Warning to Psychs: How would your practice records look to the FBI?

As sen in this report

Until recently, a psychologist in a Southeastern state had a thriving practice in geriatric psychology, working with patients in nursing homes. Then the health-insurance company that acts as the Medicare carrier for his state had his records audited.

The report of that audit said that several dozen patient records had been reviewed and all of them lacked sufficient documentation to indicate medical necessity. This "sampling" of records, according to the audit procedures Medicare uses, could represent all the work he had done in the nursing homes during that period--a methodology that APA and health-care providers in general vehemently oppose since it can lead to inappropriate assumptions and faulty conclusions.

Rather than questioning the few thousand dollars of claims represented by the files reviewed, the agency extrapolated to cover all his claims over the entire time period and said the psychologist had over billed by more than $500,000.

The FBI then moved in with a search warrant, seized all of his records, apparently for the purpose of a criminal investigation.

The psychologist now has an attorney and is appealing the Medicare agency's decision to an administrative law judge. His attorney asked that neither the psychologist nor himself be identified pending the legal proceedings. The FBI has not indicated whether a criminal prosecution is in the works.

After the audit, Medicare, his primary reimbursement source, suspended all payments to him.

The government's massive initiative against health-care fraud and abuse in this country is several years old, now a permanent structure and one that is expanding, according to sources in Congress, federal agencies and private consultants.

APA's Practice Directorate has monitored developments related to the enforcement push over several years.

"While the APA supports efforts to eliminate fraud and abuse in the current health-care system," said Russ Newman, PhD, JD, APA's executive director for practice, "we are similarly concerned that overly zealous fraud enforcement not cast an inappropriately wide net. The directorate is aware of many instances where Medicare carriers are using enforcement policies as cost-containment devices to curtail legitimate services."

Others working with practicing psychologists confirm that assessment.

"This is a freight train coming at psychologists," says James Georgoulakis, PhD, MBA, APA's representative to the Resource Value Update Committee that advises the Health Care Financing Administration (HCFA).

Virtually every week he gets a call from a psychologist under investigation. Accusations of over billing from $60,000 to $100,000--often more than a practice can sustain--are not uncommon, he says.

Up to now psychologists have not been scrutinized as intensely as hospitals and physicians, says Georgoulakis, director of healthcare, Holt Companies, San Antonio, Texas, and author of several books and articles on health-care compliance.

The bad news, he says, is they are vulnerable to future pressure that could be much greater.

"It's not that psychologists are dishonest people. It's that we are not educated on claims submission," he says.

Psychologists are getting in trouble, says Georgoulakis, with coding, indications of medical necessity, poor documentation, bills indicating too many hours for one day, and lack of knowledge of payment policies.

Enforcement actions can range from demands for reimbursement to civil penalties and, in some cases, even the possibility of imprisonment.

[...]

An intensified push

In recent years, Congress has pumped hundreds of millions of new dollars into the health-care enforcement effort. Much of that mandated enhancement has only recently been coming to fruition.

Attorney General Janet Reno has declared combating health-care fraud and abuse the second highest priority in the U.S. Department of Justice (DOJ), preceded only by the fight against violent crime. The HCFA budget for the effort this year is over $700 million. The battle is being carried out by the "fiscal intermediaries" and "carriers" for Medicare, state Medicaid fraud units and the DOJ's U.S. attorneys' offices around the country.

And just in the last year, HCFA has expanded the avenues of attack by funding new "program safeguard contractors" to be more focused, aggressive fraud fighters than the regular Medicare carriers and fiscal intermediaries. In addition, it mandated that the federal "peer-review organizations" in every state devote more resources to claims review.

The largest part of the antifraud effort still emanates from the federal and state governments, but private insurers have their own efforts. They also coordinate with and learn from the government's efforts.

And this ever-evolving force is not likely to dissipate any time soon, since it's motivated in great part by the pressing need to contain health-care costs, as congressional hearings and agency publications indicate. Various estimates say 7 percent to 10 percent of health-care expenditures are lost to fraud or misbilling.

Hospitals have probably been hit hardest by the enforcement push and they have come to realize that it's not just providers who are intentionally cheating who feel the heat. Most hospitals in the country have had to deal with one enforcement action or another.

And apparently psychologists who are not intending to defraud anyone are getting in trouble as well. As one example, some psychologists are not documenting correctly or in the way prescribed by the local Medicare carrier or fiscal intermediary or other insurer, say Georgoulakis and others. Medical records professionals have a saying, "If it isn't documented, it didn't happen." And if it was billed to an insurance program, say enforcement agencies in legal actions around the country, it's fraud.

Assistant U.S. attorney James Sheehan, the most prominent DOJ prosecutor in health-care fraud, has frankly indicated that the enforcement push is intended not only to root out criminals, but to change health-care practitioners' mindsets through the entire industry. Rather than seeking ways to gain maximum reimbursement, practitioners should be aiming for meticulous compliance with the rules, enforcers emphasize.

