Sexual safety is one of the biggest issues in inpatient care, with concerns not being heeded because of complacency, burnt-out staff and prejudice. Emma Dent reports

If you are a woman - or man - who has been touched up or had someone expose themselves to you, then you would, at the very least, expect that your complaint would be taken seriously by the police. Hopefully, the perpetrator would be prosecuted. Unfortunately, service users undergoing care in a mental health inpatient setting cannot be confident of any such outcome.

Inpatients - particularly women - report that care is blighted by sexual harassment, with patients regularly exposing themselves, touching other patients or speaking to them inappropriately. In the worst cases, such behaviour can lead to allegations of sexual assault.

Yet having their concerns and complaints taken seriously, say service users, is an uphill struggle. A 2006 report from by the National Patient Safety Agency, With Safety in Mind, alerted many to the issue for the first time. Although it covered the issue of safety in a number of forms, such as medication errors and suicide attempts, what really grabbed the headlines was 19 alleged rapes reported to the agency from November 2003 to September 2005.

As horrifying as these allegations were, these were among 122 reports of sexual safety incidents including consensual sex between patients, patients being exposed to and sexual advances towards patients.

'When we began looking at the data we expected to find high levels of violence and verbal abuse,' says a source close to the report. 'We thought there might be high levels of racial abuse and potentially financial abuse. We were quite horrified at what was being reported.'

'After it was eventually published it did not get the coverage you might expect but perhaps that is to be expected with a story about mental health. If this situation had been reported in any other part of healthcare there would have been absolute outrage and heads would roll,' adds the source.

National mental health director Professor Louis Appleby later looked into the 19 allegations - of which only one was pursued by the police - but as his report is yet to be made public there was further consternation from charities that the issue was not being rigorously considered.

'With Safety in Mind highlighted the issues but people started to think that 19 rapes had been carried out, which was unhelpful,' says Professor Appleby. He says sexual safety is now one of the biggest issues in inpatient care. 'These incidents can cause psychological harm. If it is not tackled it becomes an issue for the service user and colours their perception of all their experiences of inpatient care.'

Taking advantage

'It is very difficult to be definitive about the number of incidents and I do not think management is turning a blind eye to it,' says Mental Health Act Commission chief executive Professor Chris Heginbotham. 'But we do find that there is a pervasive culture where on too many wards - particularly mixed wards - women are subject to constant low-level harassment and men who may take advantage of them.'

A number of issues can contribute to making inpatient wards unsafe. The increase in community teams means that someone is likely to be admitted to a mental health acute inpatient ward only if they are extremely ill and disturbed. This means not only are they at their most vulnerable, they may also act in a way they would not usually.

However, the poor mental health of perpetrator and victim can result in one not being believed and a reluctance to punish the other's behaviour

'At best, such incidents are treated as part of life on an inpatient unit,' says Paul Farmer, chief executive of mental health charity Mind. 'At its nihilistic worst, there is an attitude that patients cannot be believed because they are mad. Disbelief is built into the system.'

Professor Appleby disagrees that incidents are not taken seriously, although he concedes this may have happened in the past. He agrees that because someone is behaving in a sexually uninhibited manner because of their mental illness, it can be easy for staff not to react as they would do, for example, to someone behaving in such a way in the community.

'Staff do take it into account if someone is behaving out of character. But that will regardless have an impact on the person who is on the receiving end of being harassed, for whom it is irrelevant if the perpetrator is mentally ill or not,' he says.

Royal College of Nursing mental health adviser Ian Hulatt points out that if a service user's behaviour is sexually inappropriate when they are unwell, their care planning can be adapted accordingly.

'Both staff and service users need to feel safe and have a right to feel safe. This can be difficult to manage but good care planning should be able to address behaviour,' he says.

Campaigners point out that even the best buildings are effectively useless without decent staff and staff behaviour. Professor Heginbotham describes how on a Mental Health Act Commission visit to a female-only ward, he observed a female patient who was sexually uninhibited and had removed all her clothes being observed in her room by a male staff member.

