Michael Martin (Report) (Hansard, 21 March 1986)

§ Mr. Gerald Bermingham (St. Helens, South)

I thank the House for the opportunity to raise once again the case of Michael Martin by way of an Adjournment debate. As the House is probably aware, and as the Minister is certainly aware, the death of Michael Martin in Broadmoor some 18 months ago really lit a touch paper to a torch which began to illuminate a number of matters.

The matter moved forward from there by the appointment of an inquiry under Miss Shirley Ritchie, QC, which reported in the summer of last year. Many of us who have an interest in this area and in mental health generally waited with some interest to see to what extent the Ritchie report would be received by the Government. The initial reaction is that they accepted all the recommendations, as I understand it, except one. The Mental Health Act Commission, in a release dated the same day—30 August—urged the Government to change their mind on that recommendation. I hope that this afternoon, I can deal with that recommendation and then widen the issue into general matters which appertain to people who are detained in places such as Broadmoor.

That recommendation was one which, on the face of it, seems to any sensible man or woman to be perfectly reasonable. It recommends that people should not be administered sedative drugs, particularly heavy sedative drugs, unless it be done under the authority of and by a medical practitioner. There are few people in this land who would feel happy if they knew that the decision as to dosage for particular sedatives did not lie in the hands of a medical practitioner.

Michael Martin was detained in Broadmoor. There had been an incident, the facts of which are not pertinent now. After the incident Michael Martin was physically restrained, stripped of his clothes and injected. The injection was made by a nurse. The injection he was given was heavy—500 ml of one sedative and 200 ml of another. The tragedy was that he had already received, if my memory serves me correctly, some 400 ml of a further sedative earlier that day. He had eaten and they put him in a side room. He choked to death on his own vomit. Of course, certain physical injuries had been sustained when he was restrained, but that issue need not concern us this afternoon.

Any of us who considers those matters with any care appreciates that in mental hospitals there are occasions when people should be, need to be and have to be restrained for their own safety. How they are restrained should be the subject of careful training. How they should be dealt with medically must, of necessity, mean very careful medical training.

When one puts a drug into a human being, sometimes against his will, one cannot predict with complete certainty what will happen. The tragedy in Michael's case was that the mixture or the cocktail—call it what one will—of drugs undoubtedly led to vomiting, as the report shows, and to his death. I do not blame the staff of Broadmoor in any way. I do not seek in this Adjournment debate to cast any aspersions on them. I hope that we can learn some lessons from that tragedy, and ensure that it never occurs 586 again and that the standards in the secure mental hospitals of Broadmoor, Rampton, Moss Side and Park Lane are raised.

The people who serve in those institutions take on an onerous task. Unless, as a society, we give them the assistance that they need, we are not fair to them nor to the patients in those hospitals. If it means—it must mean this—that we have to increase the staffing levels in those four institutions, so be it, because a society that is not prepared to help the weakest in its midst, and those in greatest need, is a pretty poor society. People find themselves in secure units because they are said to have committed a criminal offence—one accepts that the majority have, but sometimes they have not. They are, through no fault of their own, deemed to be extremely ill. Mental illness is not a glamorous subject. It does not excite great headlines. Few people are prepared to fight the corner for it, but I assure the Minister that those who are prepared to do so will continue to press and press on those matters.

The more I read of the Ritchie report, and the more carefully I consider how the terms of reference were interpreted, the more I believe that only one narrow aspect of the matter has as yet been explored. The exploration that one seeks is in no way an attempt to criticise what has happened. We hope that the exploration is in the spirit of seeking ways to prevent tragedies in the future and to improve and enhance the standard of care in hospitals.

The one recommendation that the Government could not accept states: The decision to administer heavy sedatives should he made by a doctor and not by nursing staff. The decision should he made at the time of the incident by a doctor in attendance on the ward. He should be made fully aware of the extent of the violence immediately preceding his attendance and the quality and quantity of food recently consumed by the patient. My next remark is in no way critical of the nursing profession. Is it right to put upon the nurses at Broadmoor the onerous decision of making decisions about the injection of heavy sedatives? The Mental Health Act Commission says no, and most of the members of the medical profession to whom I have spoken say no. Everybody says no, but the Government say yes. I accept that it will mean that doctors will have to be in attendance on the wards at Broadmoor, perhaps around the clock. I accept that it will mean more doctors. But is that not a small, and, indeed, the right price to pay? Such important decisions could then be taken by those trained to take them. The staff at Broadmoor would be the first to say that their training should be longer and more intensive. It is not adequate for the decisions that have to be taken. The same applies to Rampton, Park Lane, and Moss Side, and the other secure hospitals. Some mental hospitals, including Rainhill in my constituency, have secure units attached to them. The same principle must apply. If we are to learn any lesson from Michael's death, let it be that expertise must be brought to bear when administering heavy sedatives.

