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Runaway Patients

Report to the GNC Trust Len Bowers RMN PhD Professor of Psychiatric Nursing Manuela Jarrett RMN BSc Research Assistant Nicola Clark MA MSc Research Assistant Frank Kiyimba RMN Research Assistant Linda McFarlane BSc Research Assistant September 1998 Department of Mental Health Nursing City University London E1 2EA

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Contents Executive summary....................................................................................................1

Introduction to the project..........................................................................................5

Literature review ........................................................................................................8

Methodology ............................................................................................................19

Overview of data and analytic methods ...................................................................24

Findings 1: Absconding events and consequences ..................................................30

Findings 2: Assessment of variables impacting on absconding rates ......................37

Findings 3: Characteristics of absconders................................................................42

Findings 4: Going and returning ..............................................................................46

Findings 5: Life on the ward and reasons for leaving..............................................62

Findings 6: Absconding and ethnicity......................................................................87

Findings 7: Nurses' perceptions ............................................................................102

Findings 8: Relative and carer perceptions ............................................................114

Discussion of findings............................................................................................120

Conclusions and recommendations........................................................................137

Appendices.............................................................................................................140

References..............................................................................................................161

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Executive Summary Aims of the project

To discover: the characteristics of absconding patients from acute admission psychiatric wards; high risk times and places for absconding; how patients left and returned to the ward; the reasons given by patients for leaving the ward; nursing staff responses and reactions to incidents of absconding; the responses of patient relatives or significant others to incidents of absconding; and to investigate the relationship between rates of absconding, ward atmosphere and ward design. Literature review

Incidents of absconding from inpatient care are high risk events which have been linked to serious harm to self and others. Varied definitions of absconding and methods of calculating the rates of absconding make comparisons between studies difficult. Nevertheless, it is clear that absconders are more often young, male, from disadvantaged groups, and suffering from schizophrenia, as compared to admissions generally. Roughly half of abscondings take place while the patient is temporarily off the ward with permission, the remainder of absconding patients use an assortment of means to make their escape. A large variety of reasons for absconding have been elicited from patients or advanced as possibilities by researchers. Only six evaluative studies of interventions impacting upon absconding have been reported in the literature, but no firm conclusions can be drawn from them. Methodology and analysis

The study took place in three NHS Trusts in the East End of London. Twelve wards were studied, situated in five hospitals at different sites. All absconders from these wards between 5th January 1998 and 28th May 1998 were identified and included in the study. A control group was identified by selecting, for each absconder, the patient on the same ward who followed them in alphabetical order by surname. A sample of relatives or significant others was assembled by asking absconding patients for permission to approach somebody close to them, and were interviewed by telephone. A convenience sample of qualified nursing staff were interviewed, stratified by ward.

The final sample consisted of 175 absconding patients and 159 controls. There

were 498 absconding events generated by these 175 patients. 52 of these patients were interviewed on their return to the ward a total of 62 times. 24 ward nurses were interviewed in person and 6 relatives/carers interviewed by telephone. All interviews were taped and transcribed except those conducted by telephone. Analysis was conducted using SPSS and QSR NUD.IST computer software.

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Key findings 1. A predictive profile of the absconder is: young; male; a firstborn child; from an

ethnic minority group; of the Muslim faith; living with partner or parents; with a diagnosis of schizophrenia; having had a number of transfers between wards, refusals of medication and involvement in officially reported ward incidents in the previous week; considered by nursing staff to be a risk to self or others; someone who has absconded during previous admissions; and has had previous contact with the police.

2. Absconding is linked to other forms of patient noncompliance and difficult

behaviour. These behaviours are more likely to arise out of common patterns of failed relationships between patients and psychiatry, not through individual patient personality or characteristics.

3. There is indicative evidence that there are at least two different groups of

absconders with differing characteristics, most readily distinguished by age, gender and marital status.

4. Both ward security/supervision and professional-patient relationships are likely

have an influence upon the rate of absconding, although the efficacy of the former should not be assumed nor overemphasised.

5. The majority of absconds occur during the first few weeks of admission to hospital,

most patients who abscond do so from the ward, the main route of exit is via the ward front door, and the most common destination is home.

6. No relationship could be found between absconding and day of the week, number

of days since last ward round, the weather, individual inpatient keyworkers nor any association with the professional discipline of the patients' community keyworkers.

7. Consultant psychiatrists working on the same ward can differ significantly by the

rate at which their patients abscond. 8. Negative outcomes to absconding are rare (4% of absconding events), but

potentially serious. Predicting which absconds are high risk is a difficult and almost impossible task.

9. Most absconders return by themselves, some are returned by relatives, and some

are returned by the police. 10.Of those returned by the police, most are brought back by a couple of police

officers who call at the home. A few absconders are brought back by large numbers of police in riot gear. The numbers of police officers used does not seem to relate to any reasoned assessment of risk.

11.Patients abscond because they are bored on the ward, frightened of other patients,

feel trapped and confined, have household responsibilities they feel they must

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fulfil, feel cut off from relatives and friends, or are worried about the security of their home and property.

12.Psychiatric symptoms also contribute to the decision to leave, but in nearly every

case patients can give additional and rational reasons for their abscond. 13.Some patients leave impulsively and in anger following unwelcome news about

delayed permission for leave or discharge. Others leave specifically in order to carry out some activity outside the hospital. Most are engaged in entirely normal social and household activities while away.

14.The attitude of absconders to their illness and its treatment divides them roughly

into two groups: "refusers" and "disputers". The Refusers deny that they are ill, assert that they feel well, and consequently believe that there is no need for them to be in hospital. The Disputers, on the other hand, did not deny that they were ill and in need of treatment. Instead they disagreed with the nature of what was being offered and the way their problems were perceived by psychiatric professionals.

15.Relatives and carers of absconders feel that communication with the hospital staff

is poor, and are either not informed about the abscond, or not informed about the patients return. In some embarrassing circumstances it is relatives who inform the ward staff that a patient has absconded.

16.Nurse feel vulnerable to being blamed for absconding and insist that even on the

best run ward patients can still abscond. They often feel blamed by managers or by medical staff, and frequently blame each other for lapses in procedure and the supervision of patients.

17.Although patients from ethnic minority groups abscond more frequently, detailed

analysis shows that each ethnic group has a rather different relationship with psychiatric services that alters the pattern and impact of absconding.

18.Comparison with previous literature and studies leads to the conclusion that

absconding rates in the study districts were not atypical in any way. 19.Different organisational cultures can be detected in the three NHS Trusts of the

study, and these do impact upon absconding, its prevention, the return of patients, and staff attitudes.

20.Significant differences between absconding rates on wards were detectable. These

could not be accounted for by different ward layouts and numbers of exits, nor by staffing levels. They are therefore likely to be due to the way the multidisciplinary teams work with patients on those wards.

Strengths of the study 1. The use of triangulation between different data sets and sources of information 2. Large sample for quantitative analysis covering 5 hospitals and 12 wards

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3. Large sample of patient interviews, 62 in all 4. Interviewer training 5. Cross checks on coding of interview data 6. Computer aided qualitative data analysis 7. Critical review of data interpretation by the research team Weaknesses of the study 1. The use of case notes for diagnostic and other data is unreliable 2. The East End of London is a special community with high levels of deprivation, a

multitude of ethnic minority populations, and high numbers of refugees 3. Small numbers of women and certain ethnic minorities in interview sample may

have biased the results Recommendations 1. Some form of home care and home security service for psychiatric inpatients might

be highly valued by those who worry about their property. 2. Nurses may wish to involve relatives and carers (subject to patient agreement) to a

greater degree in the patient's care on the ward, and when seeking their return to hospital following an abscond.

3. Psychiatric service providers may wish to discuss with the police some form of

prioritisation system for absconders who pose different risks, plus some communication over which absconders may pose a risk to the police involved in their return to hospital.

4. There may be a role for Community Mental Health Team staff (perhaps in

conjunction with duty systems) in the return of lower risk absconding patients. This does not necessarily mean physically returning the patient to hospital, but may mean a call at the patient's home and persuading them to take a hospital financed taxi back to the ward.

5. Psychiatric staff (of all disciplines) may wish to renew their efforts to understand

and deal with the patient's worries about home life and responsibilities. 6. Multidisciplinary care teams may wish to consider transfer to a locked intensive

psychiatric care environment, or discharge, for every patient who absconds more than two or three times during a single admission

7. A controlled trial of an nursing intervention to reduce absconding rates, based upon

the findings of this study, should be undertaken as soon as possible.

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Introduction Unauthorised absence of a patient from the ward arouses genuine concern on the part of the professionals responsible for their care. Yet despite many years of interest in this topic, what little is known about what patients abscond, why and how they do so, and what strategies can be used to contain the risks of such behaviour, is dispersed across a wide body of literature spanning many years. This review seeks to bring together for the first time the findings of published research to date on the issue of absconding. The link of absconding to serious self harm and successful suicide is quite clear, and has been apparent in the published literature for some time. Crammer (1984) reported that 26% of British inpatient deaths took place after the patient had run away. Sundqvist-Stensman (1987) has given a similar figure (30%) for Swedish inpatient deaths, and Niskanen et al (1974) report 20% for suicides in Helsinki psychiatric hospitals. The most recent figures from the Confidential Inquiry into Homicides and Suicides in the UK (Appleby, pers. communication) show that 22% of inpatient completed suicides took place while the patients concerned were absent without leave.

Absconding can also result in serious self neglect or death through exposure. Aspinall (1994) relates the story of a case that ended in the death of a patient after six days of absence from the ward, and in harsher climates than that of the UK, frostbite has been reported.

There is a similar, although less direct link, between absconding and violent behaviour. Powell et al (1994) noted that the act of attempting to abscond could itself precipitate violence, and Milner (1966) reports that in 3.6% of incidents of absconding the patients were aggressive to relatives. In addition, there are accounts in recent UK enquiry reports of homicides perpetrated by patients who have absconded. Kenneth Grey killed his mother after absconding from an open psychiatric ward in 1994, Jason Mitchell murdered his father and two neighbours after absconding also in 1994, and Kevin Rooney stabbed an acquaintance to death after absconding the day after he was admitted in 1991 (Sheppard 1996). Other risks associated with absconding can be missed treatment with possible longer duration to remission, or the complete loss of contact with psychiatric services.

Even without any of the above consequences, absconding may lead to catastrophic loss of confidence in the psychiatric services by relatives who expect the hospital to be a 'place of safety'. When things do go wrong, there is a possibility that legal action may be taken. Molnar et al (1985) identified five cases in the US courts in which compensation had been sought for the consequences of absconding: two cases where patients had been struck by cars, one suicide attempt, one assault and one murder.

Finally, it is worth pointing out that there may be possible benefits to the

patient from absconding, although none of these have been demonstrated or quantified by research so far. The absconder may gain a sense of independence and liberation

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from their actions, plus a decrease in paranoia due to no longer being under observation. If the patient has responsibilities to others, those dependants might gain companionship and support from the absconder returning home.

Aims of this study 1. To identify the characteristics of absconding patients from acute admission

psychiatric wards 2. To identify high risk times and places for absconding 3. To determine how patients left and returned to the ward 4. To assess the reasons given by patients for leaving the ward 5. To describe nursing staff responses to incidents of absconding 6. To assess nursing staff reactions to absconding 7. To assess the responses of patient relatives or significant others to incidents of

absconding 8. To investigate the relationship between rates of absconding, ward atmosphere and

ward design Overview of study design

A prospective study of absconding from acute admission psychiatric wards, comparing absconding patients with a non-absconding control group. Absconders were interviewed about the incident on their return to the ward. Qualified nursing staff and patient relatives were also interviewed. Individual wards were assessed for complexity of layout and ward atmosphere. The research team

This project took place in the East End of London and was conducted by the research team in the Department of Mental Health Nursing, St Bartholomews School of Nursing, City University. It was conceived and initially designed by Prof. Len Bowers. Further contributions to the study design were made by Nicola Clark, who also contributed to the analysis, and to interviewer training. Manuela Jarrett was the full time project research assistant and undertook the majority of the data collection and inputting. Frank Kiyimba conducted the interviews with nursing staff and took the lead in their analysis, aided by Nicola Clark. Relative/carer telephone interviews were conducted by Linda MacFarlane. All those mentioned have contributed to the writing of this report.

Project management and leadership was provided by Professor Len Bowers,

who is solely responsible for all final decisions about the methodology of the study, the analysis of the data, and the findings presented in this report.

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Anonymity Three NHS Trusts, twelve wards across five hospital sites, took part in this study. Although all are located in the East End of London, they will not be identified in this report. Individual wards will be represented by numbers and individual Trusts by code letters. Interview material will be identified only by a code number. Original interview tapes will be eventually destroyed, so that there will be no way of identifying respondents thereafter. When this report is presented to staff in each of the participating Trusts, they will be provided with an additional key sheet that identifies (a) the code letter of their Trust (b) the code numbers of wards in their Trust. Whether they wish to make that information public will then be a matter for them to decide. Acknowledgements The research team would like to thank, first and foremost, all those nurses and patients throughout the East End of London who co-operated with the research and consented to be interviewed or otherwise provide data. We have tried very hard to stay true to what you have told us. We hope that if you read this report, you will recognise within it an accurate description of yourselves. We would also like to thank the managers and other clinicians within the participating Trusts, who gave us full access and supported our data collection in every possible way. Funding This research was funded by the GNC Trust, and we would like to thank the Trustees for supporting research into psychiatric nursing care.

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Literature Review Literature search methodology The initial literature was identified by conducting electronic searches on CINAHL (1982-97), PSYCLIT (1974-97) and the Cochrane Database of Clinical Trials (1997 issue 4). Search terms used were "abscond", "escape", "elope", "AWOL", "runaway" and variants. This resulted in a small core of papers from which further references on the topic were identified. All identified literature, post 1950, in English, was included. Only two non-English publications on the topic were identified. Definitions of absconding Much of the published work fails to provide an exact definition of an incident of absconding. Most studies have used officially produced statistics which have been created using a variety of criteria. Some studies include failure to return from official leave, whilst others do not. Some include short temporary absences, others only absences lasting at least 24 hours, and yet others only those absconds that result in a discharge. Regrettably, some studies fail to distinguish discharge AMA (Against Medical Advice) from discharge whilst AWOL (Absent With Out Leave). These differences make comparisons between studies difficult. In addition, reliance on official statistics sometimes means that only those absences that arouse concern by nurses and medical staff are counted, as other absences without permission are 'waited out', or result in the patient being placed on leave. It is possible, therefore, that the repeated finding that compulsorily detained patients are more likely to abscond may only reflect the degree of concern and responsibility felt about these patients by professionals. Rates of absconding in different settings

It is not easy to construct a meaningful measure of absconding that can be

extracted from the data available in the published studies, even if the definition problems described above are ignored. The best suggestion is probably that of Molnar and Pichoff (1993):

N abscondings

N patients at riskx 10

where N patients at risk equals the total number of inpatients at the beginning of the study period plus the number of those admitted in the course of the study.

This index has two drawbacks. Firstly, it fails to treat repeat abscondings differently from single occasions. Therefore a rate of say, 5%, does not mean that 5% of patients at risk abscond, as a large part of the rate can be made up by one or two patients who abscond frequently. Secondly, this measure ignores length of stay with the result that if the data collection period is short, the rate of absconding produced is artificially low. However this effect is likely to be small, unless the proportion of long to short stay patients is extreme.

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Having arrived at a reasonable measure, the information given in the array of descriptive studies does not always provide sufficient information for its calculation. Neither is it always clear by what method individual authors have calculated their own rates of absconding. A few studies have expressed the rate of absconding as a proportion of discharges, making comparisons yet more difficult. Tables 1 & 2 show the rates of absconding by the Molnar and Pichoff formula where possible. Where not possible or uncertain, the rate given by the author has been used without alteration. Using this formula, and excluding forensic and adolescent psychiatric services, the mean rate of absconding for general psychiatric services provided by these studies is 12.6, with a range of 2 to 44. There is no detectable significant trend over time. The absconder Tables 1 & 2 also collate the characteristics of absconders identified by the many comparative studies which have been carried out. Although no absolutely consistent picture emerges from these studies, it is very evident that absconders are generally young, single and male, and tend to come from disadvantaged groups within the wider society. In London UK this means Afro-Carribean patients abscond more, in Virginia USA it means lower educational attainment correlates with absconding, and in Canada, unemployment.

Several studies show a link to compulsory detention, but as has been mentioned above, this may be an artefact of medical staff and nurses translating their degree of concern about patients into official absconding procedures. However this is unlikely to explain the correlation of police or court referral with absconding in several studies, and Joseph & Potter's (1993) report of the extremely high rate of absconding among those patients diverted from court.

The studies summarised in the tables span 35 years. It is only relatively recently that diagnosis has become more rigorously defined, and only a few of the more recent studies use ICD or DSM categories. It is therefore hard to draw an obvious lesson from the diagnostic information, however all the recent (post 1980) western studies of adult psychiatric settings show schizophrenia sufferers to be significantly over represented in groups of absconders. How and when patients abscond There is little in the literature about how patients abscond, and only a few studies have explored this issue in passing. Richmond et al (1991) report that the majority of abscondings occurred after patients had been given permission to leave the ward unaccompanied. However they also report that one in five abscondings happened while patients were restricted to the unit, doors were locked, and staff stationed at the doors! Except when patients ran through the door when it was temporarily opened for someone else "staff could not account for how patients were missing from the unit". The majority of Kernodle's (1966) absconder respondents said they had simply walked away from open wards, recreational activities. However some explicitly described exploiting staff lapses of attention. One proudly described how he had talked his ward physician into giving him a ride away from the hospital. Kleis et al (1991) and Antebi

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(1967) also showed that half of abscondings took place whilst the patients were away from the ward temporarily with permission. However Kleis et al (1991) also describe some of the methods used by patients to leave the ward, including via the air conditioning fixture, the window, as well as the door. Nussbaum et al (1994) describe a series of escapes from their forensic psychiatric facility in which patients tied sheets together and climbed down from windows on the fifth floor. Both Kernodle (1966) and Molnar et al (1985) identified instances when patients had been assisted to leave by visitors, who had, for example, provided street clothes to aid in their escape.

Researchers have sought to relate many general factors to absconding These include time, day, month/season as well as ward conditions such as staffing levels, experience of staff, whether the ward is locked or open. Perhaps unsurprisingly, there is much evidence of seasonal variation influencing absconding patterns. Without exception these studies have found higher rates of absconding during the warmer seasons (e.g. Bland and Parker, 1974; Molnar et al, 1985; Falkowski et al, 1990). A number of studies have also explored patterns relating to days of the week, and with few exceptions have generally found no significant correlations. Swindall and Molnar (1985) also reported a higher rate of absconding on Saturdays. Times of day have also been explored for patterns with little success, although Cancro (1968) found that absconding usually took place in the evenings, and at mealtimes, but were rare during activities.

Just one study looked at staffing levels and found that the best staffed ward

had the lowest rate of irregular discharges, but this ward also had the most experienced medical staff. The ward with the least experienced medical staff had the second highest rate of irregular discharges, forty-three per cent of which were AWOL (Siegel et al, 1982). Why patients abscond

Lewis and Kohl (1962) believed from their study of eleven patients who had

absconded from open units over a one and a half year period that there was no single factor which caused the person to abscond, but rather three or four factors which interplayed to act as a trigger. They speculated that one of the possible factors in absconding is that patients may not necessarily be running away from the hospital so much as running toward a significant family member. Often the family member would be someone with whom the patient had an ambivalent relationship. Other explanations for absconding cited in the literature include the tendency of absconders to be impulsive (e.g. Meyer et al, 1967; Altman et al, 1972a); a greater inclination towards non-compliance in general (e.g. Altman et al 1972a; Goodrich and Fullerton, 1984; Chandrasena and Miller, 1988); fashions or fads within the ward community (Weaver et al 1978); and a propensity to act out under stress (Altman et al 1972a). Cancro (1968) speculated on the possibility that patients feel threatened by over caring doctors who ‘are filled with therapeutic zeal’. He claimed support from this theory based on the finding that particular doctors had higher rates of absconding patients.

There are very few studies which have given patients the opportunity to

express their reasons for absconding. One of the earliest studies into this topic was carried out by Muller (1962) and included interviews with patients. Classifying their

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reasons into categories, he found that "treatment failure" accounted for a major factor in absconding in fifty per cent of cases. This category encompassed the doctor/patient relationship; issues to do with medication; and problems concerning active symptomatology. The next most cited category of reasons related to family troubles. This included lack of visitors, relatives who were unwell and relationship problems. A small percentage of patients quoted being influenced by other patients as a factor in their absconding, others had left to obtain alcohol, and few had left to spend recently acquired money. There was no clear reason found in just eight per cent of cases.

In a rare qualitative study, McIndoe (1986) interviewed five patients in-depth

about their reasons for leaving without consent. A number of themes emerged which McIndoe referred to as relating to a "sense of meaninglessness". The patients’ reported that they did not feel that it was necessary for them to be admitted to hospital. They felt their problems were manageable without this intervention, but their physicians had disagreed, leaving them with a lack of understanding as to why they should be hospitalised. Once in hospital, the patients’ felt their treatment plan was useless, failing to recognise and address their problems and situation. To further compound this sense of meaninglessness regarding their stay in hospital, they also were unclear as to what exactly was the role of the nurse.

The issues raised in this study differ from those which emerged from the study

carried out by Falkowski et al (1990) in which three quarters of the absconders agreed to be interviewed about the reasons they left. Nineteen per cent of the patients in this study referred to being disturbed by other patients as a reason for leaving the ward. A further seventeen per cent described the stigma of being in a psychiatric hospital as a major factor influencing their decision to go AWOL. Other reasons reported were: disliking the staff (13%); disliking the food (11%); disliking the ward (8%); lack of privacy (7%); and responding to hallucinations (5%). Interestingly, this study revealed that in over half of the cases there were no changes made in the management of care of the patient on their return to the ward. Evaluative studies

Table 3 summarises the few evaluative studies of interventions impacting upon the rate of absconding. These studies are generally methodologically weak and badly described. There is little that can be concluded from them with great confidence.

Two studies (Cancro 1968, Molnar et al 1985) have examined the impact of

decreasing security by the unlocking of ward doors, and both of these have found that the rate of absconding increased as a result of these measures. It is therefore possible (although untested as yet) that locking wards may significantly reduce absconding, although this is likely to be unpalatable to many, and may have negative consequences in other areas.

Battle & Zweier (1973) and Maratos & Kennedy (1974) both sought to

evaluate the impact of the introduction of groups to the ward situation. The study designs do not inspire confidence, as Battle et al had only a very small sample, and the Maratos et al study was unfortunately confounded by the researcher moving from one

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ward to the other at nearly the same time as the conditions crossed over. For what it is worth, both these studies managed to demonstrate decreases in the rate of absconding.

Richmond et al (1991) devised a battery of measures to reduce absconding,

implementing these on one ward while reserving others as controls. This design appears to have lacked randomisation, and the data provided is scant and hard to interpret. Nevertheless a demonstrable effect was shown, although it is impossible to know which of the elements of the combined intervention were significant.

Finally, Gudeman et al (1985), in their study evaluating a set of changes made

to admission wards towards less restrictive care, found a significant decrease in absconding. Although this final study was uncontrolled, the trial period was lengthy, which would appear to rule out short term experimental effect as a cause of the improvement.

In short, there are no thoroughly convincing, well designed, rigorously carried out trials of interventions to reduce absconding. However, on currently available evidence it does seem likely that open wards are likely to have more absconds than those that are locked, that group activities giving patients a voice on the ward may decrease absconding, as may any one of a range of measures like: partial hospitalisation, regular checking by nurses, use of a sign-out book, patient involvement in treatment planning, contracting with patients about off-unit privileges, and early discharges for patients who clearly intend to leave. Discussion The potentially serious outcomes of absconding indicate that further research is a priority. The findings reviewed above do not lead to sufficiently firm conclusions upon which to base inpatient care. Future research in this area should be more rigorous in its design, use a clear definition of an incident of absconding, and provide sufficient data for the Molnar and Pinchof formula to be calculated. Such research needs to address several related issues. It would seem likely that the rate of officially notified absconds may be substantially lower than the true rate. When the risk is judged to be low, quite often the psychiatric team will wait to see if the patient returns, or phone them at home to ask them to return, before invoking the official abscond procedure. Identification of the true rate of absconding and its relationship to the official rate would enable us to discover whether officially notified absconds really are more likely to result in negative outcomes than those which are not. It might well be, for instance, that the repeated finding that compulsorily detained patients abscond more frequently is only an artefact of the fact that these are the patients whose absconds are most likely to result in official procedures. Also, using a wider definition of absconding that includes failure to return from leave, would help to find out whether these patients shared the same characteristics, or were equally at risk as those who departed from the ward. Although some studies have attempted to solicit the patient's point of view on absconding, these have either used extremely small samples (McIndoe 1986) or have analysed responses into pre set categories (Falkowski et al 1990). Advances in

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understanding the motivation of patients who abscond may help us to devise strategies to reduce the associated risks, as may more detailed information on exactly what methods they use to leave the ward. In addition, no study has yet reported on the impact of absconding upon staff and the organisation of the psychiatric hospital, nor upon patients' relatives and their trust in the professionals. The statistical methods used in the published studies are basic and can be improved upon. A more certain profile of the absconder could be developed allowing better prediction, by using more sophisticated statistical techniques that address not just single variables, but also interactive effects. Greater research focus upon patients whose absconding is at a high risk of negative outcome may enable more specific and useful profiling.

Lastly, interventions to reduce absconding need to be devised and tested in rigorous clinical trials, using control groups, blinding, and randomisation if possible. Only then will we have nursing strategies to reduce absconding risk in which we can have confidence.

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Table 1 Descriptive studies - U.K. Study Type of Service Type of

Study Abscond definition

Absconder Characteristics

Diagnoses Abscond Rate*

Antebi (1967) One 1000 bed Psychiatric Hospital (All Saints)

Prospective identification of absconders followed by analysis of case notes. Compared to total Hospital population.

Leaving the Hospital grounds without permission, or failing to return from leave.

Young, Male, Criminal record (No significance tests)

Psychopathic personality (No significance tests)

2.8 (?)

Falkowski et al. (1990)

One 670 bed Psychiatric Hospital (Springlield Hosp., London)

Interviews of 100 absconded patients

Absent without permission and cause for serious concern

Male, older, Compulsorily detained, Afro-Caribbean background

Schizophrenia most frequent (No significance tests)

Not reported

Joseph & Potter (1993)

One Psychiatric Hospital Admissions arising from a Court Diversion scheme

Not defined 46

Milner, G. (1966)

District General Hospital Psychiatric Unit of 220 beds (Oldham DGH)

Prospective comparison of absconders over 18 months with a control group

Not defined History of absconding, Poor work record, Frequent suicidal attempts, Antisocial behaviour

No significant findings 7

Muller (1962) 1000 bed psychiatric hospital (Powick Hospital)

Prospective analysis of all absconders over 9 month period with interviews of the absconders and staff, compared to total hospital population

Official reports, leaving the grounds without permission

Schizophrenia, Paranoid psychosis, Psychopathic personality (no significance tests)

Neilson et al (1996)

Acute psychiatric wards in Sheffield

Retrospective case note analysis of a random sample of 246 admissions

Not provided Compulsorily detained 34.5

Tomison (1989)

316 bed psychiatric hospital (Barrow Hospital, Bristol)

Prospective contingency table analysis of absconders over one year compared to sex matched control group, and to all admissions that year

Absence of a patient sufficient to cause concern on the part of trained nursing staff

Male, Young, admitted via police or courts, compulsorily detained

Schizophrenia or Personality Disorder (in females)

8.7

* See text for method of calculation, except where otherwise stated

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Table 2 Descriptive studies - other countries Study Coun-

try Type of Service Type of

Study Abscond definition

Absconder Characteristics

Diagnoses Abscond Rate*

Altman et al (1972a)

U.S. 5 State Mental Hospitals, 3 Community Mental Health Centres, 2 Schools for the Mentally Handicapped (Missouri)

Retrospective contingency table analysis. Some analyses statistically invalid

Official returns of absence without permission

Male, Caucasian, Single Acute brain syndrome, Personality Disorder.

3.6

Altman et al (1972b)

U.S. 5 State Mental Hospitals, acute treatment centres excluded (Missouri)

Retrospective discriminant analysis of two sets of Hospital statistical returns

Official returns of absence without permission

Single, Catholic, Male, Student, Court referral

Personality disorder or sexual deviation

4.4

Atkinson (1971)

U.S. 4, 24 bed open psychiatric wards (Neurpsychiatric Institute, UCLA)

Retrospective contingency table analysis of hospital records over six years of absconders vs. AMA discharge vs. regular discharge

Official discharge classification (i.e. absconders who returned not included?)

Young, Female aged 51-60 years

Personality disorder 3.5 (of

discharges)

Bland & Parker (1974)

Canada One 700-1000 bed Psychiatric Hospital (Alberta Hospital)

Retrospective analysis of case notes of absconders for two separate one year periods

Not defined Young, Male, Compulsorily detained (No significance tests)

Personality disorder, Alcohol and drug abusers, Adolescent adjustment reaction (No significance tests)

13.1

Cancro. (1968)

U.S. One 100-200 bed Psychiatric Hospital (Menninger Memorial Hospital)

Unclear. Four years data in all, spanning 1957-66

Not defined Young, Male (No significance tests)

20.4-28.4 (?)

Chandrasena (1987)

Canada 145 bed Psychiatric Hospital (Royal Ottawa Hospital)

Retrospective contingency table analysis of the case notes of AMA vs. AWOL vs. Regular discharges

Only those discharged while absent without leave

No fixed abode, unemployed, Single

Schizophrenia Dysthymia 2.9 (of

discharges)

Coleman (1966)

U.S. One Veterans Adminstrations Hospital (Salem, Va.)

Retrospective contingency table analysis of case records, absconders compared to control group (matched?)

Official reports Previous absconds, rejected by family, Catholic, Caucasian

2

Cooke & Thorwarth (1978)

U.S. Regional Forensic Psychiatric Centre (Norristown State Hospital)

Retrospective analysis of case notes of absconders vs randomly selected control group

Not defined Agitated, anxious, paranoid, psychotic symptoms

15

John et al (1980)

India One 805 bed Psychiatric Hospital (NIMHANS, Bangalore)

Retrospective contingency table analysis of case notes of absconders over one year vs all Hospital admissions

Missing from the ward without permission for more than 24 hours

Young, Male, Mania, Schizophrenia 3.3

16

Kashubeck et al (1994)

U. S. Residential treatment centre for adolescents

Retrospective analysis of case notes of absconders over five years compared to control group matched for age, sex, and race over same period.

Not defined History of absconding, suspected history of sexual abuse, parents whose rights had been terminated

Affective disorder Not reported

Kernodle (1966)

US One 2500 bed State Mental Hospital (Eastern State Hospital, Virgnia)

Case note analysis and 160 interviews of absconding patients, over one year, compared to total hospital population

Not defined Young, Male, Divorced or Separated, Lower Educational Achievement (no significance tests)

Personality disorder (no significance tests)

4.2

Kleis et al (1991)

U.S. Acute care, 170 bed, private psychiatric hospital (More than 30% of patients adolescent)

Retrospective analysis of case notes

Leaving the Hospital grounds without permission, or failing to return from leave.

Young, Male. (no significance tests)

Affective disorder, Alcohol or Drug use (no significance tests)

1.8 (of

discharges)

Levy (1972). U.S. Residential 10 bed treatment centre for adolescent girls

Description of absconders over nine year period

Not defined 38

Lewis & Kohl (1962)

U.S. Two open psychiatric wards in a large General Hospital (Payne Whitney Psychiatric Clinic, The New York Hospital)

Analysis of records, plus interviews with absconding patients, their relatives, and members of the treatment team. 11 cases in total.

Not defined Previous absconds, poor impulse control, history of poor motivation, compulsorily detained, pressure from relatives to leave, psychotherapeutic stress, mistakes in medical judgement

Paranoid ideation Not recorded

Meyer et al (1967)

U.S. 25 bed open psychiatric unit in a University Hospital

Prospective analysis of case notes & interview of therapists, over two years, compared to a control group matched for age, sex and race

Any unauthorised absence necessitating staff intervention

Psychotic disorder 44

Miller et al (1983)

U.S. Two general psychiatric wards and one alcohol and drug abuse treatment unit, in a rural community mental health facility

Retrospective discriminant analysis of case note data, 100 AWOL vs 100 non AWOL discharges

Those discharged while absconded

Depression, Substance use

Not recorded

Molnar et al (1985)

U.S. 80 bed psychiatric ward in a county general hospital

Prospective comparison of absconders over one year with a control group

Any unauthorised departure of a patient from the hospital grounds

Young, compulsorily detained

Schizophrenia 5.5

Molnar et al (1993)

U.S. 500 bed urban state hospital (Buffalo Psychiatric Centre)

Retrospective case note analysis of absconders over a one year period

Official incident reports Young, Male, Involuntary criminal legal status (no significance tests)

32

17

Morrow (1969)

U.S. 280 bed maximum security building in the grounds of a state hospital (Fulton [Missouri] State Hospital)

Retrospective contingency table analysis of records of absconders compared to a control group matched for type of admission and age

Escapes, no clear definition provided

Unemployed, History of alcoholism, Oldest children, Young, Transfers from prison

Mubarak et al (1989)

India One 805 bed Psychiatric Hospital (NIMHANS, Bangalore)

Comparison of all absconders in 1977 with all in 1987

Official reports - escape register

Young, Male, First admission

Mania, Organic psychosis 3.3(1977) 2.6(1987)

Narottam et al (1977)

India Psychiatry department of a Medical College (K.G.'s, Lucknow)

Retrospective contingency table analysis of case notes of absconders over one year compared to all regular discharges

Missing from the ward without permission for more than 24 hours or not returned from leave

Young, Male, Single, literate, moderately well off, urban dweller (if male, opposite if female)

Acute schizophrenia 11.6 (of

discharges)

Nicholson et al (1991)

U.S. State forensic unit (Oklahoma)

Retrospective analysis of all records of 'Insanity Acquitees' over six years, absconders compared to regular discharges

Not provided Previous hospitalisations, Prior Arrests, Fewer years of education

No significant findings 8.2

Nussbaum et al (1994)

Canada Medium Secure Forensic Unit (METFORS, Toronto)

Retrospective contingency table analysis of case notes of absconders over 15 years, compared to all other patients

Not provided Antisocial Personality Disorder

< 0.002

Richmond et al (1991)

U.S. Two 30 bed acute admission wards and one 30 bed psychogeriatric ward (VA Medical Centre, Memphis)

Prospective analysis of absconders over one month

Not provided Previous absconds (no significance tests)

Schizophrenia (no significance tests)

9.3

Sommer (1974)

U.S. State Mental Hospital (Bronx State Hospital)

Contingency table analysis of absconders in one month compared to two control groups: regular discharges and patients granted home leave

Leaving the ward without consent - official definition

Young, Puerto Rican, Previous absconds, Previous home leave with consent

Psychosis, paranoid schizophrenia

2-3 (?)

