Mapping Offender-Patient Pathways

Abstract

Previous reviews have described services for offenders with mental disorder in several European countries, but we wanted to understand how these might apply in an individual case. We used process mapping to record pathways taken through the legal process and other services by offenders suspected of having committed a homicide in four EU countries—Austria, Finland, the Netherlands and the UK. All have the facility to meet some urgent mental health needs at any point in the criminal justice pathway, but countries differ in when evidence on the relevance of mental disorder to the offence may be introduced into the legal process. All countries provide some sort of specialist health service, but the nature of its administration and its placement differs. Austria’s specialist inpatient services are provided entirely within the prison system, the Netherlands in either the Joint Departments of Health and Justice TBS system or prison hospital units. In Finland and the UK, inpatient services are all health service based and clinical input to prisons by health service employees only. Development of offender pathway maps is likely to assist mutual understanding of services. They could be used to inform patients, relatives and victims about what they may expect of the months and years which follow first involvement with the criminal justice system. They may help us to learn from each other’s similarities and differences what works best.

Appendix: Briefing Note: Preparatory Questions for Care Pathway Interviews

1.1 Introduction

This briefing note will prepare you for the care pathway interviews we will be conducting at the conference. We have listed key questions below which are broken down into stages. This should support a detailed discussion during interview and encourage some reflection in advance. Our intention is to clearly and visually describe the care pathway for mentally disordered offenders in a range of countries. This builds on work already completed for both Denmark and the UK (Danish Pathway attached for reference). You will be involved in the review and approval of the relevant pathway(s) once completed.

We would like to thank you for your time and contribution to this work.

1.2 The Case Study

We would like to use the following scenario to explore the questions below.

The police are called by a neighbour to a residential property where there has been a serious disturbance. The police attend the scene and find a man who has stabbed his wife multiple times. The wife is dead and the man is in a highly agitated state.

1.3 Care Pathway Interview Questions

1.3.1 Arrest

Stage	Question	Things to think about
Arrest	What happens at the scene of the crime if? i. the police do not suspect any mental health issues? ii. the police do suspect mental health issues?	Consider who is contacted at this point by who. Where the suspect is taken to (e.g. police station/hospital/other)
Arrest	What assessment will be done by who at this stage?	Consider capacity, fitness to be interviewed, etc.
Arrest	Assuming there is a mental health concern following assessment, what would happen next?	Where is the person held? Who is responsible for him? What legal framework is detention under at this time and who decides this? Is this the Court, Police, Judge, Psychiatrist/Doctor, Minister?

1.3.2 First Court Hearing

Stage	Question	Things to think about
First court hearing	At the first court appearance, which court in your legal system would this be?	Are there specialist mental health courts available? Who would bring this action? i.e. police, state, private, other?
First court hearing	Does the accused have to make a plea at this stage?	What are the available pleas?
First court hearing	Would a psychiatrist be present?	How are psychiatrists appointed? What will they be asked to advise the court on? What are the limits of their authority at this stage?
First court hearing	Who raises concerns on mental health in the court setting?	Is this a lawyer, judge, magistrate?
First court hearing	Assuming it is deemed that the person had an active psychotic illness, what would happen next?	Where is the person held? Who is responsible for him? What legal framework is detention under at this time and who decides this? This may be Court, Police, Judge, Psychiatrist/Doctor, Minister, etc. What is needed to make this order and who carries it out? Are there logistical/practical considerations here, e.g. bed availability?

1.3.3 Care/Detention Provided in Interim Period

Stage	Question	Things to think about
Care/detention	What (mental) healthcare services are available to the accused during detention?	What level of psychiatric input is available during this period and in what setting? How long might this period be? Is there any interaction with the court in this period?

1.3.4 Trial

Stage	Question	Things to think about
Trial	Are there circumstances where the defendant would not reach the trial stage?	What is the threshold for this? At what stage could this occur and who would authorise this via which legal framework?
Trial	What kind of trial would take place in what type of court?	Who would represent the suspect, what type of court would this take place in? What input would psychiatric services have in this process? Are there special psychiatric defences and are they absolute?
Trial	Assuming there is no dispute on the facts, and the offence is psychotically driven, what would happen to the defendant?	(Where is the person held? Who is responsible for him? What legal framework is detention under at this time and who decides this? This may be Court, Police, Judge, Psychiatrist/Doctor, Minister, etc. What is needed to make this order and who carries it out? Are there logistical/practical considerations here, e.g. bed availability, etc.? Does the judge have the ability to override psychiatric opinion?

1.3.5 Post-trial Assessment

Stage	Question	Things to think about
Post-trial assessment	What type(s) of assessment(s) would be done following conviction to review the mental state of the defendant?	Is this to inform sentencing or simply a legal requirement to assess periodically? Who will be the recipient of the assessments? Is the defendant able to challenge these assessments?

1.3.6 Transfer or Discharge

Stage	Question	Things to think about
Transfer or discharge	What are the circumstances in which the defendant can be transferred or discharged from one setting to another (e.g. prison to hospital)?	Can they be discharged to the community from hospital, or transferred to prison? Who would make this decision? How often might this be reviewed? Can defendants be transferred from prison into the hospital/psychiatric system following a mental health concern?