'It was wholly inappropriate,' he says.

But the physical environment of wards is key. Guidance says sleeping, bathing and toilet facilities for inpatients must be single sex, although there is considerable disagreement over what constitutes single-sex accommodation. The use of facilities such as psychiatric intensive care units, which care for the most disturbed and unwell of inpatients but may not be built for that purpose, is also of concern.

Mixed-sex wards

Results from the 2005 and 2006 Healthcare Commission Count Me In surveys of all inpatients (including those in psychiatric intensive care units and secure accommodation) found that service users reported that 78 per cent and 55 per cent respectively were staying in mixed-sex accommodation.

Healthcare Commission head of mental health strategy Anthony Deery believes there is some confusion in trusts about what single-sex accommodation actually is.

'I don't think we know if the figures on mixed-sex wards are accurate or not,' says Mr Deery. 'But for a woman to have to go through a male area to reach a female area is unacceptable. And there are still wards that have not even achieved single-sex sleeping areas yet. This is not a debate that we should be having in 2007.'

Others point out there is little point in having, for example, a women-only bedroom corridor if it is accessible by male patients or if women have to walk through a mixed-sex day room to get to a toilet.

Nor, when it is in place, is single-sex accommodation always adhered to. A notification process by the Mental Health Act Commission on women admitted to male wards - even if only for a short time - two years ago, found that in six months more than 10 women had been admitted to them.

'That in itself is a threatening situation and a form of abuse and we did not get good answers as to why it was happening,' says Professor Heginbotham. 'It showed a level of complacency.'

Up to£30m in funding announced in April specifically for improving sexual safety was due to be allocated by the end of October. Professor Appleby says the funding will be earmarked for schemes including providing single-sex accommodation, creating women-only areas, dedicated washing and bathing facilities and women-only outside spaces.

Although dealing with sexually inappropriate behaviour and risk assessments are part of mental health nursing training, Professor Heginbotham believes that a lack of adequately trained and experienced staff can exacerbate poor levels of safety.

'There are units with very distressed service users that have sickness levels as high as 20 per cent. That means high use of bank and agency staff. Bed-occupancy levels of over 100 per cent, insufficient staff, staff who are not adequately trained and do not have a wide enough experience to cope with issues of sexual safety and without adequate resources and management support mean that they get very tired. So much of what they do becomes custodial in nature and they burn out, become unable to cope with the realities of life on an inpatient unit,' he says.

'These are not easy patients to deal with and not enough attention is paid to gender issues in mental health as a whole. But it can be done,' Professor Heginbotham adds.

Recording of incidents is another major issue.

Although the majority of the incidents recorded by the NPSA in With Safety in Mind were categorised as 'no harm', the agency can only record physical harm; not psychological harm or distress.

As this does not take into account the psychological distress caused - particularly as victims are already in a fragile mental state - this is widely seen as unhelpful and unable to fully mark the amount of damage caused.

There are also limitations on how incidents can be recorded. Unless something is reported and classed by a trust as a 'serious untoward incident' - to an extent a classification subject to the views of the incident recorder - it will not be reported to its strategic health authority. Nor do SHAs routinely collect data on how many sexual safety incidents have been reported on their patch or all incidents reported to the NPSA.

'The NPSA is not the place to have serious criminal allegations reported to,' says Professor Appleby, but he and others acknowledge that both reporting and recording of incidents is poor.

'The lack of data is part of the problem. If someone has a legitimate concern, their complaint should be adequately pursued. But service users' experiences of the justice system (see below) tell us that it is very difficult to make a complaint, to get that complaint taken seriously and to get an allegation recorded and reported, whether it to be verbal, physical, or in a small number of cases, sexual abuse,' says Mr Farmer.

'It is mainly service users reporting this, although health professionals too get frustrated. And the NPSA can only operate with the information it has got.'

