Prison study reveals high rate of self-harm after release and mental health failures

One in 15 newly-released prisoners attend hospital for self-harm but emergency departments are failing in their obligations to conduct comprehensive mental health assessments, new research shows.

A groundbreaking study of former prisoners, published in the Australian and New Zealand Journal of Psychiatry this month, has revealed high rates of self-harm following release from prison.

The post-release period is often seen as one of high risk for prisoners. It can be a time of significant upheaval and difficulty, leaving them without the intensive support services offered in prison, and exacerbating isolation, anxiety and other mental health issues.

The study examined the experiences of more than 1,300 prisoners by linking in-depth, pre-release interviews to emergency department and state correctional records.

The researchers found 83, or 6.4%, of the prisoners presented to emergency departments for self-harm. Twenty were hospitalised for self-harm twice and 14 presented three or more times.

Self-harm accounted for 5% of all emergency department presentations by the prisoners. That is 10 times higher than the proportion for the general population.

Eight had self-harmed within three months of release, 27 between three months and a year, and 48 after more than a year.

The study also revealed that only 29% of prisoners who had self-harmed were given a comprehensive mental health assessment.

The study’s authors described that as “extremely concerning” and as potentially in breach of the Royal Australian and New Zealand College of Psychiatrists’ guidelines.

One of the report’s authors, Murdoch Children’s Research Institute research fellow and psychologist Rohan Borschmann, said the guidelines required those assessments to be conducted when a patient presented with signs of self-harm.

“They state clearly that every person who presents to an emergency department following self-harm should be given some form of psychiatric assessment,” Borschmann said. “Our finding that only three in 10 people were receiving that was quite disturbing.”

Before this study, there had been no published data about rates of self-harm among newly-released prisoners.

Borschmann said the data showed the need for the provision of continuous healthcare services to prisoners before and after release.

“First and foremost there needs to be a better link-up between the healthcare provided in prison and the healthcare provided after release from prison,” he said.

“Ideally, that would involve continuity of healthcare beginning before they’re released from prison … and working with them through that often difficult period of transition.”

Borschmann urged governments to avoid making moral judgments on who should or should not receive proper healthcare.

“People who end up in prison typically have very complex lives and they’re often victims of things themselves,” he said. “It’s a moral issue to comment on who deserves treatment more than others. There really needs to be a shift away from that ‘they’re just bad people’ style of thinking.”

• Crisis support services can be reached 24 hours a day: Lifeline 13 11 14; Suicide Call Back Service 1300 659 467; Kids Helpline 1800 55 1800; MensLine Australia1300 78 99 78; Beyond Blue 1300 22 4636

Prison study reveals high rate of self-harm after release and mental health failures

Coroner says hospital"s "failures" led to death of woman after caesarean

The death of a young mother just hours after she gave birth to her second son was a result of “failures, inadequate diagnosis and treatment” at the hospital caring for her, a coroner has said.

Frances Cappuccini, 30, died at Tunbridge Wells hospital in Pembury, Kent, shortly after giving birth to her son, Giacomo, by caesearean section. She suffered heavy bleeding and was anaesthetised, but went into cardiac arrest and died at 4.20pm on 9 October 2012.

The inquest at Gravesend old town hall in Kent heard Cappuccini lost more than two litres (around four pints) of blood after the C-section. She was subsequently operated on for a postpartum haemorrhage but never woke up from the anaesthetic. The inquest criticised the care given to her, including a piece of placenta that was left in her womb.

Senior coroner Roger Hatch said the caesarean section was not carried out with enough care and that checks should have been made to ensure nothing was missed. He said: “The result of this failure led directly to the subsequent series of events which tragically led to the death of Frances.”

Coroner says hospital"s "failures" led to death of woman after caesarean

Has government learned the vital lessons of public service failures?

From the failure at Mid Staffordshire NHS foundation trust that led to the mistreatment of hundreds of patients, to the Rotherham children’s services scandal, we have seen been high-profile crises in public services that have had direct and disastrous effects on people’s lives.

Managing failure is a vital skill, and new research from the Institute for Government aims to understand how government can best respond to – and learn from – such events more effectively. It focuses on failures in four key public services, hospitals, local authorities, children’s services and schools, and ways to restore services quickly. A few common themes emerge:

The first lesson is to avoid some of the most common responses to failure, including blame and restructuring. It’s human instinct to find an individual to blame: 70%-80% of inquiries across a range of industries and professions attribute tragedies to the error of particular individuals. But this instinctive response usually fails to understand or to address why it was that an individual thought it best to act in a given way. The impulse to restructure in the wake of a crisis has a similar appeal – it feels like you are at least doing something – but will be effective only if linked to the actual causes of failure, which are frequently rooted in behaviour or culture.

One example is Doncaster metropolitan borough council, which was found to be failing by an Audit Commission inspection in 2010. by the Audit Commission. The communities secretary, John Denham subsequently appointed commissioners and service quality improved. They were withdrawn a year earlier than planned, in 2014.

Related: May’s Whitehall reshuffle shows disregard for evidence and expertise

In Doncaster, the turnaround was based in part on reconnecting the council with neighbouring authorities. It had become insular, and as it detached from its peers, it lost its sense of what good looked like.

This was a common phenomenon across our case studies; one teacher, appointed to a school just weeks before it was tipped into special measures, recalled that it was absolutely crystal clear the second they walked in that building that the school was failing. “What was terrifying was that it wasn’t clear to the people inside it.” To overcome this insularity, organisations began rebuilding links with their peers, including them on improvement boards or by making use of sector-specific services such as the Local Government Association’s peer challenge tool.