* See text for method of calculation, except where otherwise stated

18

Table 3 Evaluative studies

Study Design Sample Intervention Outcome Battle & Zweier (1973)

Prospective time-sample, ABA, 10 weeks for each phase

Non random sample of 8 men who had absconded at least three times since admission

Twice weekly group psychotherapy (client centred) 50% lower rate of absconding during treatment periods (p < 0.05 by chi square)

Cancro (1968) Natural experiment, before and after, no control

All patients in one 100-200 bed US psychiatric hospital

Before = closed hospital with elaborate and intensive searches for missing patients. After = open hospital (no further detail given).

Absconding rate (as % of admissions) increased from 20.4 to 28.4, i.e. by 39%.

Gudeman et al (1985)

Before and after, no control

All patients admitted to a 70 bed mental health centre attached to a teaching hospital over 38 months

Before = 2 standard wards to which patients were admitted, with a 25 bed day hospital programme. After = all patients admitted to day hospitals (100 places) with an Inn (if required) and an Intensive Care Unit

Numbers of absconds decreased by 54% (p < 0.001 by t test)

Maratos & Kennedy (1974)

Crossover trial Two acute admission wards over 22 weeks, crossover at end of week 9.

Weekly, hour long, community meetings Number of abscondings decreased by more than 50% under the experimental condition (possibly results confounded by the experimenter working on both wards during the experimental condition)

Molnar et al (1985)

Before and after, no control

All patients on one 80 bed psychiatric ward over two years

Before (year one) = doors frequently and on one zone always, locked. After (year two) = doors unlocked except for temporary high risk situations.

Absconding rate increased from 2.5% of all admissions to 7% of all admissions

Richmond et al (1991)

Before and after controlled trial

All patients on three wards. After one month, one ward introduced the intervention with the other two serving as controls for 7 months. No information on how experimental ward chosen.

Identification those at risk of absconding with hourly checks by nurses with written records. Use of a sign-out book for those with off-unit privileges. Increased patient involvement in treatment planning. Formal contracting over off-unit privileges. Early discharges with intensive follow up.

50% reduction in absconding from the experimental ward. (No statistical tests given)

19

Methodology Sample

The study took place in three NHS Trusts in the East End of London. Twelve wards were studied, eleven were mixed gender, sectorised acute admission wards with bed numbers ranging from 15 to 25. The twelfth was a combined female only acute care ward and mother and baby unit. The wards were situated in five hospitals at different sites throughout the East End of London.

All absconders from these wards between 5th January 1998 and 28th May

1998 were identified by the researcher (MJ) and included in the study. A control group was identified by selecting, for each absconder, the patient on

the same ward who followed them in alphabetical order by surname. A small number of these became eventually absconded themselves, in which case they became part of the absconding sample and were deleted from the control group.

A sample of relatives or significant others was assembled by asking

absconding patients for permission to approach somebody close to them. A convenience sample of qualified nursing staff were interviewed, stratified by

ward. A minimum of two staff per ward were interviewed. The sample of staff was opportunistic, in that the researcher (FK) visited each ward on a regular basis, seeking a time when the ward was quiet enough for a staff member to be released for interview, and seeking consenting volunteers from those staff on duty at the time. Definition of absconding incident

For the purposes of this study, an incident of absconding was defined as the absence of a patient from the ward, without permission, for more than one hour. All absconding patients were included in this study, regardless of whether they went on to become officially reported, placed on leave, discharged, or otherwise processed. Preparation for the study

Prior to commencement of the study managerial support and permission were obtained from Directors of Nursing, Nurse Advisors, and and those with operational management responsibility for the wards. Following appointment of the lead Research Assistant on this project (MJ) further meetings took place with these same managers, and subsequently with the ward managers and other ward staff in the different hospitals.

Police liaison officers were also visited by the Research Assistant (MJ) and

informed about the study.

20

Training in conducting research and telephone interviews was provided by a Senior Research Assistant (NC), who also reviewed and gave feedback on pilot interviews and interviews conducted early in the study. Data collection Quantitative data on absconders and the control group

Using the literature previously reviewed, plus discussion and thinking around the topic, the research team (LB, MJ, NC) identified those characteristics of patients which might be relevant to absconding, and additional data about absconding incidents that it would be useful to collect and explore. This list was then refined into a smaller number of variables that were both of interest and feasible to collect.

A data collection instrument was designed for use by ward staff to identify

incidents of absconding, and what nursing actions were taken when (see appendix 1). The same form was used by ward staff to note when and how the patient returned to the ward. Staff were encouraged to ring the absconding hotline to notify the researcher (MJ) of a new incident of absconding. The researcher also made visits to the wards, initially three time per week, getting to know the staff, asking about absconds, checking official reports and bed states, and instructing on how to complete forms correctly.

Compliance with the submission of data was fair. Inner London psychiatric

wards are known to be under extreme pressure, with high morbidity, bed occupancy, levels of patient violence, and difficulties with recruitment and retention of nursing staff (Johnson et al 1997, Gournay et al 1997). With this in mind, the burden placed upon nursing staff to submit data was kept as small as possible. On some wards there was some initial suspicion about the motivation of the researchers, however this evaporated as the study continued, aided by the fact that the researcher doing the data collection (MJ) was herself a psychiatric nurse. Continued compliance with the study over the data collection period was assisted by feedback of the interim report to ward managers.

Once an abscond was identified, the researcher would collect information

about the patient and the identified non-absconding control (see appendix 2). This was composed of 32 variables: Ward Consultant Keyworker (ward nurse) Community keyworker discipline (Community Psychiatric Nurse, Social Worker, etc.) Current Mental Health Act status (if detained and under which section of the act) Mental Health Act status on admission to hospital Date of admission Age Gender Marital status Ethnic origin Religion

21

Sibling order (order of birth in family of origin) Accommodation (e.g. public housing, private housing, etc.) Living group (who the patient lives with, e.g. spouse, parents, etc.) Occupation (full time, part time, unemployed etc.) Duration since last employment Highest level of educational achievement Source of referral Diagnosis (casenote diagnosis by ICD 10 categories) Current medication Risk as identified in care plan (e.g harm to self or others, etc.) Number of ward transfers of patient in previous week Number of official ward incident reports for patient in previous week Number of medication refusals by patient in previous two days Whether patient absconded on a previous admission Previous contact with the police Previous contact with forensic psychiatry or the courts Previous admissions to psychiatric hospital History of suicide attempts History of self mutilation Whether patient expressed intention to leave the ward in 24 hours prior to abscond A further 9 items of additional information about the absconding incident were also collected: Date and time of abscond and return Location of incident (where the patient absconded from) Security status of the ward at time of abscond (whether locked, etc.) Level of observation of the absconding patient Number of other patients on high level observations at time of abscond Whether patient was confined to the ward at time of abscond Risk outcome (whether any harm came to the patient or anyone else during the incident) Staff on duty at the time of abscond (by grade and agency/non agency) Changes in care following the abscond Most of the above items were obtained by scrutinising ward records, medical notes and nursing notes. Where gaps existed, nursing staff on duty were asked verbally for information about the patient, or the ward situation at the time of the abscond. Interviews of absconders

Using the literature previously reviewed, plus discussion and thinking around the topic, the research team (LB, MJ, NC) identified suitable questions for inclusion in an interview schedule for patients who had absconded. This was then piloted and modified as appropriate. The final schedule may be found in appendix 3.

These interviews were conducted on the ward following the patients return.

Ward staff were asked to indicate whether patients were well enough to consent to be interviewed. Interviews were taped and fully transcribed.

22

Interviews of nursing staff

Using the literature previously reviewed, plus discussion and thinking around the topic, the research team (LB, MJ, NC) identified suitable questions for inclusion in an interview schedule for nursing staff around the topic of absconding. Interviews were semi-structured, and focused on the procedure taken when patients abscond, how staff feel about absconding, risk assessment and observation policies on the ward, team management of absconding. Interviews were designed to last 30 minutes. The interview schedule was then piloted on two wards and modified as appropriate. The final version may be found in appendix 4.

These interviews were conducted on the wards during April, May and June

1998. Interviews were taped and fully transcribed. Interviews of relatives / significant others The research team (LB, MJ, NC, LM) developed an interview schedule suitable for conducting by telephone with the relative or a significant other of patients who had absconded. Patients were asked, after having been interviewed themselves, whether they would give permission for an appropriate person to be approached for a telephone interview. If they did so consent, the person was contacted by phone and asked for their consent for the telephone interview to take place. These interviews were conducted between April and August 1998 by a member of the team (LM). The final schedule may be found in appendix 5. Ward data Information on admission and bed occupancy rates for the study period were provided by managers and IT departments in the three NHS Trusts. Two of the research team (LB and MJ) composed a simple measure of ward observability. These rating were made in conjunction with the ward managers during early 1998. A copy of this scale can be found in appendix 6. During April - July 1998, a minimum of five nursing staff from each ward included in the study completed the staff version of the Ward Atmosphere Scale (Moos 1974). Data analysis

Quantitative data was entered on to SPSS for computerised statistical analysis. All interviews were taped and fully transcribed using the system detailed in

appendix 8. They were then imported into QSR NUD.IST, a qualitative data analysis computer package, for coding and analysis. The vast majority of coding for patient

23

interviews was determined in advance. Further codes were developed and discussed in the research team during analysis, before they were introduced and used.

The coding system for the staff interviews was developed by the researcher

who carried them out (FK), after discussion with the team. Ethical approval

Ethical approval for the study was obtained from the ELCHA research ethics committee on 4th August 1997, reference P/97/180.

No patient was approached for interview unless the ward staff confirmed that

they were well enough to take part. Signed consent was sought from patients and others prior to interview by the researcher. Full information about the study was given to respondents at the time of consent. Notices about the study were put up in the wards so that patients and staff would be aware in advance that they may be asked for interviews.

24

Overview of Data and Analytic Methods Quantitative data on absconders

The final sample consisted of 175 absconding patients and 159 controls. There were 498 absconding events generated by these 175 patients. The mean number of absconding events per patient was 2.9 and the median 1. The distribution was skewed and is presented in the chart below:

Number of absconds per patient

No. of absconds

40342616131110987654321

No.

of p

atie

nts

100

80

60

40

20

0

Data collected on these patients can be explored using two different varieties of comparisons with the control group. The patient based approach enters each absconding patient only once into the analysis, regardless of the number of times they have absconded. This method is probably most useful to illuminate the reasons why patients abscond. The event based approach enters all absconding episodes into the analysis, and disregards the fact that some events are generated by the same patients. The strength of this approach is that it can help determine the risk factors for absconding in a population of psychiatric patients. Both approaches have been used in this study.

Variables collected on absconders and their controls were of different types.

Some were nominal (e.g. diagnosis), and some interval (e.g. absconding rates). A variety of statistical approaches to exploring the data have thus been used. Chi square tests have been used to assess differences between absconders and their controls, and the z test of equality between the proportions (Cohen 1988) to assess variations between wards and hospitals. Pearson correlations have been used to further explore the relationship between rates of absconding and other variables. SPSS was used for the majority of the statistical work, but for the z tests a reusable spreadsheet calculation was devised.

25

Ethnic categories used in this study Any set of ethnic minority groupings or categories are, to varying degrees, artificial. Those chosen for this study are no different, with some groupings spanning a wide range of cultural diversity (e.g. African) and others being determined by a narrow definition by national origin (e.g. Bangladeshi). The categories chosen for this study were selected with a view to assembling adequate numbers in each set so that some more generalised statements could be made, and were based on local knowledge of the population in the East End of London. Even so, some groups whom the research team initially hoped to discover more about (e.g. Turkish) were hardly represented in the wider study at all. In this study ethnic tags were taken from medical and nursing case notes. The adequacy of this procedure is open to question, as it is unclear how these judgements were made in the first place and whether they would be representative of self definitions of ethnicity by the patients concerned. Nevertheless staff in the East End of London are well aware of ethnic issues, many are themselves from various minority communities, and it is general policy to seek the patients own definition of their ethnic background. In the light of this, it was considered that case note definitions would be good enough for the purposes of this study. No solution to these problems is satisfactory. Each study has to make its own compromises about definitions in order to proceed. The choices made during this study are presented here so that the interpretations and conclusions reached can be accurately assessed by the reader. Interviews of absconders Fifty two people (which constituted 29% of the total number of absconders in the study) were interviewed a total of sixty two times (some were interviewed more than once following repeat absconds). Interviews were conducted when the patient returned to the ward, if they gave consent, and if there were no language barriers.

Their ages ranged from nineteen to sixty three years old, with most being thirty five years old or under. There were forty one men and eleven women. Almost two thirds had a diagnosis of schizophrenia and half of the sample were admitted involuntarily but by the time of the absconding incident a further seven were being detained under the Mental Health Act.

Trust awol patients (%)

awol episodes (%)

pts interviewed (%)

E 80 (46) 213 (42.8) 21 (40) O 59 (33.9) 202 (40.6) 23 (45) S 35 (20.1) 83 (16.7) 8 (15)

total 174 (100) 498 (100) 52 (100)

26

ward pts awol

(%) episodes

(%) pts interviewed

(%) 1 12 (6.9) 30 (6.0) 3 (5.8) 2 12 (6.9) 50 (10.0) 5 (9.6) 3 14 (8.0) 23 (4.6) 5 (9.6) 4 17 (9.8) 36 (7.2) 2 (3.8) 5 13 (7.5) 80 (16.1) 4 (7.7) 6 12(6.9) 69 (13.9) 4 (7.7) 7 8 (4.6) 13 (2.6) 1 (1.9) 8 17 (9.8) 25 (5.0) 7 (13.5) 9 18 (10.3) 47 (9.4) 6 (11.5) 10 4 (2.3) 6 (1.2) 3 (5.8) 11 23 (13.2) 45 (9.0) 6 (11.5) 12 24 (13.8) 74 (14.9) 6 (11.5) totals 174 (100) 498 (100) 52 (100)

Patients interviewed

Number % of total Gender Male 41 78.8 Female 11 21.2 MHA status Involuntary 33 63.5 Informal 19 36.5 Diagnosis Schiz. 32 57.7 Other 20 42.3 Age 35 & under 30 57.7 36 & over 22 42.3

Patients interviewed Number % of total Ethnicity afro-carrib. 12 23 bangladeshi 5 9.6 other african 5 9.6 somali 3 5.7 other asian 1 1.9 white eur. 25 48.1 other) 1 1.9

The interview sample is representative of absconders by Trust, ward, age, diagnosis and Mental Health Act status. The sample of men is on the whole representative of the men in the total absconding study in all respects. However, the sample of women being only 11 forms just 16% of the total number of women in the study. This in turn affected the ethnic representation of the female interviewees in that women from Bangladeshi backgrounds were not represented at all, while all other groups were under represented. The reasons for this were twofold (a) less women than men absconded (36 compared to 64%) and (b) there were different outcomes or consequences for women who absconded compared to men. Women were far more

27

likely to be placed on leave or discharged while absent, whereas men were much more likely to be required to return to hospital. Much of the data presented in this study is based upon 62 interviews of 52 absconders. Although this is a large number for any qualitative interview survey, and does well represent the views of absconders, the numbers from some ethnic minority groups are small. Numbers from all ethnic groups except white european and afro caribbean were very small. Therefore any general conclusions reached from the interview data of this study about the smaller groups of ethnic minority absconders must be considered to be highly tentative, even bordering on the speculative. Nevertheless, the data does raise interesting and important questions which will be presented here. All interviews were transcribed in full and analysed using the software package QSR NUD*IST. Codes for the content analysis of this material were devised in advance in conjunction with the design of the interview schedule. These codes were of two kinds, factual and referential (Seidel & Kelle 1995). The factual codes used denoted NHS Trust, gender, age group, diagnosis, Mental Health Act status and ethnicity. The referential codes were linked to specific interview questions and covered various topics such as how the patient left, the reason they gave for leaving, where they went, what they did, their thoughts about ward life and psychiatric professionals, etc. A small number of additional referential codes were introduced during the data analysis, following discussion with the full research team. The majority of coding was completed by the project research assistant. Checks for accuracy and comprehensiveness of the coding were made by the project leader. Some additional coding based on searches for key words was also conducted. Analysis of the data then proceeded mainly by intersecting the referential and factual codes and examining the data so generated. For example, reasons for leaving were intersected with Mental Health Act status to explore the different reasons for leaving given by those who were compulsorily detained on the ward, versus those who were informal patients. This approach enabled the summary of large amounts of data by the use of matrix analysis (Miles and Huberman 1994) and resulted in the tables presented in subsequent chapters of this report. The matrices produced were examined jointly by the research team for interpretation. In turn this lead to the identification of areas of further interest, where more detailed content analysis was undertaken by examining the transcripts in more detail. Occasional chi square tests were used to test the significance of quantified qualitative data (Kelle 1995). Staff interviews

Twenty four interviews with staff members from the twelve wards in the study were conducted between April and June 1998. These were tape recorded and transcribed by secretarial staff. Each tape was then listened to again by a member of the research team who corrected any errors in the transcript. Documents were then imported into QSR NUD*IST for analysis.

28

Factual codes were determined in advance, referential coding was devised using simple content analysis following scrutiny of the transcripts. Matrix analyses were examined by the research team for interpretation and further analysis. Relative/carer interviews

Patients who had absconded from the ward were approached to request their consent to interview one of their relatives/carers. The conditions and aim of the interview were explained both verbally and on the consent form. The conditions being that the interview would take place over the phone, would last fifteen minutes to half an hour, and the information would be treated confidentially. In addition, no information revealed by the patient in their interview would be passed on. This was doubly ensured by the fact that the two different researchers were involved in interviewing patients and relatives respectively. It was explained that the purpose of the interview was to ascertain the relatives views about the ward, the care that the patient was receiving, and in what way, if any, had the absconding incident impacted on the relatives’ perception of the staff and treatment afforded to the patient.

The recruiting of relatives began in mid April. However, the task emerged to

be much more difficult than initially anticipated. The reason for this was a) some patients simply did not have relatives/carers around or were not in contact with them b) some said their relatives had no idea they were presently in a psychiatric ward and they did not want them to find out c) some did not wish their carers to be contacted since they felt their relatives already had too much to worry about d) and some refused on the grounds that they felt sure that the relatives would refuse.

Once consent was obtained, a different researcher (LM) for them to contact the

relative or carer and see if they would agreed to be interviewed. Nine clients gave the name and telephone number of a relative they were happy for us to interview. Of those no contact was made with 2, due to wrong phone numbers and a phone number no longer in service being given by the clients. A number of attempts were made to elicit other contact numbers but to no avail. None of those who were actually contacted refused, although one person consented but was unavailable for interview during the data collection period. At the end of this process, six carers were interviewed between April and September 1998. Notes were taken of the responses during these phone calls and the small amount of material produced dealt with via simple content analysis. GENDER RELATIONSHIP CLIENT 5 male

1 female

RELATIVE/CARER 3 male 3 female

2 brother /1 father 1 sister, 1 mother, 1 partner

29

Sequence of analysis Transcription of patient interviews began with the commencement of data collection and continued until some weeks after data collection had finished. Coding of that data followed at the same pace and to the same schedule. Informal results and feedback were therefore provided to the team quickly and continuously. Similarly, the quantitative data were inputted onto SPSS immediately and some interim charts and tables were explored three months into the data collection period. Following the close of data collection, the quantitative data was the first to be thoroughly analysed. The results of that analysis shaped the preliminary questions that were addressed in the qualitative analysis of patient interviews. Some themes elicited from the qualitative results have lead to further quantitative analyses. Analyses of the nurse interviews and patient/carer interviews took place last and was informed by previous results. A triangulation (Denzin 1977) strategy has thus been followed. The different data sets from the different strategies have informed the analysis and interpretation of each other. This strategy works well with an exploratory study such as this.

30

Findings 1:

Absconding events and consequences Leaving the ward

At the time of the absconding event, 35% of absconders were confined to the ward, and were more likely to be confined to the ward, even at time of first absconding, than were the controls. 15% had a risk of absconding noted in the care plan (as opposed to 4% of the controls who did not abscond), and 15% were on regular intermittent nursing observations. In short, a significant but apparently small proportion of patients who abscond are recognised as an absconding risk, and nursing action is taken to prevent absconding, but is not always successful.

58% of absconders expressed to staff their intention of leaving the ward within the 24 hours preceding the abscond. Again this underscores the fact that even when the absconding risk is known, effective nursing action is not always taken. This could be due to a range of factors, and is not necessarily an indication of the inefficacy or inefficiency of nurses.

On 1% of absconding incidents the ward door is locked when the patient absconds, and for a further 11% of incidents a nurse is stationed at the door to oversee people leaving and entering. For the remaining 88% of occasions the ward is open at the time of absconding.

In contrast to the previous literature which reports that about half of absconders leave whilst temporarily off the ward with permission, in this study 82% of absconders left directly from the ward, 14% whilst temporarily off the ward, and 3% failed to return from leave. This indicates that any effort directed towards the reduction of absconding does not need to focus primarily upon the granting of leave or permission to leave the ward. Staff issues There is no association between the individual inpatient keyworkers and absconding, nor any association with the professional discipline of the patients' community keyworkers. Simple contingency table analysis of numbers of controls vs. absconders by consultant shows that some consultants do have significantly greater numbers of absconders than others. At first sight, consultants 2, 7, 8 and 10 appear to have high levels of absconds.

31

9 7 16

56.3% 43.8% 100.0%

41 7 48

85.4% 14.6% 100.0%

24 8 32

75.0% 25.0% 100.0%

26 14 40

65.0% 35.0% 100.0%

2 3 5

40.0% 60.0% 100.0%

30 13 43

69.8% 30.2% 100.0%

66 4 70

94.3% 5.7% 100.0%

8 1 9

88.9% 11.1% 100.0%

13 7 20

65.0% 35.0% 100.0%

46 6 52

88.5% 11.5% 100.0%

3 2 5

60.0% 40.0% 100.0%

36 11 47

76.6% 23.4% 100.0%

11 6 17

64.7% 35.3% 100.0%

72 19 91

79.1% 20.9% 100.0%

38 18 56

67.9% 32.1% 100.0%

48 13 61

78.7% 21.3% 100.0%

10 3 13

76.9% 23.1% 100.0%

10 11 21

47.6% 52.4% 100.0%

3 4 7

42.9% 57.1% 100.0%

1 2 3

33.3% 66.7% 100.0%

497 159 656

75.8% 24.2% 100.0%

Count% withinConsultantCount% withinConsultantCount% withinConsultantCount% withinConsultantCount% withinConsultantCount% withinConsultantCount% withinConsultantCount% withinConsultantCount% withinConsultantCount% withinConsultantCount% withinConsultantCount% withinConsultantCount% withinConsultantCount% withinConsultantCount% withinConsultantCount% withinConsultantCount% withinConsultantCount% withinConsultantCount% withinConsultantCount% withinConsultantCount% withinConsultant

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

Consultant

Total

Absconder ControlControl vs absconds

Total

Consultant * Control vs absconds Crosstabulation

p < 0.001 by chi square

However this effect might be confounded by ward. Most consultants work on only one ward, thus any high or low rate visible in the table below may well be due to the impact of particular ward nursing teams, rather than the individual consultant. There are, however, several consultants who share wards, and their absconding rates can be

32

contrasted. The effect of the individual ward is thus controlled, and using the z test of equality between the proportions, the different admission rates of these pairs of consultants can also be taken into account. When pairs of consultants absconding rates are examined as a proportion of their admissions over the study period, the following table is produced:

Sig. differenceEvents Patients

Pair 1 ! "Pair 2 ! "Pair 3 " "Pair 4 ! "Pair 5 " "Pair 6 " "

This table shows that there can be significant differences between consultants in the numbers of their patients who abscond. The fact that these differences only emerge at the event level is probably due to the small numbers in the patient based data. Timing of absconding Most absconds occur during the first three weeks following admission, as the following chart shows:

Duration from admission to abscond

(Event based)

No. of days from admission to abscond

423.00323.00

178.00162.00

141.00123.00

96.0085.00

74.0065.00

56.0048.00

40.0032.00

24.0016.00

8.00.00

No.

of a

bsco

nds

30

20

10

0

Patient based data is even more positively skewed, with 66% of all first absconds occurring in the first two weeks following admission. This would indicate that there is either a "settling in" period for patients, or a phase when the patients illness is at its most acute, during which nurses need to be most aware of the risk of

33

absconding. However the risk of absconding never goes away completely, and some patients still abscond for the first time after having stayed more than six months.

On 51% of occasions absconders returned to the ward the same day, and a further 31% returned the next day. Those who go for less than a full day tend to return quite quickly, with half of them being back on the ward within six hours. Of the 498 absconding events monitored during this study, 9% of the patients involved failed to return at all. Two of these were still missing at the time data collection terminated, most of the rest had been placed on leave or discharged. It can therefore be seen that few patients, if any, are permanently lost to follow up after absconding from the ward.

Most absconds occur towards the middle of the day, however the chart below shows two isolated peaks at 13.00 hrs and 21.00 hrs. These tally with nurse shift change times when the ward is relatively unobserved due to the presence of the nursing team in the office, patients are checked, return from therapeutic activities, or are expected to return from temporary leave.

Absconds by time of day of departure

Time of day of abscond

23.0022.00

21.0020.00

19.0018.00

17.0016.00

15.0014.00

13.0012.00

11.0010.00

9.008.00

7.006.00

3.00.00

No.

of a

bsco

nder

s

70

60

50

40

30

20

10

0

Patients returning from absconding episodes do so in gradually increasing numbers throughout the day. They are, as would be expected, least likely to return during the small hours of the morning (see chart below).

Absconds by time of day of return

Time of day of return

23.0021.00

19.0017.00

15.0013.00

11.009.00

6.004.00

2.00.00

No.

of a

bsco

nder

s

50

40

30

20

10

0

34

63% of absconders returned of their own accord, 2% were brought back by ward staff, 8% by relatives or friends, and 13% were brought back by the police. This latter 13% represents 66 occasions when police were involved in the physical return of patients to the ward. On many other occasions they were involved administratively or in searching for the patient unsuccessfully, as they were officially notified about 47% or 230 absconding incidents. This represents a considerable investment of police resources.

Saturday is the most popular day to abscond, and Sunday the least, as the chart below indicates. However there is not a great deal of variation in absconding over the course of the week.

Absconds by weekday

Day of the week

SaturdayFriday

ThursdayWednesday

TuesdayMonday

Sunday

No.

of a

bsco

nds

100

80

60

40

20

0

In order to test whether there was any tendency for patients to abscond following unpalatable news being given in a ward round (e.g. refusal of leave), the duration between each absconding episode and the relevant ward round was calculated. Patients of those consultants holding more than one ward round per week were excluded from this analysis. No relationship with the ward round day was found (see chart below).

No. of absconds by days from ward round

Duration in days from ward round to abscond

6.005.004.003.002.001.00.00

No.

of a

bsco

nds

60

50

40

30

20

10

0

35

Nursing action on discovering an abscond The most common first nursing responses to the discovery of an abscond are to search the ward (65% of absconding events) or to wait to see if the patient returns (76%). Several people are notable for the way they are not informed about absconds. It is very rare, for example, for nurses to contact the patient's general practitioner (0.4%), consultant (7%), community keyworker (7%), or the duty doctor (17%). Relatives were only informed on 23% of occasions, and the patient's home contacted on 15% of occasions. When relatives were called, 73% were contacted within the first hour of the abscond being discovered. However sometimes relatives were not contacted until up to 24 hours later. A similar pattern is visible in data about the police. Police were officially informed on 58% of occasions. When they were informed, on 62% of occasions it was within the first hour, however sometimes they were not contacted until up to 48 hours later. Risk and absconding

21% of absconding patients had a recorded history of at least one suicide attempt, and 5% had a history of self mutilation of one form or another. 32% of absconders were considered by staff to be at risk of self harm, and were noted as such a risk in their nursing care plans. In addition, 27% were considered to be at risk from the use illicit drugs, and 16% at risk of self neglect. (These percentages and those in the following paragraph overlap slightly, as some patients were considered at risk in more than one category)

20% of absconders were considered to pose a risk to others, and 23% had a history of contacts with forensic psychiatry, courts, or prison. In addition, 5% of absconders had been involved in officially reported ward incidents.

As other studies have reported, the vast majority of absconding incidents resulted in no harm. In this study, 2.4% of incidents resulted in a patient harming themselves, and 1.6% in them harming someone else.

441 88.6 88.6 88.6

12 2.4 2.4 91.0

8 1.6 1.6 92.6

4 .8 .8 93.4

3 .6 .6 94.030 6.0 6.0 100.0

498 100.0 100.0498 100.0

NoneHarm toselfHarm toothersPropertydamageOtherDrug useTotal

Valid

Total

Frequency PercentValid

PercentCumulative

Percent

Risk outcome

Perceptions of risk appear to differ sharply for different genders of patient and for different ethic origins. It is impossible to say whether this is due to these differing backgrounds producing different kinds of psychiatric problems, or to stereotypical

36

views on the part of staff assessing risk, or to some combination of both these factors. The relationship is far from simple and certainly does not support the explanation that psychiatric professionals perceive ethnic minority patients as "big, black and dangerous".

Consider the following two tables: Perceived risk to others

Current risk to others * ethnic origin Crosstabulation

15 9 1 4 1 14 2 4639.5% 56.3% 5.0% 50.0% 12.5% 18.4% 33.3% 26.4%

23 7 19 4 7 62 2 4 12860.5% 43.8% 95.0% 50.0% 87.5% 81.6% 100.0% 66.7% 73.6%

38 16 20 8 8 76 2 6 174100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

Count% within ethnic originCount% within ethnic originCount% within ethnic origin

Yes

No

Current riskto others

Total

Afro-Carribean BangladeshiOther

African SomaliOtherAsian

WhiteEuropean Turkish Other

ethnic origin

Total

p = 0.003 by chi square

Perceived risk to self

Current risk to self * ethnic origin Crosstabulation

6 3 5 1 23 2 2 4215.8% 18.8% 25.0% 12.5% 30.3% 100.0% 33.3% 24.1%

32 13 15 7 8 53 4 13284.2% 81.3% 75.0% 87.5% 100.0% 69.7% 66.7% 75.9%

38 16 20 8 8 76 2 6 174100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

Count% within ethnic originCount% within ethnic originCount% within ethnic origin

Yes

No

Currentrisk to self

Total

Afro-Carribean BangladeshiOther

African SomaliOtherAsian

WhiteEuropean Turkish Other

ethnic origin

Total

p = 0.073 by chi square

Both these tables show statistically significant relationships between ethnicity and perceptions of risk. However it is quite clear that solely being black is associated with being considered a risk to others. For why are 'Other African' patients considered to be less a risk to others than Afro Caribbean patients. And if Asian patients are supposedly viewed differently and more positively than those of African and Afro-Caribbean origin, why are the Bangladeshi patients so frequently considered a risk to others?

Instead it is clear that each ethnic community (the white majority included) interacts with psychiatry to produce different groups of patients with different diagnoses, different problems, with different causes. Consequences of absconding

On 73% of occasions, the absconding incident made no change to the care provided to the patient upon their return. The most common alternative was for the patient to be granted leave or discharged, however this occurred to twice as many women as men.

37

Findings 2:

Assessment of variables impacting on absconding rates Relationship of absconding to the weather

Absconding rates were available for a total of 143 days (5/1/98 - 27/5/98). Weather data for those days was obtained from the Climatological Observers Link (http://www.met.rdg.ac.uk/~brugge/col.html). No significant correlation could be found between daily absconding rates and the main features of the reported weather.

Daily weather Pearson correlation with numbers of absconds/day

Significance

Sunshine hours 0.076 0.368 Rain (mm) -0.045 0.609 Rain (hours) -0.027 0.747 Maximum temperature 0.094 0.264 Frost (hours) -0.056 0.504

All these figures are low, but all are in the direction of positive correlations between absconding and good weather. However even when these weather variables are taken together in a linear regression equation, they fail to produce a significant result.

It must therefore be concluded that, in the UK at least, weather has no significant impact upon the rate of absconding. Variations between wards

Ward Beds Staff Adms Bedocc Events Patients LoS1 17 4 108 2477 29 12 22.942 18 4 104 2539 49 12 24.413 15 4 115 1521 23 14 13.234 25 4 98 3227 35 18 32.935 18 4 77 2256 79 13 29.306 22 4 74 2899 69 12 39.187 16 5 34 1816 13 8 53.418 16 4 71 1921 24 17 27.069 25 4 94 2488 47 18 26.4710 18 7 97 2620 5 4 27.0111 20 4 94 3054 47 22 32.4912 16 5 96 2616 73 23 27.25

Each Trust involved in the study kindly provided numbers of admissions and

bed occupancy by ward for the study period, enabling the calculation of absconding rates for patients (counting each absconder only once, regardless of the number of times they absconded) and events (counting each abscond separately, regardless of the

38

smaller number of patients producing these absconding events). Each ward was then compared with the total of the remaining wards, using the z test of equality between proportions (Cohen 1988). Differing methods of calculating the rates of absconding were used. Proportions of absconds by beds: This method of calculation fails to take into account whether all beds were occupied for all of the study period, nor is it sensitive to patient throughput. Proportions of absconds by admissions: The number of admissions ignores the patients who were already on the ward at the time the study commenced, and no distinction has been made between admissions and readmissions. Trust O operates a system where many patients are first admitted to a holding ward before being transferred to beds on other wards. In this case, these transfers have been counted as admissions to the destination ward, and have therefore been included twice in the admission figures. Proportions of absconds by bed occupancy: This figure includes those on leave at any time during the study period. It is perhaps the best number by which to judge real differences in absconding rates.

