APPENDIX 8

Visits

1. Members of the Committee of Inquiry, individually and as a group, visited a number of hospitals and prisons which care for and manage personality disordered individuals, both in England and abroad. We describe each service briefly below. It should be stressed that we have in no way sought to assess the quality of service provided by any of these institutions.

2. We are most grateful for the generous way in which staff at these units gave freely of their time and expertise. They have greatly stimulated our thinking.

Great Britain

(i) High Security Hospitals

3. We visited Ashworth Hospital and viewed Lawrence Ward and a number of other wards, both on the North and East Sites. We also heard evidence for two days in early February 1997 within the North Site of the Hospital.

4. In January 1998 we visited Woodstock Ward at Broadmoor Hospital. This ward is a 25-bedded unit which specializes in the psychotherapeutic treatment of young men, most of whom suffer from personality disorder. We also met a number of senior managers and clinicians.

5. The same month we visited the Personality Disorder Service at Rarnpton Hospital. This service comprises three wards, an assessment ward (Connaught Ward), a treatment ward (Evans) and a rehabilitation and continuing care ward (Hawthorns Villa). The planned capacity of the service is 42. Again we met a number of senior managers and clinicians.

6. Mr Daniels visited the State Hospital at Carstairs, Lanarkshire. Carstairs is the provider of high and medium security beds for Scotland and Northern Ireland. It accommodates on average 225 patients. Although psychopathic disorder is not mentioned in Scottish Mental Health legislation many of the patients at Carstairs suffer from disordered personalities.

(ii) Medium Security Hospitals

7. The Committee visited the Reaside Clinic, Birmingham, in April 1998. Reaside has 90 beds and is the largest NHS medium secure unit in the country.

8. Members of the Committee also visited Chadwick Lodge in Milton Keynes, a recently-opened independent sector medium secure unit. The hospital will have 40 beds. The intention is to offer long-term medium secure accommodation there.

9. We visited Kneesworth House near Royston, Hertfordshire. This is an independent sector medium secure unit with 145 beds, including a 15-bedded ward for personality disorded patients.

(iii) Prisons

10. Mr Daniels visited Grendon Underwood Prison. Grendon, established in 1962,is a therapeutic prison catering for around 225 prisoners. Prisoners can be referred to Grendon from any part of the prison system, although it only caters for men who are serving long enough sentences to allow them to receive at least 18 months in therapy. Potential inmates must be motivated to change and be willing to comply with the regime. Thus they must not take drugs or drink alcohol, or use violence. The prison does not accept prisoners on psychotropic medication. Breaking the rules or non-compliance leads to transfer back to the mainstream prison population.

11. Members of the Committee visited the Max Glatt Centre at Wormwood Scrub Prison, West London. This therapeutic wing caters for 35 men, focusing particularly on drug abuse and sexual offending.

12. We also visited the Close Supervision Unit at Woodhill Prison, Milton Keynes. This was recently set up as part of a new approach to managing the very small group of men within the prison system subject to the Continuous Assessment Scheme (CAS), the last resort for managing disruptive prisoners. These men are so disruptive within the system that they tend to be moved from prison to prison. Many are held in segregation units. Under the CAS their cases are reviewed every six weeks; if they continue to be disruptive they may be moved every six weeks from segregation unit to segregation unit. A number of these men suffer from severe personality disorders and some have been in Special Hospitals in the past (the Prison Service told us that 12 of the 40 prisoners on the Continuous Assessment Scheme as of March 1998 had been in a Special Hospital at some point in their sentence, although they were unable to give us any information on diagnoses).

13. Since February 1998 the Prison service has adopted a new approach, based on a system of five Close Supervision Centres (CSCs), each holding a small number of prisoners, with varying regimes ranging from highly restricted to more open regimes. Prisoners have the opportunity for graduated progression through the system and back into the mainstream prison estate through sustained good behaviour.

14. The CSC estate is based at Woodhill Prison in Milton Keynes (which operates three of the five centres), Hull and Durham. Prisoner entering the system go to the Structure Regime Centre at Woodhill for assessment; prisoners who continue to be disruptive or dangerous move to the Restricted Regime Centre at Woodhill with a strict, no association regime. Compliance earns a move to the Intervention Centre at Woodhill offering structured therapy and full association. There are further Intervention Centres at Hull and Durham.

15. In January 1998 we visited a number of services in the TBS ("Terbeschikkingstelling") system in the Netherlands. The Dutch system for managing personality disordered offenders has been widely studied. It is interestingly different from the UK model, as it is concerned above all with the reduction of risk to society posed by mentally disturbed offenders who are assessed as being not fully responsible for their actions. There is no treatability test; rather, the stress is on reducing the potential dangerousness of such people. The system has traditionally dealt with personality disordered offenders, although there are now increasing numbers of psychotic individuals with TBS orders.

