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Forensic Psychiatric Services – Justice With Dignity Dr.Benjamin T. M. CHAN MBBS, MPM(Hon), Dip.Foren.Psych.(London) Consultant Forensic Psychiatrist Hospital Permai Johor Bahru
Lecture Outline Historical background International conventions & standards Malaysian laws Current Practice: "A Time Bomb" The Future – "A Dream" Law: Ancient traditions ARISTOTLE morally responsible (only) if the act committed with knowledge, absence of compulsion, deliberately ROMAN LAW an insane person was "excused by the fact of their misfortune" 18th Century "Wild Beast test: J Tracy (1724) - The McNaughten Rules (1843) It is a defense to prove that at the time of committing the offence, the accused was suffering from a defect of reason from disease of the mind, as not to know the nature and the quality of the act, or that what he was doing was wrong. International conventions: (United Nations Commissioner For Human Rights) 82.(1) Persons who are found insane shall not be detained in prisons and arrangements should be made to move them to mental institutions as soon as possible. 82.(4)The medical or psychiatric service of the penal institutions shall provide for the psychiatric treatment of all other prisoners who are in need of such treatment WHO: Principles for the Protection of Persons with Mental
Illness (1991) 1. Fundamental freedoms and basic rights – All persons have the right to the best available mental health care which shall be part of the health & social care system 9. Every person shall have the right to be treated in the least restrictive environment 10. Medication – therapeutic purpose; never as punishment 17. Review body Principle 20: Criminal Offenders - Plea of Insanity/NGRI? All such person should receive the best possible available MH care (P1) Is MH care guaranteed to prisoners? Any forensic hospital for prisoners? Mentally ill prisoners kept with the general prison population? Can transfer to psychiatric facility? Royal College Of Psychiatrists, UK Recommendations re: UK Government Report: ‘Suicide is Everyone’s Concern: "Prisoners should have access to an equivalent level of health care as those outside prison" "The use of seclusion and ‘stripped cells’ for the management of suicidal prisoners should be stopped" Secure facilities for Psych Patients – A Comprehensive Policy (RCP1980) Australian Standards BURDEKIN REPORT 1993 (Report of the National Enquiry into the rights of the Mentally Ill) Mentally ill people in the community justice system must be provided with appropriate treatment Seriously mentally ill prisoners should generally be treated in health care facilities controlled and operated by the public health authorities BURDEKIN REPORT (1993) – Part 2 Seriously mentally ill prisoners should be admitted to psychiatric wards in general hospitals or acute care wards in psychiatric hospitals [unless they] cannot be safely treated [in such facilities] Mentally ill prisoners who remain in gaol must have access to adequate treatment by mental health professionals Anyone ordered to be detained in custody after being found unfit….or not guilty on the grounds of mental illness should be detained in a health facility not a prison The New South Wales Give Lower Courts discretion to refer mentally-ill defendants for assessment and / or treatment (MH(CP)Act Ss. 32-25) Make provision for the transfer of mentally ill prisoners to psychiatric hospital (MHAct Ss. 97, 98) Provides for psychiatric treatment for those found not guilty due to mental illness (MHAct, Ss. 80-89) International Practice Forensic Psychiatric Service e.g. UK, Canada, New Zealand, Queensland, S.A, Victoria, W.A. Court psychiatric diversion programmes Mental Health Courts Court Psychiatric Services Mentally Ill identified at Court or in custody Secure Forensic Hospitals in the community Psychiatric hospital; not jail Community Forensic Mental Health Services Treatment in the community for mentally ill offenders Malaysian Standards: S342 - procedure where accused is suspected to be of unsound mind S347 - judgment of acquittal on ground of mental disorder (NGRI) S348 - detention under Ruler’s Pleasure S351 - fit for discharge c/o relative Flowchart for Forensic Admissions Flowchart for Forensic Admissions Flowchart for Forensic Admissions (2) Malaysian Standards (2) Court discretion to refer mentally-ill