Admitting that recording of incidents is often inadequate, the NPSA is embarking on work to improve it in trusts. Just over 20 trusts have been asked to provide more information on 40-odd sexual safety incidents reported to the agency between January and June of the several hundred received in that time. (In total the agency receives about 70,000 reports of all kinds a year.)

'Some of the incidents that get reported to us are about service users taking their clothes off or exposing themselves. It can be argued whether such incidents are about patient safety or not. It may be more a question of dignity,' says NPSA mental health lead Dr Ben Thomas. 'We have to rely on the people doing the reporting.'

He adds that reporting in the sector is on the increase but that more needs to be done and its quality remains variable.

'We need to get an accurate picture of what actually happened and what the outcome was. If we do not get a full enough picture it can be difficult to learn from incidents and give that leaning back to the NHS. But I am happy that in the main trusts have policies in place to deal with these matters and that allegations will be properly investigated.'

Further evidence of the extent of incidents taking place in inpatient care and their effects on service users may be available when the Healthcare Commission publishes its first review of all inpatient wards. Due to be published in January, the review is set to include service users' experience of their sexual safety being compromised.

'We have taken a broad view of it, including looking at how the vulnerability of patients is assessed and how well sexual health advice is provided,' says Mr Deery. 'We are hoping that it will give us some information that we have not had previously.

Questions on sexual safety are also expected to be included in a survey of inpatient care to be launched by the commission that is likely to replace its current survey of community patients.

And formal guidance acknowledging that sexual safety in inpatient care is an issue and how to tackle it is also expected from the NPSA and Department of Health as part of wider guidance on dealing with violence and aggression. Although delayed several times a publication date has now been mooted for before the end of the year.

Time will tell if it will help to instigate the necessary change in culture to make inpatient care a safer place to be.

Accessing justice: the case for prosecution

Low levels of prosecution - the lowest in Europe - plague rape statistics in the UK. Although official figures are not available, many in the mental health sector suspect they must be even lower for people with mental health problems who report a sexual assault.

A senior source says: 'I used to run inpatient services and when an allegation was made and we called i the police we found that they were always willing to help. But they would also say that they believed the Crown Prosecution Service would not think the case would stand up in court and would refuse to prosecute it.'

This view is echoed by Paul Farmer of mental health charity Mind. Mind is set to launch Access to Justice, a campaign on behalf of service users who struggle to get justice whether they are accused of, or are victims of, crime. 'On the whole the police do a lot of very good work - although service users' experiences are variable - but it is the willingness or otherwise of the Crown Prosecution Service to prosecute that puts investigations in jeopardy,' he says.

The CPS's tendency to see service users as unreliable witnesses is a common complaint. It is alleged that because an illness may make someone lie about an incident, do something they will later regret or be unable to recall events accurately means a case would not be able to make a case stand up in court. Mind would like service users to be treated with the same status as vulnerable witnesses in other cases involving abuse, where evidence can be given behind a screen or by a video link.

'In itself receiving treatment for a mental health problem is not a reason for the CPS not to prosecute,' says a spokeswoman.

'We will always look at all the evidence. But the defence may produce a medical report that will state that an alleged victim or perpetrator is not fit to give evidence at a trial, for example if the alleged victim has made allegations before.

'Most of the time in rape cases, it is one person's word against another. It would be a concern if it was perceived that the CPS does routinely not pursue such cases as there is a perception that it does not prosecute rape cases generally. But the service does have to ask: "What would the jury think?" and whether it has a realistic hope of prosecution.

'If it does not it cannot pursue the case.'

Find out more

With Safety in Mind, National Patient Safety Agency, 2006

Mainstreaming Gender and Women's Mental Health: implementation guidance, Department of Health, 2003

Safety, Privacy and Dignity in Mental Health Units: guidance on mixed sex accommodation for mental health services, Department of Health, 2000