The British Psychological Society
Action Planned
The British Psychological Society will emphasize Pica training and management in Clinical Psychology doctoral programmes and actively support the development and dissemination of multi-professional guidelines relating to the management of Pica. (AI summary)
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Dear Dr Didcock, Regulation 28 report re: James Mark Frankish Thank you for issuing the British Psychological Society with a report regarding prevention of future deaths arising from the inquest that you conducted into the death of James Frankish. I am writing further to the initial response provided by our Chief Executive, , dated 3rd December 2019.
I have spent some time personally, and in discussion with relevant colleagues, reflecting on the issues raised in your report and what the British Psychological Society could do to prevent future deaths under similar circumstances. As you will be aware, over recent years there have sadly been a number of other preventable deaths of people with intellectual disabilities and/or autism in health or social care settings. We are extremely concerned about this fact, which we believe represents a serious health inequality in the United Kingdom.
Your report notes that the tragic death of James Frankish at the age of 21 was the result of ingestion of a large amount of non-edible plant material. James had severe intellectual disability and autism; he had also been diagnosed with the eating disorder Pica at the age of
3. Although his parents understood the risks associated with Pica, you reported that the residential care staff and health professionals who were involved with James’ care at that time of his death (which included a Clinical Psychologist), were not aware of the extent of James’s Pica nor did they fully appreciate the risks associated with Pica.
Every Clinical Psychology doctoral training programmes in the UK is accredited by the British Psychological Society, the criteria for accreditation specify that “the clinical psychology curriculum should include…… presentations of those with intellectual disability” (p23) and that “Programmes must ensure that trainees gain the following clinical experience and skills”
2
including with “service users across a range of levels of intellectual functioning over a range of ages, specifically to include experience with individuals with developmental intellectual disability and acquired cognitive impairment” (p26). Thus, all Clinical Psychologists trained on accredited courses should have foundational knowledge and skills for working with people with intellectual disabilities. The Society does not specify detailed content for training curricula, but Good Practice Guidance produced by the DCP Faculty for People Intellectual Disabilities mentions “possible physical and mental health problems and disabilities co-occurring alongside learning disabilities” (3.6). This would encompass a range of challenging behaviours and should include Pica.
In light of your report, I have written personally to the programme directors of every UK Clinical Psychology training programme to ask them to confirm that Pica, and the associated health risks including risk of mortality, are explicitly addressed in teaching on their programme.
Furthermore, I have also circulated to programme directors two articles written by British Psychological Society member, and Chartered Clinical Psychologist, , together with James’ parents, , on James’ death and guidance on managing Pica, that were published by the National Autistic Society in April 2019 (see attached).
Psychologists can also contribute to prevention of deaths in similar circumstances more broadly by promoting person-centred care planning that can build on professionals, individuals’ and their families’ expertise, to enhance safety and quality of life. A particularly tragic aspect of James’s death was the fact that his parents’ understanding of the extent of their son’s Pica, and the risks associated with this, was not transferred to the staff caring for James in the residential setting.
Whilst awareness is clearly a key issue in the prevention of future deaths, awareness is not sufficient; safe and effective management of behaviours is also critical. Pica would be considered a challenging behaviour and it is important that challenging behaviours are managed using effective, evidenced-based approaches. Positive Behaviour Support is a wrap-around model of care that is recommended in the BPS/Royal College of Psychiatry joint guidelines “Challenging Behaviour: a unified approach” (2007/2016) and the NICE guideline NG11 “Challenging Behaviour and People with Severe Learning Disabilities”. This approach should now be well established in statutory residential care settings, however we are highlighting the need to enhance community provision of Positive Behaviour Support as the Transforming Care programme reduces hospital admissions under the Mental Health Act for people with intellectual disabilities and/or autism who present with acute episodes of severe behavioural difficulties.
Clinical psychologists should not only adhere to high standards in their own direct clinical work but can also contribute to the safe and effective functioning of teams with whom they work. One of the nine core competences specified in the BPS accreditation criteria for clinical psychology training programmes is “Organisational and systemic influence and
3
leadership”. The criteria require that all trainlines should develop competence in “Indirect influence of service delivery including through consultancy, training and working effectively in multidisciplinary and cross-professional teams. Bringing psychological influence to bear in the service delivery of others.”
In my letter to clinical psychology course directors I emphasised that clinical psychologists can play a role in preventing tragic deaths such as James’, and others of people with intellectual disabilities, through their application of their knowledge and skills directly in the care of that client and also indirectly in promoting person-centred care and appropriate management of challenging behaviours within the services that they have input to.