Enforcement tools

And enforcement agencies are using hefty instruments to make their point. Other than criminal prosecutions, their primary weapon is the False Claims Act, which makes anyone who submits a false claim to the government liable for a civil penalty of between $5,000 and $10,000 for each claim, plus up to three times the amount of damages.

Although enforcers say these punishments will not be used for inadvertent errors, they can be used when a provider should have known the rules on claim submission or other activity.

Another technique investigators use is the "sampling process," such as the one used in the psychologist's case outlined above. An audit looks at what is intended to be a statistically valid random sample of records. If there are problems in those records, the agency extrapolates that percentage to cover the similar records for the same time frame, multiplying by many times the amount the government says was improperly billed. The amounts can be devastating, even if the enforcement agencies are not seeking penalties.

Although the health-care industry has objected strenuously to the sampling process, courts have upheld it in general, and the government investigators are using it regularly. Attorneys in health-care fraud and abuse indicate it can still be challenged in court in some instances.

The enforcement actions have come in waves, as the DOJ, HCFA and the Department of Health and Human Services Office of Inspector General (OIG) focus on one aspect of the industry or one particular practice and teach each other where the vulnerabilities are.

In terms of psychologists' individual or group practices, Georgoulakis says the distress calls he receives come from all over the country, but most are from New York, Texas, Florida, California and Washington, with some concentration in Ohio and Illinois. He warns that just like with initiatives against hospitals, enforcers will perfect their technique and use it in other regions.

In addition, there are several trends of enforcement actions on services in institutions. A focus on nursing homes is not a surprise, given the finding by the OIG that 32 percent to 46 percent of mental health services in nursing homes are unnecessary.

For example, as of December the Ohio Psychological Association (OPA) had documented 12 cases of Medicare auditors ruling that large portions of a psychologist's services to nursing home patients were undocumented or medically unnecessary. OPA has said the audits did not follow the published policy on medical necessity. The Medicare carrier has said they did.

In another thrust, over the last two years the OIG has found extensive, deliberate fraud involving Medicare's partial hospitalization program in a number of community mental health centers.

The OIG is continuing the investigation into community mental health centers and has moved to investigate partial hospitalization services in hospitals as well as hospital outpatient psychiatric services in general.

In one of the first major such investigations, last year the OIG audited outpatient psychiatric services of Franklin Medical Center of Greenfield, Mass., and found that of $20,871 from 100 random claims, $13,000 was for services not meeting Medicare criteria. From that, OIG projected the hospital owed more than $600,000 in repayments. Problems cited included documentation for group therapy that consisted only of checking off the patients' names; therapists' notes that could not be located; and no documentation of physician's order.

Sidney Rocke, JD, APA special counsel and formerly a health-care prosecutor with the OIG, points out that some psychologists are taking preventive action. Rocke has given continuing-education sessions on compliance for two state psychological associations as a service from the APA Practice Directorate.

"Knowledge is the best line of defense. And that includes psychologists knowing how their practices are vulnerable to attack from both the government and insurance companies."

The Prozac question

An OdEd peice from the Frederick News Post

Prozac is a brand name for fluoxetine, a drug primarily used to treat conditions such as depression, eating disorders, premenstrual mood disorder and anxiety disorders.

Fluoxetine stimulates the brain's levels of the neurotransmitter serotonin; inadequate amounts of that chemical are linked to depression. The medicine blocks unused serotonin from being absorbed by a nerve cell, sending it to another nerve cell and facilitating transfer of the chemical along the brain's synapses.

At first, the drug was heralded as a wonder treatment, with Newsweek giving the pill cover story treatment on March 26, 1990, titling one article "The Promise of Prozac."

But Benjamin Garris wasn't alone in believing something was wrong while he was on Prozac. Long before he consumed the drug, a grassroots movement spread a message that Prozac made people worse -- specifically, more violent and suicidal.

In 1989, Joseph T. Wesbecker killed eight of his co-workers and injured 12 others with an assault rifle before killing himself in Louisville, Ky. Mr. Wesbecker was taking Prozac. The drug's manufacturer, Eli Lilly, reached a settlement over the effects of the drug when a lawsuit was filed on behalf of the people killed by Mr. Wesbecker.

The scientific community also began to weigh in. In the March 1991 edition of the Journal of the American Academy of Child and Adolescent Psychology, researchers from the Yale University School of Medicine described how six out of 42 patients ages 10 to 17 with a history of psychological problems worsened while being treated with fluoxetine.

On Sept. 20, 1991, about three years before Garris was prescribed Prozac, the Department of Health and Human Services, Public Health Service of the Food and Drug Administration met with the Psychopharmacological Drugs Advisory Committee in Rockville.

The purpose of the meeting: To hold a "scientific investigation into suicidal ideation, suicidal acts, and other violent behavior reported to occur in association with the pharmacological treatment of depression."

Although all makers of antidepressants were invited to the meeting, only Eli Lilly sent representation.

A clear divide developed during the session.

