11 Forensic psychiatry11.3 Practising psychiatry in a secure setting
11.3.2 Forensic service components and patient needs
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Written by Resident Doctor Committee · Published
Levels of security
Level | Risk it is designed for | Standard on escape |
|---|---|---|
High secure | Grave and immediate danger to the public | Highest protection against escape |
Medium secure | Serious risk of harm to others | Prevent escape through combined security |
Low secure | Significant risk requiring secure care | Impede escape with proportionate security |
The Butler report (Committee on Mentally Abnormal Offenders, 1975) led to regional medium secure units, which fill the gap between open wards and the special hospitals.
Medium secure units take patients who pose a serious risk to others, including transferred prisoners with psychosis who need hospital treatment.
England's three high secure hospitals are Ashworth, Broadmoor and Rampton. Rampton provides national women's, Deaf and intellectual disability services.
Admission turns on risk, not the offence
A serious conviction does not automatically require high security, and a patient without criminal charges may need secure care.
Brief acute disturbance is often better managed in general services or a psychiatric intensive care unit.
Predominant self-harm alone usually does not meet adult medium secure criteria.
Diversion and transfer from prison
The Bradley Report (2009) reviewed the diversion of offenders with mental illness or learning disability from custody into treatment.
It lies behind national liaison and diversion services, which identify mental illness, intellectual disability, neurodevelopmental and substance use needs in custody and courts.
It also lies behind the 14-day target for transfer from prison to hospital.
Mental Health Act treatment powers cannot be used in an ordinary prison, so prisoners are transferred under sections 47/49 or 48/49.
Restriction and discharge
Restriction | Attaches to |
|---|---|
Restriction order, section 41 | Hospital order |
Limitation direction, section 45A | Hospital direction |
Restriction direction, section 49 | Prison transfer direction |
Leave and transfer of restricted patients need the Justice Secretary's consent.
Conditional discharge keeps supervision and liability to recall. Absolute discharge ends the hospital and restriction orders.
What patients need
Patients prepare for autonomy through graded leave and practice with medication, budgeting, cooking and everyday decisions.
Symptom improvement alone does not restore skills lost during a long admission.
Outcomes after discharge
About 1 in 6 men discharged from UK medium secure units are convicted of a violent offence within five years, and about 1 in 3 of any offence.
Discharged patients also have substantial premature mortality, including suicide.
Reconviction rates can be compared only when populations, follow-up and offence definitions match.