I referred earlier to the danger of the drug cocktail. A person needs to be a specialist to understand such things, and needs to be trained for years before being able to take the right decisions. The doctors in attendance at Broadmoor have specialised, and have not come straight from college. They are very experienced men. Is it too much to ask, then, that a doctor should be there to make the decision when a patient needs heavy sedation? He 587 would have to consider what food the patient had eaten, because of the risk of choking to death on vomit when sedated.

In the case of Michael Martin, a doctor was not in attendance, there was a death, and there are lessons to be learnt. The report shows that the wing where Michael was located lacked facilities. I do not blame the staff, who have to cope with horrendous problems. However, the fact that a person is mentally ill does not mean that he needs to be sitting in a chair in a group of 12 for endless hours day after day. That is not the way to help. Outdoor facilities should be available. I appreciate that that would cost money, and that it would mean more staff and greater investment. But, our society can afford that.

Let it never be said that the sick are too heavy a cost for society to bear. After all, a person goes to Broadmoor because he is ill. It may well be that he has committed an offence, but that offence may have been committed before he was ill. Of course, some patients have committed no offence, and are just ill.

Money lies at the root of our problems. The facilities are inadequate, as are staffing numbers. Even the buildings are inadequate. I have raised this subject in the hope that a life lost in tragic circumstances will not have been lost in vain. If all five of the report's recommendations can be implemented, and if the Minister gives an undertaking that he will consider some of the matters I have raised about facilities, staffing and the general conditions within secure units, that tragedy may well turn out to be one step along the road to better conditions for many.

§ The Parliamentary Under-Secretary of State for Health and Social Security (Mr. Ray Whitney)

I am grateful to the hon. Member for St. Helens, South (Mr. Bermingham) for raising this important matter. He touched on the tragic death of Mr. Michael Martin and covered broader issues, and I shall try to respond as well as I can to all his points. If I have not covered some of them, I or my noble Friend the Under-Secretary of State will write to the hon. Gentleman. I accept the hon. Gentleman's suggestion that we must learn from such tragedies, and that we must constantly strive to enhance the standards of care in such difficult cases. I pay tribute to the hon. Gentleman's consistent interest in the complex and important area of mental health and his activities with the organisation MIND.

Given the tragic case of Mr. Martin, the reaction that it caused and the inquest's finding of accidental death aggravated by lack of care, this was clearly a matter of such public concern that my right hon. and learned Friend the Member for Rushcliffe (Mr. Clarke), the former Minister for Health, decided to establish an inquiry. It was also an opportunity for the staff at Broadmoor to put their side of the story relating to the events of that day and other events. My right hon. and learned Friend invited Miss Shirley Ritchie, QC to undertake the inquiry. She sought advice on clinical matters from two highly respected clinicians—Dr. Higgins, a consultant psychiatrist, and Miss McCloughlin, a district nursing officer.

Before I talk about some aspects of the report and what has been done to improve procedures at Broadmoor 588 hospital in the light of Miss Ritchie's recommendations, and in the light of decisions taken separately, in some instances before her recommendations appeared, it is important to emphasise the context in which patients such as Mr. Martin are cared for in special hospitals. As the hon. Gentleman understands, it is a difficult job, and he paid tribute to the staff. We recognise that the physical environment is far from ideal. Broadmoor hospital is well over 100 years old, and despite the best efforts of all to improve the fabric of the building, to reduce patient numbers significantly during the past 10 years, and to advance therapeutic and rehabilitation regimes, it remains a difficult place in which to work.

Problems are exacerbated by the fact that staff are dealing with mentally disordered patients who, because they are either so difficult to manage or so prone to extreme dangerousness, cannot be satisfactorily cared for anywhere except in conditions of special security. The House will agree that we owe it to the staff to recognise that those problems exist, and that was certainly the case with Mr. Martin.

I do not wish to give details about patients, but it is clear that Mr. Martin was a young man who fluctuated sharply between moods of cheerfulness and considerable violence. During his time in Broadmoor, he made more than 20 unprovoked attacks on staff and other patients. Yet, between those bouts, he displayed a happy and lively personality. The nursing staff were fond of Mr. Martin, who was one of their younger patients, and as Miss Ritchie said in her report, he became something of a pet on the ward. However, there is no doubt that he could be a difficult patient to handle. It is to the credit of those looking after him that, while in Norfolk house, he showed some overall improvement, to the extent that consideration had been given to the possibility of a planned transfer of him back to Bexley hospital.

Miss Ritchie's report appeared in August 1985 and Ministers welcomed the care and sympathy with which the task was carried out and the skill with which she identified the problems and shortcomings that had occurred. Miss Ritchie made five recommendations, all of which were accepted except that which related to the practice of administering heavy sedatives, to which the hon. Member for St. Helen's South referred with some emphasis.