The committee heard stories from people about how they or their friends or relatives changed while under the influence of Prozac and antidepressants:

"After being on Prozac for 21 days, my wife shot and killed both of these two boys right there. She turned the gun to herself and shot herself twice. Now she's in jail for murder. This is the kind of lady that never took a drug, no mixed drinks, no alcohol, no reason to be depressed, just some nerve problems, like everybody else from time to time."

However, members of the professional psychological and psychiatric community said they believed introducing a warning system or other punitive measures for anti
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depressants would pose a serious risk for the larger community of people who are stricken with depression:

"We have certainly heard some very sad, troubling, and tragic stories and anecdotes this morning. We also know that when depression is untreated, some 15 percent of patients will kill themselves, additional tragedies, and many more suffer from untreated depression who do not suicide. But depression is eminently treatable. Once recognized and appropriately managed with combinations of pharmacotherapies and psychotherapies, the vast majority of individuals with depression can be treated effectively and lead useful and productive lives."

Representatives from the U.S. Food and Drug Administration and Eli Lilly testified that studies and trials of Prozac, which they said encompassed more than 8,000 patients, showed only a small number of adverse events and no direct connection between increased suicide or violent risk.

"Taken all together, with these anecdotal data one has to raise the obvious question. It seems likely that what we have here is a situation that we are taught in medical school," said Dr. Charles Nemeroff of Emory University, on behalf of Eli Lilly. "Things can be true, (or) true and unrelated. Patients can be suicidal, patients can be being treated with an antidepressant, yet there is no cause-and-effect relationship.

"At best, these are anecdotal reports."

In the end, the committee agreed with Eli Lilly, the FDA and the medical community, voting that no credible evidence supported a conclusion that antidepressants cause or increase suicidal or violent behaviors, and no labeling change should be made.

In September 2004, the FDA approved a warning label for antidepressants, including Prozac. The warning states the drugs can cause suicidal actions in patients under the age of 18.

Handling of ADHD students criticised

Maybe the drugs really weren't needed in the first place. As seen in this story from Australia

Schools could be failing students suffering from Attention Deficit Hyperactivity Disorder by treating them as backward, when a focus on their academic and social needs could wean them off their dependence on medication.

Sufferers of ADHD - the most commonly diagnosed psychiatric disorder among school-aged children in Australia - say teachers were often "quite condescending", treating them like toddlers or primary school students requiring remedial education.

The first study of its kind in Australia, which is to be included in Brenton Prosser's new book Seeing Red, found those students receiving traditional treatments deal with the disorder through school and adult life by relying purely on medication.

"They talked about how they feel the stigma of the label from the media, and that while they need support from school they also don't want to be labelled, in their words, as 'psycho'," said Dr Prosser, a lecturer on ADHD in schools at the University of South Australia.

"The problem is that it's not that young people with ADHD don't understand school-work, it's that schools don't understand how the students work."

The treatment of ADHD with dexamphetamines such as Ritalin has soared in recent years, with about 80,000 young people diagnosed with the disorder.

Dr Prosser said traditional teaching strategies such as remedial intervention were not viewed as successful in engaging ADHD students or supporting their learning needs, and could often lead to resistance.

He said this neglect of students' academic and social needs during primary school years often resulted in significant difficulties emerging in the middle years of school.

Schools and teachers could reduce the pressure on young ADHD sufferers by ensuring, for example, that students with hyperactivity problems did not sit tests after recess or lunch-break, when they have been out in the schoolyard.

Students who had only received medication in primary school also struggled when they came up against the greater social and academic demands of secondary school.

"It's about saying pills don't give you skills," Dr Prosser said.

"Those students who didn't have support, who had only medication, tended to say they had significant problems with ADHD and they were still grappling with adult ADHD and felt they strongly needed the medication to survive through schooling and get through life."

By contrast, students who had received support told Dr Prosser about "growing out of ADHD".

Filth and shame in an NHS hospital

In Briatain, it's not just the Psychs, although I too easily suspect they are leading the pack. As seen in this editorial on mixed sex hospital wards in Britain.

Twenty-four hours to save the NHS! I wonder how often that promise comes back to haunt Tony Blair 10 years later. Week after week reliable reports and the government’s own figures tell a disgraceful story of incompetence, debt, misery and filth in the National Health Service. That story is supported, week after week, by heart-rending personal accounts of horrors on the wards.

The broken new Labour promise that caught most public attention last week was the failure to abolish mixed-sex wards. Janet Street-Porter, the ferocious media personality, wrote about the misery of her sister when dying of cancer in a mixed-sex NHS ward. Plenty of other people have tried to draw attention to this disgrace and Baroness Knight, the Conservative peer, has been campaigning about it for years but — such is the spirit of the times — it takes a loud-mouth celebrity to get public attention.

The same thing happened when Lord Winston made a fuss about the dreadful treatment that his elderly mother received in hospital. Only then did the government stop denying that there was anything wrong.

Street-Porter published extracts last week of the diary of Patricia Balsom, her dying sister. They were horrifying. Among the miseries she endured was lying neglected in a mixed ward, where she was woken more than once to see a naked male patient masturbating opposite her bed. Her shocking stories prompted a flood of others.