Ward Event based analysisBeds Adms Bedocc.

z sig. z sig. z sig.1 1.42 0.0778 -4.30 0.0000 -2.04 0.02072 -1.35 0.0885 0.15 0.4404 1.05 0.14693 1.91 0.0281 -6.02 0.0000 -0.51 0.30504 3.15 0.0010 -2.23 0.0129 -2.77 0.00285 -4.49 0.0000 10.26 0.0000 7.04 0.00006 -2.51 0.0060 8.37 0.0000 3.12 0.00107 5.66 0.0000 -0.97 0.1660 -3.29 0.00048 2.10 0.0179 -2.21 0.0136 -1.50 0.06689 1.06 0.1446 0.73 0.2327 0.87 0.192210 14.17 0.0000 -8.55 0.0000 -6.20 0.000011 -0.48 0.3156 0.73 0.2327 -0.62 0.267612 -4.44 0.0000 6.10 0.0000 4.66 0.0000

Ward Patient based analysis

Beds Adms Bedocc.z sig. z sig. z sig.

1 -0.60 0.2743 -1.54 0.0618 -0.70 0.24202 -1.03 0.1515 -1.38 0.0838 -0.79 0.21483 1.59 0.0559 -1.27 0.1020 1.74 0.04094 -0.57 0.2843 0.58 0.2810 -0.24 0.40525 -0.45 0.3264 0.15 0.4404 -0.07 0.47216 -2.56 0.0052 -0.02 0.4920 -1.29 0.09857 -2.60 0.0047 1.16 0.1230 -0.85 0.19778 2.91 0.0018 1.81 0.0351 1.76 0.03929 -0.57 0.2843 0.79 0.2148 0.93 0.176210 -5.67 0.0000 -3.40 0.0002 -3.05 0.001311 3.70 0.0001 1.96 0.0250 1.01 0.156212 6.58 0.0000 2.13 0.0166 2.04 0.0207

39

Ward Event based Patient based

Beds Adms Bedocc Beds Adms Bedocc1 Low Low2+3 Low Low High4 Low Low Low5+ High High High6+ High High High Low Low7 Low Low Low8 Low Low High High High910 Low Low Low Low Low Low11 High High12+ High High High High High High+ location of 4 most frequently absconding patients

These apparent differences between the wards should be treated with caution.

They may reflect differences in willingness to report absconds to the researchers, rather then real differences in rates of absconding. Or they may reflect differences in deprivation and morbidity of the localities served by the wards. If these two sources of variation can be assumed to be minimal (and that is a large "if"), then the following deductions may be made:

Ward 1 has a similar number of patients who abscond, but is good at intervening to reduce subsequent repeats.

Ward 3 is a temporary holding ward. It therefore has patients at their peak time for absconding in the early days of their admission. Because many patients are subsequently transferred to other wards, they have a low rate of repeat absconds.

Ward 4 has a similar number of patients who abscond, but is good at intervening to reduce subsequent repeats (like ward 1).

Wards 5 and 6 have high absconding rates by event based figures. This appears to be due to a poor responses to first absconds (in contrast to ward 1) and the presence of some of the patients most prone to abscond repeatedly. The low patient based figure for Ward 6 reflects a high length of stay on this ward. In other words, Ward 6 has a low number of one time absconders and a high number of repeat absconders.

Ward 7 is a female only ward, and the relatively low rates of absconding are due to the fact that women abscond much less than men.

Ward 8 has a high patient based and a low event based rate. This indicates that although patients abscond initially at a high rate from this ward, they rarely repeat, possibly due to post abscond intervention by the staff.

Ward 10 has a low rate of absconding for unknown reasons. This ward has a low rate of incidents of all types (Bowers and Clark 1998).

40

Ward 12 has a high rate of absconding by all possible calculations. Again the reason is unknown. Ward observability

A simple scale to assess the observability of a ward was devised (see appendix 6). The scale scored complexity of layout, ease of visibility for nurses, and number of exits. Scoring was completed by a researcher (MJ) in conjunction with the ward managers.

Bivariate Pearson correlation coefficients were calculated for the observability scores and rates of absconding for wards, using both patient and event based data. No significant correlation was found. The calculation was repeated using number of ward exits in place of the observability score, with the same result. In fact, there was a nonsignificant trend towards absconds decreasing on those wards that were less observable or which had more potential exit points.

No firm conclusion can be drawn from this, as only twelve cases were available for analysis, and the effect of ward observability/exits on absconding would have to have been very strong to be statistically significant with this small sample. Nevertheless, the presence of a trend in the opposite direction does call into question (i) whether level of ward security has anything to do with absconding rates, and (ii) whether higher staffing levels to improve observation of patients would have any impact upon absconding rates.

However there is a small amount of support in the data for the supposition that higher staff/patient ratios reduce absconding rates. There is no correlation between typical daytime numbers of nurses and absconding rates. However when staff to bed number ratios were calculated and tested for correlation with absconding rates, there was a nonsignificant trend in the direction of fewer absconds on better staffed wards. Variations between Trusts

The same statistical method used to assess ward differences was applied to differences between Trusts. With only three cases to compare, the findings are less reliable. However it would appear that Trust S has a higher patient based rate of absconding by admissions, and a lower event based rate of absconding by bed occupancy.

Trust Beds Adms Bedocc Events Patients LoSE 87 436 12502 211 77 28.67O 89 434 11217 200 60 25.85S 50 192 5715 82 36 29.77

41

Trust Event based analysisBeds Adms Bedocc.

z sig. z sig. z sig.E -1.78 0.0375 1.08 0.1401 0.15 0.4404O -0.49 0.3121 -0.18 0.4286 1.13 0.1292S 3.01 0.0044 -1.14 0.1271 -1.58 0.0571N.B. Numerators and denominators for beds reversed.

Trust Patient based analysis

Beds Adms Bedocc.z sig. z sig. z sig.

E 3.36 0.0004 1.01 0.1562 0.54 0.2946O -2.61 0.0045 -1.81 0.0351 -0.93 0.1762S -0.86 0.1949 1.02 0.1539 0.46 0.3228

Trust Event based Patient based

Beds Adms Bedocc Beds Adms BedoccE High HighO Low LowS Low Low

No highly consistent picture merges out of this data. There is indicative (but

not convincing) evidence that absconding might be higher in Trust E than in the other two Trusts. These differences could, however, be due to variation in nursing co-operation with the research, slightly differing admission policies, or a number of other factors.

42

Findings 3:

Characteristics of absconders Characteristics of absconders

The table below shows the results of statistical tests for differences. The most relevant set of results for nursing practice are those which compare all absconding with the control group. Those variables which are statistically significant may be used by nurses to predict the patients who are most likely to abscond. The profile of an absconder is someone who is: young; male; a firstborn child; from an ethnic minority group; of the Muslim faith; living with partner or parents; with a diagnosis of schizophrenia; having had a number of transfers between wards, refusals of medication and involvement in officially reported ward incidents in the previous week; considered by nursing staff to be a risk to self or others; someone who has absconded during previous admissions; and has had previous contact with the police.

In contrast to previous studies, these results do not show that compulsorily detained patients are more likely to abscond. Previous studies have relied heavily on the use of statistics generated through the production of official reports. The definition of an abscond used in this study (absent from the ward without permission for at least one hour) has shown that only 47% of absconds are officially reported. These official reports are more likely to be made if the patient is compulsorily detained (they are completed for 58% of detained patients who abscond, but only for 35% of informal patients who abscond). The fact that previous studies report detained patients absconding more frequently is thus an artefact of their methods.

Event based analyses are excellent for the identification of risk factors for use as practical predictors in the ward setting. Patient based analyses show that when absconders are examined in detail, their characteristics are not very different from the control group. This may indicate that the propensity to abscond is not a derivative of patients enduring psychological or personality characteristics, but is instead a product of other factors, such as the social context within which they find themselves.

About half (55% in this study) of all patients who abscond do so only once in the course of their admission to hospital (in this report these are called single absconders). The remainder abscond more than once, and some abscond many times (in this report these are called multiple absconders).

Neither single nor multiple absconders considered separately are any more readily distinguished from controls than when they are considered together. However when they are compared with each other (in an event based analysis), it can be seen that single absconders are more likely to be female, older (over 35 years old), and not single. These are preliminary indications that the type of patient who absconds only once may be different, and do so for different reasons.

43

All analyses confirm that absconding during a previous admission is strongly associated with the propensity to abscond during the current admission. Variable Absconds

vs controls (event based)

Absconds vs

controls (patient based)

Single absconds

vs controls

Multiple absconds

vs controls

Single absconds

vs multiple

absconds Age +++ ++ + Gender +++ + + Marital status + Sibling order + Ethnic origin +++ Religion +++ Education Living group + Accommodation + Employment ++ Time since last employment + Diagnosis +++ No. ward transfers in past 7 days

+++

MHA status on admission No. of medication refusals in past 2 days

++ + +

No. of incident report forms in past 7 days

+++

Previous admission Previous contact with the police

+++ +

Previous contact with courts or prisons

History of self mutilation AWOL on previous admission +++ +++ +++ +++ Previous suicide attempt Risk (self neglect) ++ + + Risk (to others) ++ Risk (to self) +

All results by chi square test, + = p < 0.05; ++ = p < 0.01; +++ = p < 0.001

The strongest variables were selected from the above list, and collapsed into dichotomous variables for preliminary logit loglinear analysis with control group vs. Absconders as the dependent variable. First results showed significant higher order combined effects for female gender, young, schizophrenia, white European and Christian. Comparing these results with the previous contrast between single and multiple absconders, it would appear that gender might be the most significant variable. Chi square tests were thus used again, but this time treating male and females as separate populations. The statistical power of this analysis is lower due to the smaller sample sizes. Yet significant differences can be seen, and the following results were obtained.

44

Variable Female

absconds vs. Female

controls

Male absconds vs. Male controls

Male vs. Female

absconds

Age +++ +++ Marital status + +++ Sibling order ++ Ethnic origin +++ +++ Religion +++ +++ Education Living group + + Accommodation ++ +++ Employment + + Time since last employment +++ Diagnosis +++ +++ No. ward transfers in past 7 days

+++ ++

MHA status on admission ++ ++ No. of medication refusals in past 2 days

++

No. of incident report forms in past 7 days

++ +

Previous admission Previous contact with the police

++ ++ ++

Previous contact with courts or prisons

+

History of self mutilation AWOL on previous admission

+++ +++ +++

Previous suicide attempt Risk (self neglect) + ++ Risk (to others) ++ Risk (to self)

All results by chi square test, + = p < 0.05; ++ = p < 0.01; +++ = p < 0.001

In contrast to female controls, female absconders had a history of absconding on previous admissions, were more likely to live alone, and have had previous contact with the police, forensic psychiatric services, prison and the courts.

In contrast to their controls, male absconders were more likely to live in council accommodation, be under 35 years of age, have a history of absconding on previous admissions, suffer from schizophrenia, be from a Bangladeshi, Somali, or other African ethnic background, unemployed, living with a partner or with parents, married with a stable partner, refused medication, been transferred from another ward, or been involved in an officially recorded incident within the previous week, compulsorily admitted under the Mental Health Act, have had previous contact with the police, be of the Muslim or Sikh faith, be considered at risk of self neglect and/or a risk to others.

The sharpest contrast is produced by comparing the male and female absconders with each other. In case these were usual differences between male and female psychiatric patients, not connected with absconding behaviour, males and females in the control group were contrasted on the same variables. Similar

45

differences were found for previous contact with the police and diagnosis, and these may therefore be considered typical differences between male and female patients, regardless of the propensity to abscond. For other variables however, either no differences exist between male and female controls, or the differences are in the opposite direction. The following table summarises the results:

Male Female In council accommodation or homeless Private rented, or housing association

accommodation Aged 35 years and under Aged 36 years and older Absconded on a previous admission Not absconded on a previous admission Bangladeshi or Somali Afro-Caribbean or white European Unemployed In some form of employment Less recently employed More recently employed Living with parents or partner & children Living alone Single Separated/divorced Compulsorily admitted on a treatment order Compulsorily admitted for assessment Muslim or Sikh Christian or no religion At risk of self neglect Not at risk of self neglect Risk to others Not a risk to others A first born child An only child Transferred between wards in past week Not transferred between wards in past week Official incident report in past week No official incident report in past week

These findings indicate that female patients who have a difficult relationship with inpatient psychiatry and who are prone to break the rules are different from males who exhibit the same behaviour pattern. They may therefore have different reasons for absconding, and different remedies may be appropriate. The issue of gender will be returned to when consideration is given to the outcome of absconding incidents, their official reporting, and risk management.

Unfortunately, this study was not powerful enough to establish separate predictive profiles for male and female absconders, as the female absconders do not differ sufficiently from the female controls.

46

Findings 4:

Going and returning The findings presented in this chapter are based upon the 62 interviews of 52 returned absconding patients, except where otherwise stated. Analyses of the interview data have been summarised in matrices which can be found in Tables 1 - 7 at the close of the chapter. Leaving the ward The majority of absconders found it easy to just walk off the ward, as illustrated in Tables 1 - 5. Just under 60% of interviewees had absconded in this way.

pt: I just walked through the door ..I went round that way so I walked past the office ..no one was about so I walked out the door. (P10811) pt: I just walked out. (P10902) pt: just walked out (P11909) pt: the door was open ...that door wasn't locked ..I just opened it and left ..that's it ... (P12703)

Seeing the unlocked door was interpreted by some patients as a message that they were free to leave, or that leaving without permission would be easy, or that they were being dealt with unfairly because other patients could come and go as they pleased.

pt: the door was open .. I knew the opportunity had presented itself (P62311) pt: well it wasn't that .. I was standing next to the door .. and I was watching all these people walk in and out freely .. like you know .. I thought to myself like you know .. I can't ..you know ..( P21306) pt: I just wake up and saw there was nobody sitting near the door ..there's ( ) nurse sitting near the door and I thought .. you know it's a chance for me to run away ..and I just ran away (P30408)

However, some patients were cautious or devious in making sure they were not spotted by nurses and prevented from leaving.

pt: no I thought ..(..) do it in secret........ oh yeah I crept round there.. yeah I crept round ..wasn't nothing to do with the staff's fault ..it was my fault...cause I'd stormed out of the ward round Wednesday when he said to me come back when you're sober ..I stormed out and I come in here (bedroom) and J followed me out quick so I thought I'll wait until she goes back in the office ..then I'm going to go. (P10811)

47

pt: yeah .. well I told one of the staff .. the one that stands in the way of the phonecall .. I was .. but at that exact moment .. there was another patient they had to keep an eye on .. and there was that one man there .. and when he's gone to see the other patient .. I absconded then .. once he went to see the other patient ..( P30303) pt: it was locked .. they unlocked the door and I sneaked out. int: how did the door get unlocked? pt: the staff opened it .. the domestic. int: oh the domestic opened it .. and while her back was turned ...? pt: yeah .. I sneaked out. (P60411)

Some patients literally 'did a runner'. pt: I rushed .. I walked but I rushed. int: did you have to look out to see if the coast was clear? pt: no I just rushed out. (P12912) pt: it was just the door was open .. I just ran .. just jumped .. jumped .. the open door.. and then just run down the stairs and run out. (P60308) pt: yes ..I was thinking about going home .. and so I just left the ward ..sort of ran off you could say (P31902)

Tables 2 - 5 show that nearly all those who literally ran were young, male, involuntarily detained sufferers of schizophrenia. This is likely to be indicative of the fact that they are observed by nurses more closely and find it more difficult to abscond. Destination and activity Roughly two thirds (63%) of absconders went home on leaving the ward, and while there engaged in normal life activities like housework, shopping, decorating, sleeping, eating, watching television, household repairs, looking after children, chatted to family, socialised, played games/sports, cleaning, etc. All absconders, not just those who went home, largely engaged in normal everyday activities while away. Table 3 shows that the behaviour of involunatrily detained patients may have been slightly more disturbed and unusual while away from the ward, however the difference is not massive.

pt: I just went to my house ..I just went to my place. (P11508) int: right...was there anything in particular that you wanted to get off the ward to do? pt: no ..I just wanted to get home. int: you just wanted to get home ...did you go straight home? pt: yeah. (P11909) pt: ...I went home ...I then phoned them up and ( ) saying that I'm at home at the moment yeah ..I did phone them and told them that I am at home ...that they know I'm safe enough ... (P12703)

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The next most popular destination (32%) were the houses of friends or relatives. Male absconders were more likely to visit friends and engage in social activity (Table 2).

pt: no I just rushed out .. I thought I go home but I don't have a key on me .. nothing .. so I went to a friend of mine and they brought me back here. (p12912) pt: I just went to my mates house .. I was being a big poof and kissing and everything (P21312) pt: I went to my mate's house (P21706) pt: I don't know .. I just go all over .. I usually go to my brother's off licence .. he's like a brother to me .. and he gives me a few cigarettes now and then .. and I just sit there .. pass time .. (P42912)

A few went to the pub, and 11% admitted to smoking cannabis while away from the ward. Even when absconders did not go to the pub, many drank alcohol while away, 19% in all.

pt: walked round for a while ...then went to the pub ..had a few cokes and watched the football match. (P11502) pt: well .. drinking in the pub ..public house .. it was all um brandy Martell .. brandy .. I can't remember much after that .. I went home and slept it off but I .. I never slept very good .. I only woke up about six am the next morning .. after drinking brandy .. which was normal .. you know .. anyone would .. if they had problems wouldn't they .. mental problems .. (P20509) pt: I got drunk and stoned and I come back the next day (P21308)

And a few went to religious services. pt: I didn't sleep the first night .. second night I slept in a cardboard box .. down Farringdon .. went to church .. went to Mosque .. they didn't like me because I was shouting .. in the Mosque .. (P61710) pt: went to church (P60411)

One patient refused to be seen by a local priest from the mosque for healing rituals. pt: then they said that ..they're going to get a priest at my home you see .. for that thing yeah .. the priest can pray something .. from the Koran yeah .. the Holy Koran .. and to control myself I said that .. I broke this master plate you see .. I lost my temper yeah .. I smashed a plate and I said .. which motherfucker wants to come and control me .. I'll rip his arse from .. I said that yeah .. at that time I lost my temper you see .. I don't like priests .. all these things .. because I don't believe in priests .. it's a whole load of bullshit . (P21809)

Very few patients appear to have left the ward with no specific destination in mind, however those that did tended to wander the streets.

49

pt: I was just strolling out...taking fresh air ..looking around.. yes ...that's it ..just getting fresh air ..that's all. (P12109) int: and where did you go in those three days? pt: all over .. I went to the A1s, the B2s, the B3s .. int: sorry what are the A1s and B2s . pt: A1s are the high roads .. the highways .. the B2s are the train tracks, the B3s are the trains ..that's the classification of transport. int: so did you not go to your uncle's house? pt: I did not. I went the other direction .. int: where did you sleep at night? pt: anywhere.. on the concrete. int: on the concrete? did you sleep all three nights outside? pt: I did. (P31311) pt: I just walked the streets (P40211)

Two patients attempted suicide following their abscond from the ward, one in response to persistent command hallucinations.

pt: no I just wanted to go home and I bought some paracetamol ..I only took about twenty though and they was knocking at my door so I couldn't do any more because they were a blister packs ... (p10811) pt: no the voices just said like go for a walk .. so I went for the walk and then half way .. then they told me to go home .. so I walked home .. then as soon as I got in .. they said take the pills .. take pills and I kept looking at the bottle trying not to listen to the voices .. I put on my radio full blast .. I put my tv on full blast but it didn't help so in the end I just took them. (P40211)

Returning to the ward The majority of absconders return to the ward by themselves (43% of the interview sample). However this obscures that fact that many came back in response to pressure from others(Table 7): Expectation that the police would call

pt: I don't know .. I didn't really want to .. but I had come back I know.. .. because if I didn't come back .. they send the police ..don't they. (P61708)

Verbal pressure from friends and relations pt: not only because I didn't have no medication at home .. in fact I have got medication at home but not as much as .. not that much but it's not ..that's not the reason why .. the reason why is I came back here because my mother wanted me to and my sister wanted me to ..(P31902)

Lack of any alternative place to go int: so what made you decide to come back?

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pt: there's no where for me to go. (P10902)

Additional reasons for returning voluntarily are laid out in Table 7, and include feeling cold, hungry, unwell, in need of medication or of treatment for medication side effects. A further significant number are physically brought back to the ward by friends and relations.

int: how did you return to the ward? pt: by tube with my brother ..( ).(P11508) int: and you came back by yourself? pt: no ..my sister dropped me off here. (P12703) pt: yeah .. yeah .. all my family were going .. oh you're going to be in so much trouble for this .. and all this .. you know .. and I wasn't going to come back ..it's just that my sister came and got me last night .. I wasn't planning on coming back .. but my sister come and got me last night .. they see that I was bad .. my other sister .. and .. the ones that took me out and dropped me off at my mum's and they .. they just see that .. I ..they could see I was bad and they said come on come back to the hospital so they rung up the hospital and said don't have a go at him or anything .. you know .. and um .. brought me back ..(P20308)

Rather more rarely, the ward nursing staff themselves return a patient to hospital. This appears to happen when there is serious and urgent concern about the patients condition, or when the patient is spotted close to the hospital.

int: so you said you returned to the ward with staff ..staff brought you back .. pt: I was telling them I didn't want to come back ..they said no you've got to .. (P10811) int: so you ran out in the road and then what? pt: got caught. int: who did you get caught by? pt: the nurse. int: and then what happened? pt: they brought me back to the ward. (P60306)

Actions of the police in returning absconding patient seems to be very variable. Those occasions on which large numbers of police in riot gear arrived at patients' front doors were graphically described by interviewees.

pt: well .. the police brought me back .. I didn't recognise them at the time because I'd had the council come round .. because I'd put in a request for some repairs to be done .... you know it sounded like someone from the council . [......] ..come out and I opened the door .. I said what's going on .. they had crow bars .. there were all riot police with shields .. I said what's going on .. and they er said to me that um .. well HERE'S A WARRANT HERE ... not well you've run away from hospital and we've got to take you back there .. HERE'S A WARRANT HERE .. AND IT SAYS HERE LOOK AT THIS MR N ..: they had a video camera .. as well .. there was about

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.. twelve .. at least fourteen police out there .. twelve policemen .. with riot shields [.......].. so like I unlocked the door .. [......].. come out .. I said what's going on .. I said there's no need for all this .. and I said I haven't done anything to warrant this .. you know .. I thought to meself .. but like you know .. it was like a life and death .. situation you know .. something warranting that .. so I come out .. and er you know .. I don't know exactly what they said .. they just said stand in the corner like .. you know .. so .. put your arms up .. you know ..so I did that like that and then they .. they started holding me ..pulling me .. you know .. dragging me down on the floor .. and all that ..put me face on the floor .. pushing it like that .. and sort of all that treatment .. so I thought there's no use struggling .. but .. they can really hurt you .. like you know and I thought .. like you know ...I've got to say something anyway because if they don't .. they just give you more you know ... apply pressure on you cause they put handcuffs on and they weren't the loose .. you know loose with the chain .. they were stuck like that .. and er they put them on really tight .. and they was bending me arms like that .. so .. actually I had big swellings on there ..[.......] .. and they brought me to hospital .. (P21306) pt: the police came ... I was having sex with my girlfriend in bed .. having sexual intercourse and .. I shouldn't be telling you this really should I .. I was having sex .. and a police officer came to the door and said I'm PC C from S N police station .. can you open the door please .. int: so you opened the door and the police were there .. how many police were there? pt: twenty officers. int: twenty officers?! that's a lot of police? pt: four police cars and two vans .. int: you said it was int he middle of the night .. what time was pt: three o'clock in the morning. (P60411)

By contrast, on other occasions patients seem to have used the police more like a taxi service.

pt: they .. cause my brother came round .. and said to me that I had to go back to the hospital .. and I said that I wasn't going back .. so he said to me .. I had to go back .. so I said all right then .. so I just waited and then called the police .. so the police came round and got me .. and brought me back to the hospital .. and stuck me in the hospital again .. (P21706)

Mostly returns by the police were relatively sedate affairs where the sight of the officers in uniform, plus a few words of conversation, persuaded the patient to return peacefully. However it should be borne in mind that even two police officers carry the implicit threat of force if co-operation is not forthcoming.

int: so you left .. how did you feel when the police turned up at your place to bring you back? pt: I felt threatened but felt ..but then they started talking to me .. and they just willingly brought me back. int: how many police were there? pt: two... there might have been three at one stage .. no there was two.(P52507)

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Tables 2 and 3 show that male involuntary patients are those who are returned by the police. It would appear that such patients are viewed as particularly dangerous and uncooperative. Table 3 appears to show that two informal patients were returned by the police, however close inspection of the interview responses of these patients shows that general practitioners and social workers were in attendance. It therefore seems likely that the patients were being compulsorily detained for the first time, after leaving the ward whilst still informal. Differences between Trusts Table 1 examines any potential differences between the three NHS Trusts in the study with respect to leaving and returning. From the data collected in this study these appear to be minimal. There is little apparent difference in method of leaving, destination, activity, or method of return. Each Trust appears to be equally well supported by the police. However when the larger numbers of the quantitative data set are examined, some differences do emerge. As the following table shows, Trust E has higher levels of absconders while patients are off the ward, as compared to the other two Trusts. Trust S has the lowest number, with nearly all absconders leaving from the ward (p < 0.001 by chi square test). This may reflect more risk taking in Trust E.

163 168 78 409

76.9% 82.8% 94.0% 82.1%

11 1 12

5.2% .5% 2.4%

28 30 2 60

13.2% 14.8% 2.4% 12.0%

10 4 3 17

4.7% 2.0% 3.6% 3.4%

212 203 83 498

100.0% 100.0% 100.0% 100.0%

Count% withinNHS TrustCount% withinNHS TrustCount% withinNHS TrustCount% withinNHS TrustCount% withinNHS Trust

Ward

Temp. offward(escorted)Temp. offward

Failed toreturn fromleave

Place ofabscondingepisode

Total

E O SNHS Trust

Total

Place of absconding episode * NHS Trust Crosstabulation

Trust E also has the lowest rate of absconding patient return by the police (8% of absconders, versus 17.2% in Trust O and 16.9% in Trust S, p = 0.001 by chi square test). Police were no less likely to be informed about an absconding patient in Trust E. However Trust E absconders were no more likely to have risk to others noted in their care plan. Instead dramatically higher levels of risk to others were noted in Trust O care plans (55% of care plans, versus 10% in Trust E and 16% in Trust S, p < 0.001 by chi square). Trust O also uses a higher number of Treatment sections (as opposed to Assessment sections) of the Mental Health Act when admitting patients who subsequently abscond. Absconding patients in Trust O are also much more likely to be placed on intermittent nursing observations in the 24 hours preceding the event (34%

53

of absconders, versus 1.8% in Trust E and nil in Trust S, p < 0.001 by chi square). Risk to self is identified much less frequently among absconders from Trust S, and Trust E absconders were more likely to have a history of suicide attempts (26% of absconders, versus 15% in Trusts O and S, p = 0.013 by chi square test). There is no difference between Trusts in the proportion of absconding patients with a forensic history of any kind. The pattern of negative outcomes of absconding incidents by Trusts is complex and the full table is presented below. It would appear that harmful outcomes are slightly more common in Trust O, and that drug use during an absconding episode is less likely in Trust S. This cross tabulation is significant by chi square test (p = 0.002), however eleven of the cells have frequencies of less than five, making the result problematic.

192 173 76 441

90.6% 85.2% 91.6% 88.6%

3 6 3 12

1.4% 3.0% 3.6% 2.4%

2 6 8

.9% 3.0% 1.6%

1 3 4

.5% 1.5% .8%

3 3

3.6% .6%

14 15 1 30

6.6% 7.4% 1.2% 6.0%

212 203 83 498

100.0% 100.0% 100.0% 100.0%

Count% withinNHS TrustCount% withinNHS TrustCount% withinNHS TrustCount% withinNHS TrustCount% withinNHS TrustCount% withinNHS TrustCount% withinNHS Trust

None

Harm toself

Harm toothers

Propertydamage

Other

Drug use

Riskoutcome

Total

E O SNHS Trust

Total

Risk outcome * NHS Trust Crosstabulation

The pattern of ward security status between Trusts is also complex. Ward security status was only logged in this study at the time an abscond occurred. Thus only the ineffective application of security measures has been recorded. Those occasions on which such measures were successful were not identified in this study. The following table shows that Trust O is marginally more likely to have the door locked at the time of an abscond, however Trust S is much more likely than the others to have a nurse stationed at the ward door (a so called 'door stop') to prevent unauthorised departures by patients (p < 0.001 by chi square). These figures may indicate that the use of 'door stops' is not an effective strategy to prevent absconds, as 52% of absconders in Trust S managed to avoid them.

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2 10 12

.9% 4.9% 2.4%

1 5 43 49

.5% 2.5% 51.8% 9.8%

209 188 40 437

98.6% 92.6% 48.2% 87.8%

212 203 83 498

100.0% 100.0% 100.0% 100.0%

Count% withinNHS TrustCount% withinNHS TrustCount% withinNHS TrustCount% withinNHS Trust

Locked

Door stop

Open

Securitystatus of ward

Total

E O SNHS Trust

Total

Security status of ward * NHS Trust Crosstabulation

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Table 1: Methods by Trust trust method of leaving destination activity method of return

E

13 walked off ward 6 failed to return from agreed time out 1 ran out 1 was angry and told staff when left

12 went home 5 visited friends 1 visited family 1 went to the pub 3 wandered the streets

17 took part in normal life activities 2 also smoked cannabis 3 wandered the streets 2 made suicide attempts

5 with police 12 of their volition 1 with ward staff 3 with relatives and friends 1 unknown

O

13 walked off ward 4 ran out 1 was angry and told staff when left 1 failed to return from agreed time out 1 walked away from their escort 1 made an excuse to leave the ward and then left 1 failed to return from leave 1 left via the fire exit

10 went home 2 wandered the streets 1 delivered flowers to a woman he had been accused of stalking 1 went to the social club 2 went out with friends 1 went shopping 6 visited friends 2 visited family 1 ran out in the road 1 went for a walk

24 took part in normal life activities 4 also smoked cannabis 1 delivered flowers 2 wandered the streets 1 sorted out burgled house 1 ran out in road

11 of their own volition 5with police 1 with police and ambulance 5 with relatives and friends 1 with ward staff

S

7 walked off ward 1 failed to return from leave

4 went home 1 went for a walk 1 visited the pub 2 visited friends 1 visited family

9 took part in normal life activities 1 also smoked cannabis

7 of their own volition 1 with police 1 with police and social worker and ambulance

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Table 2: Method by gender methods place activity method of returning males * 2 failed to return from leave

* 6 were out unescorted for agreed short periods of time * one was with a nursing escort for a walk in the grounds * 1 made an excuse to leave the ward temporarily and then absconded * 1 left via the fire exit * 5 ran out the main door * 26 simply walked out

* 21 went home * 16 visited friends * 3 went to the pub * 3 visited family * 1 went shopping * 4 wandered the streets

* 37 were undertaking ‘normal life’ activities * 7 of these smoked cannabis * 1 attempted to visit a woman he had been accused (and sectioned) for stalking * 3 simply wandered the streets * 1 sorted out his flat that had been burgled

* 11 were returned by police * 20 returned of their own volition * 1 returned with their social worker * 2 were returned by ambulance * 8 returned with relatives or friends

females

* 1 was out unescorted for an agreed short period of time * 7 simply walked out * 2 informed staff they were leaving while angry and were considered awol after days had elapsed. * 2 ran out of the ward

* 8 went home (1 not before she’d done a trip to Manchester!) * 1 visited friends * 1 went for a stroll * 1 ran out in the street and was caught by staff in the street and brought back.

* 6 undertook ‘normal life’ activities * 2 made suicide attempts * 1 went for a stroll * 1 visited home to collect an awaited letter * 1 ran out in road

* 1 returned with police * 7 came back of their own volition * 1 returned with friends * 2 returned with ward staff

‘normal life’ activities include going home to do housework, visiting friends, going to the pub, sex, decorating, etc.

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Table 3: Method by Mental Health Act status mha status method of leaving destination activity method of return informal 9 walked off the ward

7 asked to leave the ward for a short period of time 1 made an excuse to leave the ward and then absconded 1 left via the fire escape 1 was angry and informed staff she was leaving

6 went home 6 visited friends 3 visited family 2 went to the pub 2 wandered the streets

15 took part in normal life activities 3 also smoked cannabis 2 wandered the streets 1 spent time sorting out their home which had been burgled 1 made a suicide attempt

11 of own volition 6 with relatives and friends 1 with police and ambulance 1 with police/sw and ambulance 1 with police 1 unknown

involuntary 21 walked off the ward 6 ran out 2 asked to leave the ward for a short period of time 2 failed to return from leave 1 was angry and informed staff she was leaving

17 went home 5 visited friends 2 visited family 3 wandered the streets 2 went for a walk 1 went met up with friends and went out with them 1 went to the social club 1 delivered flowers to a woman he had been accused of stalking 1 ran out in the road.

