses. 

 

This is because services are repeatedly fractured into teams aligned with particular functions and diagnoses in keeping with the current ideology in the Department of Health and academic psychiatry: for example, assertive outreach, crisis response, home treatment, long-term, short-term, assessment, mood and anxiety, psychosis, personality disorder, drug and alcohol use and so on.  While this model may be logical for physical health care, where medical science has managed to refine pathology into smaller and smaller disorders requiring very different treatments and expertise, mental health is way behind this level of sophistication, though it will almost certainly reach it eventually.

 

What this means is that patients move from service to service, depending on which aspect of their difficulties is to the fore; or different aspects of their disorder and personality are parcelled up and allocated to different teams and treatments, fragmented services neatly but clumsily mirroring the internal fragmentation which many, if not most, patients are struggling with.  When they are getting to know the ropes of having a serious and unpleasant mental disorder, and especially when it is developing or maturing, as in Phillip’s case, what they need is, first, continuity to improve the chances of their building some kind of protective, therapeutic and confiding relationship; and, secondly, someone who is able to relate to them as a whole person, rather than a collection of discrete disorders.

 

This not complicated stuff but inquiries, into childcare disasters as well, invariably make it so. Mental illness is relatively easy to treat, although a still limited understanding of pharmacogenetics (the genetically determined response of individual patients to different medicines) often means that it may take years of trial and error to find the most effective one, or the most effective combination. And there is no evidence that inquiries and reports actually reduce risk over time, while there is evidence, both from research and from straightforward, empirical common sense, that if you optimise treatment, for example by stopping command hallucinations telling a patient to kill, risk will be reduced. 

 

In fact, reports such as this may actually make services less safe:

 

1. By conveying that complex and time-consuming procedures and policies should be applied to every case, when they should only be invoked in those cases where risk has been properly assessed to be medium or high. This is more likely to happen where the inquiry is led, as in this case, by a forensic psychiatrist who is used to working with high risk all the time. 
2. By spraying a blizzard of all-encompassing recommendations (rarely implemented, thereby adding to organisational anxiety) which befuddle senior management and consume a vast amount of time and, more important, thinking.
3. By taking the emphasis and focus away from making protective clinical relationships and relentlessly working out what the optimal treatment may be.
4. By denting the confidence of clinical staff on the ground and contributing to an atmosphere of therapeutic nihilism and helplessness because, instead of seeing that there are solutions which largely lie in their hands, they begin to believe that their practice must be guided by a kind of powerful bureaucratic satnav, a failure to follow which means they will be off-piste and in danger of an avalanche of criticism.

 

In the sad case of Phillip Simelane, there are perhaps three, simple and key lessons.  He fitted, of course, the stereotype of the dangerous, marauding black man for the public and press but sadly mental health services also operate in the shadow of the stereotypical picture of the kind of patient who poses serious risk. His ordinariness to clinical staff on the ground almost certainly meant they were off-guard and not projecting forward in the case and thinking about where, if the circumstances were right, it might lead.  Stereotype-driven services, apart from anything else, are risky ones.

 

Secondly, bureaucratic, pressure-driven responses (sending an opt-in letter to test motivation and the likelihood that someone will turn up for an appointment) must be tempered by careful thought about the capacity and state of mind of the recipient. Most important of all, a focus on factors which may attend mental illness – in his case, personality or identity difficulties, vulnerability and isolation – mustn’t obscure the need to treat the illness itself: in other words, explanation of a problem ought not to be mistaken for its management. This was the misunderstanding in the flawed Mental Health Act assessment which came to the conclusion that he did not need enforced assessment and treatment.

 

Thirdly, there is another cultural or even political factor which leads risk to gather or pool in mental health services.  This is the focus on the secondary task – say, promoting recovery or whatever may be the phrase of the moment – at the expense of the primary task: the detection and management of risk.  The latter is what the public, families and patients themselves want and expect from services.   Staff, on the other hand, tend to see risk management as an irksome, marginal task, imposed by anxious and defensive managers, which takes them away from some imagined therapeutic world where the potential for violence, to self as well as others, can be wished away.  This is another manifestation of the “rule of optimism” highlighted by Louis Blom-Cooper in his report into the killing of Jasmine Beckford in 1984 which, typically, was noted but never inculcated into everyday practice.

 

The institutional waters will close over the Simelane report as quickly as they do every other inquiry.  And vivid, helpful lessons for good practice will not cross the barrier into organisational and cultural memory.  In spite of the diligence and thoroughness of its contributors, it will sadly generate no added value of any kind.  This is partly because administratively-minded panel-members will always tend to produce concrete, administrational recommendations rather than soft, clinical ones; but also because the language of reports, with their subtext of blame, failure and inadequacy sent ex cathedra down the hierarchy to low-status clinical staff on the ground, is not intelligible to them.  We learn from those who we respect and have confidence in, and who we believe are interested in us and what we do.  Clinical practice is improved, and stays improved, not when directives are issued by remote experts working to different, often defensive, imperatives but when simple, key lessons are incorporated, through leadership and supervision on the job, into the day-to-day clinical activity, systems and culture of groups of staff who are directly providing a service to patients.