The late Eileen Fahey, for instance, dying of cancer, was put onto a mixed geriatric ward where confused people wandered about without supervision. One man with dementia regularly masturbated at the nurses’ station and tried to get into women patients’ beds; he was a threat to them all but staff took no notice, according to her daughter Maureen. Other patients have to give answers to intimate questions in the hearing of other patients. One deaf old man was repeatedly asked when he last had an erection, until tears ran down his cheeks.

A former midwife described eloquently on Radio 4 the indignities of being in a 24-bed mixed-sex ward, stripped of all dignity and intimidated. Bedlam was the word she used, and it applies even more accurately to the secure psychiatric mixed ward in London endured by Susan Craig last year, after a breakdown. She suffered regular sexual harassment, with mentally ill men groping her and exposing themselves. The nurses disbelieved her and told her husband she was “flaunting herself”.

If so (I don’t believe them), their job was to protect a patient from her own folly. Instead they chose, in modern cant, to blame the victim.

Sexual harassment is only a small part of the problem. Many people, both men and women, feel their modesty is violated by such closeness to random members of the opposite sex, even when they are not threatened.

Patients lie naked, half washed and forgotten, their sick and ageing flesh exposed to everyone, while nurses rush elsewhere. It is commonplace to have to walk to filthy mixed lavatories with gowns wide open at the back. At a time of sickness and anxiety many people are profoundly embarrassed to be surrounded by a clutter of bed pans, colostomy bags, nakedness, cries of pain and sweat, blood and tears — their own and other people’s.

All this is much worse, for many, when they are surrounded by members of the opposite sex; shame and anxiety are not the best bedfellows of hope and healing.

Much has been written about the rape of modesty and the death of shame. However, it is still true in this weary country that most men and women prefer to perform private bodily functions alone if possible, and among their own sex only, if not. That’s why we have separate public lavatories and separate changing rooms in shops and clubs and pubs. That’s why people put up towels on the beach. That’s why women give birth in female wards, not in mixed wards or not — I hope — so far.

Admittedly there are some who believe that mixed wards are not a problem, but our prime minister is not one. “Is it really beyond the collective wits of the government and health administrators to deal with the problem?” he demanded in 1996, flying high on vectors of dizzying youthful indignation as leader of the opposition. “It’s not just a question of money,” he went on. “It’s a question of political will.” Well, he said it and he promised to end mixed-sex wards by 2002

What we have come to expect of new Labour promises, following failure, changing the goalposts, more failure and exposure, is denial. Sure enough Patricia Hewitt, the health secretary, was sent onto the Today programme in denial mode last week.

Although the Healthcare Commission watchdog found that on average 22% of patients have to stay in mixed-sex wards, rising to 60% in some hospitals, Hewitt’s officials at the Department of Health say the government has achieved its target of abolishing mixed-sex wards, with 99% of trusts providing single-sex accommodation.

It is not difficult to spot the problem with that claim. It is not the same as saying 99% of patients get single-sex accommodation; it may be “provided” for very few. There has been the usual goalpost shifting: hospitals can claim they are providing single-sex accommodation by putting screens between beds in mixed-sex wards. Brilliant.

Hewitt admits there was a problem of perception; she even admitted that there was a “clear gap” between patients’ experiences and figures provided by hospital trusts to the Department of Health. One does tend to have a problem of perception, I find, if one is being misled.

My feeling is that mixed-sex wards are not the worst of NHS hospitals’ problems, although they demonstrate them. They demonstrate the incompetence and deviousness of hospital management in general, and they also show something worse. In all the stories I’ve come across what stands out is the ignorance, incompetence, laziness and heartlessness of all too many nurses, who are allowed to neglect and insult their patients without supervision and without sanction — in single-sex wards just as much as mixed.

Blair did not just promise to abolish mixed-sex wards, he also promised to save the entire NHS. He believes in divine judgment; I wonder how he will answer.

Another Psychiatric Disease Under Fire

As seen in NewsDay A situation where criminal activity became a mental disease, and then became a profit motive?

Nowhere is the controversy surrounding Munchausen syndrome by proxy fiercer than in England, the country where the diagnosis was first identified.

The two doctors most closely associated with the syndrome - Roy Meadow, who wrote the article introducing it in 1977, and David Southall, who used covert video surveillance to record parents hurting their children in hospitals - in the last few years found themselves fighting for their medical licenses and reputations. In 2004, the British government ordered the review of more than 250 cases of parents convicted of killing their children on the basis of testimony from Meadow, Southall and other experts dating back a decade.

"I think in England the accusation has been thoroughly trashed by the media and also by professionals who realize now that this really got out of hand, and particularly that it was very easy to blame mothers when that wasn't what was happening," said Eric Mart, a psychologist and Munchausen expert from New Hampshire who has testified on behalf of accused parents in dozens of cases. The acquittals "have really stifled accusations of Munchausen syndrome by proxy."