26 took part in normal life activities 4 also smoked cannabis 1 delivered flowers to a woman he had been accused of stalking 1 ran out in the road 3 wandered the streets (1 thinking about committing suicide) 1 made a suicide attempt

21 of own volition 9 with police 4 with relatives and friends 2 with ward staff

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Table 4: Method by diagnosis diagnosis method of leaving destination activity method of return schizophrenia 23 walked off the ward

5 ran out 3 failed to return from agreed time out 2 failed to return from leave 1 made excuse to leave ward 1 left via the fire exit

13 went home 2 wandered the streets 11 visited friends 2 went to the pub 1 went shopping 3 visited family 1 went for a walk 1 delivered flowers

14 took part in normal life activities 2 also smoked cannabis 2 wandered the streets 1 delivered flowers 1 sorted burgled flat

22 of own volition 6 with police 1 with police, sw, and ambulance 1 with police and ambulance 2 with relatives and friends 1 unknown

other 10 walked off the ward 3 ran out 5 failed to return from agreed time out 1 walked away from escort 2 informed staff angrily that they were leaving

10 went home 1 went to the pub 1 went for a walk 3 wandered the streets 5 visited friends 1 ran out in the road

16 took part in normal life activities 4 also smoked cannabis 3 wandered the streets 1 ran out in road 2 made suicide attempts

16 of own volition 4 with police 2 with ward staff 1 with relatives and friends

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Table 5: Method by age group age method of leaving destination activity method of return under 35 23 walked off ward

6 failed to return from agreed time out 5 ran out 1 walked away from escort 1 failed to return from leave

12 went home 1 went to the pub 12 visited friends 1 went shopping 3 wandered the streets 1 ran out in road 1 visited family

31 took part in normal life activities 3 also smoked cannabis 3 wandered the streets 1 sorted out burgled flat 1 ran out in road

24 of own volition 8 with police 5 with relatives 1 with ward staff 1 unknown

over 35 13 walked off ward 3 failed to return from agreed time out 2 ran out 1 failed to return from leave 1 made an excuse to leave ward 2 angrily informed staff they were leaving 1 left via the fire exit

11 went home 2 went to the pub 3 visited friends 3 wandered the streets 1 visited family 1 delivered flowers 2 went for a walk

12 took part in normal life 2 also smoked 3 wandered the streets 2 made suicide attempts 1 delivered flowers

18 of own volition 1 with police 1 with police, sw, ambulance 1 with police and ambulance 2 with relatives and friends

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Table 6: Returning to the ward

Method of return Police Ambulance SW/CPN Friend/relative Ward staff Of own accord

How it happened

12 interviewees had been returned by the police Full riot squad of 12 policemen with shields arrived at door, another reports 20 policemen arriving at his flat at 3 a.m. Others report 2-4 policemen calling round Most are picked up from their home address Some feel threatened or frightened by the police, a few are restrained or handcuffed, most come quietly 1 Rang the police and they took him back 1 Taken by the police while on the streets

2 interviewees were returned by ambulance On one of these occasions the police also attended

These professionals occasionally attend with the police. In the patients view they do not appear to play a significant role, but their presence is noted

9 interviewees mention that relatives and/or friends played a role in their return Usually they accompany the patient all the way back to the ward

2 interviewees were brought back by ward staff One appears to have been followed into the street outside the hospital and forcibly returned In the other case staff interrupted and prevented a suicide attempt by calling at the patients home

3 Walked back 7 Came back by public transport Sometimes patients returned by themselves after the ward staff ring them at home, one returned in a cab ordered by the ward 2 returned once they knew the police had been officially notified about the absence Occasionally relatives or friends persuade the patient to return by themselves Sometimes patients ring the ward staff to let them know they are returning

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Table 7: Reasons for return - those patients who came back voluntarily (or semi voluntarily with relatives) Relatives and friends use a lot of verbal pressure in order to persuade the patient to return "int: right .. your brother talked you into coming back? pt: yeah .. it took a long time to convince me" To give the Dr another chance 2 To get medication to relieve side effects Cold Hunger Not wanting to get the nurses into trouble Not wanting to get relatives into trouble 2 To avoid being picked up by the police 2 returned for a CPA meeting 4 Nowhere else to go 2 Only wanted to be out for a little while, knew they would have to return To get medication for symptoms Threat of physical violence from relative 3 feeling unwell and in need of care 2 To get discharged, or discharge in view and not "wanting to ruin things" End of activity they had left for, e.g. "int: what made you decide to suddenly come back? pt: the football match had finished." Nothing to do at home

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Findings 5

Life on the ward and reasons for leaving Why did absconders leave the ward? Tables 1 - 5 summarise the reasons patients gave for absconding from the ward in some detail. The main reason for leaving without permission could not always be elicited during the interview, and for some, the main reason was linked to psychotic thinking or symptomatology. More details on this are provided below. However for most interviewees, the main reasons for absconding were very diverse, ranging from medication side effects to wishing to see relatives. No one main reason for leaving predominates over others, with some patients leaving because they feel well, others to drink alcohol, other because they are angry about a care decision, and yet others because they feel neglected by staff. In addition, it was quite clear from the interviews that most patients had more than a single reason for absconding from the ward. Their main reason or trigger for leaving was set against a background of discontent with their social situation as a patient on an acute psychiatric ward, the treatment they were receiving, or negative relationships with professional staff. These themes are explored in more detail below. Angry leavers Using the interview data, a distinction can be made between those absconders who angrily leave (AL) from the ward, and those who are going to (GT) some other place or activity. This division is not neat and tidy in every case. For example 'going to' something can be done angrily, especially if a request to leave the ward to do something in particular is refused by the staff. For example, one lady wished to visit the grave of a close relative at the local cemetery, and when the request was refused, she left the ward very angrily. Another example would be the equivalency between 'angrily leaving' the ward to get away from stuffiness, or 'going to' fresh air. Nevertheless, it was possible to draw a distinction for over half the cases fairly easily. The findings from this analysis are summarised in Tables 3 and 4. Just over one in four of absconders fell clearly into the category of being an angry leaver. Immediate triggers for leaving angrily were refused requests for leave:

pt: they said they were going to give me some leave and they didn't give me any leave .. and I was better so I just left and I came back after a few days. (P21706) pt: and the next day I found out I wasn't entitled to no leave .. so I absconded .. I walked out and came back ..(P62301)

Refused requests for discharge:

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pt: the night before ..I didn't sleep at all ....because of my tribunal and er ...my tribunal wasn't successful ..that's why I left ...left the ward without saying anything to anybody well I got my letter from the tribunal saying you know on the face of the envelope saying and when I looked at it ..it said cannot be discharged yeah ....so I felt very angry ...and then I just left the ward ...basically then I just ran away ...because I know if somebody wants to catch me then they can yeah ..then I took a black cab to my home... (P12703) pt: no. I had no intention of leaving the ward ..I just felt like yesterday ..the reason why I left yesterday is because I was taken for a FOOL you know ..getting all prepared ..getting all dressed up ..in the end he didn't have no intentions of letting me go. (P11508)

And a variety of other frustrations and arguments. However, as Table 3 shows, not every angry leaver had an immediate prompt for their absconding. many left angrily on the basis of long term dissatisfaction with being a psychiatric patient. Restrictions on the patients freedom, unhappiness with enforced treatment, or feeling well and yet still being in hospital, were all sources of frustration and anger for patients.

pt: I'm not a prisoner! I come here for help yeah ..if I go out I need help .. I will come back .. I'm the one who come first place .. nobody brought me here .. do you understand? int: yes .. nobody brought you here .. you came here .. pt: on my own .. (P21704) pt: I felt much better .. I've been better for a long time now and they still keep me in hospital. (P21706) pt: yeah .. I came in of my own free will darlin' .. and the way I got treated in X ward ..was DISGUSTING! Wouldn't anybody go apeshit if they all surrounded you saying you should take this .. you should take that and you should do this .. HOW DO THEY KNOW WHAT THESE DRUGS DO TO PEOPLE UNLESS YOU TAKE 'EM YOURSELF! (P22003)

In contrast to the angry leavers, those who left the ward to 'go to' something had more longer term reasons for doing so. In fact only 3 of the 18 patients (29% of the total number of absconding events) who fell into this category had any immediate trigger for leaving, and for two of these the trigger was sight of the open door and an opportunity to abscond. The GTs left primarily for social interaction with friends and relatives, and to look after their household and family responsibilities. Table 4 shows the proportion of ALs to GTs by gender, Mental Health Act status, age, ethnicity, diagnosis, and NHS Trust. No clear pattern can be seen, and no chi square test was significant. None of these variables appear to be related to whether an absconder leaves the ward in anger or not.

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Planned versus impulsive leavers Table 7 contrasts those who plan to leave with those who leave suddenly and impulsively. Numbers in this table are incomplete because not every interview provided enough information about the abscond in order to determine exactly what occurred. However it is clear from this table that such sudden absconds are more common amongst those who are involuntarily detained in hospital. For these patients the presentation of a visible opportunity to leave, or receiving some bad news about leave or restrictions, can result in sudden and immediate action. It is also apparent in the table that involuntarily detained patients are much less happy to be back on the ward. Instead they are angry about their return and vigorously express the feeling that they would rather be at home.

int: right .. how do you feel about being back in hospital now? pt: I feel bad .. I want to go home (P21706) pt: no .. I want to leave as soon as possible. (P22306) pt: angry.. I don't like it at all. (P60306)

Psychiatric symptoms as triggers for absconding

34% of those interviewed had 'mental state' reasons for absconding. This is likely to underrepresent the numbers for whom this was a contributory cause to absconding, because some absconders (13%) were too disturbed be readily interviewed upon their return to the ward. Patients' mental state as a reason for absconding is therefore likely to be more important and prevalent than the interview data alone suggests.

Table 5 examines in more detail the 34% or 18 patients interviewed whose mental state contributed to their absconding. A small number of these patients could not give a clear account of their abscond or its reasons, and in one or two cases interviews were terminated prematurely because it was clear that patients were not in a fit state to give informed consent or to be interviewed at all. It can be seen from the table that a wide variety of psychiatric symptoms can lead to absconding. The most obvious of these are command hallucinations (voices telling the patient to abscond) or paranoid delusions that compel the patient to run away in order to seek safety. Anxiety, worry and restlessness also propel patients into leaving the ward without permission. Thought disorder or disorganised thinking might contribute to absconding decisions through confusion or inability to understand or comprehend one's predicament. However what is also apparent from table 5 is that psychiatric symptoms do not, by themselves, fully explain absconding. Not even for this group of patients. Instead it can be seen that all the reasons described below also contribute to the absconding of the acutely ill. These are normal, everyday, sensible and understandable reasons for wanting to leave a psychiatric ward without permission. The way that these can work together with psychiatric symptoms is illustrated by one interviewee:

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int: do you ever get frightened here? pt: yeah .. when a new patient comes in. int: what is it that frightens you exactly. pt: when they grab you .. it frightens me. int: have you been attacked before? pt: well ( ) just grabbed hold of my arms and wouldn't let me go .. that's the day I went missing. int: and how did he end up letting go of you? pt: because I struggled and got free. int: was there anybody around to see the incident? pt: no there wasn't .. they were all in the office. int: what happened immediately after you got free.. what did you do? pt: told a member of staff .. and then I come in here [own room] .. and got ready and just went out. int: what exactly made you want to leave? pt: that and the voices .. what I've got in my head. (P40211)

Life as an inpatient on acute psychiatric wards Returning to Tables 1 and 2, and looking also at Table 6, absconding patients feelings about being inpatients on an acute psychiatric ward are explored. Neither the social stigma of being a psychiatric patient, nor the ward environment appear to be areas of prime concern for absconding patients. Few remarked upon these issues at all, although the Trust with the oldest buildings does attract most of the criticism about the ward environments. Neither are patients concerned about the fact that they are under surveillance by nurses at all times while on the ward. What they do express great concern about are: being frightened of others; being cut off from family and friends; being unable to deal with their everyday responsibilities; being bored; and feeling trapped and claustrophobic. This is what being an inpatient meant to the sample of interviewed absconders. Many interviewees (42%) expressed feelings of fear. Some of this fear was related to psychiatric symptomatology, most was not. Patients were fearful of the whole experience of being in hospital, sometimes fearful of the staff, but mostly afraid of other patients. What a frightening place an acute psychiatric ward can be, even without any actual violence, is vividly conveyed by the story of one absconder:

pt: the patient .. A with the night staff argued all the way round to my bed .. and I had the cover of my bed ..I slung the cover off my bed because it shocked me .. this was about three four in the morning .. and I got woken up .. middle of the night .. three o'clock and I wondered what it was .. and I heard two people shouting .. a girl and .. a male and a female voice .. and I found out afterwards it was one of the patients and one of the night staff .. they were arguing for some reason int: is your bedspace quite far from this lady's bedspace? pt: yes it is .. int: ok .. so then that morning .. what were you thinking that morning? pt: well I was terrified .. I couldn't go back to sleep afterwards and I was depressed over it .. didn't get enough sleep .. and I just wanted to go home .. after that ..

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int: were you frightened that you were going to be harmed? pt: yeah .. in a way I thought I was going to be harmed .. that's the reaction it brought on in me .. I got very frightened .. and fidgety .. started shaking .. and I had to make meself a cup of tea to calm me down .. horlicks I mean .. (P30303)

It is easy to imagine the degree of shock involved in being woken in this way in the setting of an acute psychiatric ward. Patients fears about each other are quite ubiquitous.

pt: there is this patient I was bit scared of him .. I don't know .. at first I sort of had a crush on him and then it sort of turned into sort of like and obsession or something .. and I always thought that he was going to come and knock on my door and maybe try and do something and I used to tell the staff that and they thought no it's not going to happen (P52009) pt: the new bloke just arrived and he just sort of grabbed my two arms and he wouldn't let go .. I was just frightened of him. int: was he angry? pt: yeah .. so I just left the ward. (P40211)

Any disturbance on the ward can raise a patients level of anxiety and fear, even if they are not involved. Events at night seem to elicit particularly strong feelings of vulnerability. 26% of absconding patients mentioned feeling isolated from friends and family, and 42% felt homesick. Not all absconders had these feelings. Some were visited very frequently, and yet others did not desire any contact with their family. However for those that wanted more contact and did not get it, being in the acute psychiatric ward could be a lonely experience. Hence most absconders went home or to family and friends on leaving the ward, and many gave social contact as a reason for leaving the ward.

pt: that's right .. the thing is if I'm not at home I feel that my younger brothers and sisters .. they feel ill .. there's something done in the face .. or something like that you see .. if I'm not home. (P21809) pt: yeah .. I just left to go round and see family .. (P42804)

The patients home (when they had one) was a source of worry and

preoccupation for absconding patients. This and other everyday responsibilities created reasons for patients to need to leave the ward without permission. Thus some patients left the ward to obtain personal property from home, others left to deal with unpaid bills, keep the home clean, or just to check on the house in case of burglary.

I: right so all the time that you're in here you're aware that it's.. pt: ..empty ..yeah. I: do you worry about that? pt: they can't get much ..all they can get is the television. I: so it's not something that particularly bothers you?

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pt: well ..I wouldn't like to lose my television ..but that's all they can get...it is pretty safe there really because we've got intercoms and a locked door so they have to buzz but if anybody was smashing my window or that next door would come out ...cause they're old ladies and they keep an eye out ... (P10811)

Indeed, patients are quite right to worry about the security of their house and property while they are in hospital.

int: so how do you feel about being back in hospital now? pt: terrible. int: in what way? pt: my house is burgled .. I have nothing left when I go back .. if I wasn't here nothing would have happened to my house ..simple as that. int: do you feel angry about that? pt: I feel very angry. int: who do you feel angry with? pt: with myself. int: what about with the staff here .. the doctors .. nurses? pt: everybody ..everybody. (P51510)

Other patients worry more about their responsibilities to others, with children and elderly relatives both being mentioned as in need of care and attention from the patient.

pt: yeah .. I worry about my kids .. and my mum and dad .. just keep worrying. (P42912)

On top of these worries about events and people within hospital, and social networks and other responsibilities outside hospital, absconding patients also found being on the ward a very boring experience. 42% talked about feeling bored.

int: do you feel more tired when you're back on the ward or do you sleep..? pt: ..to pass the time? int: yeah .. pt: to pass the time. (P10902) pt: well as far as I'm concerned there's not much to do .. you just end up smoking ..walking up and down . (P31912) pt: like I just keep on doing .. I don't get that really frightened .. I just get bored .. I just keep thinking about what might happen next cause I'm always too bored .. it's like I'm locked up in a prison .. (P21706)

This latter interviewee links feelings of being bored with feeling locked up. 58% of the interviewees mentioned similar feelings.

pt: n...well sometimes I get the claustrophobic feeling .. (P10902) int: was there any particular reason you wanted to go to your flat? pt: yes.

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int: and what was that? pt: to get away from these walls? int: so you didn't want to be on the ward itself? pt: they lock you in. (P60411) pt: I had no leave and they took my leave away .. I just felt very trapped ..confined .. just had to get out of .. off the ward. (P60308)

Treatment Many absconders were seasoned inpatients, having had a series of previous admissions. Table 8 shows that their expectations of inpatient hospital care were modest and realistic, with the most frequently anticipated form of treatment being medication.

int: so what kind of thing were you expecting when you came here? pt: basically treatment. int: what sort of treatment? pt: medicine. (P20605)

Opinions about the medication actually received in hospital were divided and predominantly negative, as shown in tables 13 and 14. Medication was seen as not required at all due to feeling well, the wrong type, not as good as what had previously been prescribed on other occasions, producing unwanted side effects, given in too high or too low a dose, or given by injection when it should be oral, or in syrup when it should be tablets. In fact there was a great deal of negative talk about medication in the interviews of absconding patients. Disagreements about medication can be reasons for patient to abscond.

pt: well .. they went apeshit! the lot of people .. the lot of them went apeshit! they all wanted to give me an injection .. cause I wouldn't take it orally .. they're not allowed to enforce people ..to fucking take medication like that darlin'! REGARDLESS OF THEIR BEHAVIOUR darlin'! People going up to people like that have got every fucking right to complain! (P22003)

However the recognised need for medication can also be a reason to return: int: so you were at home and then what made you decide to come back to the ward? pt: I don't know .. I just wanted some medication so the voices would go. (P40211)

Table 14 shows that views about medication were equally as negative, whether the patients were compulsorily detained or not. Some absconders were positive about their medication regimen, most were not and were full of a variety of complaints about it.

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Absconding patients views about doctors and nurses In parallel with their predominantly negative views about medication, doctors and nurses were harshly judged by the absconders (see tables 9 - 12). Doctors were seen as distant, disbelieving of patient reports, authoritarian, inaccessible and not having sufficient time to listen to patients' problems. Involuntary patients who absconded had more extremely negative attitudes towards doctors. These were linked to the doctors actions under the Mental Health Act, and to medication related issues. Just as some absconders were positive about about medication and doctors, some were also positive about nurses, commenting favourably on their availability and friendliness. However again the dominant view was negative. They were seen as powerless in comparison to doctors, bossy, and unwilling to spend time with patients. The role in enforcing medication was particularly disliked. In the case of nurses, Mental Health Act status did not seem to influence absconder views (table 12). It should be emphasised that some absconders did hold positive opinions about nurses, doctors and medication. However, these positive views were held in relatively smaller numbers. Additionally, these views are not representative of patients as a whole, only of the absconders. Feeling well and feeling ill

Three themes could be identified in the interviews which described conflicts between the interviewees and both medical and nursing staff over differing perceptions of ‘wellness’. The first theme is a scenario that’s probably familiar to most psychiatric nurses. The patient is saying they are well, the staff disagree.

‘I don’t feel ill anymore .. there’s no need for me to be in hospital at the moment .. the main problem has disappeared .. I've been high .. and now I’m coming back to my stability .. the doctors can’t see that I thought to myself .. I just felt within myself I couldn’t cope with being here any more .. it was making me feel too down.’

Twenty three of the fifty two people interviewed fell into this category. The majority of whom agreed that at some point during the course of their stay in hospital they had felt mentally unwell. Even those admitted under section were not querying whether they had been unwell, but rather whether they were ill enough to warrant an admission to hospital. Eleven had come into hospital voluntarily and seven of these were later detained under the mental health act. Out of the twenty three, having to remain in hospital even though they believed themselves to be well was not particularly an issue for about ten people. They appeared to accept that this is what staff thought would be the best thing and were content to wait to be discharged, albeit they were expecting to be discharged fairly soon. However, for the rest being detained in hospital against their will when they felt well enough to go home was proving to be a major source of conflict with the staff.

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The quote below is typical in that most described an improvement in their mental state during the course of their stay, but talked about a prolonged stay in hospital as being detrimental in that it exacerbated their sense of isolation, most of the interviewees had less contact with family and friends while in hospital, and also increased their concern over issues in their life outside the hospital, such as accommodation and relationships.

‘I’ve made it quite clear to the staff the situation I’m in .. they’ve seen me communicate with people well .. they’ve seen me take action while under pressure .. they’ve seen violence against me and I’ve done the appropriate thing.’

This group were, on the whole, angry at their treatment by the psychiatric system. Those admitted informally described the process whereby they had been able to identify when they were becoming unwell and had sought help voluntarily. At this point, their judgment about their mental state was seen as accurate and therefore valid and a stay in hospital was suggested, to which most readily agreed, having already anticipated this as a probability when they made contact with the services.

However, once admitted, things alter and in particular the perception of the patient’s ability to judge their own mental health changes. At some time it is decided that they are no longer fit to assess themselves and their judgment is now perceived as incorrect and therefore invalid. From the point of view of these interviewees the consequences of initiating contact with the services and agreeing to a stay in hospital were profound. Having acknowledged that they required some sort of help, most later found themselves detained against their will with all the treatment necessities and restrictions that a section incurs. What came across in the interviews was a strong sense of not being valued, of feeling betrayed, of being up against the system, and consequently of feeling trapped while in hospital and, as in this quote, not knowing what to do to convince staff that they were well enough to go home.

The second theme was much less common but has potentially serious consequences. It is simply the reverse of the first scenario. That is to say the staff think the patient is well enough to go home but the patient disagrees, believing they need to stay in hospital.

‘well I can’t be discharged .. because I’m not well enough .. I realise that now .. see I was going out and testing meself .. I wanted to test meself to see what I’d be like .. I want to get out of this whole regime but I can’t because ’m not well enough .. but I go out and I test meself to see if I can do and then I fall apart.’

The patients in this group had also sought help voluntarily and agreed to be admitted to hospital. At first sight, it seems paradoxical that they should be in my sample since by definition if you wanted to remain in hospital then how could you hope to achieve this by absconding? Women in particular would be much less likely to achieve their desired outcome of an extended stay because, if you’re a woman and you go awol chances are you’ll be discharged or placed on leave in your absence.

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However, as can be seen from the quote, absconding from the ward and the events during the abscond can be acts designed to demonstrate just how unwell the patient believes they are. To be told you are well enough to go home when you see yourself as unwell, is taken as a rejection. These interviewees described not being believed by staff and the response to this was to abscond and partake in self-destructive behaviour. An awareness was shown that their behaviour was seen as ‘attention seeking’ but deny this was the case. They talked about their conduct as actions not primarily aimed at eliciting a response from the team (not least because the team response would not necessarily be the preferred one), but rather as a response to how they are feeling at the time.

‘Only today, being told that I don’t suffer with deep depression .. I suffer with binge drinking .. which is a load of rubbish .. I suffer with depression .. I said to the doctor you don’t know me .. you don’t know how I feel .. how can you judge me .. he don’t don’t know how I feel inside .. I said it’s like being in a black pit and trying to climb out of it .. he was meaning to be hard.’

This quote is from a patient who was back on the ward having absconded and taken an overdose after being told by her doctor that she was not clinically depressed and was therefore ready to be sent home on leave. It seems that at least in some instances, the very fact that you can identify and talk about your problem is considered proof that you do not require professional intervention, and that in fact staff fear such intervention serves only a negative purpose in that it condones and encourages the patient to see themselves as ill when this is in direct conflict with what staff believe. Indeed, this woman was told by a member of the team that a sure sign she wasn’t really suicidal was that she could talk about it rather than just getting on with it.

On initially making contact with the mental health services, presumably these people were taken seriously when they communicated their problems since they were admitted to hospital. However, in common with those quoted in the first theme, they related the view that once in hospital, the ability to judge their own mental state was seen as irrelevant. Both medical and to a lesser extent nursing staff, were perceived as setting themselves up not simply as experts on mental illness, but also as experts on the subjective experience of the illness. The result was that the patients believed their opinions were being trivialised and hence their experiences invalidated.

A third theme was also identified in which people were saying they knew they were ill or had been ill, they knew the staff also perceived them as being ill, but the conflict arose over the way the way the problem was being defined.

‘I was able to tell the nursing staff .. but it would be the same thing ..sort of question they’d ask me .. is the television talking to you ..can you hear your name on the radio .. I’d be telling them no .. it’s nothing like that you know .. it’s just .. I know it’s my mind ..it’s just not intact you know .. but they all ask the same sort of questions .. all of them.’

Most people talked about their illness in terms of it affecting their ability to function on a day to day basis, so that being able to cope became a central means of defining their state of mind. They talked about trying to communicate with staff about how

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they were feeling but, like the patient quoted here, described being met with responses which focused on symptomatology. They felt they were not being listened to, or acknowledged, and were being asked questions which held no relevance for them. This led to feelings of deep frustration and anger, and a belief that they had little say in their own treatment since both medical and nursing staff had already made up their minds about what the problem was and how it should be addresses. Of course, many will say that the reason staff focus on the symptomatology is that treating the symptoms will enable the patient to cope. However, for those people who may have shown typical symptoms on previous admissions but don’t on this occasion, or who don’t consider their symptoms to be a primary problem or even a problem at all, the issue is more complicated. As one man said ‘I only hear voices they don’t disturb me.’

‘my main problem is I’ve got mental disorder .. and I know that I’ve got it .. cause I know that I’ve got mental illness .. I can feel it in my brain .. every time it hurts .. like I get afraid of people cause of it .. I keep getting ill .. so I come back to the hospital to take my medication.’

The interviewee quoted here described being in a state of perpetual fear when he is unwell. A number of people in this sample talked about ongoing anxiety/fear as core feelings of their ‘unwellness’, which they mostly did not relate to hearing voices or other obvious symptomatology. Their anxiety was often exacerbated by having to keep quiet about it for fear of the consequences. Trusting staff was seen as too risky. These patients claim that experience has taught them to limit what they reveal to staff. Experience which includes having leave denied, being detained further in hospital, or having medication increased or administered forcefully. The result is a situation where patients are desperate for help but at the same time are terrified of the help they may receive. Many in of this group, including the person quoted, complained about their medication and were seen as non-compliant. However, most appeared to want some form of medication, just not the particular drugs they were on at the time, which they felt offered them no relief from their state of mind.

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Table 1:Reasons for leaving by NHS Trust - I Trust Main reasons Stigma The ward environment Other patients

E

Akathisia Angry at delayed access to Dr Angry at refused leave Attacked by fellow patient Feel well Feeling neglected by staff 2 Homesick 2 Housework No clear reason elicited 3

Obtain money, finance 2 Psychotic reasoning 2 See relatives, missing them 2 Self hamr Speak to wife To avoid taking medication Told by solicitor by phone that he was free to leave Trapped, locked in

Mentioned by 3 "I don't want people to think I'm mad anymore" " there are things that happen when I'm ill .. for instance you know the way I behave ..and neighbours the things that they see that I do .. and they don't understand that it's because I'm sick"

Noise: snoring disturbs sleep, ward front door bell Not being allowed to smoke cannabis

Unwelcome physical contact from other patients Fear of new patients who are unpredictable Assaults, fear of assaults The freedom of an open ward evokes fear of what might happen

O

Angry at enforced medication Angry at refused discharge 2 Angry at refused leave 2 Angry at restricted leave Bored Couldn't wait for official leave arrangements to happen Drink Drs don't understand my problem Feeling neglected by staff Feelwell

Finance/housework Homesick 2 No clear reason elicited Other patients disturbing 2 Psychotic reasoning 2 See girlfriend before transfer to locked ward Visit relatives/friends 2 Went to check on house and found it had been burgled

Mentioned by 1 " I don't want her to know I'm here...... she might think I'm crazy. int: so she has no knowledge that you've ever been in a psychiatric hospital? pt: no.. she thinks I'm living in Ireland"

Lack of freedom to make snacks and beverages when desired " the food's lousy" Lack of privacy: " this ain't even private .. it's my room ..[gestures to noise from adjoining room]" Institutional: " it's not a warm or comfortable environment.. it's very much like industrialist .. metal beds .. metal like beds The ward is cold

Don't know what to say to them Got involved in a fight Noisy at night, keep you awake Frightening to be suddenly awoken by another patient in the middle of the night Arguing between other patients, and between other patients and staff is intimidating

S

Angry at not being allowed out to the shop Bored and fed up Drink

Homesick 3 Overslept whilst on leave See relatives, missing them

Mentioned by 0 Dislike of non British food Not allowed to drink alcohol

Delusional and paranoid fears about other patients

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Table 2: Reasons for leaving by NHS Trust - II Trust Social Responsibilities

E

Isolated, no friends or relatives Missing family, wanting more visitors Some relatives close, and relied upon a lot, others rarely seen when patient is ill Visiting relative get irritated by patients behaviour while ill More likely to be visited by relatives on a closed ward

Cleanliness and tidiness of home 2 Risk of burglary Potential loss of job through absence Bills to be paid, need to deal with important letters 2 Find somewhere to live 2 Admissions and illness cause worry to the children, and affect their lives Worried about losing flat while in hospital

O

Not all family members care enough to keep in contact during an admission Missing children/family 2 Family bring in all meals Worry about family when head of household Whole family visits in shifts, keep in touch with reality Family don't visit at all 2 Have lots a friends, daughter, girlfriend, but they don't visit - asbconds to see them Hiding admission from girlfriend Suddenly turning up at home after absconding frightens the family Visitors are not allowed onto the ward 3 Family live too far away to visit Have visitors every day Uses telephone to stay in touch, but no privacy

Oldest man, household leader Care of sick elderly relative with arthritis Flat burgled while in hospital 2 Deal with unpaid bills Access personal property On last admission flat was stripped of property, including all the furniture Care of daughter ill with flu Need to check on post and flat Care of mother who has dementia Care of elderly father

S

Worry about younger siblings while away in hospital Family get upset by illness and decrease contact during admission Patient doesn't know what to say to visiting relatives, doesn't want them to visit Contact from some relatives is unwelcome Missing family while in hospital Children don't visit, don't understand what's wrong

Elderly parent not on the phone Access of personal property (clothes) Lost job due to illness Admission caused loss of place on college course

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Table 3: Immediate versus longer term reasons for leaving

Triggers/Reasons Immediate 48 hours before

Angry leave from

Requested leave refused at ward round 2 None in particular 7 Got letter from tribunal refusing discharge Prompt access to Dr refused 2 Lies told about him at tribunal Assault by another patient and auditory hallucinations Argument with nurse about visitor being denied access Leave decision postponed because meeting delayed

None in particular 6 Fed up, frustrated Restrictions, not allowed to make tea Frightened by another patient during the night Enforced medication 2 Unhappy with medication Feels self cured Feeling locked in

Go to None in particular 10 Opportunity 2 Sudden urge

Just want to be out 2 Wanted a drink Homesick, worried about house 4 Awareness that being on a sec 41 meant that he would not get leave for a long time Missing company of friends Nurse would not spend time listening to account of bad dreams Refusal of permission to visit grave None in particular Needing access to post Known childcare need Planned response to expiration of section Disagreement with staff about leave request

Other None in particular 5 Sudden urge Overslept while on leave Member of staff told him to leave Psychotic reasoning or don't remember 5 Telephone conversation with solicitor Auditory hallucinations Having to wait for leave escort

Asked to go on leave when patient did not think she was ready Unable to relax Wife said she didn't want him back home Considered himself cured Planned in conversation with another patient Psychotic reasoning or don't remember 5 Ward too boring to return from leave Nurses neglecting me Just want out Anticipating official leave

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Table 4: Angry leaving from versus going to

Angry leave from Go to Other Gender 14 Male

3 Female 14 Male 4 Female

13 Male 4 Female

MHA 4 Informal 13 Involuntary

9 Informal 9 Involuntary

6 Informal 11 Involuntary

Age 8 35 & under 9 36 & over

14 35 & under 4 36 & over

8 35 & under 9 36 & over

Ethnicity 5 Afro-Caribbean 3 Bangladeshi 1 Other African 0 Somali 1 Other Asian 7 White European

5 Afro-Caribbean 1 Bangladeshi 4 Other African 2 Somali 0 Other Asian 5 White European

2 Afro-Caribbean 1 Bangladeshi 0 Other African 1 Somali 0 Other Asian 13 White European

Diagnosis 10 Schizophrenia 7 Other

12 Schizophrenia 4 Other

8 Schizophrenia 7 Other

Trust 7 E 9 O 1 S

6 E 7 O 5 S

8 E 7 O 2 S

No result significant by chi square

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Table 5: Patients whose mental state is implicated in their absconding - reasons and triggers for leaving

Mental state Other reasons/triggers Schizo- phrenia

Erotomania (attachment to doctor who would not see her immediately on demand) Vague paranoid ideas about what others on the ward were saying to each other Couldn't relax or sit still (?akathisia) Account of abscond marred by mild thought disorder or disorganised thinking Not hearing voices this admission, reason for being on the ward is "having a fever" Anxious, restless, irritable "My mind is not intact" Poisoned by the tablets given by nurses Florid paranoia: food and drink on the ward poisoned, people on the ward are going to murder the patient, fear of imminent death Command hallucinations from the TV

Left to sort out unpaid bills at flat Sudden awareness of implications of sec 41 Refused leave at ward round 2 Feeling bored, locked in, trapped Homesick Objects to medication side effects Fear of other patients Restrictions on behaviour and activity Isolation from family, missing family 2 Lack of privacy

Other diagnoses

Suicide attempt linked to anger at misdiagnosis by doctor Fed up Major anxiety and panic (left to treat self with street drugs) Garbled account, with references to "voices" and "superstitions" Very garbled account Frightened by bad dreams Hearing voices, mind racing Depressed, feel really sick Garbled account of abscond, claims to have met Mike Atherton while away from the ward Vague flights of ideas Command hallucinations, voices told patient to abscond 2 Loss of concentration, preoccupied Feels a burden to others Suicidal impulses

Homesick 2 Dissatisfaction with medication Refusal of permission to go to the shop Missing family/friends Boredom, nothing to do 2 Delayed access to doctor, not seen at ward round, and no specific date given for CPA meeting Assaulted by another patient The doctors preach at you Refused permission to visit grave Feeling trapped, locked in Worry about elderly mother Visitor refused access

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Table 6: Feelings about being on the ward or absconding Freedom, liberation, power

"I think it was like three good days of my life cause I was free .. and having a good time" "I saw my mum and dad ..I saw my own place after two ..two weeks ..my own room with my own things you know ..my own car ..you name it ..it was completely different ...it was freedom when I went over there you know" "as long as they give me my medication and like able to be you know to well freely go about my business you know" The feeling of freedom is mentioned by 6 other absconders

Anxiety, fear

Nervous and fearful about coming into the psychiatric hospital 2 Anxiety as a psychiatric symptom Unhappy about lax sharps policy and fears being cut by another patient wielding a razor in the middle of the night Frightened by an argument between another patient and a member of staff during the night Frightened that other patients "might come in and kill me" during the night Other "commotions" between patients and staff evoke fear, the ward id "disturbing" 2 Worry about practical issues: visas and residency, not able to attend appointments about this, dependent relatives Fear of the staff Frightened all the time on the ward vs feel safe on the ward Frightened by criticism from others Frightened by the experience of C & R Fear of sexual assault by another patient Fear arising out of paranoid delusions of poisoning or plots 2 42% of interviewees expressed some feelings of fear, the remainder explicitly denied any such feelings

Trapped, locked in

These are mentioned by 58% of interviewees Claustrophobic Like a prisoner, or being in a prison 3 Unable to go out when you want Linked to being detained under the MHA Use of keys by the staff symbolically emphasises this feeling Not wanting to be on the ward "I feel like I'm in a cage" Linked to the ward door being locked on occasion 2

Observed, monitored, watched

No interviewee mentioned this, noticed it, or complained of it at all

Boredom Mentioned by 42% of interviewees Sleep a lot to pass the time 2 Smoking "you just end up smoking ..walking up and down" "Chat, talk to people, socialize" Activities mentioned: watching TV, read a book, play table tennis, listen to music, playing games, OT groups Not enough books to read "boredom .. there's nothing to do in the hospital.. all I have to do is stand for all day .. stand in one place for all day and don't even go out .. ain't got nothing to do in there" Several respondents link their boredom to not being able to go out Some report that they are bored all the time, and one gave it as a reason for not returning from leave

Homesick 42% of patients mention that they prefer to be at home, with their family if they have one "wanted to get home" 7 "int: do you wish to go home? pt: yes.. yes .. yes"

Isolation 26% of interviewees mentioned feeling isolated from their families and friends This is clearly linked to feelings of wanting to go home Two patients also felt ignored and neglected by the staff

Anger This is linked to refusals of leave or discharge, negative tribunal decisions, delayed access to doctors, and enforced medication

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Table 7: Planned versus impulsive leavers

Involuntary Informal Planned leaving

2 Left with clear plan to commit suicide 3 Watched and waited for opportunity to leave 4 Planned to be away for a specific and limited period of time Left with a specific task to carry out Secured funds for transport first None packed their bags before leaving

2 Planned to be away for a specific and limited period of time 1 Packed bags before leaving 2 Left with a specific task to carry out Planned for half hour

Impulsive leaving

10 Sudden decision, impulsive leaving

4 Sudden decision, impulsive leaving

How feeling on return

Rather be at home Happy to be back Feels punished Feels will be punished in future Bored 3 Regretful 4 Not too bad/all right Warm and safe 2 Rather be at home 2 Angry to have been brought back Pleased because people cared enough to bring them back to the ward Hate it

3 Happy to be back Regretful 4 Not too bad/all right Rather be at home Feel bad regardless of location Frightened of the voices Feel stupid/chagrin Terrible (due to flat being burgled)

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Table 8: Expectations by Trust trust general specific expectations expectation failures expectation surprises

E

medication 9 place to stay / peace of mind / group and 1:1 therapy / short stay (2 weeks) / nice quiet long rest ‘nurses to come and talk to me about my problems’ ‘medication .. and moral and friendly support’ ‘to be looked after well and get better’.