There is no doubt that the administering of sedatives is a difficult issue in all hospitals, and especially so in hospitals such as Broadmoor in the circumstances which I have described. Section I of Miss Ritchie's report discusses this issue in detail and the responsibilities that attach to it. It quotes in full the notice issued on 8 October 1984 by the medical director to all nursing staff and doctors in Broadmoor. The effect of the notice was to forbid the administration of any medication unless it had previously been prescribed in writing by a doctor. The issue of a prescription in writing is known as the PRN basis, and it specifies in advance the circumstances in which particular forms of medication may be administered to a named patient. The effect of insisting that a decision to administer heavy sedatives should be made by a doctor and not by nursing staff and of specifying that the decision should be made at the time of the incident by a doctor in attendance on the ward would be to prevent medical and nursing staff at the hospital from using the PRN practice, to which I have referred, which is generally accepted as being available for use by medical and nursing staff in hospitals. As I have 589 said, this was the only one of Miss Ritchie's recommendations that was not accepted by the Department.

The effect of the recommendation would have been to remove from the nursing staff at Broadmoor hospital, and Broadmoor hospital alone, the professional responsibility of a qualified nurse to exercise judgment in the administration of properly prescribed medicines.

The hon. Member for St. Helens, South has suggested that everyone agrees with Miss Ritchie and that no one agrees with the Department's view. That is not so. Among others, the Royal College of Psychiatrists, the United Kingdom Central Council for Nursing, Midwifery, and Health Visiting and the Royal College of Nursing have all confirmed that they agree with decision not to accept this one recommendation of the Ritchie report.

There is no doubt that when the tragic incident involving Michael Martin occurred there was a degree of confusion and lack of precision. I think that it is clear that the effect of the two notices that have since been issued by the medical director is to remove all uncertainty and ambiguity and to ensure that the practice at Broadmoor hospital will conform with the most demanding standards that might be applied in any other hospital. The responsible medical officer is involved in evey decision to employ advance prescribing. He specifies the dosage of a particular drug to be administered in defined circumstances to a particular patient. For example, in the case of a patient who is thought likely to have a disturbed episode, it might be decided that it would be in the patient's own interests if drug treatment were given immediately. If at the same time there are contra-indications, senior nurses will seek medical guidance and will not administer the drug automatically.

Multidisciplinary working, underpinned by clinical teams concerned with the overall care of the patient, is practised in Broadmoor as in other psychiatric hospitals. Decisions on medication are taken in that context. There may be occasions when it is essential that a patient is given medication without delay. Advance prescription is decided in the light of discussions between the members of the clinical team. Following the administration of such a prescription there would be a full review by the clinical team. That is in step with current thinking on crisis intervention throughout the National Health Service.

The hon. Gentleman said that some members of the Mental Health Act Commission are not disposed to accept the Department's view. Baroness Trumpington has had discussions with the chairman of the commission and we are continuing to investigate the issue through a working 590 party. I emphasise that this situation obtains throughout the Health Service and has been extremely carefully considered. We shall have to move carefully before we go in the direction urged by the hon. Gentleman.

All the other recommendations in the report by Miss Ritchie have been adopted. That is a demonstration of our commitment to continue improving as best we can our care and treatment of such patients, given the inherrently difficult problems.

Prior to that inquiry, a number of matters were already under consideration or had been acted upon by the hospital. For example, there was training in restraint for staff. Just before Mr. Martin's death the hospital management team decided that Broadmoor hospital staff should undertake such courses and begin training before the end of 1984.

During 1984, the Department had in progress a comprehensive review of seclusion policy and procedures in the special hospital service. In April 1985 a report constituting policy for local application was sent to each hospital. That is another concern emphasised by Miss Ritchie's report.

On 15 October 1984, the hospital provided nursing staff with written guidance about the internal movement of patients in Norfolk house. The number of beds has been reduced in Norfolk house, where Mr. Martin was established, from 39 to 36, and the staff has been increased by one. The hospital management team has plans to reduce from three to two the wards in Norfolk house. A key element is the provision of a re-socialisation unit on the top floor. The scope for occupational therapy has been considered carefully by the hospital management team. It is seeking improvements.

We have been talking about an extremely difficult and emotive case. Everyone concerned was deeply disturbed by it. When tragedies such as this occur it is essential to learn from them. Whether or not mistakes are made, we can always learn. That was the objective in conducting the report. I am confident that we and the hospital authorities generally have learnt from the Ritchie report. We can take some comfort from that. We must always keep on trying, but we shall never reach perfection in such a difficult area.

We shall keep the administration of sedatives under review. The circumstances in which sedatives may be prescribed have been carefully examined. We are talking about a longstanding practice which has been found to be adequate and, indeed, necessary, given the type of emergencies that inevitably arise from time to time.