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What's not okay in hospital?

So often, things happen in hospital that are normalised, accepted and legitimised as part of that hospital's 'status quo' of care, practice, treatment and decision making. Many with lived experience of being admitted into mental health hospital settings, and those whose loved ones have been, talk about having never known, or been told, what actually isn't okay in these environments.

FDNH have put together a guide for current patients, families and loved ones to help identify what isn't good practice or treatment, and the signs of when something in hospital has the potential to be serious. Note, however, that this guide is not exhaustive; there are many things that hospitals might do that aren't okay, but below is a good indicator of when a hospital might have developed a culture where these things are normalised and overlooked. 

If you find that any points in this guide are happening in a hospital where you or you loved one is, see our Emergency Plan on actions to take. 

Communication
  • Staff make you feel like you’re naughty, being a nuisance or badly-behaved for being distressed or having an incident.

  • Staff appear dismissive or annoyed when you’re struggling or asking why a decision has been made, or why you have to do something (i.e. staff say ‘you know why you’re here’, instead of clearly explaining and reassuring, even if that means they have to repeat themselves).

  • Unclear and vague communication (i.e. staff tell you the doctor ‘says so’, without explaining why). Staff don’t allow you to have a conversation about an aspect of your care, and instead respond with a ‘that’s how it is’ attitude.

  • Agency (non-permanent) staff don’t have appropriate and thorough handovers about individual patients, appear to not know how to support individuals and get patients mistaken for one another.

  • Family members are not informed of incidents that you have been involved in; for patients under the age of 16, an individual with parental or carer responsibility must be informed of any incidents that take place involving the patient. This includes incidents on the hospital's part (like restraints and administration of PRN medication and sedatives- family members must be informed of both lawful/correct procedures and when an error is made).

Mixed Messages
  • Staff give opinions about, or disagree with, your family members.

  • Staff telling you what they think is best, rather than engaging in a transparent dialogue to work out the next steps and best route for ongoing care and recovery (e.g. without consulting with all of the hospital team, family and community team, staff say that you would better in a residential care setting rather than being discharge home with an appropriate care package).

  • Staff talking or gossiping negatively about other staff and/or patients; calling people names, laughing at others. This includes the whole team (cleaners, cooks, OTs, etc).

  • Staff and/or patients have established a hierarchy of who is considered the most ‘ill’ in the hospital and therefore deserving of more care or to be taken seriously (e.g. those sectioned are somehow ‘better’, those with eating disorders ‘don’t have a real psychiatric illness’, or people diagnosed with personality disorders are ‘tricky’ patients).

  • Staff ‘pick and choose’ which patients are allowed to speak to the CQC inspector during inspections, and actively ‘steer’ inspectors away from speaking to certain patients.

Care/treatment
  • You aren’t given access to education, particularly if you are under 18. Access to suitable education is a legal right and cannot be denied on the basis of illness.

  • There are not enough activities to do every day, and staff are not actively encouraging activities outside of groups and therapy sessions. 

  • OT, therapy and therapeutic spaces do not happen on a weekly basis, and an activity timetable is either not in place or not being used by staff.

  • You’re prescribed medication without being given information on the drug, or options for alternative medication if you disagree or have problems with the side effects.

  • You’re given the wrong medication, staff do not apologise or record it as an incident and inform the relevant safeguarding and regulatory bodies.

  • You don’t see, or are offered, copies of your incident reports and there is no clear or substantial reason for this.

  • When you, your family or another patient queries an aspect of care/treatment, the reason given by managerial-level staff is to assert that such aspects are beyond their control (i.e, the patient themselves did not engage, or an incident that occurred was simple human error and ‘won’t happen again’).

Care Planning
  • You are not involved in planning or discussing all aspects of your care.

  • You are not offered or given physical copies of your care plan.

  • You don’t feel enabled or allowed to challenge all aspects of your care plan that you disagree with, want a review of, or are simply irrelevant.

  • Your care plans don’t document: why decisions are made, detailed steps for discharge, what the patient can do if they disagree or want an update to their care plans, a detailed and individualised de-escalation and distraction plan.

  • Your care plan is written using accusatory language, that makes you feel you’re to blame, and contains deterministic ideas (i.e. you currently won’t/refuse to a certain aspect of treatment, not can’t/find difficult to).

  • When you do challenge or question any aspect of your treatment or care planning, the hospital team say things like 'you're on a section so you don't have a choice'.

Physical Environment
  • You don’t feel safe or comfortable in the physical environment of the hospital.

  • The environment is unclean, there is blood on the walls, broken furniture, cracked windows, etc.