‘I expected good medication but I didn’t get none .. I’ve been getting worse and worse’ ‘nothing .. not too much’ ‘nothing in particular’

choice in type of meds (liquid, tablets, injection), having facilities like an art room, not as many rules to follow as expected. ‘I thought they might discharge me because I’d had a drink’.

O

medication 9 short stay (1 week) ‘a bit of restitution from the pressure from the outside world’ 2 regular food companionship ‘I came here for me throat .. I had a cough ..tonsilitis’ ‘lots of nurses and lots of rules’

‘they’ve put me on diazepam and melleril .. and I’m getting worse’ ‘when I see Dr X he was really offish with me .. that made me feel I wasn’t getting any help’ ‘I’m not quite sure really you know .. staff treat you differently .. they’ve got things like OT and stuff’ ‘to get some help .. I was hearing voices .. I wanted the voices to go away’ ‘I don’t understand why I’m here’ ‘more freedom ..less drugs ..they pumped me up full of drugs last time and they’re trying to do the same thing now’ ‘I’ve had enough of the hospital ..I’ve been in hospital for three months ..all I came in for is so that I could stay here for about a week or somthing and I’ve been here three months and about a week now!’

‘I was expecting it to be a rough unpleasant .. violent in a way .. which once I’d been here and everything .. I found it was a very pleasant ward to be in .. a lot better than I expected’ ‘I had visions of them sort of forcing it (meds) down my throat but they didn’t’ ‘people want me in strait jackets’

S

medication 4 to be able to go out short stay 2 rest from family

length of stay: ‘it’s turned out to be longer than I expected ..’ expected 2 or 3 weeks stay in hospital

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Table 9: Doctors by Trust

about doctors E O S

’m frightened of the consultant because she doesn’t seem to want to let me go’ ‘I mean as the doctor said to me if somebody really wanted to kill themselves they would just do it’ (re registrar) ‘he’s nice .. but I went in Wednesday and I was drunk .. he said come back when you’re sober .. that’s when I ran home’ (same pt re consultant) ‘can’t tell the doctor .. it would take too long’ ‘they’re so busy’ (having to wait to see dr) ‘Dr 14 is all right .. I like him .. he’s a good man .. and apart from that I don’t hardly know any other drs’ (although pt doesn’t agree with meds treatment) ‘I’ve known him very well since I became a pt here’ re able to talk to dr

‘I think he’s a very sarcastic person .. he seems to think he could just see you and then he knows what’s wrong with you .. which I think is wrong’ (re Dr 4) ‘when I see Dr 4 I didn’t have a chance to say a word because he said what he had to say and that was it .. as blunt as that’ (re Dr 4) ‘what gets me .. why can’t they be polite back to me .. I’m always polite to him’ (re Dr 4) ‘he had his opinions and they were made up before .. I was totally honest .. I told him everything .. but it didn’t influence his thoughts in any way I don’t think what I said’ (re Dr 4) ‘I don’t like them doctors .. they’re too bossy’ ‘I find talking to them a lot harder .. because they normally think they know it all’ ‘I hate his guts’ ‘I get on all right with the doctors’ ‘he’s great’ ‘I get on very well with the doctors .. like a house on fire’ ‘I haven’t got a very good relationship yet because I’ve met him only about two times .. and he’s a busy guy’

male pt prefers male doctor ‘the doctors .. they believe the nurses .. they never listen to the patients’ ‘he will say what do you know about medication .. I am the doctor’ ‘I can’t talk to them .. they don’t understand .. I tell them what’s wrong with me and they don’t want to know’ ‘they don’t really want to know .. they just want to get on with what they’re doing .. you can’t tell them that .. it’s them that tell you’

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Table 10: Doctors by Mental Health Act status

about doctors positive negative informal

erotomania ‘I get on very well with the drs .. like a house on fire’ ‘she’s good’ ‘I like him .. he’s a good man’ (although doesn’t agree with meds he’s on) gets on ‘all right’ but does not discuss anything with dr ‘ I just like keeping things to myself’ ‘I’ve only seen him once .. it’s ok .. he’s a busy man’

‘he was really offish with me .. I didn’t have a chance to say a word .. he said what he had to say and that was it .. as blunt as that’ male pt prefers male drs ‘I don’t think I’d be able to tell them .. it would take too long’ (re voices) ‘he’s always talking to me like I’m a very high quality good precious boy’ ‘I can talk to them but they don’t understand’ ‘I find talking to them a lot harder because they think they know it all’ ‘they don’t really want to know .. they just want to get on with what they’re doing’

involuntary

‘I’ve got a very good relationship yet becasue I’ve only met him two times .. he’s a busy guy’ ‘the doctors seem quite good’ ‘I get on all right with the drs’ ‘I get on with the drs well’ ‘he’s great’ get on ‘all right’ with dr ‘when I speak to my consultant I don’t have an opinionated self’ (meets dr half way so gets on well)

‘being told that I don’t suffer with deep depression .. the doctor said to me if somebody wanted to really kill themselves they would just go off and do it’ ‘he’s a very sarcastic person’ ‘why can’t they be polite back to me .. I’m always polite to him’ ‘the doctors .. they believe the nurses .. they never listen to the pts’ ‘he will say .. I am the dr .. what do you know about medication .. I have nothing to say to him’ ‘I don’t like the doctors they’re too bossy’ ‘I worry about them .. what the nurses and drs are doing to me .. giving me medicines ..without a reason’ ‘they’re so busy ..I’ve been sitting here patiently for a whole week waiting for a doctor’ ‘I’ve seen him once’ ‘I feel frightened of the consultant because she doesn’t seem to want to let me go’ ‘I hate his guts’ ‘he has his opinions and they were made up before .. he listened but it didn’t influence his thoughts what I said’ ‘she’s a bitch ..she put me on a section 3’ ‘I’m finished with my dr’

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Table 11: Nurses by Trust about nurses

E O S ‘the nurses seemto understand a little bit more [than drs] when I talk to them’ ‘I get on fine with them’ ‘anything that’s on my mind .. I can tell them’ ‘very good .. I get on with them’ ‘ok ..I know the staff well’ ‘they were too busy’ (after an incident) ‘I don’t get on with none of them .. I don’t talk to anyone .. I might get another injection or something like that’ ‘when they give me my tablets I just say .. didn’t matter what happened before that .. I just say not too bad’ ‘they find it difficult to look after anyone that’s psychiatrically ill and jumps around screaming on the ward and things’ ‘I feel the nurses have been neglecting me .. so I wasn’t getting anything out of being in hospital’ ‘the staff muck me about .. the day staff are all right’ ‘all those agency nurses who haven’t a clue’

‘the nurses are nice .. they looked after me’ ‘I get on quite all right with them’ 5 ‘they are friendly and giving medicine properly’ ‘I’ve got great respect for most of them’ ‘I used to feel scared talking to people in case I was a nuisance’ ‘all right ..some of them I don’t like’ ‘I like them .. you get the odd one or two that try and be pushy and bossy but as long as you do as you’re told there’s no problems’ ‘I’ve known him for years .. he’s known me for years .. he understands me a damn site better than anyone else’ (re only staff member pt likes) ‘you don’t know what to expect here .. not from the nurses .. you know .. the attitude you’re going to get from one minute to the next you know you get one good nurse .. you get one bad nurse ..they just walk around .. they don’t want to be here’ 2 ‘I feel they force me to take the medicines ..I cannot trust any nurses’ ‘it’s the psychiatrist who you tell what’s going on in your head .. not really nurses .. I don’t have anything to say to the nurses’ ‘I can’t trust them .. you talk to someone and it’s not just you and that person you talk to it’s every nurse .. it’s all the nurses you’re talking to’ (re handover/notes/etc)

‘the staff here .. they don’t listen ..even if you’re ill .. very ill .. they don’t give a shit about you .. they’re all drinking tea in the office .. nobody listens to you .. sometimes staff are too bad’ ‘the thing is the nurses can’t do nothing .. without the doctor .. you have to wait .. you’re not feeling well and they can’t do nothing about it’ ‘the staff haven’t got time for you here .. they just want to do their own thing you know .. now I don’t really speak to them because I know they haven’t got time for me ... they’re all right’

rest have very brief comments on staff ‘they’re ok’ or in 2 documents (E) - difficult to make sense of what is being said.

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Table 12: Nurses by Mental Health Act status positive negative informal

‘you don’t know what to expect here from the nurses .. the attitude you’re going to get from one minute to the next .. you get one good nurse .. one bad nurse ..they don’t want to be here’ ‘I’ve known him for years .. he’s known me for years .. he understands me a damn site better than anybody else’ (X) relationship with nurses is ‘all right’ ‘I’ve got great respect for most of them’ able to talk more to nurses than drs

‘when they give me my tablets I just say .. didn’t matter waht happened before that I just say not too bad’ ‘they find it difficult to look after anyone that’s psychiatrically ill’ generally doesn’t get on with staff at all (X) ‘you get the odd one or two that try to be pushy and bossy but as long as you do as you’re told there’s no problems’ ‘they’re too busy’ ‘I don’t get on with none of them .. I don’t talk to anyone .. I feel too shy .. too afraid ..I might get another injection’ ‘they wake me up too many times’ ‘they haven’t got time for you here’ ‘can’t trust them’ (confidential info passed on at handover, written in notes etc.)

involuntary

‘they’re very nice ..the nurses .. they seem to understand a lit bit more’ ‘the nurses are nice .. they looked after me’ ‘I get on quite all right with them’ ‘they’re all right’ (Y) ‘I get on fine with them’ 2 ‘they’re friendly’ ‘very good .. I get on with them’ ‘I know the staff well’ ‘I get on all right with the nurses’ 2 helpful talking to the nurses 1 ‘the day staff are all right’ (Z) gets on ‘very nicely’ with nurses gets along ‘very well’ with nurses

didn’t feel listened to 1 ‘I felt bad because he said it in front of everybody .. in the staff room’ ‘it’s basically no relationship .. it’s basically a relationship with medicine’ ‘staff treat you differently from other staff .. I get on with the staff all right as long as you give them the due respect they deserve they’ll be all right with you’ ‘some of them I don’t like’ ‘they don’t listen ..even if you’re ill ..they don’t give a shit about you’ ‘the nurses can’t do nothing without the doctor .. you’re not feeling well and they can’t do nothing about it’ ‘in here they don’t talk much’ (Y) ‘I cannot trust the nurses’ ‘I feel that the nurses had been neglecting me .. so I wasn’t getting anything out of being in hospital’ ‘it’s not their job .. it’s the psychiatrist who you tell what’s going on in your head .. I don’t have anything to say to the nurses’ ‘the staff muck me about’ (Z ref to night staff) ‘all those agency nurses who haven’t got a clue’

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Table 13: Medication by Trust positive negative

E ‘getting me better in terms of medication ..if I don’t want to get tablets .. I get liquids ..if I don’t want to get tablets or liquids I get injectionables’ ‘I’ve been very happy especially with the medication I’m on now’. ‘I just wanted some medication so the voices would go’ (re reason for returning) ‘I’m expected to be here for medication’ (reason for return) need medication 2

‘I shouldn’t be on medication.. there’s nothing wrong with me ..I only hear voices’ 1 felt better for not taking meds ‘no medication helps me because all I need .. if anything I suffer with depression not schizophrenia’ (pt has diagnosis of schizophrenia) ‘it’s too much medication .. my brain can’t communicate properly’ ‘I’m frightened of the injections and the way they give it to me’ ‘I was getting so many terrible effects’‘I keep getting ill .. so I come back to the hospital to take my medication’ ‘I expected good medication .. I had it for two years ..they won’t give it to me again ..it was clozaril’

O ‘you’ve got to have something to keep you going ..taking your medication to keep you stable’ ‘once I weren’t having my medication (while absconded) I realised I needed it’ ‘where I hadn’t been taking my tablets for depression .. I lose all concentration’ medication ‘sometimes’ helps ‘the medication’s been ok’ ‘I feel a lot better since taking it anyway’ ‘I didn’t have no medication .. I needed it’

‘they’ve given me tablets that are causing me other side effects’ ‘I mean I’m a well man’ ‘my construction of thought was impaired ..I couldn’t communicate properly’ (result of injection) ‘I don’t need this medication .. it makes me drowsy’ fear (feeling unsafe) of injections especially when enforced 2 ‘I don’t want to take the medicines .. they make me dizzy’ ‘they refused to stop the medicine .. I asked to stop the medicine’ ‘when I take the syrup I feel so clumpy ..I only take the tablet’ ‘syrup .. in liquid form .. I think they’ve given me too much’ ‘I don’t like the injection itself’ (as opposed to medication) complaints of side effects 2 ‘I was expecting them to treat my anxiety with either medication or some other way .. they put me on diazepam and melleril which isn’t helping me .. I’m getting worse’

S ‘I feel better without the medication because some medication causes me drowsiness ..I feel too sleepy .. if I have something on my mind .. to do something tomorrow .. and if I take the tablets .. then it makes me forget’ ‘I think they should have prescribed me something else’ ‘the medication is not working’ ‘ the right medication would make me feel happy’ ‘ I was on injections .. that helped me but I was getting side effects and I come off it’.

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Table 14: Medication by Mental Health Act status positive negative informal ‘once I weren’t having my medication (while absconded) I

realised I needed it’ ‘where I hadn’t been taking my tablets for depression .. I lose all concentration’ ‘I didn’t have no medication .. I needed it’ ‘I wanted some medication so the voices would go’

‘they refused to stop the medicine .. I asked to stop the medicine’ ‘I was expecting them to treat my anxiety with either medication or some other way .. they put me on diazepam and melleril which isn’t helping me .. I’m getting worse’

involuntary ‘you’ve got to have something to keep you going ..taking your medication to keep you stable’ medication ‘sometimes’ helps ‘the medication’s been ok’ ‘I feel a lot better since taking it anyway’ ‘I was always going to take the medication .. and the injection even though I didn’t like the injection .. I never missed one in 20 years’ like choice offered of meds (tablets, syrup etc) ‘I’ve been very happy especially with the medication I’m on’ ‘I’m expected to be here for medication’ (reason for returning)

‘I shouldn’t be on medication .. I only hear voices’ felt better without medication 1 feel fear (unsafe) about injections especially enforced 1 ‘my construction of thought was impaired ..I couldn’t communicate properly’ (result of injection) ‘I don’t want to take the medicines .. they make me dizzy’ ‘they’ve given me tablets that are causing me other side effects’ ‘I mean I’m a well man’ ‘no medication helps me .. I suffer from depression not schizophrenia’ ‘the medication ain’t working’ (wants different meds) ‘I just want to stop it’ ‘the injection is making me worse’ ‘I was getting so many terrible [side] effects’ ‘I come back because I need my medication’ ‘syrup .. in liquid form .. I think they’ve given me too much’ ‘I think they should have prescribed me something else’

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Findings 6:

Absconding and ethnicity

The reader is reminded of the cautions expressed in the chapter giving an overview of the data. Numbers in some of the ethnic minority categories are small, and any generalisations made about such groups in this report must be considered to be highly tentative. Stronger conclusions can be drawn about white Europeans and Afro Carribbeans, who were well represented in both quantitative and qualitative samples.

It should also be emphasised that all ethnic groups of absconders had many

things in common. Few like being in hospital, they feel bored, trapped, worry about their families and responsibilities. The text below examines only the differences between groups in order to discover more about how motivations to abscond arise differently, and how the dilemmas of a hospital admission are differently accented for ethnic minority groups. Afro-Caribbean absconders Table 1 shows that Afro-Caribbean absconders were no more likely to abuse cannabis while away from the ward than the white Europeans (22% and 24% of each group respectively). On balance, this group is more negative than positive in their attitude to medication (Table 3). It would appear from table 4 that a high number of absconders in this group were without accommodation outside hospital, however examination of the quantitative data set shows that only 8% of absconders from this group were homeless, compared to 13% in the white European group. This group was, however, the most socially isolated of all, with few outside contacts during their hospital stay. Very few absconders in this group expressed any fear about being in hospital, and none admitted that they were ill, although some were willing to say that they had been ill (Table 7) . This latter point is in contrast to every other ethnic group of absconders except the Somali's, who also believed themselves to be well.

Care plans for this group rated them as at risk of harming others or abusing substances at the time of their first abscond no more frequently than for other groups. Similarly, this group of absconders were no more likely to have had previous contact with the police (at time of first abscond) or to have a forensic history. However this group (along with the Somali group) were more likely to have the police informed about their abscond (68% of absconding events, versus 20 - 44% for other groups, significant by chi square, p < 0.001). This difference was not present for first absconding events, only for subsequent ones, and is greater for male absconders than for females. It would appear, therefore, that absconding by a member of this group heightened and amplified the anxieties of staff in a way that did not occur for others.

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Bangladeshi absconders Table 2 shows this group to be proportionately more negative in their evaluation of doctors than others. This may be linked to the fact that no Bangladeshi absconder had a good word to say about medication (Table 3). No one in this group lived alone, and all expressed worries about their families. However the Bangladeshi absconders were not visited by their families while in hospital (Table 4). In contrast to the Afro-Caribbean absconders, and in common with the white European absconders this group talked a lot about being frightened in hospital (Table 5).

The quantitative data shows that although all absconders tend to be younger, the absconders from this group are particularly so with 62% of them aged between 16 and 25 years old. For most other groups only 18 - 25% of absconders were this young (significant by chi square, p = 0.027). There is a tendency for this group of absconders to be more likely to be married or in a stable partnership, however this did not reach significance. Further support is given to this interpretation by the fact that Bangladeshi absconders are much less likely than other groups to live alone (significant by chi square, p=0.004). Table 6 shows that this group are the fastest to return to hospital, with 79% being back in under 24 hours. This is likely to be linked to the fact that more absconders were brought back to hospital by relatives than for any other group.

The rarity of harm to others as an outcome of absconding makes statistical

calculations of significance problematic. However 6.3% of absconds by this group resulted in some harm to others compared to much lower numbers in other groups. Of all groups, this was the least like to be considered at risk of using drugs (5% versus a 24% average, significant by chi square, p < 0.001). Somali absconders This group of absconders seemed to be particularly cut off from their families. All were refugees and two had no family at all in the UK, and the third received no visitors while in hospital. None of the absconding Somali's interviewed felt that they were ill or need to be in hospital (Table 7). As with the Bangladeshi group, the quantitative data shows Somali absconders to be significantly younger also. This group (along with the Afro-Caribbean group) were more likely to have the police informed about their abscond (70% of absconding events, versus 20 - 44% for other groups, significant by chi square, p < 0.001). White european absconders White European absconders were equally as likely as the Afro-Caribbean's to abuse cannabis while away from the ward. In addition, they were the only absconding group from which a small number went directly from the ward to the pub (Table 1). This group had the most positive attitude towards medication, although there were still significant numbers who were full of complaints (Table 3). In contrast to the Afro-Caribbean absconders, and in common with the Bangladeshi absconders this group talked a lot about being frightened in hospital (Table 5).

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There was a non-significant tendency for this group to have proportionately

more affective disorders and proportionately fewer in the schizophrenia category than other groups. Absconders from this group are much less likely to have been compulsorily admitted to hospital (34% versus 50 - 65% for most other groups, significant by chi square, p = 0.001). Care plans for this group rated them as at risk to themselves at the time of their first abscond much more frequently than for other groups (41% versus 10 - 18% for most other groups, significant by chi square, p = 0.001). In line with these findings, absconders from this group were very much more likely to have a history of suicide attempts (38% versus 5 - 12% for most other groups, significant by chi square, p < 0.001).

The rarity of harm to self as an outcome of absconding makes statistical

calculations of significance problematic. However 5.8% of absconds by this group resulted in some harm to self compared to much lower numbers in other groups.

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Table 1: Method by ethnicity ethnicity method of leaving destination activity method of return afro-caribbean 9 walked off ward

1 ran out 2 failed to return from agreed time out 1 informed staff and left while angry

4 went home 2 visted family 3 visited friends 2 wandered streets 1 delivered flowers

9 took part in normal life activities 2 also smoked cannabis 2 wandered streets 1 delivered flowers

2 with police 8 of own volition 2 with relatives and friends

bangladeshi 3 walked off ward 2 ran out

4 went home 1 visited friends 1 wandered streets

4 took part in normal life activities 1 wandered streets

2 with police 4 of own volition

other african 3 walked off ward 2 failed to return from agreed time out

2 went home 1 went for a walk 2 visited friends

5 took part in normal life activities

1 with police 4 of own volition

somali 1 walked off ward 1 failed to return from leave 1 failed to return from agreed time out

3 went home 2 took part in normal life activities 1 sorted out burgled flat

3 of own volition

other asian 1 walked off ward 1 visited friends 1 took part in normal life activities

1 own volition

white european

15 walked off ward 1 failed to return from leave 4 failed to return from agreed time out 3 ran out 1 left via the fire exit 1 made excuse to leave ward 1 walked away from escort 1 informed staff while angry

14 went home 3 went to the pub 7 visited friends 2 wandered the streets 1 ran out in road 1 went for a walk 1 visited family

18 took part in normal life activities 6 also smoked cannabis 2 made suicide attempts 2 wandered the streets 1 ran out in road 1 went for a walk

4 with police 13 of own volition 3 with ward staff 4 with relatives or friends 1 with police, sw and ambulance 1 with police and ambulance 1 unknown

other 1 walked off ward 1 ran out

1 went home 1 went shopping

2 took part in normal life activities

1 police 1 self

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Table 2: Doctors by ethnicity positive negative afro-caribbean

‘the doctors seem quite good’ ‘I get on with the drs fairly well’ ‘I get on with the drs well’ ‘when I speak to my consultant I don’t usually have an opinionated self’

‘I think he’s a very sarcastic person’ ‘I feel like swearing at dad dr because he’s always talking to me like I’m a very high quality good precious boy’ ‘they’re so busy’ ‘I’m finished with my dr’

bangladeshi

‘I’ve only met him about two times so I want to see how it goes today’

‘he will say what do you know about medication I am the doctor .. I have nothing to say to him’ ‘I don’t like them drs they’re too bossy’ ‘I’ve seen him once’ ‘I worry about what the nurses and drs are doing to me .. giving me medicines without giving me a reason what’s wrong with me’

other african

‘I get on all right with the doctors’ ‘I’ve known him very well ever since I became a pt here’

‘they get on with what they’re doing .. they don’t really want to know’

somali gets on ‘all right .. not bad’ with drs ‘they believe the nurses .. they never listen to the pts’ other asian ‘he’s a good man’ white european

‘I told Dr 14 I loved him’ ‘I get on very well with drs like a house on fire’ ‘he’s great’ ‘she’s good’ ‘I’ve only seen one dr ..he’s all right’ ‘I’ve only seen him once .. that’s ok .. he’s a busy man’

‘as the doctor said to me if somebody really wanted to kill themselves they would just do it’ ‘he was really offish with me .. he never give me a chance to say anything .. he said what he had to say and that was it .. as blunt as that’ male pt prefers male drs ‘I don’t think I’d be able to tell them ..it would take too long’ ‘why can’t they be polite to me .. I’m always polite to him’ ‘I can’t talk to them .. they don’t understand’ ‘I find talking to them a lot harder .. because they think they know it all’ ‘I’m frightened of the consultant .. she doesn’t seem to want to let me go’ ‘I hate his guts’ ‘he has his opinions and they were made up before .. it didn’t influence his thoughts in any way what I said’ ‘she’s a bitch’

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Table 3: Medication by ethnicity positive negative afro-caribbean

like choice offered of meds (tablets, syrup etc) ‘I’ve been very happy especially with the medication I’m on’ ‘sometimes the meds can’t help as much as it’s expected to ..I think it’s just based upon the illness itself .. the illness just has to go away the same way it came’

‘I know the drug that used to help me ..clozaril .. they won’t give me that drug’ ‘syrup .. in liquid form .. I think they’ve given me too much’ ‘my construction of thought was impaired ..I couldn’t communicate properly’ (result of injection) ‘I shouldn’t be on medication .. I only hear voices’ ‘no medication helps me because all I need .. if anything I suffer from depression’ ‘I expected good medication .. I had it for two years .. they won’t give it to me again .. it was clozaril’

bangladeshi 1 complain about side effects ‘they’ve given me tablets that are causing me other side effects’ ‘I mean I’m a well man’ ‘when I take the syrup I feel so clumpy ..I only take the tablet’ ‘I don’t want to take the medicines and I’m scared of the injections aswell’

other african ‘the idea is to continue on medication .. but right now I’m feeling fine .. I want to go home’

somali ‘they refused to stop the medicine .. I asked to stop the medicine’ white european

‘once I weren’t having my medication (while absconded) I realised I needed it’ ‘where I hadn’t been taking my tablets for depression .. I lose all concentration’ ‘medication’s been ok’ ‘I feel a lot better since taking it’ ‘I didn’t have no medication .. I needed it’ 2 ‘I was always going to take the medication .. and the injection even though I didn’t like the injection .. I never missed one in 20 years’ ‘I wanted some medication so the voices would go’

‘the medication ain’t working’ (wants different meds) ‘I don’t like the injection itself’ (as opposed to medication) ‘I was expecting them to treat my anxiety with either medication or some other way .. they put me on diazepam and melleril which isn’t helping me .. I’m getting worse’ feel fear (unsafe) about injections especially enforced 1 complaints of side effects 1 meds caused nightmares ‘I don’t need this medication .. it makes me drowsy’

other asian ‘I just want to stop it’ ‘the injection is making me worse’ ‘I was getting so many terrible [side] effects’ ‘I come back because I need my medication’

other ‘you’ve got to have something to keep you going ..taking your medication to keep you stable’

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Table 4 (Part 1) Responsibilities by ethnicity accommodation family/friends/isolation afro-caribbean

4 people in hospital due to lack of accommodation: ‘I feel like I ought to get out and get myself a flat you understand .. a couple of times I’ve been out to get myself a flat.’ 5 lived alone; none were worried about their unoccupied property while they were in hospital.

most isolated both inside and outside hospital: ‘I’m a bit of a loner because of this sort of illness.’ ‘I have not friends and family to go to the house to do anything at all.’ Those completely alone more likely to be above 30yrs/age. Only 2 people had long term partner, 1 also had child. Although both in regular contact, neither were visited on ward by partners. ‘it would be good if there was some form of communication .. a two way thing .. whereas I could see my girlfriend and she could come up here and visit me .. and then like with my daughter .. then like she could also feel safe.’

somali all were refugees. only issue talked about re accommodation was one person had their flat burgled while in hospital: ‘they took the tv .. the video .. hi fi system .. £220 .. they took everything .. I have nothing left when I go back .. if I wasn’t here nothing would have happened to my house ..simple as that .. I feel very angry.’

two people had no family at all in this country: ‘cause I’m on my own in this country .. they have a family to bring something here .. what I need from outside .. I don’t have any of those things .. I don’t have anybody .. I have to do it myself.’ third person lived at home with family but was never visited by family while in hospital.

other african

one person was homeless: ‘I’ve been homeless in this country for three months .. and I don’t want to be in hospital but I don’t have my own place.’ Two lived alone but were not concerned about their empty property: ‘my neighbours will look after my flat.’

One person had children; ‘I miss them a lot .. they don’t like to come to hospitals .. they don’t know what to say to you so when I do see them it’s that .. mummy where have you been .. like I know you’ve been in hospital but how come you haven’t come to see us .. you can come up and see me .. like there’s nothing stopping you .. but it’s like oh this is a psychiatric hospital.’ One person missed out on a college course due to their illness and subsequent admission to hospital.

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Table 4 (Part 2) Responsibilities by ethnicity accommodation family/friends/isolation white european

2 people had had their home burgled during hospital stays: ‘the last time I was in hospital it all got fucking stripped of furniture .. the lot and everything ..telly ..fridge .. microwave ..double bed.’ This group missed the conforts of their own home: ‘it’s not a warm or comfortable environment .. it’s very much like industrialised sort of thing .. metal beds and everything .. I went to my flat and I went to sleep in my own bed .. I just wanted to sleep in my own bed.’ ‘we just have a little place .. it’s really really lovely .. it’s my pride and joy.’

Many in this group were living with or near family and friends and missed having frequent contact with them: ‘people have got to have contact with their family while they’re here .. it calms them down a hell of a lot and it makes them act different.’ How family were coping without the patient was also a source of worry. ‘the reason I went absent without leave is because I miss my family terribly and I wanted to be at home with them.’ ‘I do worry about me mum a lot because she’s not well .. it’s not easy for her to get about.’ 2 people had children and in both cases they expressed deep concern for their offspring. ‘I was sort of craving for my wife and kids in a way .. I was worried about them .. I was very anxious and like fidgety .. and I kept on thinking and thinking and when I got round there .. my wife told me my youngest daughter was very ill with that new flu and I thought to myself well it must have been that that I was feeling.’ ‘my youngest is upset .. me eldest had to get a letter from the doctor’s like .. a certificate because he’s at university .. he’s got some exams to put in .. where he hasn’t been able to concentrate he had to get a certificate so that he could put them in a bit later.’ A number of people described feeling cut off while in hospital: ‘[I live] with me mum and dad and brother .. I see them now and again .. I don’t talk to them that much .. they don’t visit .. I don’t want to see them in here because I don’t know what to say to them.’ Three people lost jobs as a result of their illness and subsequent admission to hospital.

95

Table 4 (Part 3) Responsibilities by ethnicity accommodation family/friends/isolation bangladeshi and indian

Two people were married and had children; the rest were all living at home with family. A lot of concern was expressed for parents and siblings: ‘In the house I’m the eldest .. there are older brothers and sisters but they moved away .. so at the moment I’m the household leader if you want to call it.’ ‘I worry about my kids and mum and dad.’ ‘I worry about my younger brothers and sisters.’ Although none in this group lived alone, only one was regularly visited in hospital. ‘I have to phone them to come and visit me .. if I don’t phone them to tell them to come .. they will not come.’ ‘I had a lot of contact before but not this time.’

other This person lived alone in council accommodation and is aware that if his property remains empty beyond a certain period of time it will be repossessed by the council. Since his stay in hospital was proving to be a considerably long time this was a great worry to him. ‘I thought what am I going to do .. am I going to lose me flat.’ ‘when I went awol I had to sort out bills that are unpaid with my flat for a long time and I was really worried about it .. I couldn’t see to talk to anybody that would help me with it.’