In the decades following Meadow's 1977 article, which described a mother who injected her own blood into her child's urine and another who poisoned her child with salt, the number of Munchausen accusations in the United Kingdom and beyond began rising. But criticism of Meadow and the diagnosis mounted following two high-profile acquittals in cases that had relied on his expert testimony.

In January 2003, Sally Clark, a lawyer, won an appeal of her conviction for killing two of her children after it was disclosed that at least one boy had a serious bacterial infection. Her conviction four years earlier had been based largely on Meadow's testimony that there is only a one in 73 million chance of two SIDS deaths in a single family, a statistic that has since been discredited.

In December 2003, Angela Cannings, who was convicted of killing two of her children also largely on the basis of Meadow's testimony that she was a Munchausen mother, was freed on appeal when a judge learned there was a history of SIDS in her family. Following these acquittals, Meadow lost his medical license but won it back on appeal.

Southall, a British pediatrician, launched a study using video surveillance to try to identify Munchausen parents in 1986. Over the next eight years, the controversial videotapes, some of which show mothers appearing to suffocate their children or removing their IV tubes, led to Munchausen accusations against 23 parents and 33 total abuse prosecutions. He was investigated by England's General Medical Council, which stripped him of his right to work in child protection but allowed him to keep his medical license, after testifying against the husband of Sally Clark.

The acquittals of Cannings and Clark, coupled with the rising influence of mothers publicly fighting Munchausen accusations, led many in England to begin calling Munchausen the "discredited" diagnosis, and the number of cases there has dropped dramatically. Some say, however, that the pendulum has swung too far - pointing out, for instance, that four of those captured on video by Southall pleaded guilty - and is creating a climate in which practitioners are afraid to make any child abuse accusations at all.

"The strongest piece of scientific data are those 39 cases published by David Southall. You just have to read those cases to know that if this is out there, it's something you want to protect children from," said Herbert Schreier, a child psychiatrist who co-wrote the book "Hurting for Love." "And the reality is that now nobody wants to go near these cases."

Psychiatrists fight against mental health services reform

It seems that psychiatrists in Isreal are fighting tooth and nail against Mental Health Reform. As seen in this report, it seems like they are protesting the end of a profitable business as usual system. While we present the report, we remain ever so skeptical of their arguments. It's always about the money, y'know.

The long-awaited reform of mental health services that will transfer responsibility for them from the Health Ministry to the four health funds will in fact "trigger their collapse," according to the Israel Medical Association (IMA) and the Israel Psychiatric Society. The two groups issued an emergency call on Wednesday to prevent its implementation on January 1.

Representatives of the two organizations, joined by heads of the Israel Society for Pediatric and Adolescent Psychiatry, the Government Doctors Union, the Psychologists Association and Social Workers Union, called for an urgent revamping of the reform so it would not harm patients and professionals in the mental health field.

The agreement reached in recent months by the Health Ministry and the Treasury for implementing the reform is a "serious perversion" of the planned reform, whose roots go back to recommendations of the 1989 State Judicial Commission on the Health System, they said.

"It will cause many patients to be thrown into the street without any treatment for them," they said.

Instead, they called for "a real reform, which is vital and necessary, in cooperation with the organizations of professionals who treat them."

When the National Health Insurance Law went into effect in January 1995, mental health services were supposed to be transferred gradually by the ministry to the health insurers, but the Treasury opposed it on the grounds that it would cost a lot of money and it never happened.

The main arguments in favor of the reform were that treating mental illness like physical illness would eliminate much of the stigma of psychiatric and psychological problems and that the ministry had an inadequate budget for services.

The IMA, the psychiatric society and the other professional organizations favored the reform concept, even though it has already led to the elimination of 4,000 psychiatric hospital beds, with stress placed on treating patients with newer medications and psychiatric and psychological counselling in the community.

But the Treasury, "which never supported the reform, searched for ways to make it fail, and it is carrying out only a reform of reducing services," the medical representatives said.

According to an agreement signed in September by the Health and Finance Ministries, 50 community mental health clinics and stations owned and run by the Health Ministry will be closed.

In addition, said opponents to the reform, the Treasury was allocating only NIS 160 million extra for implementation instead of the 300 million that is the minimum needed for the health funds to set up and provide adequate services.

"What is the logic of closing facilities before new ones open in the community?" they asked. "Why close clinics that have proven themselves to be professional and beneficial?"

Dr. Jacob Polakiewitz, head of the ministry's mental health services, denied the claims and charges.

The ministry will transfer to the health funds the NIS 1.1 billion it has spent each year on mental health services, including NIS 760 million for hospitalization and NIS 430 million for community-based services, he said. In addition, the health funds will share an additional NIS 40 million a year over four years, for a total of NIS 160 million more.

"Government psychiatric hospitals will continue to function as today, but the health funds will purchase services from them to treat their members. The health funds cannot provide community services on their own today," said Polakiewitz, "so initially they will purchase services from the existing clinics. They will then either purchase clinics or hire some or all of the professionals for their clinics or independent professionals."

