There are many ways of trying to make sense of tragedies involving people with serious mental illness (Nottingham attacks: series of errors led to Valdo Calocane being discharged, review finds, 12 August). Calls for new guidelines, revised legislation and improved “risk assessment” are well-intentioned but unconvincing, not least because that is what has been happening since the Clunis report 30 years ago. They miss how complex and deep the problems are.
NHS clinicians operate in a context of rationing and scarcity, manipulated by their own organisations with talk of “efficiency savings”, “flow” and “productivity”. This can make it sound as if the problem is staff who are slow, lazy and inefficient. The service values high “churn” and rapid discharge, and sees every admission as a failure of community care.
Furthermore, there are highly fragmented services, which can protect clinicians from seeing the consequences of their decisions as the patient moves from one team to another. Further still, there is an ideological commitment to respecting patient autonomy that spills over into respecting autonomies that are deeply distorted by psychotic illness, where the patient is certain that there is nothing wrong with him; psychosis that often contains a seductive invitation to collude with this denial.
It is extremely difficult to practice careful, thoughtful psychiatry in this context. Over time, clinicians (both general practitioners and mental health professionals) begin to experience that they rarely see anyone with psychosis get better. They begin to believe that the patients are not treatable or cannot benefit from services. And this of course makes it even easier to discharge them prematurely. You cannot legislate your way out of a fundamental resource problem and a deeply ingrained, distorted culture.
Doctor Simon Wilson
Consultant Psychiatrist, London
I have just retired after 30 years as a psychiatric nurse in a community mental health team. I would like to give you some context on the tragic events in Nottingham. Mental health services everywhere are under enormous pressure after years of neglect and budget cuts. There are not enough inpatient beds, so it is difficult to admit people who are very ill, even if they are in custody under the Mental Health Act, and inpatient teams have to be quickly discharged to poorly staffed community teams.
There is a lack of trained staff, funding and social resources – all the result of repeated broken promises. Community mental health teams are particularly affected by this, as they are in the thick of it. Jobs are under high pressure, exacerbated by understaffing and rising demand. It is impossible to operate at a good level.
This context is always missing from a locally focused review following a shocking incident. Staff working on the frontline are acutely aware that they are being ‘held to account’, but they are in an impossible situation and are understandably inclined to manage the tension by looking away – by discharging patients they do not have the resources to help effectively. It takes a superhuman capacity not to be demoralised by the situation. Can we be surprised that staff leave and it is impossible to replace them?
Dr. Geoffrey Searle
Bournemouth
Anyone with experience of mental health or who has recovered from severe psychosis knows that the sufferer’s world is completely dominated by delusions and hallucinations which in some cases can lead to violent behaviour that they would never exhibit if they were healthy. Severe paranoid psychosis is not something that the sufferer can manage without skilled and assertive therapeutic intervention, which is sadly often lacking in our current mental health system.
I have every sympathy for the victims in this case and the relatives of those who lost their lives. I also feel sympathy for the family of Valdo Calocane and for Calocane himself. They too have been seriously let down by the mental health system and will have to live with the consequences for the rest of their lives. They are also victims and deserve our understanding and compassion.
Lin Bigwood
Retired Psychiatric Nurse, Bristol
