Annual Report 2015 26th May 2016 Table of Contents Page Foreword 5 Chapter 1: Background 8 Introduction 9 Vision, Mission, Commitment 9 Organisational set-up 11 Vacancies as on 31st December 2013 in order of priority 11 Management Committee Meetings 11 The Agenda up to end 2018 12 Chapter 2: Performance 16 Implementing the Mental Health Act within the Office 17 Mental Health Database Monitoring and Management System 18 Analysis of applications processed by the Commissioner 19 Mental Health Review Committee 25 Curators 25 Interface with mental health service provider entities 26 Training for patients and carers in patient advocacy 29 Interface with the Police 29 Media Presence and Participation 29 Influencing Legislation 30 Reform of Justice (Civil Procedure) Legislation 30 Other Legislation 32 The Vulnerable Voter 33 Influencing Policy 35 Parliamentary Committees on Health and Social Affairs 36 Mental Health 37 Substance Abuse 39 Child and Adolescent Mental Health Services (CAMHS) 40 Youth Policy 41 Investigation of Complaints 42 Allegations of breach of human rights 42 Customer Relations Unit 43 Visits and Audits 43 Visitation Report 2015 43 Incident Reporting 48 Working in Partnerships 49 Meetings 49 Working together on specific actions 50 Health Literacy 50 Mental Health and Well-Being Expo 53 Working with the Ministry responsible for Health 54 Country Cooperation Strategy with WHO Europe 54 Organ and Tissue Donation 55 2 Selection Boards 56 Membership of EU Presidency Teams 56 Other Health Policies and Strategies 56 Participation in Conferences, Seminars, Workshops & other events 57 Participation in local events 57 Participation in Overseas Conferences 60 Chapter 3: Professional Development 70 Continuous Professional Development 71 Involvement in Academic and Professional Development of others 73 2015 in Pictures 76 Appendices 80 Appendix 1: Functions of the Commissioner 81 Appendix 2: Mental Health in Youths 83 Appendix 3: Proposal for extending care to persons with mental Health problems in association with psychoactive substance abuse 91 Appendix 4: Report on Visits to Mental Health Licensed Facilities Conducted in 2015 99 Appendix 5: Incident reporting in mental health licenced facilities 2015 141 Appendix 6: Launch of the Malta Health Literacy Survey Report 2014 155 Appendix 7: Proposal for legislation on organ and tissue donation 173 3 ...promoting and upholding the rights of people suffering from mental disorders ...jinġiebu ‘l quddiem u jiġu rispettati d-drittijiet ta’ nies li jbatu minn diżordni mentali 4 Foreword In its fourth full year of operation, the Office is proud to report steady progress in the implementation of its assigned responsibilities as the authority to promote and protect the rights and interests of persons with mental disorders in Malta and Gozo. Following the full entry of the new Mental Health Act in October 2014, the first priority was to ensure that the strict timeframes of involuntary care are fully respected by all concerned, that patients are reviewed regularly and not detained against their will longer than is necessary, and that patients are formally discharged from involuntary care or detention where applicable. This has practically been achieved but it is unfortunately not supported by the necessary IT infrastructure that can hasten the administrative process and provide less laborious ways of obtaing performance data. In this report you will find the first outcomes statistics of the new legislative set-up. 801 applications and notifications processed, 435 persons detained against their will for observation monitored, 224 treatment or detention orders issued, 100 discharges approved and 12 persons certified as lacking mental capacity. More importantly we commenced the year with 54 persons on long term treatment order as hospital in- patients and we ended the year with 48 persons on long term treatment order, of whom more than half (25 out of 48) were on community treatment orders, a notable and welcome shift towards monitored involuntary care in the community. The second priority was the assessment and quantification of the level of compliance with the rights of persons with mental disorders within the various service provision set-ups. Improvements have been made since the visit in 2014, although the extent cannot be measured tangibly. Patients seem to be better kept. Staff seemed more receptive to the needs of the patient and more collaborative. Medicines are being stored in a better way and the wards are somewhat cleaner. We found no evidence of torture or cruel, inhuman or degrading treatment within mental health licensed facilities in 2015. However, beyond basic medical care which is being provided, interventions and activities that help patients in wards to maintain