The ministry official said he understood the fear of cuts, but that the intention was to expand rather than shrink services. Patients who suffer from anxiety, depression or trauma from life experiences would continue to get treatment, but from the health funds rather than the ministry, he said.

Only two percent of the population now receives psychiatric treatment, said opponents of the reform, while the norm in the Western world is 4% - and those countries do not suffer the stresses of war and terror and the history of suffering in the Holocaust that Israelis do.

Increasingly, psychiatrists' time with patients has been limited. Under the new program, only people with diagnosed psychiatric disorders will receive help, while those who suffer from stress and trauma from life events and experiences will be ineligible.

The reform would not save money, the opponents argued, as without real therapy, patients would suffer breakdowns and have to be hospitalized again.

Children and adolescents suffering from mental problems, especially those in the periphery, would suffer the most from the reform, the mental health professionals charged. Rehabilitation of patients would be dealt a death blow, they continued, as hostels, protected living arrangements, clubs and sheltered workshops that employ them would be wiped out from lack of budget.

The reform, they maintained, has "turned into the Treasury's reform, without any support from mental health professionals who dealt with the issues for 11 years. There is not one single factor that supports it. All think it will be a disaster."

Earlier this week, at a Jerusalem public health conference, Health Minister Ya'acov Ben-Yizri said he was proud that responsibility for mental health services would finally be moved to the insurers.

"One can't solve every problem in advance, but we will go ahead even if it steps on some toes and hurts the prestige and the livings of some groups," he said. "There will be special committees to monitor implementation and deal with problems. If we wait, it will never get done."

They're getting away with murder - British mental health services are in turmoil

An interesting opinion piece in the Times Online, regarding the sheer incompetence of psychiatry in Britian.

If you ever feel like overdosing on euphemisms, I advise doing time with the mental health lobby. This is something I have done on and off, out of journalistic interest. These people do heroic work with sufferers, and campaign to highlight their needs. But their determination to stamp out stigma can lead them to rewrite reality. Illness has become health. Patients have become clients. Savage attacks on other people have become “untoward incidents”. Now last week’s devastating inquiry into the death of 50-year-old Denis Finnegan, murdered while cycling through Richmond Park by a paranoid schizophrenic, John Barrett, is being twisted by powerful groups who put patient “rights” above public protection.

A respected consultant psychiatrist neatly summed up his profession’s hostility to inquiries. “Being retrospective,” he said, “they foster a simplistic notion of the preventability of homicides”. Really? What last week’s inquiry showed was that Finnegan’s death was wholly preventable, caused by gross incompetence and arrogance — from the tribunal that discharged Barrett in the absence of his doctor, to the psychiatrist who gave him an hour's leave from hospital, to the nurses who failed to warn the right people that he had not returned.

Once again — and I am a bit of a connoisseur of these inquiries — we read of “cumulative failure”. An innocent person is hacked to death by someone with clear warning signs: in this case, violent voices in his head. But the psychiatrists always know better.

The Barrett inquiry is crystal clear: the South West London and St George’s Mental Health Trust, which “cared” for him, is incapable of putting its own house in order. Yet the trust blithely issued a confident statement last week about improvements already made. The whole reaction has been surreal. On Friday the Royal College of Psychiatrists insisted that “all the professionals involved in this inquiry [must] be supported” and announced that it is planning — a seminar. Shouldn’t someone be sacked? No. I can find only one example of a psychiatrist resigning after a murder inquiry, and that was in 1997.

The Mental Health Alliance, a group of 80 charities, is concerned only to emphasise that Finnegan’s death was “extremely rare”. This is a familiar refrain from those who fear the public will shun schizophrenics. But it borders on falsehood. When I called the Department of Health this week, I discovered that between 55 and 63 people are killed every year by people who have recently been in contact with mental health services. At about 10 per cent of the total murder count, dare I say this is quite a lot?

The charity SANE believes that at least one in three of those murders is preventable. Its analysis of 69 such inquiries finds that in half the cases, professionals had ignored warnings from family and friends. Some psychiatric patients refuse treatment. What is less well known is how many others are denied it, even when they or their relatives are crying out for it.

The Barrett inquiry vividly describes the culture that seems to be endemic among the lunatics running our asylums. “Too much confidence,” it finds, “was placed in clinical judgments unsupported by evidence and rigorous analysis.” There was a preference for “engaging” with patients, over “intervening”. There is an understandable reluctance to act in loco parentis for adults who may at times be perfectly capable.

But the jargon of “empowerment” creates nonsenses. It means a manic depressive choosing not to “engage” with social services, which then walk away. It means a schizophrenic choosing whether or not to take medication, even if he has a violent history. It means setting Barrett free to buy a packet of knives and take a taxi to Richmond Park. In most cases, treating people who have lost their reason as though they were rational beings leads to misery and neglect. In a few cases it leads to death.