‘I’ve got a few family and friends .. they help quite a lot when they can.’

96

Table 5 (Part 1) How people felt on the ward by ethnicity feeling bored/homesick feeling trapped feeling frightened afro-caribbean

1 person complained of feeling bored: ‘ there’s nothing to do .. I thought golly I’m gonna explode .. my brain will explode if I sit here and wait any longer .. and I thought oh there’s no way I’m sitting here waiting .. whatever the consequences may be .. I just went.’ ‘boredom .. no that’s not the right word .. lets just way I wanted to be at home .. I was missing my home.’

4 people talked about feeling trapped: ‘I felt like I was a prisoner.’ ‘I feel trapped in a place I don’t want to be in.’

Just two people in this group described feeling frightened and in both cases their fear was related to the way they perceived their treatment on the ward: ‘when I first came to live here I was frightened a bit .. when they’d lock me in and grab me and all that.’ ‘[I was frightened] of the nurses because they find it difficult to look after anyone that’s psychiatrically ill .. you don’t get taken care of properly if you don’t behave yourself .. assessed to make sure you’re not ill .. so you can go home.’

somali ‘it’s like a prison.’ ‘I feel trapped here .. I get more depressed in here .. I’m not a prisoner! I come here for help .. if I go out and I need help .. I will come back .. I’m the one who came here in the first place .. nobody brought me here .’

2 people in this group talked about their fear on the ward which also related to treatment issues: ‘I’m scared of the medicine .. it might give me side effects.’ ‘frightened .. I get worried here because they want me to get trapped here.’

other african

2 people complained of feeling bored in hospital: ‘there’s nothing to do in hospital .. all I have to do is stand for all day .. stand in one place for all day and don’t even go out .. ain’t got nothing to do in here.’ ‘they don’t really do much here .. I just really wanted to be at home .. I mean I prefer everything like I do at home .. I do my housecleaning .. I do whatever .. it’s my home .. I can do what I like.’

‘I’m like in prison because they don’t allow me out.’ ‘it’s like I’m locked up in a prison .. I’m always trapped on the ward .. I can’t even go out .. ain’t got any leave.’

97

Table 5 (Part 2) How people felt on the ward by ethnicity feeling bored/homesick feeling trapped feeling frightened white european

6 people talked about feeling bored during their admission: ‘I didn’t come back because I thought it would be too boring.’ Some related feeling bored to feeling unwell: ‘I don’t do nothing .. but I’ve got nothing to do .. there’s things to do but I don’t really feel like doing them.’

This group related their sense of being trapped to their state of mind: ‘when I first came here I had a feeling of being trapped.’ ‘there’s no way out apart from running.’ ‘I’m sick .. like depressed .. I’m trapped in here because I like go home and I have rows with my brother so I can’t live at home.

Almost half of this group expressed fear/anxiety while in hospital. A further 50% of these related their fear to their state of mind at the time: ‘[I felt frightened] all the time .. anxious .. frightened of the voices.’ ‘I think my illness made me sort of frightened ..once I barricaded me door without the nurses knowing so I could get a good night’s sleep.’ Others were frightened of events on the ward: ‘there was a lot of trouble on the ward the previous night and I got a bit frightened .. I had the cover slung off my bed .. I was terrified.’ 2 people were anxious about their treatment: ‘I do sometimes [feel frightened] because I can’t go out.’ ‘it’s the tablets that are making me feel anxiety.’

98

Table 5 (Part 3) How people felt on the ward by ethnicity feeling bored/homesick feeling trapped feeling frightened bangladeshi and indian

1 person in this group said they were bored on the ward. ‘in fact I feel very bored in the hospital .. when I’m at home time passes quickly .. you’re bored in hospital you see.’

‘it’s like I feel I’m here .. I can’t go out .. so I’m inside here .. I have to go out and then I can’t got out so I can only wait .. just do a runner.’ ‘yeah I feel trapped .. it’s too much medication .. my brain can’t communicate.’

Half of this group talked about feeling frightened on the ward. They were the only group to express fear of other patients: ‘like he go to the dining room or dinner room and keep coming and keep looking at me .. keep staring at me .. they’re criticising me.’ ‘I’m frightened of the people here .. people bully you and all that .. just like to be left alone.’ 2 people talked about anxiety related to their mental state: ‘I see things that’s not there.’ ‘sometimes I get frightened of myself and sometimes I get frightened of what I’ve done .. I don’t remember what I’ve done.’ There was also fear of medication ‘I’m frightened of the injections and the way they give it to me.’ ‘I’m scared of the injections as well.’

other this person talked about having nothing to do on the ward but lots to sort out at home: ‘I go out mainly back to my flat to sort out like .. so it takes the monotony of being in hospital all day .. it’s not worth me sitting down idle doing nothing because I only think about doing something.’

99

Table 6

50 60 33 17 15 42 5 7 229

58.1% 78.9% 50.0% 53.1% 42.9% 32.8% 50.0% 63.6% 51.6%

22 9 21 8 14 58 5 2 139

25.6% 11.8% 31.8% 25.0% 40.0% 45.3% 50.0% 18.2% 31.3%

3 1 2 4 1 8 19

3.5% 1.3% 3.0% 12.5% 2.9% 6.3% 4.3%

3 3 1 2 1 10

3.5% 3.9% 1.5% 1.6% 9.1% 2.3%

8 3 9 3 5 18 1 47

9.3% 3.9% 13.6% 9.4% 14.3% 14.1% 9.1% 10.6%

86 76 66 32 35 128 10 11 444

100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

Count% withinethnicoriginCount% withinethnicoriginCount% withinethnicoriginCount% withinethnicoriginCount% withinethnicoriginCount% withinethnicorigin

Lessthan 24hours

Between 1and 2days

Between 2and 3days

Between 3and 4days

4 days ormore

Durationof abscond

Total

Afro-Carribean BangladeshiOther

African SomaliOtherAsian

WhiteEuropean Turkish Other

ethnic origin

Total

Duration of abscond * ethnic origin Crosstabulation

p < 0.001 by chi square

100

Table 7 (Part 1) Feeling well or ill by ethnicity feeling well and wanting to go home about feeling unwell - defining the problem feeling unwell at time of interview Afro-Caribbean

10 people felt they were well enough to go home at the time of interview: ‘I was just basically surprised by the lack of need .. for me to be here.’ ‘I shouldn’t be on medication .. there’s nothing wrong with me .. I only hear voices .. they don’t disturb me.’ ‘now I’m better .. cause I’m really good .. because I know that I’m doing well .. and I’m a hundred percent.’ ‘I don’t feel ill anymore .. there’s no need for me to be in hospital at the moment .. my main problem has disappeared .. I’ve been high .. and now I’m coming back to my stability .. the doctors can’t see that I thought to myself.’

‘I’ve been getting worse and worse and worse.’

Somali all three people in this group felt they were well enough to go home: ‘I’m well now there’s no need to be keeping me here.’

other African

‘the first time when I was like actually ill .. I came in here for about three months cause I was actually ill .. I was hearing voices ..... they started asking me questions if I’m hearing voices I told them no I don’t hear no voices no more.’

‘I was able to tell the nursing staff ..I was able to tell them and that but it would be the same sort of question they’d ask me .. is the television talking to you .. can you hear your name on the radio .. I ‘d be telling them no .. it’s nothing like that you know .. it’s just I know it’s my mind .. it’s just not very well at the moment .. my mind you know .. it’s just not intact .. but they all ask the same sort of questions .. all of them.’

‘maybe I kill myself .. I just wanted to leave everything .. just to die .. I came back because of my medicine .. I was feeling bad.’ (absconded day before and was being discharged that day)

Bangladeshi and Indian

‘I feel very well and I still feel strongly that I shouldn’t be here .. I should be discharged.’ ‘they feel that I’m not getting well .. to myself I think I’m well.’

‘my main problem is I’ve got mental disorder .. and I know that I’ve got it ..cause I know that I’ve got mental illness .. I can feel it in my brain .. every time it hurts .. like I get afraid of people .. cause of it.’ ‘I keep getting ill so I come back to the hospital to take my medication.’

‘I wanted to die actually ..I went out for dying .. but I couldn’t do it .. I was a coward.’ ‘I was hearing voices .. I want the voices to go away .. I see things that’s not there.’

101

Table 7 (Part 2) Feeling well or ill by ethnicity feeling well and wanting to go home about feeling unwell - defining the problem feeling unwell at time of interview white European

‘I make really a song and dance because I don’t want people to think I’m mad anymore.’ ‘I feel I’m responsible enough to lead my own life and I don’t want to be in hospital.’ ‘I’m better off with employment not in a hospital.’

‘at the beginning I wasn’t well I wanted to leave the ward at certain times when I wasn’t allowed to. I don’t think the nursing staff actually knew why I wanted to leave the ward. I had problems at home.’ ‘I must have been ill and I couldn’t handle it no more .. I thought people were going to kill me on the ward so I just packed up and run away .. I thought I was going to die anyway .. I thought someone was going to kill me anyway.’ ‘I’m entitled to be sick after losing my son .. but I’m not mentally ill.’ ‘I had no concept of time .. I have now I think .. but then I had no concept of time at all .. I felt as though I was in a parallel universe .. I had to walk a certain way .. irrationally .. very irrational.’ did it frighten you? ‘very much.’

‘I’m in hell in the head .. another voice in my mind .. I used to have voices all the time .. I know you couldn’t live without a certain amount of voices but my voices are a lot.. I feel ever since I got to hospital I got worse in all my illnesses.’ ‘I just wanted some medication so the voices would go.’ ‘I became frightened because I was given a tablet by a doctor ..and I’m still feeling the effects of that tablet now .. since then the tablet has made me feel very hyperactive and suicidal.’ ‘it’s like everywhere I go I think a lot of the devils are possessing me .. repossessing me .. I think too much .. my mind is racing .. I think all weird stuff .. like I’m hearing voices and that.’ ‘I got into a state outside so I just come back.’ ‘being told that I don’t suffer with deep depression ..I suffer with binge drinking which is a load of rubbish .. I suffer with depression ..I’ve had it since I was so high.’

other ‘I would say that I was ill .. I was really ill you know .. because I couldn’t understand what they were saying unless it was explained to me .. you know .. I didn’t know what was going on .. if they were sitting round looking at each other .. like if I was telling you something .. your mind is working it out at the same time .. trying to understand it .. and I thought like I can’t hear none of that because like I’m ill.’

102

Findings 7:

Nurses' Perceptions How staff feel

A range of feelings were described, from fear to relief. The nurses interviewed found it hard to generalise about their feelings, but stressed that it depended on the nature of the client who had absconded.

“It depends on the patient the situation and what what was happening on the ward at the time.” 207 “It depends on their mental state , I think the assessment is main factor in deciding when to start worrying and not to start worrying. I mean if somebody’s obviously suicidal or a harm to themselves or to other er and you’re quite concerned and there’s no point wasting time. But if its somebody who’s informal, who has been doing quite well, we’re planning the discharge and they’d been going out by themselves um for a few hours even ... It’s a matter of risk assessment.” 201 “Um it depends on the patient, um and how much of a risk they are , if ones ones at risk of er harming themselves or someone else or is quite vulnerable then there’s anxiety, um, if if the patient’s not so much at risk then , as, a few patients who abscond quite regularly um so there’s not much surprise when they do abscond.” 107

Specifically, 17 nurses spoke of worry and concern when patients abscond, with 6 using the term anxious. Feelings of guilt (N=1), responsibility (N=1) and disappointment (N=1) were rare in this sample. The majority (N=17) spoke of feelings of relief when a patient returned safely to the ward.

Interviewees were specifically asked if they had ever felt relief when patients absconded. Sixteen of the twenty four agreed that there were times when a patient leaving the ward was a relief, this was generally when the patient was difficult to manage (especially noisy or violent) or when they felt they were in hospital inappropriately.

“You don’t basically feel relieved if its someone that you really think should be on the ward, sometimes you feel a little relieved and someone’s a bit of pain in the arse and they’ve gone and you know they’ll be back at some point and you know they’re really not going to get up to much mischief outside” 113 “I don’t know, you feel relieved in a way. Patients who are really manic or really noisy or really intense and give you a really hard time It’s nice to get a break from them when they’ve gone, (laughs). Patients like that are normally the ones we’re more worried about when they have gone so, just getting a bit of piece and quiet I suppose from them” 210

103

Dangerous Acts

Although negative outcomes to absconding are relatively rare, they do happen on occasion. Three nurses spoke of their experience of patients who were involved in dangerous acts whilst they were away from the ward. Two spoke of suicide (attempts) and one spoke of a client injuring themselves as they tried to escape from the ward.

there are times when you know we’ve had, we’ve had patients abscond who have gone out and and harmed themselves or have um killed themselves. 1061909. I've known of someone who’s actually gone absent, but he was informal. And then he took a massive overdose, and he was you know ill for quite some time after that. 2122709. There was an incident where some, a a client on the ward was being specialed by two RMN's er and he broke free, got through the fire escape in the male dormitory and jumped from the landing on the fire escape on the first floor and he hurt his ankle. 1131305 There was a patient who was informal and went off the ward, and went to up a building, and was going to, and wanted to jump off, 2052211

These stories underline the fact that an abscond can have serious consequences. It is because every nurse knows of stories like these, or may have experience of these actual events, that nurses' dominant feeling is of anxiety and worry for the patient when they abscond. Risk Assessment

The interviewees referred to informal risk assessment in twenty cases. All nurses stressed that risk assessment starts from the time the patient is admitted and it is on- going .

“Um risk should be assessed first um the minute the patient comes in, if they’re a risk to themselves or to others, um. They’re normally assessed daily and we do that normally from um getting to know the people, having a quick chat, also keeping up to date with what’s happening in the ward round, handovers, notes, if there’s anything in the notes.” 207

A specific tool was being used in seven wards, but three nurses (from different wards) referred to the tool being new, and one said that it was not being used.

Um well in the past, well we’ve just implemented a new, well we’re in the process of looking at a new er a new risk assessment tool but in the past its been based on the assessments that are done er on admission and on the subsequent time after admission by the the multidisciplinary team. 1061909 .

104

Well we’ve got a new risk assessment tool at the moment which we use but before we had one that was really bad but you just look at their past history and I mean different people approach it in different ways but I go through their past notes, past history, whatever people have told me about them and their behaviour on the ward so, is other professionals, community professionals. 2101204. Um I mean we’ve got a risk assessment tool but it’s not tend, it doesn’t tend to get used to be honest, (OK) um its quite an old one, I know the um trust is looking into sort of risk assessment sort of generally um and they’re trying to develop something that’s a bit more user friendly um so in terms of assessing risk it is um, its a bit ad hoc really, to be quite honest. 301

For many nurses although there was a statement of risk to self and others noted in the admission assessment in the notes , the risk posed by the patient who was missing was only discussed once they had absconded, in relation to who should be notified.

“Well everybody’s assessed from the day of admission really risk assessment is an ongoing thing...um but um...when the patient’s gone AWOL then it becomes more of an urgent thing really. 2010702.

Patient observation

Risk assessment and absconding was linked by many nurses to nursing observation levels for individual patients, and the policies that determine them. All the interviewees felt that although they are involved in deciding the patient’s observation levels, - these levels remain unclear and at times confusing.

The thing is close obs is a very difficult thing and at times it could be cloudy in the sense that it could be that the patient doesn’t need to be on close obs but , obviously if the staff believe that a patient should be on close obs we sit down and discuss it amongst ourselves (.) and then inform the doctor in charge of the client....1042402. Yes they do but that’s, that’s only like, if they actually do the ward round, if they actually assess somebody, if they saw someone and they felt there was a major change in their mental state and they were at risk of like I say harming themselves or others, they will place them on observations, but you know the the psychiatrist, the consultant isn’t on the ward very often so they actually take into account what the nursing staff, how we feel and the the junior doctors or SHO’s, whoever’s available at the time....2091104.

Although some observation levels are decided by the consultant, and the junior doctors, fifteen nurses felt that most of the observation levels are decided in the ward team meetings and it is a joint decision.

Yeah its decided, well its not necessarily a consultant but one of the doctors would be involved, if the nursing staff feel that

105

an observation record could be changed um, .....it needs to come from , to come from close obs onto unobtrusive obs you can um discuss it er with the ward doctor um and they can change the obs level otherwise its decided in ward rounds, or management rounds. 1070106. Um should be a joint decision really between nursing and medical staff. 1051803. But as I say, you usually try to make it a team decision and also going on the person who’s admission who’s probably got the best view of the assessment that they’ve just done. Erm, it’s usually a consultation between everyone. 2042111.

Eight interviewees emphasised that, they have the power to commence close observation if they felt the patient was at risk.

The consultant only comes maybe once a week at the best twice a week and she doesn’t really know what’s going on in-between. Like when we think a patient is at risk we will put them on obs, straight away. 2030607. “If you feel that the situation was fairly bad, we have enough staff so we can start it.But of course I will you know if if it happens for example in the evening fine, so then I need to inform the the senior nurse in charge, ..But yeah if if there’s something we need that someone needs to be on some kind of obs so.. 2060803

However, these interviewees stressed that although they have the power to commence close observation, they cannot stop or reduce it without consulting the medical team, in fact it is the medical team which is responsible for stopping close observation.

...they’re either decided by the nursing staff there and then or usually they’re decided in conjunction with medical staff of course but that’s not always possible er otherwise nursing staff will will sign a level A, B or C observation to to a client, um now nursing staff can assign that level of observation or they can increase a level of observation er making the observation more intensive but what our policy is, nurses don’t reduce observation level er unilaterally, we always reduce in conjunction with medical er recommendation so we always liase with medical staff if we’re going to reduce someone’s observation levels but we don’t always liase with medical staff if....1131305.

Nineteen nurses mentioned that they have disagreed with the doctors over risk assessment. This implies that sometimes nurses perceive risk differently from the doctors. Such conflicts affect decisions not just about observation levels, but also about leave and discharge.

.normally the the medical staff would take our opinions quite seriously, occasionally you know they don't or they’ve a differing opinion about the patient. ....... sometimes, one of the consultants in particular has been what we thought, overcautious with patients who we thought aren’t really that much at risk um whereas the other, there’s a , the other consultant tends to be a little bit more carefree and maybe

106

doesn’t consider people as much at risk sometimes . 1070106. I have been talking with doctor that I did not agree with the point of view. Because I think that the doctor has once given someone leave, and I thought according to my assessment being with the patient more than the medical, I felt the need to, that person would be a risk if he goes. So I have been, have been in conflict with doctors. 1092808.

Some nurses questioned the efficacy of intermittent nursing observation: there's a hundred ways and a hundred reasons someone can abscond you know, there's there's two qualified staff, two unqualified on the floor on on the ward, um someone say on level B observations, its an open ward environment er one staff member is answering the phone, another staff member goes for a pee and the two um unqualified staff maybe serving dinner and during that fifteen minute observations, even if you're following the fifteen minute observations if if you er literally, exactly know their whereabouts every fifteen minutes to the on the second on the dot, in fifteen minutes a client could have left the ward and be at X station and be half way to London 1030305

And under such circumstances, nurses still feel that they may be blamed if something goes wrong:

Sometimes yeah sometimes, if er someone was on level B observation who's um maybe aggressive tendencies or maybe even homicidal tendencies have been increasing um er recently and prior to either being transferred to the um locked ward or being placed on level one observations that client happens to abscond during that period then um they they do feel.........that they will be held responsible and you know something may go wrong and they will be blamed. 1030305

Even arms length, constant, close observation can fail to prevent an abscond sometimes:

if they're on close observation, they can still sort of abscond they can hit you and then just disappear. 2020501

It is for these reasons that nurses report that carrying out close observation is stressful: if the patient is some kind of close observation or special obs so then it feels like oh God I have failed, you know I haven't managed to keep the patient here. Although this can happen to anyone you know, if there is only one person doing the close observation which means that you have a patient you know, that you can see, see her all the time so it could be just the second when you watch somewhere else that that she is going but I think that you feel sort of like a failure there ... it could happen to anyone you know and especially if you're got two hours of close observation, so its quite a long time if someone is really high abscondance risk, it is like quite stressing. 2060803

107

Not only can close observation be a negative experience for nurses, but patients don't like it much either:

well at the moment we've got a patient who's been on obs for a long time because she's um at risk from er absconding and there's basically no support at all for this, from the management, It's just they basically want her kept on the ward and that's OK for them to say but they don't take into account the feeling of the patient, like what if they want to go for a walk and sometimes if somebody's been on observation for over a month its hard to keep somebody on a ward when you know that when when the weather's nice outside, when you want to get a bit of exercise its just like that, You feel very unsupported because when somebody is on observations because they're an absconsion risk it takes up a lot of the nursing hours and if you're doing an observation for maybe three to four hours that means you've only got three to four hours working on the ward of you're doing a seven and a half hour shift. 2070907

Blame for absconding and the nursing team

A few members of staff saw absconding as inevitable from wards that are not locked.

It could happen to anyone you know and especially if you’re got two hours of close observation, so its quite a long time if someone is really high abscondance risk , it is like quite stressing . 206 But I don’t think people blame each other, it may be my interpretation but I don’t think so. I think it’s quite easy to happen on this ward, because the observation levels are not very good. 205

The most common place to lay blame was with the nurse observing the patient or observing the door. Specifically, eighteen nurses spoke of blaming one another.

if you know you asked a member of staff to keep an eye on a patient and the patient absconds of course you’re going to come back to that particular staff and ask them what happen, where were you when the patient absconded you know. 108 "Why did you let this patient go, why were you not watching her?" These things do happen but they shouldn’t happen if you know what I mean. If you’re doing the job properly, it wouldn’t happen, "Where were you at, why was you not watching her?” 20330607. there may be occasions you know when staff go oh you know bloody idiot, he let so and so out but not that often I don’t think. 301

There was some discussion as to the unsuitability of agency staff and nursing assistants to do observations.

108

People can still wander off unbeknown to the agency staff because obviously you know, they’re shown round, they’re introduced to the patients but they’re not er built up a relationship etc. 205 the job is that they know who they’re looking out for .You know whether they’re an NA or and RMN common sense tells you you’re sitting by the door for a reason and that’s not just to sit by the door and look at the wall it’s to monitor patients. 2081004.

Nine nurses spoke of managers blaming the nurses when a patient absconds

from the ward and five mentioned punitive measures given to nurses following an absconding incident. This led to ten nurses feel insecure about their jobs.

they again er, um fearful that the the management will scapegoat them and point their finger at them ... its fearful that you’re you’re going to be blamed in some way for this happening. 1030305 I mean you’re only safe to play it by the book basically, er otherwise er, any short cuts you find your way, yourself on your way out.201

Nurses who talked of punitive measures also mentioned that they were not being supported by the management.

Well generally, I’m not talking about X Ward but generally, er there have been instances whereby patients have absconded and er they’ve scrutinised the policy and er examined everything to ensure that everything that could have been done was done and where they found that er not everything which could have been done was done or this or that person was not consulted or whatever, er there have been punitive measures , yes, people have been disciplined, people have been suspended, etc etc. and um.......they may not necessarily have done it on this particular ward but this is a very small community and obviously one of the things, well if it can happen to so-and-so, well it can happen me. 201110702 Um, yeah I think like when people absconding and you know ..... At the end of the day if anything does happen when people abscond, it does actually you know a lot of the onus is on the nurses who are on duty at that time and that has actually happened in the past .When one person did abscond, and what happened the nurse didn’t document this apparently, there was something, and the nurse was actually suspended from duty for a time. 2091104.

Two nurses felt that the medical team have blamed them when patients have absconded.

We received plenty of um advice and criticisms informally generally about instances and in fact about the general rate, we’ve had criticisms certainly from one consultant, quite regular criticisms and little graphs in fact to show that

109

instances of absconding have increased over the previous three months or what have you know so we get that kind of feedback certainly 1131305.

Specifically, ten nurses felt that their jobs were on the line as a result of patient’s abscond.

I think with certain high risk patients, um if I were to be on duty and um a high risk patient absconded and er the decision was probably postponed to, there there there, there is er a certain culture in the unit for certain patients to be er circulated um to, around about ten o’clock or midnight in case they come back, stuff like that ..If then I was to hear that the patient was found somewhere floating in the river or something, yeah, I would definitely resign or something I mean you’re only safe to play it by the book basically, er otherwise er, any short cuts you find your way, yourself on your way out . 2010702. Yeah like I said earlier on if the person is at risk and he goes out of the ward I feel like if anything happens it means if I will be free I’ll be asked to talk and that sort of thing so its like you think there’s something here for you to I mean ... to give evidence something like that so you feel insecure. 3021512

Agency nurses The reliance on agency staff to cover the wards was seen almost universally by the interviewed nurses as having a negative impact on absconding and on patient care as a whole. They may be blamed for letting the patient leave the ward as in the following examples:

when you're using a lot of agency staff you know and there's somebody on the door and you know the patient is brought back and they will say to you well I've just walked out the door past so and so and it does happen. 1061909 agency staff don't always listen to the handovers as closely as they should and you know you go round and you bring them around and you describe, you know I've had had incidents where I've like brought an agency nurse around, showed them the people that I didn't want leaving the ward, they've let that person go and they've stopped a relative you know because they obviously weren't actually paying attention. 1061909

The following quotes illustrates the fact that agency nurses cannot make a full contribution to the ward nursing workload, nor do they carry the same responsibility as the permanent staff::

I think that the main things is er, is happening because you see sometimes there is only me qualified and then there's two or three agency nurse, so everything come on top of the one nurse. 1092808

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Because you feel its your registration if anything does happen (sure) you know you were the one, you were the permanent nurse, "oh I'm an agency nurse I was only there for one shift" you know and there's that feeling yeah. 2091104 if you've say got two permanent members of staff and two agency nurses who don't know the ward then you know two permanent members of staff will be wandering around doing things, I think it would be more likely that people would abscond 3014112

The heavy use of agency nurses also decreases the overall quality of staff-patient relationships:

you're using sort of predominantly bank and agency staff who don't know the patient, who don't know the ward er,. ... levels of frustration among the clients increases often because maybe they can't talk to their key nurse or whatever (sure) so therefore they they get frustrated and go off. 1061909 Sometimes it helps if you've got the key nurse of a patient around when they're upset because they would've established a longer term relationship then, with the patient. And be able to quickly sit down and chat with them or relate to them. And on this particular ward, there are quite a number of agency nurses and it is very difficult when there are so many new faces coming into the environment, that there are likely to be more absconcions. 1123010

Suggestions on how to reduce absconding The most common suggestion from the interviewed nurses was that staffing levels should be increased. 80% of the nurses advanced this as an effective way to reduce absconding incidents.

another thing that would help, ... it would certainly in increase or decrease the chances of people absconding is a higher staff to patient ratio ... so that you know somebody can go to the loo and somebody can be on the phone and there will still be er nurses on the ward who are you know, keeping an eye out on these patients 1030305 Yes it does, I would say that's true, without any hesitation , if you don't have good staffing levels there is a possibility of patients abscond easily. 1042402

This was the only method of controlling absconding that had high levels of support from the nurses interviewed. The objective of higher staffing levels was not just to increase patient observation and security, but also to promote better nurse-patient relationships:

If staff levels were increased you would have a greater input in, not necessarily staff levels increase on it's own, you would need to make a greater input into the patients. 1113006

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The remaining ideas were mentioned by small numbers of nurses: • increased facility to transfer patients to a locked intensive care environment • better teamwork with hospital security staff • improvements to ward design to promote general observation or observation of the

ward door • less reliance on agency staff • targeting nursing resources on the high risk patients • use of adequate levels of sedation • use of one to one close observation and adherence to observation policies • more time for the nurses to discuss patients problems with them, so the nurses can

know their needs and deal with them • increased availability of short term, escorted leave • reduce ward bed numbers • allocating a member of staff to stay by the door and prevent patients from leaving • community meetings and open discussion about absconding • locking the ward door

Opinions were divided about some of these absconding prevention methods. Some nurses felt that they would work, others declared that they did not. There seems to be a natural repugnance among nurses to the idea of locking the door. The following two nurses treat the idea as ludicrous and only worthy of laughter:

I can't think of anything unless you're going to go to severe measures in locking the door and things like that (laughter) which I don't think is fair on an open ward. 2070907 (laughter), Well I could say lock the ward 1042402

And the next interviewee rejects the idea because it is considered to be counter therapeutic:

since er, since I have been in nursing people have always absconded and we haven't found the right solution unless they're locked up you know somewhere, but its not very therapeutic just locking everybody up. 2020501

Yet one felt that this strategy would at least have the benefit that it would work, although this respondent was careful to not to imply support for the idea:

if you want someone to be one hundred percent safe then the only way to do that to to to, the only way to stop someone absconding one hundred percent is to have a locked environment 1030305

These varying responses, and the one that follows reflect the fact that nurses find themselves on the horns of a dilemma. The only way to prevent absconding that they perceive to be totally effective is to lock the ward door. Yet this runs contrary to their commitment to a liberal, non-coercive care environment:

Um I mean the obvious thing is you have a locked door but I don't think (laughter) we should have a locked door, I think we're an open ward and we should stay like that um, but I

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think at the same time there is, there is an inevitability that you know some people are gonna go. 3011412

Variation between Trusts In every Trust the dominant feeling when a patient absconded was that of worry and concern, and of relief when the patient returned. Nevertheless, also in all of the Trusts, the majority of nurses interviewed admitted sometimes feeling relieved when a difficult or frightening patient absconded from the ward. Mostly, nurses blamed each other for the absconding incidents. Against this background, Table 1 shows some variations between the three Trusts in the study. Trust E: small numbers of nurses in this Trust admitted feelings of frustration and anger towards patients on their return from an absconding incident. No nurses from other Trusts gave this type of response. Trust O: nurses in this Trust had higher levels of anxiety and panic following an abscond, and higher levels of relief upon the patient's return. This Trust also had the highest level of blame between all parties, and the highest number of nurses who felt that their jobs were insecure because of absconding by patients. Trust S: a lesser number of nurse were interviewed in this Trust, and no variations from the average in terms of nurse responses and blame can be seen.

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Table 1: Feelings and blame about absconding incidents by Trust Trust NURSE FEELINGS BLAME

Pt. going Pt returning Relief (at pt going) Blame Punishment Job insecurity E 1/10 anxiety or panic

1/10 disappointed. 8/10 worried / concerned 1/10 felt responsible. 0/10 felt surprise or guilt

5/10 relieved. 1/10 happy. 0/10 sad. 2/10 frustrated. 1/10 angry

6/10 said yes. 4/10 said no

8/10 nurse to nurse 1/10 management to nurse 0/10 medical staff to nurse

2/10 yes 2/10 felt insecure

O 4/9 anxiety or panic 4/9 worried / concerned. 1/9 responsible. 1/9 surprised 1/9 mentioned guilt. No one felt disappointed

7/9 relief. 1/9 happy. 0/9 felt sad, frustrated, or angry.

6/9 said yes. 3/9 said no

7/9 nurse to nurse 6/9 management to nurse 2/9 medical staff to nurse

1/9 yes 6/9 felt insecure

S 1/5 anxiety / panic. 5/5 worried / concerned. 0/5 felt surprise, guilt, disappointment or responsibility

3/5 felt relieved. 1/5 felt happy. 0/5 felt sad, frustrated, or angry

4/5 said yes. 1/5 said no.

3/5 nurse to nurse 1/5 management to nurse 0/5 medical staff to nurse

3/5 yes 2/5 felt insecure

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Findings 8

Relatives and Carer Perceptions Awareness of absconding episode

All of those interviewed were aware of the specific abscond incident asked about. However only one of the six found out about that particular incident through being informed by the hospital. Of the remaining five: Two became aware when the client turned up at the relative/carers home. Two became aware when the client phoned the relative/carer and indicated they had left the hospital. One became aware by going to visit the client in hospital, only to discover that the client was no longer there.

Lack of awareness by ward staff that a patient had actually left the ward was one area of concern.

"X rang me from a station ... she said she'd had enough, that everyone was having a go at her, that they think she is mad ... I said ‘X , you've got to get back, just walk round the block, relax, get some fresh air.’ We were 20 minutes on the phone but then she says she's going to go back, back to the hospital. I was concerned, so then I phoned the hospital - they weren't aware she'd left. I wasn't happy about that ."

Whilst it sometimes appeared difficult for relatives to understand how it was possible for patients to go AWOL, nevertheless some tried hard to give ward staff the benefit of the doubt and to understand what the problems might be for them. However 5 out of the 6 had experienced more than one AWOL, and at times this seemed to leave them struggling with conflicting emotions.

"...they've got a job to do and he's not the only patient, but sometimes I get upset - he's supposed to be there, and then they phone me and say he ain't. We don't need the police round here - I get annoyed like of course - you tell me he's gonna be locked up - but then he's out again." "He was sectioned on the Tuesday, on the Wednesday morning somebody said to me, ‘that's your brother walking up there.’ I said 'no! it can't be' - but it was! So he'd got out even with the section happening!"

Another issue raised by a number of relatives, again both in terms of the

specific incident and past experiences, was the lack of communication by staff when they were aware that an absconding incident had taken place.

"We went up to see him, he wanted cigarettes, that's how we found out, because he wasn't there. The ward doesn't contact us at all, they never contact me. As far as I know, he can go out when he likes."

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Further, there were also occasions when wards did not reciprocate information sharing, thus leaving relatives with negative feelings about the hospital. For example, a relative informs staff that a patient is AWOL, but staff do not get back in touch to let the relative know that a patient has returned, and how she or he is.

"... there wasn't any phone call to let me know she went back, or that she was committed."

Asked about feelings towards the hospital, one person said "Irresponsible. It's not the first time it's happened. I phoned once before and they just said he's off the ward, we don't know where he is - that was it. I felt scared that time, I had fears about safety. They don't communicate with me, they are secretive."