16. The system operates roughly as follows. When a person accused of a serious offence is thought to have been suffering from some form of defective development and/or pathological disturbance of mind at the time of the alleged crime such that he cannot be regarded as wholly responsible for that crime, if proved, a judge can request an assessment of his mental condition to be carried out. The purpose of this assessment is, first, to assess whether the person has a disorder, and to what extent he can be held responsible for his actions; and, second, if a disorder is present, how strongly that disorder is linked to the offence. This leads to a recommendation as to the degree of responsibility the defendand should bear for the crime, if proved, on a sliding scale from "fully responsible" to "not responsible", and a judgement as to whether this person would be likely to commit another crime on the basis of diminished responsibility.

17. When a person is found to have diminished responsibility and to be dangerous a TBS order (roughly equivalent to a "hospital order") may be ordered. Assuming the defendant is found guilty he is sentenced to a particular term, depending on the nature of the offence and the degree to which he is regarded as responsible, and to a TBS order. After serving his sentence he is then sent to be assessed at the Meijers Institute in Utrecht, which determines which of the TBS clinics he should be treated at. He then goes on to a clinic. The staff in TBS Clinics are predominantly social therapists rather than trained psychiatric nurses, reflecting the emphasis on "resocializing" the TBS patient.

18. The TBS order is reviewed every two years, if possible by the same judge who originally imposed the TBS order. The judge can order release from the order against the hospital's advice. In principle a TBS order can last for life, although the average is around five or six years.

19. The Committee visited the Pieter Baan Centre and F.S. Meijers Institute in Utrecht; the Dr S. van Mesdag Clinic in Groningen and the Van der Hoeven Clinic in Utrecht. The Pieter Baan Centre is the main assessment centre for remand prisoners. Prisoners referred to the Centre spend seven weeks there being assessed by a multi-disciplinary team, led by a lawyer, and consisting of a psychiatrist, psychologist, social worker and a social therapist. The team has access to criminal records and, if the individual under observation agrees, to any clinical notes. The Centre has 32 beds, divided up into four wards. At the end of the seven weeks a report is produced advising the court on the degree of responsibility the prisoner bears for the offence (the assessment team work on the assumption that each person under observation is guilty) and the likelihood of recidivism, and make a recommendation as to whether or not that person should be made subject to a TBS order, if found guilty.

20. The F.S. Meijers Institute is located next door to the Pieter Baan Centre. Its main function, as mentioned above, is to assess which TBS clinic is most suitable for a given individual. It has 32 beds in four wards.

21. The Dr S. van Mesdag Clinic is possibly the nearest equivalent to a high security hospital in Holland. It has 145 beds, soon to increase to 180. The patient population is roughly equally divided between psychotic and personality disordered men.

22. The Dr Henri Van der Hoeven Clinic in Utrecht is very similar to an English medium secure unit (the Reaside Clinic was closely modelled on it). It has 85 beds within the Clinic and 15 based outside. It operates very broadly on a therapeutic community model.

Germany

23. We visited two hospitals in North Rhine-Westfalia, Düren and Eickelborn. North Rhine-Westfalia is the largest Land (state) in Germany, with 18 million inhabitants out of a total population of 80 million. German law allows for the compulsory detention in a psychiatric hospital of mentally disturbed offenders, drug addicts and alcoholics. The issue in law is whether a individual is not responsible or in part not responsible for the criminal act in question and whether in view of his or her condition he or she is likely to reoffend seriously in the future.

24. Düren was built in the mid-1980s as a so-called "forensic village", designed to provide a complete therapeutic milieu. All the buildings, including the wards, are laid out along a main street; there are also extensive grounds, all within the secure perimeter. Some 120 patients, all men, are housed there; approximately half suffer from personality disorders, half from psychoses. The perimeter wall itself is invisible from outside the hospital.

25. The Westfalian Centre for Forensic Psychiatry at Eickelborn is the largest forensic facility in Germany with over 300 beds. It is located within a larger hospital; the forensic wards are surrounded by individual fences. The wards themselves have something of the feel of Rampton, being located in two or three-storied houses. The Centre caters for patients with personality disorders, mental illness and learning disability, and for drug addicts.

Switzerland

26. We visited the Sociotherapeutic Centre at Champ-Dollon Prison in Geneva. This centre houses 11 severely personality disordered prisoners in a wing of a remand prison; the Centre itself is run by the University Institute of Legal Medicine, although a number of prison guards work on the wing. The prisoners are usually young men who have repeatedly demonstrated violent behaviour or sexual misconduct, and who have feelings of anxiety and depression. None are psychotic. The wing is run as a highly-structured community.