Last Friday, the Government launched proposals for community treatment orders (CTOs). These would compel formerly detained patients who pose a risk to the public to take their medication or return to hospital for treatment. A vast lobby is massing against this. The Mental Health Alliance is comparing CTOs to ASBOs, and muttering about human rights. But they will only apply to a small number of potentially dangerous individuals. They could provide greater stability for people who are on the misery-go-round between prisons, hospitals and the “community”. The lobby makes much of the Barrett inquiry’s finding that the problem was not lack of legislation. But the inquiry does support CTOs.

Compulsion is tricky territory. But that does not justify selective deafness about the findings of such an important investigation. The light that such processes shine may explain why there is now a concerted effort under way to circumvent them. Finnegan’s brother was originally offered an internal review by the mental health trust, and told he would have to sign a confidentiality contract to read it. It was only with the support of the Zito Trust, one of the sanest charities, and John Reid, then the Health Secretary, that he got an independent inquiry.

Others have not been so lucky. Haringey Primary Care Trust has just completed an internal review into the case of Ismail Dogan, who stabbed six people in North London in 2004, killing one. His mother had appealed for help after he had stopped taking his medication, but got none. Will Haringey publish?

We cannot get away from what happened to Denis Finnegan by giving it another name. It was murder, and someone needs to take responsibility for it.

Documents show violations Cape Fear Valley Medical Center

As seen in this report from the Fayetteville Observer

A 13-year-old girl with a history of depression and suicidal thoughts went to Cape Fear Valley Medical Center in January 2005 for treatment.

Within five minutes the emergency room psychiatrist — who had seen her before — called her a criminal and told her to leave and not return. But she did.

On the way back to her Fayetteville group home, and upset about the hospital visit, she suffered a skull fracture and internal injuries when she jumped from a car traveling 40 mph. This time she was treated in intensive care.

The incident was categorized by state investigators as one of the most severe violations that can occur in a hospital, and it became part of a series of violations that have made Cape Fear Valley perhaps the most heavily cited hospital in the state in the past three years.

The state conducts the investigations for compliance with federal Medicare and Medicaid standards.

Joyce Korzen, Cape Fear Valley’s chief operating officer, said violations found by the state always have been corrected, and the hospital has never lost eligibility to receive federal funding or been penalized with fines.

Cape Fear Valley, a private, nonprofit corporation, has previously disclosed that space and staff limitations in its emergency department have caused patients to wait several hours for treatment. But documents obtained from the N.C. Health and Human Services Division of Facility Services provide details on other major violations that have been previously unreported.

From January 2005 to June 2006, the state determined three instances when Cape Fear Valley was out of compliance with requirements to receive Medicare and Medicaid funding because of six major violations. Each time, the federal Centers for Medicare and Medicaid Services, known as CMS, issued Cape Fear Valley a termination date for losing funding.

Losing such funding would cost the hospital about two-thirds of its $1.2 billion annual operating budget. The 394-bed acute care facility is Fayetteville’s largest.

The psychiatrist who denied treatment to the 13-year-old girl resigned five weeks later, but state inspectors have found similar violations since then. Mistreatment of another suicidal adolescent was among more federal violations that were resolved just two months ago.

Many of the violations were found in the treatment of psychiatric patients whose emergency room visits have increased due to cuts in state mental health services that have affected many hospitals. But the number of violations at Cape Fear Valley, along with other violations that did not involve behavioral care, is believed to be among the highest in the state.

“I’m not aware of a system or hospital in the last three years that’s had that number,” said Cecilia Boone, a Facility Services hospital surveyor.

Boone leads the state’s investigations on complaints about federal emergency treatment standards. She was involved in all three of the recent inspections at Cape Fear Valley and said the hospital was cited with another major violation in 2004.

The state is not required to keep track of how often hospitals are cited, and CMS did not have immediate information to compare the number of Cape Fear Red Lake Indian Reservation Valley’s violations with other North Carolina hospitals.

More at the Link

Charges have been dropped against the naked prosecutor

On October 12th we had reported on an apparent new side effect of psych drugs, namely Nude Behavior. A public prosecutor had been caught running around naked after hours at the office. His defense blamed the episode on a side effect of the psych drugs his was taking.

In this update, we can say that charges have been dropped against the naked prosecutor. Apparently there was a problem in the briefs.

Charges against a former city prosecutor accused of public indecency were dropped Tuesday because they were improperly filed, his lawyer said.

Authorities had charged Hamilton prosecutor Scott Blauvelt after a guard monitoring a security camera saw a naked man in the county office building the night of Oct. 5.

The previous night, security video had captured Blauvelt, who has since been fired, naked in another area of the building, where city offices are located, authorities said.

Blauvelt’s attorney, Mike Gmoser, said that charges were dropped because Blauvelt had been charged under a law no longer in effect, and that prosecutors have not decided whether to refile charges.

Blauvelt, 35, was suffering from a bad reaction to medication prescribed for depression and to control seizures related to a 2005 traffic accident, Gmoser said.

The Madness of Massive Psych Drugs Combinations for Children

As seen here, a sad tale on what we are doing to our kids. It looks like that the more drugs the kids are on, the more it is a case of getting all of the side effects without any of the supposed benefits.