  • The ward is over-stimulating and there is no access to a low-sensory area that patients can go to without being let in by staff.

  • The food is poor quality, or there is no access to a kitchen/canteen to make drinks or food without requiring staff to access.

  • You are not able to make your sleeping space individualised (blankets, bedding from home, teddies, photos, bedside ornaments, etc).

  • You don’t have access to outside space, or outdoor access is frequently denied because of short-staffing, other incidents, or staff are ‘too busy’.

  • When you, your family or another patient query the lack of access to outside spaces and facilities, the reason given by managerial-level staff is to assert that access was offered, and instead blame the patient themselves for declining/refusing said access.

  • Before CQC carry out a planned inspection, staff make active attempts to improve the physical environment (cleaning, removing broken furniture, painting over stains/blood on walls), but make no attempts to do this outside of CQC inspections.

Reactive Practice
  • Staff make no attempt, or very little attempt, to utilise de-escalation techniques for you or other patients before using chemical and physical restraint (e.g. staff have a 5 minute ‘chat’ with a patient and then use restraint).

  • Staff ignore or appear unaware of signs of distress for you and other patients,  and only respond once an incident has occurred.

  • No therapeutic interventions are attempted before an incident, or there are little attempts to work with a patient to identify patterns of distress and actively supporting a patient to utilise staff support, distraction techniques, etc.

  • It feels like staff hand out chemical restraints (injections, sedatives such as lorazepam or diazepam) to make their job easier.

  • Staff use inappropriate or illegal holds during restraints (you are entitled to know the type of restraint the hospital uses).

  • Restraints are taking place multiple times a day for you or other patients, and there is no clear documented plan for reducing restrictive practices in care plans. This includes people who are being restrained to be fed through a nasogastric tube.

  • Restraints are used as a first resort, even when you or other patients don’t appear acutely distressed and/or at risk of harm to self or others.

  • Agency members of staff are carrying out restraints when they may not be trained in the same restraint training and practice that the hospital uses.

Use of threat/coercion
  • The MDT uses a section as a reason to stop leave, visits, or access to education without a well-documented and justified reason; it can’t just be because they consider you/loved one as ‘too high risk’. Any decisions in regards to removing home leave or access to the outside world must be made in line with care plans that details a plan on how to manage and support; the decision cannot be made on a whim.

  • Similarly, staff take away ‘privileges’ (e.g. access to outdoor spaces, phones, craft materials, etc) after an incident without any discussion with the patient and collaborative plan documenting individualised plans for reducing risk and de-escalation techniques.

  • Saying, ‘if you don’t do X, we’ll take away/stop Y’, or using threat of restraint to make you do something or comply with any aspect of your care plan (like meals, medication, group or therapy sessions).

  • Staff tell patients to ‘behave themselves’ when CQC visits to carry out inspections.

Relationships
  • You and other patients are being put in the position of providing emotional support for one another.

  • You have to help, or intervene, in incidents involving other patients. This might include having to physically or verbally stop someone from harming themselves, or using restraint-like methods when another patient is experiencing high levels of distress.

  • There are signs of staff members grooming patients. Individual or multiple staff members may appear to have ‘favourite’ patients, with the intent to isolate you or another patient from other professionals in order to enact abuse, usually sexual in nature (if you're not sure what grooming or sexual assault means and consists of, or even if you are sure, have a look at this guide). This might look like; a staff member repeatedly requesting to be placed on a patient’s 1-1 supervision, requesting or volunteering to be the accompanying staff member on a patient’s supervised outings/leave. It also involves emotional isolation; the staff member might use emotional connection and security to make you or another patient feel they can only rely on (and be safe with) the staff member themselves, or create a narrative of ‘us’ (the staff member and patient) verses ‘them’ (the hospital, family and other professionals).

  • Similarly, there are signs of patients grooming other patients, particularly if there is a substantial age difference between patients (i.e. a 12-year-old and a patient who is 17 years old). In this case, another patient might use similar methods to isolate you or another patient in order to enact abuse.

  • Staff seem to allow, overlook, or make little attempt to manage assaults (physical and sexual) between patients.

  • Staff appear to have an attitude of disbelief towards noticeable and potentially inappropriate relationships between staff and patients; they might not regard it as true when spoken about, avoid raising concerns for fear of repercussions, or identify the patient as manipulating, coercive or unwell and therefore the ‘relationship’ is not abusive and the responsibility of all staff is alleviated (i.e. patients diagnosed with a personality disorder might be blamed for the staff member’s ‘weird’ behaviour, because the patient is ‘too attached’).

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