defendants for assessment and / or treatment - NIL Provides for psychiatric treatment for those found not guilty due to mental illness (CPC XXXIII) Make provision for the transfer of mentally ill prisoners to psychiatric hospital (Prison Act) SUHAKAM Tan Sri Lee Lam Thye Report Reported in the Press: No abuse or neglect BUT gross shortage of staff – all categories Overcrowding Total Forensic Admissions: 1991 – 207 1996 – 305 1999 – 310 2000 – 344 2001 – 385 Forensic Admissions Permai 1991 – 70 1992 – 83 1993 – 67 1994 – 81 1995 – 74 1996 – 78 1997 – 63 1998 – 88 1999 – 111 2000 – 118 2001 – 140 Hospital Permai Admissions Trend All Admissions: Y1991 – 2593 Y1996 - 1916 Y1997 - 2003 Y1998 - 1933 Y1999 - 1740 Y2000 - 1875 Y2001 - 2017 Forensic/Total Admissions (%)* Y1991 – 204/7655 Y1996 – 300/6886 Y1999 – 301/6247 Y2000 – 332/6056 Y2001 – 369/5532 ‘Pleasure’ Patients – Permai Admissions 1991 – 6 1996 – 21 1999 – 27 2000 – 29 2001 – 33 NB: 2/3 no hope of discharge 1/3 discharge after 5 – 15 years Current Practice – the Sky’s the LimitAs directed by the courts (i.e. hospital has no say) – no limit to number of forensic patients (c.f. UK) No regulations, No policy re: safety, provisions, funding, staffing ‘Purpose-built’ forensic centres – 0 all built with prison designs or upgraded standard wards Some Sec.348 patients waiting >10 yrs in prison Current Status – ‘A Time Bomb’ Malaysia: Forensic psychiatrists – 3 whole country (part-time) Medical Officers – no dedicated officers Forensic trained nurse – 0 WHO: Psychiatrist 1:20 acute/60 chronic patientsMO 1:60 UK: 1:20 (ac.forensic) 1:40(chr) ‘A Time Bomb’ Paramedic Staffing numbers(B/P/M/S) – Divided: 5 2+1 3 6 UK10D/4N min SRN Shift: 5.5 2+1 1.5 1 Night: 3 2+1 0 1 No Patients E2001: 212/119/19/28 No. wards: 2 ½, 1 ½, 1, 1 No. Manslaughter cases(B&P&M): 156pts (41.3%) Case Vignette 1: Hj. Ahmad 35 y.o. Malay Male Insurance executive Performed haj, came back ~10days prior admission Aggressive, assaulted wife Charged with Voluntary Causing Hurt, sent to Permai for psychiatric evaluation Next morning referred to Hospital Sultanah Aminah DIED! Postmortem - Meningoencephalitis Case Vignette 2 – ‘I lost my son’ 27 y.o. Chinese male forklift driver from Karak 2nd son died 6 days after delivery (Aug 1999) Engrossed with religion Feb 2000 – ‘wife a follower of Satan’ è strangled her to death Charged in court è Permai 13/3/2000 Very disturbed è challenging many other patients to fight Died 20/3/2000 = head injuries More Problems – Inadequate community mental health services Shortage of acute inpatient beds High percentage of referrals to psychiatric hospitals Inadequate staffing of community and inpatient services No medium & long term rehabilitation places except in psychiatric hospitals The Consequences Mentally-ill treated in inpatient units far from family Premature discharge whilst still ill Increased burdens on family, carers and community health services Increased homelessness amongst mentally ill Increased criminalisation of mentally ill Increased suicide rate amongst mentally ill " The Dream" Central London Compared hospital psychiatric admissions via Local Courts with compulsory admissions from the community 214 court admissions vs 214 community admissions 2 years prior to admission vs 2 years post-discharge Court Diversion Program Results Four-fold increased recognition of mental illness Time from arrest to admission decreased seven-fold Effective with both minor and serious offences Replaces remand prison as site of diversion In 2 yrs after diversion vs 2 yrs before: Significantly less: convictions sentences property offences What’s in the Pipeline? Hospital Bahagia RM8 64 bedded unit – work just started Hospital Permai Johor Bahru new block ‘at all cost’ New hospital – 5+1/2 forensic wards Hospital Sentosa renovations for existing ward Local Initiatives, no coordination, no expertise Doing a Difficult Job Well but hidden cost/tragedies The Future -‘Task Force One?’ HC Judge, Senior psychiatrists, forensic psychiatrists, MA, Police, Prison, others Current needs – beds/wards/norms/training National Policy Plan of Action Comprehensive Review for nationwide forensic services Forensic/Secure Community Units – design brief Court Diversion programmes Community Forensic Services
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4th
Johore Mental Health Convention 