Doncaster also avoided the risk of pursuing an unsustainable recovery based on temporary appointments or relying on external support. The commissioners were clear that ownership should remain with the council. The test for ending the intervention was not whether services had returned to a good standard, but whether commissioners were confident that the council could reach that point without further external support. In contrast, in Tower Hamlets in 2014, the commissioners sent in by then-communities secretary Eric Pickles formed an executive board and replaced the council in the day-to-day running of services.

Failure is not going to go away, but at least we can minimise its impact if the government is prepared to learn lessons from the past. There is plenty of scope for improvement.

Oliver Ilott is a researcher at the Institute for Government.

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Has government learned the vital lessons of public service failures?

NHS"s bureaucratic failures put lives at threat

The NHS is a massive organisation that employs well in excess of a million people. Inevitably, items will often go wrong: the management and employees are only human. Most people would sympathise with staff who find themselves below huge stress, which may properly influence the good quality of their determination producing. Nonetheless, when it comes to dealing with the overall health of the nation, errors must be recognized swiftly and resolved.

These days, The Sunday Telegraph discloses a serious issue with the management of sources. It is astonishing to uncover that some locum medical professionals are getting paid up to £3,000 per shift by hospitals desperately short of staff in in excess of-stretched Accident and Emergency units. In 2013, the bill for hiring locum medical doctors (which involves fees to agencies) reached virtually £250 million, new figures suggest.

Having to pay this kind of huge amounts to plug gaps was only supposed to happen in moments of crisis, but our investigation confirms that it has become a matter of program in some NHS trusts. The dilemma is a mix of poor management and a national shortage of consultants, some thing that the Government clearly demands to tackle because failure to invest in recruitment is forcing trusts to commit exorbitantly on locums alternatively – a decidedly false economic system. Of program, the need for a lot more physicians is itself a solution of the increasing burden on A&ampE, which several individuals use merely simply because they cannot get an appointment with a GP. And the ring-fencing of the wellness budget, a Coalition promise, has led to a squeeze on social care. For want of a handrail, for instance, accidents will come about and end result in a journey to A&ampE.

Meanwhile, one more horrific story displays how undesirable choice-creating could be costing lives. A complete of twelve households are now taking legal action towards Bristol Royal Hospital, in which as numerous as 20 children died or suffered extreme right after-effects following cardiac treatment. On Friday, Sir Bruce Keogh, the country’s most senior medical doctor, met parents who told him that sometimes there have been so number of nurses offered to care for their children that they were forced to clean up vomit, monitor oxygen amounts and administer medicine by themselves. In one specifically distressing case, a child boy’s operation was delayed 5 occasions in one week. Only when he was deemed an “emergency” was he operated on. He died a few hours later on, following issues.

Sir Bruce thanked this newspaper for assisting to expose the scandal, for getting “identified and brought to light the failings at Bristol”. He also explained that the NHS often fails to support men and women when items go wrong all also usually, individuals with grievances are treated in a bureaucratic, cold method. Sir Bruce mentioned, rightly, “We can’t just say ‘sorry, we’ve accomplished our best’ and move on.”

The great information is that there is a expanding push for transparency in the NHS. For instance, the Government is operating to release league tables of overall performance that need to not only highlight failures, but also encourage review of greatest practice. The well being service needs to seem at itself honestly and rigorously. It can’t proceed to fall back on comforting myths about it getting “the envy of the world”. Failure to get things proper – to preserve adequate amounts of staffing and to control that personnel nicely – can be a matter of existence and death.

NHS"s bureaucratic failures put lives at threat

Failures to intervene pinpointed in case of murdered four-yr-previous Daniel Pelka

Delays in information getting shared by agencies, staffing troubles and inadequate training led to failures to intervene in the situation of a 4-year-previous boy beaten to death by his mom and stepfather, a report has located.

Daniel Pelka died of a head damage soon after a campaign of abuse by his mom, Magdelena Luczak, and his stepfather, former soldier Mariusz Krezolek, the two of whom had been final 12 months jailed for a minimum of 30 many years for his murder.

An independent report by Coventry Safeguarding Kids Board on Wednesday identified delays in data getting shared by wellness professionals, school workers and social employees along with staffing troubles and inadequate training led to failures to help Daniel.

A severe case overview published by the board final 12 months found that Daniel was “invisible” at occasions, with numerous probabilities missed by agencies to support him.

The new report comes right after Edward Timpson, kids and families minister, requested a more in depth examination of why errors occurred following the publication of the damning serious case overview.

The report, carried out by independent authorities, located there have been delays in recording details on social function data. The delays had been due to the difficulties concerned in managing the volume of details in relation to domestic violence and inadequate administrative support inside children’s social care, the report stated.

The report also located “unacceptable delays” in circulating the minutes of a technique meeting that looked at a broken arm suffered by Daniel in 2011. In particular, there was “inadequate management oversight” to make sure that the minutes had been circulated, the document said.

It also mentioned that this kind of delays have been not uncommon at the time due to work pressures in children’s social care, including inadequate administrative help.

The report also found that overall health guests and Daniel’s school nurse did not have a total picture of his family’s circumstances simply because there were no family information inside local community well being solutions. Central allocation of overall health visitor duties this kind of as developmental checks or new birth visits resulted in a lack of consistency in function with the household, the report said.

Daniel’s college was unable to type an accurate evaluation of require and risk to the pupil owing to inconsistent use of its recording programs and information not becoming brought together in a central location, the report found. This was due to lack of powerful leadership within the school and insufficient college-focused education and external scrutiny in relation to the improvement of risk-free, effective little one safety methods, it additional.

Failures to intervene pinpointed in case of murdered four-yr-previous Daniel Pelka