or regain lost skills are sorely lacking. Smoking policies need revision. The vast majority of service users (89%) 5 state that they feel treated with repect and dignity. An overwhelming 93% of users feel that staff were kind and caring towards them. The same cannot be said about safety and the care environment in wards. Safety measures and the physical environment are in dire need of improvement in most wards in Mount Carmel Hospital and in both wards in Gozo General Hospital. Substantial improvements are necessary for the objective of dignified care in a safe and suitable environment to be reached. Respect and dignity towards patients by dedicated staff cannot be expected to make up for lack of investment in the physical environment of care facilities. Patients are still far from being empowered about their rights. Less than 25% claimed that their rights had been explained to them. Although nearly two thirds (65%) of repondents feel they have participated in their care as much as they wished, it is difficult to assess the extent of such particiaption. Patients tend to be reluctant to submit reports on threats from staff or other patients, possibly fearing retribution. Privacy is not always being respected and seems to be very low on the priority list of certain staff. There is no established policy on use of mobile phones, making communication more difficult and increasing risk of isolation. Documentation in patient files is conducive to safe quality care. The presence of informed consent to treatment forms in 63% of files is encouraging. 40% of files had written evidence that a responsible carer had been identified by the patient. It is unacceptable that the working diagnosis was easily retrievable only in 40% of patient files. Multidisciplinary care plans were absent in 90% of files. The most shocking finding is that only 1% of files contained all the requirements of the Mental Health Act. The third priority is advocacy for reform of mental health and well-being services. A revised mental health policy, strategy and action plan reflecting the principles of the Mental Health Act is essential. The health literacy survey has shown serious gaps in mental health promotion and prevention that must be addressed. Mental disorders must be mainstreamed within the health sector with acute psychiatric care moving to the acute general hospital setting, and the mainstay of care must be community- based where the general practitioner is supported by community services and 6 specialised services. Dignified residential accommodation is required for long term patients and those who unfortunately do not make it through rehabilitation. Care services for children, adolescents and youths with psychiatric problems (CAMHS) should follow youngsters until the age of 25 years and transition to adult services should happen gradually and when the youngster is ready for transition. Young people with challenging behaviour have the right to adequate aftercare and rehabilitation leading to their social integration. This is best achieved through specific supervised residential facilities in the community. Substance abusers are disrupting the care processes for deserving cases within Mental Health Services. This is a complex issue which requires a concerted approach involving mainly Mental Health Services, FSWS, Sedqa, Caritas and OASI. Mental health must also be mainstreamed outside health care settings involving education, housing, social welfare, social security, employment, youth services, sport, local councils, correctional services, and probation services. Sustainable employment prospects for persons with mental disorders remain poor. There is a very high economic cost tied to mental health problems in terms of reduced quality of life, loss of productivity, and premature mortality. This report demonstrates the extensive work performed by the small and multi-skilled team at the Office in 2015. I thank them all for their professionalism and hard work, for their loyalty towards vulnerable persons and for the achievements outlined in this report. This Office will continue to provide effective strategic leadership in ascertaining that the rights of persons with mental disorders are protected and upheld. Dr John M. Cachia 26th May 2016 Commissioner 7 Chapter 1: Background 8 Introduction The Commissioner for the Promotion of Rights of Persons with Mental Disorders is established in Article 5 of the Mental Health Act (Cap 525). Appendix 1 lists all the functions assigned to the Commissioner by the Act. This report covers the performance of the Office of the Commissioner from 1st January 2015 up to the 31st December 2015 and is being drawn up in accordance with Article 6 (1) (n) of the Mental Health Act. The Office is proud to see that as a