Asked if the incident had affected their relationship with, or faith in the hospital, one respondent said:

"No. You can't just blame them all the time. They are understaffed - but I don't know - I haven't really got a lot of faith in the hospital anyway."

In response to the same question, one other person admitted to not having much faith in the hospital, whilst a further two felt it had not affected their relationship, one because ‘staff do a difficult job’. One relative would have liked an investigation into both why staff were unaware of the AWOL, and why they did not keep him updated after he had informed them about it. The sixth respondent was more concerned about what he felt were unanswered questions about a client’s psychiatric history. Feelings about absconding episodes

In terms of the specific incident referred to, none of the relatives /carers had any fears about their own safety, though one expressed concern about the safety of their mother, whom the client had harmed on a previous occasion. More in evidence was a concern for the well-being of the client, with 3 of the 6 saying they had felt worried. Of the other three, one was ‘not really over-worried’. Other feelings experienced were: annoyance - because the abscond had resulted in a hospital move to one less preferred by both client and relative, and into a locked ward which the relative felt made it worse for the client; anger at the hospital, fear, frustration, stress and a feeling of having been let down by the hospital. Reasons for leaving

Despite the emotions aroused, no relative or carer felt that the incident had affected their relationship with the client. Lack of any bad feeling from respondents towards clients who absconded, appeared connected to either having some insight into or empathy with, the reason the client went AWOL, or because of a belief that the illness was to blame, and that the client did not intend to cause worry.

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"Being AWOL - I was in two minds about it, because I've been in there. I was beaten up by a patient in there, so I understand why he wanted to leave - sometimes I did too. As a patient the way you are treated by staff can also make you want to leave. I felt unsafe in that environment - I can say things now, but when you are in there you don't have a voice." "My brother is mentally sick. He wouldn't have done it in his right mind, so it's a waste of time being angry or whatever with him, he doesn't mean to cause any worry."

Other reasons given by relatives/ carers were: • a desire to sort out affairs, particularly housing • a desire to visit people • boredom • the result of people on the ward ‘having a go’ at the client • prompted by possession of his bus pass and house keys • a desire to get out How hospitals should deal with awol incidents

Unlike their views on some issues, relatives seemed less clear about how hospitals should deal with absconding incidents, and tended to reiterate the need for ward staff to consider the information and other needs of relatives.

"The nurses apologised but doctors don't give you nothing. Nobody tells you anything - they say 'don't worry' but that's all very well for them. I would like more information from the hospital when something like this happens - they could let you know straight away and keep you informed - what's happening, when he's back, how he is, what happened and so on."

5 out of the 6 were involved in some capacity in the specific absconding incident, in that they either informed the hospital and encouraged the patient to make their own way back, were involved in searching or organising a search for the patient, or took the patient back themselves. Three of the six were satisfied with the way in which the client returned to the hospital on this specific occasion, but on the basis of past experiences also, issues were raised about the process. In particular there seemed to be conflicting feelings about the use of the police.

"..sometimes we do have a job getting him back - it’s like everyone is passing the buck. I’m thick skinned, I just get on with it, but I do get cut up, believe me ... I ring the hospital, they say ring the police, the police say they don't have no authorisation, they need it from the hospital. Last time when the police was here they had to talk him out of the house - then they can take him so long as he's out, - unless he's smashing up the place ..." "... the police kept coming round. I wasn't very happy about it. X was on ITU at the time, they let him out for a little while by

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himself. He decided to come home and they phoned the police. I didn't like it - we've got nosy neighbours; the police, they were in the back garden, the front garden, that's what the neighbours said - I wasn't there at the time ... I suppose the police ought to come though really, if X is a danger to himself or others."

How hospitals could prevent absconding

Thinking about a client who left to sort out his affairs, one relative felt that escorted leave would be the answer.

"He should be given the opportunity to go out and follow things up that he wants - like a job and a flat - with an escort."

Another felt that staff would be hard pressed to do any better than they were already doing. Suggestions by the remainder included: • implementing a system where a client could negotiate time off the ward by

informing staff of his or her intended whereabouts • the ward should have only one door and that should be locked • patients should be kept under close observation • when a patient is ‘not great’, a nurse should be with him or her at all times. Relative perceptions of client care

Half of the respondents were clearly unhappy about the care their family member was receiving.

"It needs improving. I think his medication needs to be adjusted for him, tailored to his needs. I don't think it is at the moment. They need to listen to what he wants, not what they think is best. He needs emotional support and therapeutic support, as well as medication. They should also give him advice and information about his diagnosis and condition - encourage him to have contact with organisations and groups which will help him move on. He needs positive images."

Other issues included lack of help to maintain the client’s life outside - for example help with housing, help to be independent, and help to ensure bills were paid; again, the absence of information giving to relatives and carers; a perceived lack of qualified staff and a need for advocacy.

The other three were positive on the whole, although some reservations were expressed by two of the three about the medication the client was receiving.

Whether happy or unhappy with care, three out of six questioned the efficacy of hospital generally, wondering if it was in fact the most appropriate environment for clients.

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Relative involvement in client care

Only one person felt involved by staff. "Yes - they do involve me. I was up there last week - the staff do allow that now, they send me a letter when there’s a group meeting"

3 people did not feel involved in client care and of those, 2 felt they would like to be. The third was unsure. The remaining 2 felt involved through their own or the client’s volition, not because the staff included them. Both would have liked to be more informed by staff.

"Yes, I do in the sense that [client] phones me. I mean I would like to be - the hospital could keep me informed but I can't be available 24 hours a day. "

Whilst relatives who did not feel very involved in client care but would like to be, there was also an issue about getting the balance right - between what it’s fair to expect of themselves as ‘carer/relatives’ and what can legitimately be expected of the hospital. There was also some sense that they need to get on with their own lives, and that the hospital needed to respect their time.

"I have tried like, going to meetings and that, but the last one, I went up for it, then they kept me waiting for 1.5 hours, so in the end I left. The hospital could help by getting that right, and by letting me know things. "

One reason given for sharing information was based on practicalities: " If I knew about his medication for example I could help him. Like when he turned up at the weekend, there was stuff [medication] left here from before, but I don't know any more what he's on so I felt I couldn't give him any of it."

Interest in research findings

When asked, all the respondents said they would like a summary of the research findings, and one said

"It's nice to know you're doing this - it might help change things - improve care and stop the AWOLS. "

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Summary

Regardless of the extent to which relatives and carers were involved in either the absconding incident or the care of the patient generally, there can be no doubt that they are affected in some way when a patient goes AWOL. Some experienced a great deal of worry, some anger, and some a whole range of feelings. Whatever the emotion, findings also suggest that improved communication by ward staff could reduce at least some of the negative impact of an absconding incident on relatives and carers, who found it hard to understand how such incidents could occur. Despite negative feelings about absconding, relatives were disinclined to blame clients and more likely to feel angry with the hospital. nevertheless efforts were made to understand the difficulties ward staff might face in this respect.

Lack of communication did seem to be a wider issue in that relatives generally felt uninformed about the care of clients, and to some extent excluded by staff from being involved. There were also indications that some relatives were unhappy with the care received, and half the sample had asked themselves how appropriate a hospital environment actually was.

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Discussion of Findings This study is the largest and most comprehensive examination of absconding from acute psychiatric wards to date. It is the first to study three comparable hospitals and twelve comparable wards over a significant period of time, and the first to interview in depth a large number of absconding patients. In addition, this is the first study to systematically assess the views of nurses, and of patients' relatives about absconding. The ability to triangulate findings between these different sources of information strengthens the conclusions that may be drawn from findings. Equally as important was the fact that this study was the first to use an objective definition of what constitutes an abscond, that is, absent from the ward without permission for more than one hour. Thus the findings discussed here do not rely on official statistics. In this study it has been discovered that official statistics are biased by perceptions of risk and by the operations of mental health legislation. Absconds of informal patients are less likely to enter the official record, despite the fact that many informal patients feel equally coerced to be in hospital as those who are compulsorily detained (Monahan et al 1995). The effects of this bias in previous studies may have been many. For example, absconding rates are liable to have been underestimated, and the degree of risk associated with absconding over estimated. Also, work done previously on delineating the characteristics of absconders will apply mainly to legally detained absconders only. Who absconds In this study, event based analysis of the data shows that absconders are: young; male; a firstborn child; from an ethnic minority group; of the Muslim faith; living with partner or parents; with a diagnosis of schizophrenia; having had a number of transfers between wards, refusals of medication and involvement in officially reported ward incidents in the previous week; considered by nursing staff to be a risk to self or others; someone who has absconded during previous admissions; and has had previous contact with the police. This picture does confirm some of the findings from the literature, namely that absconders tend to be young, male, suffering from schizophrenia and come from disadvantaged groups. Previous studies have found that single patients are more likely to abscond than those who are married, however this was not confirmed in this study. The discovery in this study that absconding during previous admissions predicts future absconding has not been described before. It is hardly surprising, however.

The other main feature of the event based analysis is the link that it draws between many different forms of difficult and noncompliant patient behaviour. Patients who abscond are also those who refuse medication, are involved in violent incidents, have been involved with the police, and have needed to be transferred between wards. They are also those who are considered by nurses to be high risk, presumably based upon their past history. These findings indicate that all these patient behaviours are likely to be related in some way, either driven by some common

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characteristics of the patients themselves (perhaps a difficult and disruptive personality or behaviour pattern) or a recurrent and typical failure of relationships between psychiatric services and patients. The latter explanation is supported by a further analysis of the data. Event based comparisons between absconders and controls are best for the identification of factors predictive of absconding. For in this type of analysis, the more frequently an individual patient absconds, the more heavily their characteristics are weighted. This is fine for drawing up a predictive profile of the absconder for use on the ward. For the interest of ward staff is who, among the current set of patients on the ward, is most likely to abscond today. However, if we wish to know the characteristics of patients that contribute to their individual propensity to abscond, a patient based analysis is to be preferred. In other words, absconders need to be entered only once into the analysis, regardless of the frequency of their absconding, and compared to the controls. This is the first study of absconding to have carried out a patient based analysis of absconding, and the findings are that differences between absconds and controls mostly disappear. If the propensity not to comply was a characteristic of the individual, it should be linked to other individual characteristics such as gender and age. However at this level of analysis it is not, and this indicates that the origin of absconding and other noncompliant behaviours is more likely to be in the social relationship between patients and the psychiatric services. It is possible that this study was not large enough (175 absconders and 159 controls) to show significant differences at a patient based level of analysis. Nevertheless it is clear that if differences do exist at the patient based level of analysis must be small. They are certainly smaller than those large differences which are readily identifiable at an event based level of analysis. Of course it is possible that there is more than one type of absconder, and these different types of absconders may have significantly different characteristics and reasons for absconding. There are two ways of approaching this in the data analysis. Subgroups of the absconders can be compared to equivalent subgroups of the, e.g. married absconders to married controls. Or subgroups of absconders can be compared to each other, e.g. married absconders compared to all other absconders. This latter method heightens the contrast, provides the most detailed picture and has been used to compare single/multiple absconders, and male/female absconders. Most absconders do so only once. Contrasting them with those who abscond on multiple occasions shows that they are more likely to be older, female, and not single. Many of these one time absconders have what must be, from the patient's point of view, a successful outcome: 38% are placed on leave or discharged. Developing this analysis further by contrasting male and female absconders. The findings show a multitude of differences between the two groups. These contrasts provide indicative evidence that there may be at least two groups of absconders, with different characteristics, social situations, patterns of noncompliance, and relationships with psychiatric services. Some of the strongest differentiating variables between these groups are age, gender, and marital status.

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The evidence from this study has two important implications for further research. The first is that study in the diverse fields of noncompliance (medication refusal, treatment refusal, compulsory care, inpatient violent incidents and absconding) should be brought together as these phenomena are likely to be inter related. Secondly, there are liable to be subgroups of difficult and noncompliant patients, and future research should be constructed with a view to explicating these differences. How and when

In contrast to the previous literature which reports that about half of absconders leave whilst temporarily off the ward with permission, in this study 82% of absconders left directly from the ward, 14% whilst temporarily off the ward, and 3% failed to return from leave. This indicates that any effort directed towards the reduction of absconding does not need to focus primarily upon the granting of leave or permission to leave the ward. This study did not try to establish the efficacy of commonly used nursing interventions to prevent absconding. These are, typically, instituting special observation of the patient, stationing a nurse at the ward door to prevent unauthorised departure, or temporarily locking the ward door. However, although these were not evaluated during this study, it was established that 15% of absconders were being specially observed at the time of their abscond, and that 11% of absconds occurred despite the fact a nurse was stationed at the door. 1% of absconds occurred even though the door to the ward was locked. Nurse interviewees showed in their replies that they were well aware that acute psychiatric wards were relatively insecure and that all these methods of preventing absconds could be overcome by patients. The patient interviews contain accounts of exactly how they got out of the ward despite these measures. No firm evidence could be found for a relationship between staffing levels and absconding rates. Additionally, the failure to find any relationship between ward observability and absconding rates suggests that physical security does not have a very large impact.

There is, therefore, some support for the assertion that if patients are determined to abscond, they will succeed in doing so despite the security precautions of nurses. Also, that preventing absconding may be less a matter of providing physical security and supervision, and more to do with professional-patient relationships. Nevertheless, the patient interviews show that some absconds were prompted by the sight of open ward doors and the ease of getting away. The fact that high numbers of absconds take place at handover time when nurses are in their office also implies that absconding patients exploit lack of supervision to make their way off the ward. Common sense also says that locking the ward door must be at least partly effective in reducing absconding. Therefore both factors, security/supervision and professional-patient relationships are likely have an influence upon the rate of absconding. Faith should not be placed in physical security measures alone. As the majority of absconds occur during the first few weeks of admission to hospital, interventions to prevent absconding should target patients who are relatively

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new to the ward. This pattern may be due to patients being more acutely ill and absconding because of psychiatric symptoms during this period of time. Or it may be because it takes some time for staff to establish good relationships,. or for patients to settle in to ward life. However as the mean length of stay was 28 days during the study period, the tailing off of absconding may simply reflect the fact that there are fewer patients with longer lengths of stay to abscond. No relationship could be found between absconding and day of the week, number of days since last ward round, or the weather. This latter finding was a surprise, since previous research had found seasonal variation in absconding rates (e.g. Bland and Parker, 1974; Molnar et al, 1985; Falkowski et al, 1990).

No association was found between individual inpatient keyworkers and absconding, nor any association with the professional discipline of the patients' community keyworkers. There is therefore no evidence that the interactional style of individual nurses in any way precipitates absconding. However numbers of inpatient keyworkers were very large, and their caseloads small. Any relationship would have to be extreme to be statistically visible within the data.

The results do, however, show that individual Consultant Psychiatrists can have an influence upon absconding rates, separate from the effect of the ward and its nursing team. It is not known what aspect of the Consultant Psychiatrist's approach, style, treatment emphasis, method of relating to their patients, or other factor, influences absconding rates. This topic merits further investigation. Where they go and what they do Interviews with the absconders emphasised the ordinariness and normality of absconding from the ward. Few of those who left the ward engaged in any kind of bizarre activities. The majority went home, did some cleaning, cooking, watched television, saw relatives or friends, went out for a drink or a walk in the park, etc. As other studies have reported, the vast majority of absconding incidents resulted in no harm, 2.4% of incidents resulted in a patient harming themselves, and 1.6% in them harming someone else. The very normality is underlined by the fact that 96% of absconds were successfully resolved without any harm coming to the patient or anyone else. This can be compared with Milner (1966) who reported that 3.6% of absconding incidents resulted in aggression towards relatives, and Walsh et al (1988) who report figures of 6% for self harm and 1.4% for harm to others. Nevertheless, some of the instances of self harm or attempted self harm occurring during the study were potentially serious. Because the numbers were so low, no particular features of these high risk absconders could be identified. Given that acute psychiatric ward inpatients are nearly always admitted for reasons of safety, and given that so many absconds have such trivial outcomes, professional staff are placed in a very difficult position when trying to assess which absconds should be considered emergencies and result in calls to the police or other services for urgent action. On chance grounds alone, prediction that an abscond is likely to result in high risk behaviour is most unlikely to be correct. Because false positive predictions are much

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more frequent than true positives, other agencies are likely to lose confidence in the psychiatric services as a result. If they arrive in a hurry at the patient's home only to find them relaxing in front of the television, they will feel their time has been wasted. The is most likely to happen with the police who will be most relied upon when psychiatric staff consider that there is an emergency situation. The opposite scenario is just as worrying, if not more so. The abscond may be judged low risk when in reality it is not. That this is sometimes the case is shown by the fact that some patients in this study who harmed themselves or others returned to the ward by themselves or were taken back by relatives. A further illustration of the difficulty facing staff when an abscond occurs is given by data on risk assessment. Many absconders had histories of harm to self or others, and many (70%) had these risks mentioned on their care plans. Yet very few came to any harm during their abscond. How and why absconders return Most patients stayed away from the ward no more than a day or two, and most returned to the ward by themselves, again underlining the normalcy of their behaviour. However the simple fact that most came back by themselves conceals the fact that many still felt coerced, either by their friends and relatives who persuaded them to return, or because they knew that the police would be informed, or because they had nowhere else to go. Of those who refused to return, many were physically returned to the ward by friends or relatives. Occasionally ward nurses would leave the ward to return absconders, but this was very rare. Mostly they searched the ward, waited, or informed others about the abscond and requested them to take action. Those most likely to be informed were the police, but the decision to do this could take some time. The low frequency of calling the patients home (by telephone) or relatives is of note. Given that most patients return by themselves, and that significant additional numbers are returned by relatives, using these contacts might be an effective and efficient way of getting patients back to the ward. Little use is made of community teams, who appear to see themselves having little or no role in the return of absconding patients. Milner (1966) reports that a community worker with specific responsibility for returning absconding patients can be effective in many cases. However, in busy inner city mental health teams where workers have full caseloads and diaries booked full of appointments with patients, there are unlikely to be spare workers or spare time to carry out this task. This form of absconder return may have advantages over the use of the police, as it would less threatening and coercive. If backed up by ambulance staff, it may be found very acceptable by patients. On the other hand, it may be less effective at returning those who most need to be back on the ward, and in cases of recalcitrant patients, help from the police would still be needed. Some assessment of the personal safety of the workers concerned would also have to be made, as they may be exposed to undue risk by seeking to persuade disturbed patients to return to the hospital.

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This uncertainty about the actual risk posed by absconding psychiatric patients is also expressed in the variable response of the police to requests to return patients. This variability is not obviously linked to the risk history of the absconders concerned, but seems to be determined more by the some factors (unknown) within the police organisation or characteristics of individual officers. For example, although most absconders are returned to the ward fairly amicably when a couple of police officers call around at their house, sometimes a large number of riot police will call at the patient's house, sometimes in the small hours of the morning.

The use of this level of force can be justifiable. The potential for serious injury is present in any confrontation, and when in their own home patients may have access to weapons. A London police officer was recently killed during an operation to capture and take to hospital a disturbed psychiatric patient. The use of large numbers of police in riot gear should be seen in the light of such incidents. The potential exists for improved liaison between the police and psychiatric services. This could be beneficial in many ways to both services. Following the Reed Committee Report (Dept. of Health 1992) many advances have been made in this area in relation to mentally disordered offenders, particularly in the development of court diversion schemes (Cohen and Midgley 1994). Due to absconders not being offenders, they appear to have been forgotten in discussions about liaison between the police and psychiatry. Joint action over absconding patients is long overdue for review. Absconding takes up many hours of valuable nursing and police time. Any potential opportunity to save these scarce resources should be seized, while still maintaining patient and public safety. Why do patients abscond The primary or main reasons given by absconders for their behaviour are diverse. Moreover, these reasons or triggers for absconding need to be set against a background of the absconders discontent with their position as a patient on an acute psychiatric ward. Even those who gave psychotic or plainly incomprehensible reasons for their departure from the ward, backed these up by additional and quite sensible reasons for why they did not like staying. If nothing else, the interviews of absconders reveal how unpleasant an experience it can be to be admitted to a psychiatric ward. For some, admission to hospital is a profoundly socially isolating experience. Many of the absconders complained that they did not see enough of their family and friends, and worried about how they were getting along or managing whilst the patient was in hospital. The social and family networks of psychiatric patients tend to be restricted and frail (Brown and Harris 1978). Admission to hospital places a further stress upon these networks, which although they can appear frail and superficial to the outside observer, may be highly prized by the patient. It is particularly striking how one in three male patients went directly to visit friends or seek friendly companionship on absconding from the ward. It is all to easy for the psychiatric professional to have a rosy view of the nature of the acute psychiatric ward as a friendly community of people. Just because people are severely mentally ill does not mean that they have so

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much in common that they must be friendly, understanding and supportive to each other. In fact, they are more likely to be like any other random group of people temporarily gathered together: superficially polite towards each other with the blossoming of friendship comparatively rare. For the patient who has defective social skills, making and securing friendships on the ward may be difficult or impossible. Thus, even in the midst of people with similar difficulties, being a patient can be a lonely experience. Not only may other patients not be sufficient to replace the gap left by absent friends and relatives, they may also be positively frightening. The commonplace media picture of madness as uncontrolled violence (Philo et al 1994) also permeates the patients' views of each other. They may be sure that they themselves pose no threat to others, but they are by no means sure about the other patients on the ward not posing a threat to them. Occasionally these fears are overlaid with paranoid ideation or delusions, producing a powerful motivation to abscond or leave. More frequently, just plain unembellished fear of assault is motivation enough. Any confrontation between patients, or between patients and staff, can raise the anxiety of patients to unbearable levels, even if only verbal. Events that happen suddenly, or at night when people feel most vulnerable, are particularly likely to arouse fear and lead to absconding. Of course patients' fear of assault is not groundless. Violent events do happen on psychiatric wards (22.5 incidents per 100 beds per year, Noble and Rodger 1989), and they are sometimes, albeit rarely, very serious. Being on the ward can also make patients feel bored, trapped, and claustrophobic. Although some hospitals in this study had occupational therapy support to the inpatient acute wards, the nature and extent of this varied. There are many unanswered questions about ward based activities for acutely ill psychiatric patients. It is not really known what sort of activities are feasible or appropriate in this context. Neither have any been assessed for their palatability to patients and effectiveness in relieving boredom. Lastly, there is a grey area in that some such activities can be seen as work, or therapy, or entertainment. The appropriate emphasis for in patient contexts is not known. Patients worry a great deal about their homes and flats while they are in hospital. Not only are they homesick from friends, neighbours and relatives, they are homesick quite literally for their homes. Many have not travelled a great deal or widely, and may not be used to being away from home. Many are relatively poor and may have taken a good deal of time to accumulate property of get their house arranged in the way they wish. It is sobering to think of the elaborate preparations made by an ordinary healthy person before they leave their home to go on holiday: checking appliances to make sure they are switched off, emptying the refrigerator, making arrangements with neighbours to collect mail, giving a friend a key and asking them to check every so often, setting a burglar alarm, etc. All this just for two weeks holiday. For the psychiatric patient admitted to hospital their is little time, ability or resources for this preparation. Everything happens in a hurry, if not as a surprise to the patient. Little wonder that they worry about their home, worry about their bills being paid of their electricity cut off, worry about the home become stale and dirty, and most of all worry about being burgled.

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This latter is a serious and rational worry, as many patients live in areas where burglary is very prevalent and likely to befall any unoccupied property. Two absconders had their flats burgled while they were in hospital. Crudely extrapolated, this appears to suggest that 1 out of 26 patients admitted will have their homes broken into while they are in hospital. This high risk is confirmed by other absconders, who related how this had happened to them on previous admissions, and how they worried about it happening again. The emotional upheaval caused by burglary is well known, and in addition, psychiatric patients are psychologically vulnerable people with few financial resources. Little surprise, then, that worry about their homes and the practical affairs related to their upkeep, maintenance, and financial management, leads some patients to abscond.

A significant number of absconders (one in four) leave "in a huff" with the staff, particularly when requests for leave and discharge are turned down. Some described how they had made great efforts to appear at their best at ward rounds, or to present their case in the best possible light, only to be refused in a way that made them feel they were unimportant. Perhaps psychiatric professionals don't always realise how emotive and how important it is to the patient to get a positive response to their requests. To the staff, refusal is no more than a trivial delay in the patient's orderly progression towards discharge. To the patient, emotionally and practically, it might be considered a disaster - a crisis that may be further complicated and exacerbated by their mental state.

Other angry leavers appear to be locked in to a relationship characterised by

long term conflict with psychiatry. This conflict is magnified and renewed by the restrictions placed upon them as a psychiatric patient. Restrictions might be small, solely a result of the needs of community living (e.g. smoking rules), or large and related to compulsory care under the mental health act (e.g. enforced medication). Regardless of their source or purpose, to the unwilling psychiatric patient, all of them chafe and grate, feeding anger, annoyance, and irritation. It is not therefore surprising that the sight of the open ward door is a temptation that cannot always be resisted.

The attitude of absconders to their illness and its treatment divides them roughly into two groups: "refusers" and "disputers". The Refusers deny that they are ill, assert that they feel well, and consequently believe that there is no need for them to be in hospital. Most admitted that they had been unwell and in need to treatment, but in their eyes the illness had come to an end and the need for treatment and hospitalisation had evaporated. The Disputers, on the other hand, did not deny that they were ill and in need of treatment. Instead they disagreed with the nature of what was being offered and the way their problems were perceived by psychiatric professionals.

With the Refusers, if persuasion and reasoned argument fail, and if the risks

posed are viewed to be great enough, staff have recourse to the provisions of Mental Health legislation. Compulsory care is instituted and both parties have to tolerate the consequences. For the staff this means facing the ongoing hostility, and anger of the patients, and rejection by them. For the Refusers this means putting up with legally authorised restrictions. It is for these patients that absconding is most likely to result in forceful return to hospital by the police. In this situation, nurses deliberately distance

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themselves from the legal situation, and portray themselves to the patient as equally imprisoned by the legislative framework, i.e. we don't like making you stay or enforcing your medication, but the situation forces us to do so. In this way they make a small amount of potential room for the building some tenuous form of alliance or relationship with the patient. It must be suspected that for the hard core of Refusers eventual discharge results in the sundering of links with psychiatry and the rejection of follow up treatment - until the next crisis and compulsory admission. Other reach some form of accommodation with psychiatry as, over time, the view of the staff on their mental state starts to match their own. The Disputers tended to conceive of their problems in a wholly different way from the staff. Either they would lay claim to what was, in their own eyes, a more appropriate diagnosis of their problems, or they would conceive of their predicament in terms of their ability to cope with daily life, or their cognitive ability. These different views led to a variety of conflicts, usually either over medication, or whether the patient was fit for discharge. One absconder left in anger to prove how really ill she was, other left because they felt they were well enough (in terms of coping) to go home. These conflicts also led to eventual alienation between the patients and staff. The perennial questions of staff about textbook psychiatric symptoms clued in these patients to the fact that these were the staff's criteria for wellness. Thus they started to hide from the staff their real thoughts and feelings. Alternatively, if the patient felt in desperate need, but staff refused to agree with the patient definition of that need or to rate it with the same urgency, patients would behave in ever more extreme ways trying to seek the response they needed to soothe their distress. Perhaps patients do not even always know what that response is, only that the staff response that they do get is unsatisfactory. This latter pattern is very similar to that termed malignant alienation (Morgan & Priest 1984), or to patient behaviour otherwise described in relation to the care of patients with borderline personality disorder (Gallop et al 1989). This absconding research demonstrates that these negative patterns of interaction between staff and patients are not restricted to personality disordered patients, and are common among those who abscond. The experience of Refusers and Disputers in relationship to absconding highlights several issues. Firstly that one way to reduce absconding would be to improve staff-patient relationships. A second might be to be more open with patients about the reasons for admission to psychiatric hospital. Admission is seldom primarily about treatment, although treatment in the form of medication usually plays a role. There is no psychiatric treatment that cannot be delivered to a patient at home (Marks et al 1994). The reason for admission is primarily about safety, the safety of the patient or the safety of the public. However it is often uncomfortable to say this to patients, so instead the word 'treatment' is used as a euphemism, typically "we'd like you to come in for some treatment". What a shock therefore, when the new patient arrives on the ward, to find that they are detained there, seldom see their doctor, and are largely left to their own devices. Given they have been told what may be referred to as 'the big lie', it is not surprising that they become confused about what is going on the ward, and what exactly they have to do in order to get discharged. More openness about the reasons and criteria for admission and discharge may not lead to more

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agreement, but it may lead to more understanding and compromise between staff and patients. The attribution of absconding to psychotic causes and reasoning only accentuates alienation between staff and patients. To do so constitutes the medicalisation of absconding, and the treatment of absconding patients with higher levels of sedation. This is a suggested strategy by some nurses, as their interviews show. However this implies a dehumanising picture of the acute psychiatric patient as totally incompetent person whose behaviour is the meaningless product of a disordered brain. This does not match the reality of daily life on the ward. Patients can still talk reason, read the newspaper, play games, etc. Whole areas of their life and competencies are untouched or only slightly undermined by their psychiatric symptoms. The use of the illness as an explanation for difficult behaviour is too easy, too lazy, and contrary to daily experience of the nursing care of patients. Mental disorder clearly plays some role in absconding, but not by itself. To write everything off as irrational behaviour means that listening to the patients will cease and understanding disappear. Moreover, it distances staff relationships with patients and adds to the very problems that this research has shown contribute to their absconding. Given all the above, it must be expected that what absconding patients have to say about staff is unlikely to be positive. In fact it comes as a surprise that they have anything good to say about psychiatric professionals at all, but some do, commenting favourably on the friendliness of nurses and expressing respect for doctors. However the majority of comment is unfavourable, with doctors seen as distant, disbelieving of patient reports, authoritarian, inaccessible and not having sufficient time to listen to patients' problems, and nurses seen as powerless in comparison to doctors, bossy, and unwilling to spend time with patients. Relative and carer views of absconding Perhaps the most striking thing to come out of the telephone interviews with relatives was how poor the communication between them and the hospital was' although the sample was very small, so conclusions must be tentative. However most felt as if they were left completely in the dark. And this was in relation not just to absconding but to many other issues as well. The interviewees did not know or understand how the ward operated, nor the difficulties of keeping patients in hospital even when they were detained under the Mental Health Act. The fact that most interviewees discovered the absconding incident for themselves, or even in the worst cases were the ones who informed the ward staff that the patient had gone, was not conducive to confidence in the care provided on the wards. The quantitative data confirms that relatives/carers are seldom informed about an abscond (23% of occasions), even though a substantial number (8%) were brought back to the ward by them. Even if they are informed about the abscond, ward staff may fail to let them know when the patient has returned. No wonder one respondent felt that the nurses were deliberately secretive. The interviews reveal that the carers are seldom worried about the safety of others during the patients abscond, but that more frequently they worry about the

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safety of the patient. They do blame the hospital not the patient, and can feel angry and let down by those whom they trusted to care for the patient. In combination with the fact that they feel left in the dark much of the time, this does not facilitate teamwork between the staff and significant others in the patients life - a lack of teamwork that must surely overflow into relationships around community care when the patients are discharged. In addition, lack of communication may make the relatives/carers feel less welcome to visit on the ward, contribute to the patients’ feelings of isolation, and thus to their desire to abscond in the first place. The six interviewees did register acutely uncomfortable feelings about the use of the police to return absconding patients. They agree that it is necessary, but felt deeply upset about that necessity. In addition, one interviewee related how difficult they had found it to persuade the police to take the absconder back to hospital. None criticised in any way the methods used by the police in carrying out this task.

It is not easy to see how ward staff should respond to these mixed feelings. Perhaps an opportunity for the relatives to attend for a post abscond debrief with the nursing staff would help. In that meeting the staff could explain their difficulty in managing the patient, and ease the relatives feelings about the necessity for police intervention. Plans for managing the patient in future could then be agreed, and a channel of communication opened with the nursing staff. Meetings like these would not have to be formal and could take place during visiting hours. At present it would appear from these interviews that staff hardly talk to relatives/carers at all. Of course not every absconding patient has a significant other to be this involved in their care. The difficulties in recruiting interviewees for this part of the study illustrate that. However, if this is the case it only underlines how socially isolated some patients are, and how fragile and tenuous are their social networks. Nurses views on absconding Nurses are well aware of the potentially serious outcomes of absconding (e.g. Sheppard 1996, Crammer 1984), hence their feelings on discovering an abscond are primarily those of anxiety and worry for the patient. This they have in common with the absconding patients' relatives and carers. Exactly what action the nurses then take, they explain, depends upon the assessment of risk posed by the patient. Should the patient be considered low risk, then the staff may be willing to wait a little while to see if they come back, however if considered a high risk the police may be informed immediately. In one case related by a patient absconder interviewee, the nurses from the ward went immediately to her house and intervened after she had taken an overdose. Risk assessment was viewed by nurses almost in two ways. The first was that a risk assessment took place on admission. In some Trusts, apparently, the nature of that assessment was laid down by policy and special forms were used. The second view of risk assessment that emerged was that it was a continuous process throughout admission, and that the judgement of risk had to be made anew and again once a patient absconded. Presumably this would be to take into account the behaviour and

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speech content of the patient during the preceding week and preceding 24 hours, as well as a longer term perspective based on the history of the patient, maybe accumulated over many years psychiatric treatment. Few of the nurses mentioned any uncertainty about the risk assessments which were made. Perhaps this indicates a degree of confidence which is not warranted by studies which have assessed the ability of psychiatric professionals in this field. Monahan (1981) has pulled together evidence that positive predictions by psychiatric professionals are correct no more than one out of three times. This estimate is based upon predictions for patients being discharged from hospital, and may well not apply to absconders. Some have suggested that short term predictions of risk may be more accurate. Nevertheless, the nurses in this study appeared to express a degree of confidence about their ability to accurately predict risk that is simply not warranted by any empirical study. For these nurses, risk seems to be a defined quantity possessed by a patient at a particular point in time, moreover it is one that is transparent and known to the staff. Even when this assessment is called into question by doctors and conflicts emerge, nurses still seem fairly certain of their assessment of risk. Only two of the interviewed nurses expressed any uncertainty about the accuracy of risk assessments. The nurses views on constant observation and absconding do match those of the literature. The initiation and termination of constant observation is usually determined by doctors and nurses together (Duffy 1995), it does not always work (Pauker and Cooper 1990), it is stressful for nurses to undertake (Phillips et al 1977), and not particularly well tolerated by patients (Pitula and Cardell 1996). The divided opinions of nurses on other methods of preventing absconding reflect the fact that they do not know of any evidence to say which would be effective or not. Their emotive reaction to the issue of locking the ward door, and their clear commitment to a liberal psychiatric ethos where it remains open, is of interest. There are at least two psychiatric units in nearby inner London where all ward doors are kept locked all the time. In those places the staff find these measures unexceptionable, and in their view effective. Such strongly contrasting differences in emotive commitment to different methods of psychiatric nursing care are common internationally (e.g. on mechanical restraint, Bowers et al 1995). It would seem they may also exist between different locales in the UK. The vast majority of nurses were convinced that increased staffing levels and stability, plus less reliance on agency staff, would decrease absconding. This was not solely because they felt that patients would be better observed by staff who would be able to recognise them. In addition it was because they felt that nurses would then have time to get to know the patients properly as people, thus being better able to meet their psychiatric nursing care needs. The authors of this report are not aware of any empirical study that addresses the issue of psychiatric nurse staffing numbers per se. Changes in staffing and staffing instability have been anecdotally reported to have negative outcomes in patient behaviour (James et al 1990). Actual staff-patient ratios are the outcome of bargaining, negotiation, budgetary issues and historical factors. The absence of any thread of empirical evidence is startling. These nurses may well, therefore, be correct. More nursing staff may mean fewer absconds. Even if they are correct, locking the door whilst keeping staffing levels at current levels may be

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equally as effective. The type of environment produced, however, may be more impersonal and less desirable.