In recent years health and care professionals in the field of intellectual disabilities have set an excellent example of interprofessional working to improve service user outcomes and the British Psychological Society has supported the Learning Disabilities Professional Senate since its inception. We will actively support the development and dissemination of multi- professional guidelines relating the management of Pica.
Please do not hesitate to contact me if you would like any further information on any of the above.
I have spent some time personally, and in discussion with relevant colleagues, reflecting on the issues raised in your report and what the British Psychological Society could do to prevent future deaths under similar circumstances. As you will be aware, over recent years there have sadly been a number of other preventable deaths of people with intellectual disabilities and/or autism in health or social care settings. We are extremely concerned about this fact, which we believe represents a serious health inequality in the United Kingdom.
Your report notes that the tragic death of James Frankish at the age of 21 was the result of ingestion of a large amount of non-edible plant material. James had severe intellectual disability and autism; he had also been diagnosed with the eating disorder Pica at the age of
3. Although his parents understood the risks associated with Pica, you reported that the residential care staff and health professionals who were involved with James’ care at that time of his death (which included a Clinical Psychologist), were not aware of the extent of James’s Pica nor did they fully appreciate the risks associated with Pica.
Every Clinical Psychology doctoral training programmes in the UK is accredited by the British Psychological Society, the criteria for accreditation specify that “the clinical psychology curriculum should include…… presentations of those with intellectual disability” (p23) and that “Programmes must ensure that trainees gain the following clinical experience and skills”
2
including with “service users across a range of levels of intellectual functioning over a range of ages, specifically to include experience with individuals with developmental intellectual disability and acquired cognitive impairment” (p26). Thus, all Clinical Psychologists trained on accredited courses should have foundational knowledge and skills for working with people with intellectual disabilities. The Society does not specify detailed content for training curricula, but Good Practice Guidance produced by the DCP Faculty for People Intellectual Disabilities mentions “possible physical and mental health problems and disabilities co-occurring alongside learning disabilities” (3.6). This would encompass a range of challenging behaviours and should include Pica.
In light of your report, I have written personally to the programme directors of every UK Clinical Psychology training programme to ask them to confirm that Pica, and the associated health risks including risk of mortality, are explicitly addressed in teaching on their programme.
Furthermore, I have also circulated to programme directors two articles written by British Psychological Society member, and Chartered Clinical Psychologist, , together with James’ parents, , on James’ death and guidance on managing Pica, that were published by the National Autistic Society in April 2019 (see attached).
Psychologists can also contribute to prevention of deaths in similar circumstances more broadly by promoting person-centred care planning that can build on professionals, individuals’ and their families’ expertise, to enhance safety and quality of life. A particularly tragic aspect of James’s death was the fact that his parents’ understanding of the extent of their son’s Pica, and the risks associated with this, was not transferred to the staff caring for James in the residential setting.
Whilst awareness is clearly a key issue in the prevention of future deaths, awareness is not sufficient; safe and effective management of behaviours is also critical. Pica would be considered a challenging behaviour and it is important that challenging behaviours are managed using effective, evidenced-based approaches. Positive Behaviour Support is a wrap-around model of care that is recommended in the BPS/Royal College of Psychiatry joint guidelines “Challenging Behaviour: a unified approach” (2007/2016) and the NICE guideline NG11 “Challenging Behaviour and People with Severe Learning Disabilities”. This approach should now be well established in statutory residential care settings, however we are highlighting the need to enhance community provision of Positive Behaviour Support as the Transforming Care programme reduces hospital admissions under the Mental Health Act for people with intellectual disabilities and/or autism who present with acute episodes of severe behavioural difficulties.
Clinical psychologists should not only adhere to high standards in their own direct clinical work but can also contribute to the safe and effective functioning of teams with whom they work. One of the nine core competences specified in the BPS accreditation criteria for clinical psychology training programmes is “Organisational and systemic influence and
3
leadership”. The criteria require that all trainlines should develop competence in “Indirect influence of service delivery including through consultancy, training and working effectively in multidisciplinary and cross-professional teams. Bringing psychological influence to bear in the service delivery of others.”
In my letter to clinical psychology course directors I emphasised that clinical psychologists can play a role in preventing tragic deaths such as James’, and others of people with intellectual disabilities, through their application of their knowledge and skills directly in the care of that client and also indirectly in promoting person-centred care and appropriate management of challenging behaviours within the services that they have input to.
In recent years health and care professionals in the field of intellectual disabilities have set an excellent example of interprofessional working to improve service user outcomes and the British Psychological Society has supported the Learning Disabilities Professional Senate since its inception. We will actively support the development and dissemination of multi- professional guidelines relating the management of Pica.
Please do not hesitate to contact me if you would like any further information on any of the above.