There exist two incompatible views of staffing levels on acute admission psychiatric wards. One is represented by the nurses interviewed in this study: staffing levels are too low for safe practice and doing the task of psychiatric nursing. The second, arising from research, shows that psychiatric nurses spend large amounts of time on administrative tasks in the ward office, and that they may avoid patient contact by this means. Such criticism of psychiatric nursing practice cannot easily be shrugged off, as it has been a repeated finding of research (Higgins et al 1997, MHAC & SCMH 1997, Cormack 1976, Altschul 1972) and is even reported by a patient in this study:

pt: the staff here .. they don't listen .. even if you're ill yeah .. very ill .. they don't give a shit about you .. they're all drinking tea in the office ..( P21704)

These issues (staffing levels and deployment, observation policies, locked doors) are so important that they cry out for research investigation. Certainly the nurses interviewed in this study felt vulnerable to being blamed for absconds. It was not that they felt absconds were never due to errors in nursing care. In fact several examples were provided by them of nurses stationed by the door who let patients out, or of constant observation not being carried out according to procedures. However what bothered them was the lack of acknowledgement that even when the right procedures were invoked at the right time, and carried out to the letter, given sufficient determination and commitment by the patient they could still manage to abscond. Should that occur and the patient or someone else come to harm, the nurses reflected a gnawing insecurity that they could still be blamed. Or, that in retrospect, a nurse to blame can always be found. This is no light matter. A large number of nurses came to work thinking that if a patient absconded and something went wrong, even if it was not their fault, they were at risk of being blamed, suspended, or even possibly losing their jobs. These fears may or may not have been correct, however they were present for 42% of the nurses interviewed. This may partly illuminate the difficulty in recruiting and retaining psychiatric nurses to work in inpatient areas. Ethnicity and absconding

Taken as a whole, all ethnic minority patients are more likely to abscond than their White European counterparts. This is perhaps indicative of a more dysfunctional relationship with psychiatry and psychiatric professionals. That dysfunctional relationship may arise from a variety of factors, from simple cultural misunderstanding on either side, to lack of trust in psychiatry by the patients or ethnocentric views of professionals. This study of absconding cannot answer many of the highly important questions that surround the psychiatric care of ethnic minority patients. What this study does illustrate is the deep differences between different ethnic minority communities.

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Previous research purports to demonstrate that Afro-Caribbean's are more likely to be diagnosed with schizophrenia (Harrison 1988), more likely to be detained under the Mental Health Act (Moodley & Perkins 1991), and more likely to be treated with physical rather than psychological means (Chen et al 1991). This research has been taken by some to show that psychiatric professionals use a prejudicial stereotype when it comes to ethnic minority patients, one that characterises them as "Big, Black and Dangerous" (Prins et al 1993). The research on absconding fails to support this latter assertion. For if psychiatric professionals were employing such a negative stereotype across the board, based in some way upon skin colour, then it would apply to all ethnic minority groups. Instead this research shows stark differences between absconders from different communities. For example, it is not the Afro-Caribbean's who are more likely to abscond in this study, it is instead the Bangladeshi's and Somali's, with the White Europeans being less likely than anyone else to abscond. When male and female absconders are contrasted, female absconders are more likely to be Afro-Caribbean's or White Europeans who are older and separated/divorced, whereas male absconders tend to be Bangladeshi's or Somali's who are younger and single. When assessed risk to others is considered, it is the Bangladeshi's (56%) who are most likely to be considered a risk, and the other African's least (5%). The pattern changes, as in a kaleidoscope, when risk to self is considered. Now it is the White European's (30%) who are most likely to be considered a risk and the Somali's (12%) the least.

These results illustrate that there is no monolithic black community that is universally discriminated against and the target of psychiatric racism. Instead there are a multitude of very different minority communities. Each has their own social relationship with psychiatry dependent on their culture, origin, and process by which they arrived in the UK. The problems of each, in relation to psychiatry, need to be understood on their own terms.

Making sense of these differences with the data from the absconding study is

difficult. The differences are easier to describe than explain. For example, although many of the findings about Bangladeshi absconders fit together (do not live alone, brought back by relatives, etc.), other questions such as why they are so young and why they are particularly frightened in hospital go unanswered.

One item indicative of some form of ethnic bias with regard to perceived risk

was found in the data collected in this study. The findings show that Afro-Caribbean absconders are more likely to have the police informed about their abscond than other ethnic groups. This is despite the fact that they were no more likely to have had previous contact with the police and no more likely to have had any kind of forensic history. This tendency for the police to be informed is greater for second and subsequent absconds by male Afro-Caribbean's. It may be some subtle cue, a small cultural variation of facial reaction, body language, timing of speech, vocabulary used or tone of voice, that unknowingly to the patient communicates threat to the psychiatric professional. Or, there really is a bias operating in staff's judgement of the risk to others posed by absconding patients from this background. Or, psychiatry really does, in some as yet undescribed way, assemble differently risky people from different ethnic backgrounds. It certainly seems to work that way for White European

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absconders, who have more history of suicide, are considered more of a risk to self, and account for most of the self harm attempts during absconds. However the Afro-Caribbean absconders do not have more of a forensic history behind them, nor do they account for most of the instances of harm to others logged by this study, so the tendency for the police to be informed more often is not so readily explicable.

The abscond data raises interesting questions about the complexity of the interaction between ethnicity and psychiatry. It does not provide any complete answers. Absconding rates in the East End of London Absconding rates in the East End of London by the Molnar and Pichoff (1993) formula is 38.7. It is difficult to set this figure within the context of previous studies, as widely varying rates have been reported. This figure is comparable to that reported by Neilson et al (1996) of 34.5 for acute admission wards in Sheffield. It is very different from that reported by Tomison (1989) of 8.7 for Barrow Hospital. However Tomison's figure was for the whole of a 316 bed psychiatric hospital, not just acute admission wards. Acute admission wards are likely to generate the higher rates of absconding, therefore those studies using whole hospital statistics seem likely to provide a misleadingly low rate of absconds when extrapolated to acute admission wards only. In addition, most previous studies have used official reports as an operational definition of an abscond. If the same criteria is applied to the data collected in this study, official abscond forms were only completed for 236 of the 498 absconding events. The rate for the East End of London then dips to 18.3. All that can really be said with great confidence about the rates of absconding in East London is that although they are at the top end of the range reported in previous studies, they are not exceptional. Trust level factors Some differences between the three Trusts studied were elicited in the course of analysing the data.

Trust S seems less likely to allow patients to leave the ward for short periods of time (or the staff there are better at judging who is likely to abscond when given this privilege), as only 2.4% of their absconds take place under these circumstances, compared to 13% and 15% in the other two Trusts. Trust S also appears to try to prevent absconding by stationing a member of nursing staff at the door, as 52% of their absconders leave while this policy is in operation. These modes of enhancing ward security (low use of temporary leave and high use of 'door stops') do not seem to have an unambiguous relationship to absconding rates, and it is far from clear whether they are effective or not. Trust E has the highest rate of absconding by some measures, but the data are not consistent enough to assert confidently that this represents a real difference in

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absconding rates. Only half the number of absconding patients in this Trust are returned by the police, although there is no difference in the proportion of absconders who are officially reported to the police. This may indicate a more difficult relationship between the police and psychiatric services in this locality, or that police there have fewer resources to expend on returning absconders, or give this task a lower priority. More absconders leave whilst away from the ward with permission in this Trust. This may indicate the psychiatric professionals there are confident and willing to take more calculated risks in allowing patients to leave the ward temporarily. Of all the three Trusts studied, Trust O appear to have the most differences from the other two. These findings may reflect more anxiety about patients and the harm they may come to during an absconding event. For example, more absconders are placed on intermittent nursing observations prior to their abscond, more were admitted on treatment sections of the Mental Health Act, and overall, many more absconders were considered to be a risk to others. More absconders escaped from wards which were locked in this Trust, possibly indicating that ward doors are locked more frequently. This was the only Trust from which some absconders reported that their visitors had not been allowed onto the ward, motivating them to abscond in order to see them. The interviews of staff showed the highest levels of blame for absconding in every direction, nurse to nurse, doctors to nurses, and managers to nurses, and more nurses were insecure about their jobs in this Trust than in others. Each of these findings in isolation could be explained as chance anomalies. However together they form a stronger picture, much less easy to explain away, of an organisation in which anxiety and blame are high. These findings may indicate overall low staff calibre in Trust O, with the high levels of anxiety justifiable because procedures are not being properly followed. Or they may indicate that this Trust does selectively admit patients who are more dangerous than the other neighbouring Trusts. On the other hand the findings may indicate a punitive and unsupportive culture in which staff feel highly vulnerable both from the actions of patients and from the actions of colleagues and managers, and as a result struggle harder to contain patients who are considered to pose risks to themselves and others. As can be seen from the data in the study, different NHS Trusts can have very different operational policies in relation to absconding, risk assessment and risk containment. It is sobering to realise that these differences can still exist and be quite large in Trusts which are geographically neighbouring, serve similar populations demographically, and were even in recent memory part of one organisation. These variations between Trusts indicate that psychiatric organisational culture is considerably diverse, and does impact upon patient care. Ward level factors The use made in this study of a variety of ways to express absconding rates enables a much fuller comparative picture to be drawn of the differences between wards. It can be confidently asserted that some wards have significantly higher rates of absconding across the board than others, and some lower. These variations are not

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explicable by the complexity of design or other security features of the ward that enhance or obstruct the observation of patients, or the ease with which they may leave. Moreover, some wards appear to be better at preventing further absconds after one has occurred, indicating that they may respond effectively in some way once the risk of absconding is firmly identified.

These findings provide grounds for the assertion that the way nursing staff deliver psychiatric nursing care on the wards can have a significant influence upon the rate of absconding. What the important factors are have not been directly assessed by this study. The methodology was not designed for this and does not show an association between individual wards and the reasons patients gave for absconding. Nevertheless this study has described the reasons patients have for absconding, and it may be hypothesised that on wards with low absconding rates patients have fewer of these reasons due to a different style of nursing care.

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Conclusions and Recommendations Limitations This study took place in the East End of London. It must therefore be cautioned that results may not be fully generalisable or applicable elsewhere in the UK. The East End of London is unique in several ways. Firstly it comprises part of inner city London, an environment which is known to have an exceptionally high psychiatric morbidity (Johnson et al 1997). Secondly, it contains some of the most deprived and poor areas in the UK by Jarman index (Jarman et al 1992). Thirdly, the local population is made up of high numbers of several culturally diverse ethnic minority communities. Each of these three factors must be taken into account when assessing the applicability of this research to other areas. Reliance upon nursing and medical notes for information about absconding and control patients was inevitable. Where gaps existed, the ward nurses on duty at the time the data was collected were asked to provide the information. Some data items could not be collected for some patients. These methods are not fully reliable, and the diagnostic information used in this study is liable to be particularly weak. The interview sample was biased towards male absconders. All interviews took place on the wards. Female absconders were more often placed on leave or discharged without returning to the ward, and were therefore less likely to be asked for an interview. Resources were not available for interpretation, and non English speakers were not interviewed. In addition, some returning absconders were too ill to consent to or take part in an interview, thus the sample is somewhat biased towards the more cognitively competent absconders.

It may be suggested that the accounts of absconding patients should not be uncritically accepted. They may be biased, self serving exaggerated accounts by a particularly disgruntled group of patients, containing excuses and special pleading by those who know they should not have absconded. In addition, these retrospective accounts may have been influenced by patients mental disorder, e.g. delusions, hallucinations, anxiety, paranoia, poor memory and confusion. Nevertheless the reasoning given by patients for their abscond was, in most cases, detailed, reasonable, and very believable. As few felt guilty about their abscond, it may be deduced that they had no motivation to provide self justifying accounts of their behaviour. Finally, absconders may indeed be a disgruntled and unhappy group of clients. However this research set out to discover some of the reasons why they might be so discontent. Asking them to elaborate on their discontents and complaints about ward life was therefore an intrinsic part of the study design. These content of these complaints cannot be generalised to all acute inpatients - those that stay on the ward and do not abscond may have a different perspective. However what is described in this report does accurately represent the views of absconders. The strengths of this study lie in its size, independence from official reporting procedures, prospective design, and triangulation from many data sources. The combination of qualitative and quantitative methods has allowed comparisons

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between different types and sources of information at the stage of analysis. The use of computer aided qualitative data analysis has allowed statistical testing to be applied to some qualitative interview findings, and aided in the production and application of rigorous codes and analytic procedures. Conclusions Although absconding from acute psychiatric wards in the UK is a common problem, it is not an intractable one. Findings of variations between NHS Trusts and individual wards indicate that there are different forms of psychiatric care delivery that can have a significant impact on absconding rates. Although for most patients the dangers involved in absconding are small, negative outcomes do occur, and absconding causes much anxiety for nurses and relatives/carers. It thus remains a serious problem which requires action to prevent harm coming to patients or others. It is possible to draw up a predictive profile of the potential absconding patient, and this study provides the tools with which to do that. Once done, interventions to reduce the risk of absconding may be targeted at this group, enhancing the efficient use of nursing time. Although the symptoms of mental illness do play a role in absconding, the larger picture shows that life on the ward is difficult for patients. They can feel trapped, bored, frightened, cut off from their families and friends, and have justifiable worries about their home responsibilities. These factors contribute to the decision to abscond from the ward, whether that takes place impulsively and in anger following bad news, or whether patients make a more planned exit to undertake some activity outside the ward. Methods of physical security and supervision may not be as effective as is often hoped. This study show that attention directed to the patients psychosocial problems, and to the building of a good relationship with them, may be more productive in reducing absconding. In addition, it should perhaps receive wider recognition that even when physical security procedures are followed in detail, patients who are determined may still manage to abscond from the ward. Most patients go home and undertake normal everyday activities when they get there. And most come back by themselves, under their own steam, usually the same day. Some are brought back by relatives, and those relatives can feel uninvolved and left in the dark about the psychiatric care of the patient. Those brought back by the police appear to have a variety of very different experiences of their return to hospital. Better liaison and communication between hospital, police and relatives/carers might therefore be very productive in decreasing the workload associated with returning the absconder, and in promoting patient safety. As always, more research is required. This study has shown tantalising glimpses that absconders are not all the same, and that there may be two very different groups who have different reasons to reject inpatient care. The unique characteristics of different ethnic minority groups in relation to absconding and psychiatric inpatient

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care is worthy of much more extensive exploration than could be undertaken in the course of this study. Lastly, it is now possible to construct a nursing intervention to reduce absconding based on the findings in this report. Such an intervention requires a controlled trial at the earliest possible time. Recommendations 1. Some form of home care and home security service for psychiatric inpatients might

be highly valued by those who worry about their property. 2. Nurses may wish to involve relatives and carers (subject to patient agreement) to a

greater degree in the patient's care on the ward, and when seeking their return to hospital following an abscond.

3. Psychiatric service providers may wish to discuss with the police some form of

prioritisation system for absconders who pose different risks, plus some communication over which absconders may pose a risk to the police involved in their return to hospital.

4. There may be a role for Community Mental Health Team staff (perhaps in

conjunction with duty systems) in the return of lower risk absconding patients. This does not necessarily mean physically returning the patient to hospital, but may mean a call at the patient's home and persuading them to take a hospital financed taxi back to the ward.

5. Psychiatric staff (of all disciplines) may wish to renew their efforts to understand

and deal with the patient's worries about home life and responsibilities. 6. Multidisciplinary care teams may wish to consider transfer to a locked intensive

psychiatric care environment, or discharge, for every patient who absconds more than two or three times during a single admission

7. A controlled trial of an nursing intervention to reduce absconding rates, based upon

the findings of this study, should be undertaken as soon as possible.

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Appendices

Appendix Page 1 Ward staff abscond notification form 141 2 Researcher abscond data collection form 142 3 Interview schedule for absconders 146 4 Interview schedule for nursing staff 149 5 Telephone interview schedule for relatives/carers 151 6 Index of ward observability 158 7 Notes on transcription conventions 160

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Form AContact: Manuela Jarrett Phone: 0171 505 5840 Mobile: 0966 510489

Section 1

Ward: ___________________ Date: ____________ Patient initials: _____________

Time patient noted as missing: _____________

Please tick which of the actions were taken in response to the patients absconding and at what time they were taken.

Wait_________am/pm

Community worker informed ________am/pm

Consultant informed________am/pm

Duty doctor informed_________am/pm

Duty nurse informed _________am/pm

GP_________am/pm

Hospital grounds searched_________am/pm

Missing person form circulated________am/pm

Patient’s home contacted__________am/pm

Patient placed on leave_________am/pm

Police informed_________am/pm

Relatives contacted__________am/pm

Researcher contacted__________am/pm

Social Worker_________am/pm

Ward Manager_________am/pm

Ward searched_________am/pm

_________________________________________________________________________________________

Number of staff on duty: Qualified: Unqualified: Students:

Agency: _________________________________________________________________________________________

Number of patients on high obs: Continuous: Close: (highest level (level 2/B/15 mins of observation) observation)_________________________________________________________________________________________

Section 2

OUTCOME

Date: ___________________ Time: _____________________

Patient returned to wardMethod of return: ______________________________________________

Patient seen by agency and dischargedAgency (e.g. CPN, GP, ):_______________________________________

Patient not seen by any agency and discharged

Patient placed on leave

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Form B ward:

consultant: current/previous psychiatric state -

Y N

patient:

diagnosis: previous admissions:

d.o.b.:

in-pt. k/w: known to police/courts:

gender:

date of admission: previous forensic admissions:

marital status:

source of referral: self mutilation history:

sibling order:

com. k/w (name/discipline): previous awol on this admission:

ethnic origin:

number of ward transfers in last seven days: awol on previous admissions:

religion:

risk as noted in care plan: current risk to others?

highest education to date:

mha status on admission: current risk of neglect?

living grp: accommodation: n of medication refusals in last 2 days: current risk to self? occupation:

n of incident forms for last 7 days: pt confined to ward?

time of last employment: 0-6mths 7-12mths 13-18mths 19-24mths <24mths

level of observation 24hrs prior to being noted as awol:

did patient express wish to leave ward within previous 24hrs of going awol?

Medication at time of abscondence: history of suicide attempts? approx date of most recent att:

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place/situation of absconding episode: security status of ward at time of ab.: mha status at time if different from admission:

date of change:

circumstances that led up to awol (continue overleaf if necessary): Risk outcome: changes of management of care on return on return to ward *(specify below): no change medication altered* mha status altered* ward transfer* other* ___________________________________ ___________________________________

research outcome: interviewed on (date): _______________ at (time): ________________ not interviewed due to: mental state/language difficulties/placed on leave/ discharged/failed to return/refused/ other ________________

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Codes for Form B Wards 1= 2= 3= 4= 5= 6= 7= 8= 9= 10= 11= 12=

Gender 1=female 2=male Marital Status 1=Single 2=Married/Stable partner 3=Separated/Divorced 4=Widowed 5=Other

Ethnic Origin 1=Afro-Carribean 2=Bangladeshi 3=Other African 4=Somali 5=Other Asian 6=White European 7=Turkish 8=Not known 9=Other

Religion 1=Christian 2=Hindu 3=Jewish 4=Muslim 5=Sikh 6=None 7=Not known 8=Other

Sibling Order 0=only child 1=first child 2=last child 3=any child between 1 & 2 4=not recorded mha status n of section 0=informal

Accomodation 1=Owner 2=Private rented house/flat 3=Private rented room 4=Council Accomodation 5=Housing Association 6=No fixed abode 7=Social services accomodation 8=Voluntary organisation accomodation 9=Temporary accomodation 10=Sheltered housing 11=Other 12=unknown

Living Group 1=Lives Alone 2=With partner 3=With partner & children 4=With children only 5=With friend 6=In shared accomodation 7=Does not live with children 8=With parents only 9=With parents & siblings 10=Other 11=unknown

Occupation 1=Full time employment 2=Part time employment 3=Student 4=Retired 5=Unemployed 6=Voluntary Work 7=Long term sick 8=Other

Consultants 1= 2= 3= 4= 5= 6= 7= 8= 9= 10= 11=

12= 13= 14= 15= 16= 17= 18= 19=

Place/Situation of episode 1=ward 2=OT 3=temporarily off ward escorted 4=temporarily off ward unescorted 5=failure to return from leave 6=Other

Education 1=none 2=GCSEs (or=) 3=A levels (or=) 4=bachelors degree 5=CSEs 6=masters degree 7=diploma 8=other 9=unknown

Source of Referral 1=General Practitioner 2=Self 3=Family 4=Police 5=Court 6=CPN 7=Social Services 8=Intensive care unit 9=A & E 10=General Hospital 11=Other ward 12=Other 13=emergency clinic 14=prison 15=outpatients

Security status of ward at time of abscondence 1=locked 2=door stop 3=neither

K/W Disciplines 1=CPN 2=Social Worker 3=Support Worker 4=Other

Levels of Observation 1=Continuous 2=15 mins 3=General

Risk as noted in care plan 1=self 2=others 3=neglect 4=no risk 5=none noted 6=awol 7=drug use

date of last employment 1=0-6mths 2=7-12mths 3=13-18mths 4=19-14mths 5=<24mths

Risk Outcome 1=no harm 2=harm to self 3=harm to others 4=neglect 5=harm to property 6=other 7=drug use

Medication = Name of medication and total daily dose Diagnosis = See over for ICD 10

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Research Outcome 1=interviewed rest not interviewed due to; 2=mental state 3=language difficulties 4=placed on leave 5=discharged 6=failed to return 7=refused 8=other (usually absent each time reseacher visits ward)

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PATIENT POST ABSCOND INTERVIEW

Introductions Explanations Consent Ice-breaking The Hospital Have you been in this hospital before? Have you been on this ward before? What do you think of it? Do you like it here? What did you expect when you were admitted? Did it turn out like that? What do you think of the treatment you've been given? Only use prompts for those items not raised by patient groups OT medication talking length of stay ECT How do you keep occupied on the ward? Do you feel homesick, or wish you were at home? Do you ever get frightened here? Or trapped? What do you think of the nurses? What do you think of the psychiatrists? Life at home What sort of place do you live in outside of hospital? Flat, house, hostel, rented, council, owned? Does anyone look after the place for you? Do you worry about it? If so Why? Do you have family or friends there or nearby? Have they stayed in touch with you while you've been in hospital? Visits? Is there anyone at home or nearby who you help to look after? Children, elderly relatives, friends What about pets? If so How are they managing while you are in hospital? Do you have a job? If so How will being in hospital affect that? Do you get important mail at home (e.g. housing, giros, etc.)? If so If you're not allowed off the ward, how do you get it? Leaving the ward without permission (If failed to return from leave, skip to next section) When you left the ward on xday What time did you go? Did you plan to go in advance? Did you make any preparations before you went? Phone calls, pack bag Did you intend to leave permanently? Did you talk to anyone about leaving before going? Other patients, friends/relatives, staff What did you say to them? Were the staff expecting you to try and leave? How did you leave? Did you leave from the ward itself? If not, where?

Check tape recorder functioning before starting. Do a test sentence and playback. Check tape hubs turning. Provide lots of verbal and non-verbal feedback. Use neutral follow up questions: Can you tell me a bit more about that? Can you explain a bit further? I'm not sure I understand what you mean by x? I think you're saying that x? Have I understood that right?

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Did you pretend to be going somewhere else? Did you have to watch and wait for an opportunity to get out? What opportunity? What exit did you use? Main door, back door, fire escape, window? Did anyone see you go? Who? Where did you go first? Why there? Did you go anywhere else? To do what? Failing to return from leave When you didn't come back to the ward on xday Did you plan to not to return when you first left? Did you make any preparations before you going on leave? Phone calls, pack bag Did you talk to anyone about not coming back? Other patients, friends/relatives, staff What did you say to them? Where did you go first while on leave? Why there? Did you go anywhere else? To do what? Reasons for absconding Why did you leave the ward? OR Why didn't you return from leave as arranged? (Get full answers, using plenty of follow up, exploratory questions, before proceeding to use prompts) Bored on the ward? Frightened on the ward? Wanted to be free to do what you wanted? To be alone, not watched? Official leave refused? Something happened on the ward? The staff? The other patients? Something that needed to be done at home? Someone who needed looking after at home? Someone you wanted to see who you missed? While absconded How did you feel while you were away? Frightened? If so What of? Enjoyed? If so What? Did you miss any medication? Was that good or bad? What do you think about your medication? Did you use any street drugs while away? Or alcoholic drink? Did you try contacting the ward to let them know where you were or when you would return? The return How did you return to the ward? Police? Was there a struggle or fight? Tell me how it all happened? Ambulance? How? CPN or Social Worker? How? Relative/friend? How?

Check tape hubs turning. Provide lots of verbal and non-verbal feedback. Use neutral follow up questions: Can you tell me a bit more about that? Can you explain a bit further? I'm not sure I understand what you mean by x? I think you're saying that x? Have I understood that right?

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Other? How? Voluntarily? If so Why did you return? And how? Bus? Taxi? Walked? Brought back by relative/friend? Now How do you feel about being back in hospital? In retrospect, how do you feel about having absconded? Glad? Sorry? If you weren't here in hospital, what would you be doing? Have you left the ward before this time, without staff knowing? If so Were your reasons the same? If different What were they? Do you think you are likely to leave without permission/fail to come back, again? Now review schedule to check that you have asked all the questions. If not, go back to the ones you haven't asked. Then check forms A & B with the patient to fill out any missing detail (if possible). Is there anything else you could tell me or would like to add? Thanks

Replay last part of tape to check it has recorded

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STAFF INTERVIEW

Introductions Explanations Consent Ice-breaking Risk assessment In your experience, how is risk assessed on your ward? How are levels of observation for individual patients decided? Who makes this decision? Do medical and nursing staff agree over risk assessment? If there is disagreement, how is this resolved? How would you describe the relationship between medical and nursing staff? Do you feel that your professional judgment is valued? Absconding What do you do when a patient absconds? How is the decision about what to do made? When full reply obtained, probe: discussion between nursing staff standard procedure (always?) discussion with ward doctor discussion with Consultant How do you know what to do? When full reply obtained, probe: knowledge of the particular patient read policy informed by other staff degree of risk involved Consequences of absconding Are you aware of any incidents of absconding which have resulted in incidents of self harm or harm to others? Are you aware of any incidents of absconding which have had consequences for staff? Nurses feelings about absconding How do you feel when a patient absconds? When full reply obtained, probe: Irritated Anxious Relieved How do you feel when they return? When full reply obtained, probe: Irritated Anxious Relieved What does a patient absconding mean to you and the other staff? When full reply obtained, probe: reflection of staff practice? Ward atmosphere? Policy

Check tape recorder functioning before starting. Do a test sentence and playback. Check tape hubs turning. Provide lots of verbal and non-verbal feedback. Use neutral follow up questions: Can you tell me a bit more about that? Can you explain a bit further? I'm not sure I understand what you mean by x? I think you're saying that x? Have I understood that right?

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What do you think might be useful in reducing the numbers of absconding patients? No specific prompts with this question Now review schedule to check that you have asked all the questions. If not, go back to the ones you haven't asked. Is there anything else you could tell me or would like to add? Thanks

Replay last part of tape to check it has recorded

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telrel3.doc SIGNIFICANT OTHER TELEPHONE INTERVIEW Interview with .......................................... Relationship parent 1 sibling 2 partner 3 other ............. 7 Client code Relative code Could I speak to ............................................................ please? My name is.......................................and I work for City University. Your........................(relationship) ................... (name of client) has given me permission to contact you in connection with research I’m doing in .................... hospital. It’s about patients who leave the ward without permission, and if you are willing to answer a few questions, your replies will help us understand why people leave and what effect this has on others like yourself. Is now a convenient time for me to speak to you - it will take about 15 minutes? (If not, arrange another time) ............................................... In a moment I'm going to ask my questions. I will be taking notes of your replies, but in my final report neither your name nor that of ............................ will appear. 1(i) Are you happy to take part? Yes 1 No 2 (If ‘no’) 1(ii) Is there a particular reason for that? Ask everyone 2. Are you aware that ................... left the ward/failed to return from leave on .......day? Yes 1 No 2 (If no go to Q7)

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3. How did you find out that this had happened ? phoned at home 1 phoned at work 2 other ........................ 7 4. Who told you ? nurse 1 nursing assistant 2 doctor 3 other 7 unsure (ward staff) 8 5. What exactly did they say? 6. What was your first reaction to the call? 7. What do / did you feel about .................’s leaving the ward without permission? or .................’s not returning when (s)he should have? (After full reply obtained, use prompts to ascertain responses e.g. afraid, concerned, angry, pleased, annoyed, loss of confidence, disgust in relation to:)

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(I) feelings about client’s well-being......... did you have any feelings about : any trouble s(he) might get into? /any harm s(he) might come to? / where s(he) might be? (ii) fears about own safety....... did you have any worries / concerns / fears about what ............... might do to you? (iii) feelings about the hospital? 8. Why do you think that ............... was away from the ward without permission?

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9(i). Has the incident affected your relationship with ...........................? yes 1 no 2 (If ‘yes’) 9(ii). In what way(s) ? 10(i). Has the incident affected your relationship with, or faith in, yes 1 the hospital? no 2 (If yes) 10(ii). In what way(s) ? 11(i). Has it happened before? yes 1 no 2 unsure 8 (If yes) 11(ii). Can you give me the details?

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12. How do you think incidents like this should be dealt with by the hospital? 13. And how do you think the hospital could prevent things like this from happening? Questions 14 and 15 to be asked only of those who already knew about the incident prior to this phone call 14(i) Were you involved in looking for or returning ................to yes 1 the hospital? no 2 (If yes) 14(ii) Can you tell me the details?

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15. How do you feel about the way in which ....................... was returned? Ask all 16. What do you think of the care ................................... is receiving ?

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17(i). Do you feel involved in .................’s care? yes 1 no 2 unsure 8 (If no/unsure) 17(ii).Would you like to be? yes 1 no 2 unsure 8 18. Is there anything else you would like to tell me? 19. Would you like us to send you a summary of the report when it comes out ? (If yes) Address details yes 1 no 2 Thank you very much for talking to me.

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INDEX OF WARD OBSERVABILITY HOSPITAL WARD DATE Office

use only

1. Number of rooms open to patients during daytime shifts

2. Number of independently observable zones, as demarcated by corners/doorways of the main corridor or hall

3. Number of zones visible from the main nursing office or nurses station (count from one only, not both, choosing the one with the best visibility)

4. Number of unlocked exits from the ward during daytime shifts, including windows which can be opened at ground floor level

5. Number of patient releasable exits, e.g. break glass fire doors

6. Number of exits of any sort visible from the main nursing office or nurses station (count from one only, not both, choosing the one with the best visibility)

7. Number of floors comprising ward

8. Number of beds

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INDEX OF WARD OBSERVABILITY (SCORING KEY)

HOSPITAL WARD DATE Office

use only 1. Number of rooms open to patients during daytime shifts

Score 0.5 point for each room

2. Number of independently observable zones, as demarcated by corners of the main corridor or hall

Score 1 point for each zone

3. Number of zones visible from the main nursing office or nurses station (count from one only, not both, choosing the one with the best visibility)

Score 1 point for each zone not visible

4. Number of unlocked exits from the ward during daytime shifts, including windows which can be opened

Score 1 point for each exit

5. Number of patient releasable exits, e.g. break glass fire doors

Score 0.5 points for each exit

6. Number of exits of any sort visible from the main nursing office or nurses station (count from one only, not both, choosing the one with the best visibility)

Score 0.5 point for each exit not visible

7. Number of floors comprising ward

Score 3 points for each floor

8. Number of beds Divide by 10 Sum all points.

Higher scores = less observability

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TRANSCRIPTION CONVENTIONS

The following adapted version of Potter and Wetherell’s (1987) transcription notation was used to facilitate understanding of the transcripts: material within square brackets e.g. [talking to N] indicates clarificatory information; square brackets on their own indicate that some of the script was deliberately omitted; a full stop inside round brackets i.e. (.) indicates a noticeable pause; underlining is indicative of words spoken with added emphasis; words in capitals were said louder than surrounding words; and round brackets on their own indicate material that was inaudible.

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