Their rooms are a mess, their trophies line the walls, and both have profiles on MySpace.com. Stephen and Jacob Meszaros seem like typical teenagers until their mother offers a glimpse into the family’s medicine cabinet.

Bottles of psychiatric medications fill the shelves. Stephen, 15, takes the antidepressants Zoloft and Desyrel for depression, the anticonvulsant Lamictal to moderate his moods and the stimulant Focalin XR to improve concentration. Jacob, 14, takes Focalin XR for concentration, the anticonvulsant Depakote to moderate his moods, the antipsychotic Risperdal to reduce anger and the antihypertensive Catapres to induce sleep.

Over the last three years, each boy has been prescribed 28 different psychiatric drugs.

“Sometimes, when you look at all the drugs they’ve taken, you wonder, ‘Wow, did I really do this to my kids?’ ” said their mother, Tricia Kehoe of Sharpsville, Pa. “But I’ve seen them without the meds, and there’s a major difference.”

[...]

A growing number of children and teenagers in the United States are taking not just a single drug for discrete psychiatric difficulties but combinations of powerful and even life-threatening medications to treat a dizzying array of problems.

Last year in the United States, about 1.6 million children and teenagers — 280,000 of them under age 10 — were given at least two psychiatric drugs in combination, according to an analysis performed by Medco Health Solutions at the request of The New York Times. More than 500,000 were prescribed at least three psychiatric drugs. More than 160,000 got at least four medications together, the analysis found.

Many psychiatrists and parents believe that such drug combinations, often referred to as drug cocktails, help. But there is virtually no scientific evidence to justify this multiplication of pills, researchers say. A few studies have shown that a combination of two drugs can be helpful in adult patients, but the evidence in children is scant. And there is no evidence at all — “zero,” “zip,” “nil,” experts said — that combining three or more drugs is appropriate or even effective in children or adults.

“There are not any good scientific data to support the widespread use of these medicines in children, particularly in young children where the scientific data are even more scarce,” said Dr. Thomas R. Insel, director of the National Institute of Mental Health.

Psychiatrists who prescribe drug combinations say that the ability to mix and match medications improves their chances of being able to help children who are seriously, even desperately, ill.

[...]

The controversy leaves parents in a terrible bind. Desperate to help, many agonize over whether to medicate their children.

Mothers and fathers sometimes disagree, with the dispute straining or even ending marriages. Since some psychiatric drugs can cause worrisome physical effects, parents say that they must on occasion make a terrifying choice between their child’s physical health and his mental health.

The parents interviewed for this article told their stories, they said, in hopes of gaining greater acceptance for their children and themselves. Nearly all recalled being in a store when their child threw a tantrum and feeling that onlookers branded them as bad parents. They also said they hoped to help others negotiate what many said were unequal and often fraught relationships with psychiatrists.

“We struggled so much, made so many mistakes and felt so stigmatized, I hope our story can make it easier for others,” said Jacquie Erickson of Anchorage. Her daughter, Kaitlyn Johnston, 10, has taken psychiatric drugs since she turned 5 for diagnoses that include bipolar disorder.

On Shaky Ground

Stimulants like Ritalin are by far the most commonly prescribed psychiatric medicines in children. But doctors routinely pair stimulants with antidepressants, antipsychotics and anticonvulsants, even though some of these medications can cause serious side effects, have few proven pediatric psychiatric benefits and lack clear evidence about how they interact or influence mental and physical development.

Last year, the Food and Drug Administration required drug makers to warn on their labels that antidepressants can cause suicidal thoughts and behavior in some children. Anticonvulsant drugs carry warnings about liver and pancreas damage and fatal skin rashes. The side effects of antipsychotic medicines can include rapid weight gain, diabetes, irreversible tics and, in elderly patients with dementia, sudden death. When drugs are combined, these risks compound.

Ms. Kehoe, who receives government financial and child-care assistance because her children are considered mentally ill, said she knew that there were risks to the drug cocktails. Both her sons are short and underweight for their age — a common side effect of stimulants — and she fears that the drugs have affected their health and behavior in other ways.

“But I don’t think the insurance would pay for it if the F.D.A. didn’t decide that children should use it,” said Ms. Kehoe, who herself takes psychiatric medication.

In fact, the drug agency has specifically warned against the use of Lamictal, one of the drugs Stephen takes, in children who, like him, do not suffer from seizures because in 8 out of 1,000 children the drug causes life-threatening rashes.

Stephen and Jacob’s psychiatrist did not reply to telephone messages left with an office secretary on three different days. Ms. Kehoe said that she asked him to speak to this reporter but that he refused. The boys have had 11 psychiatrists over the last three years, according to prescription records, and many more before that, Ms. Kehoe said.

In interviews, Stephen and Jacob said they hated taking their drug cocktails.

“Everybody hates meds,” Jacob said.

Ms. Kehoe said her youngest son, Lucas Keck, was showing signs of attention deficit disorder and might soon need to start medication.

“I see the hyperness in him,” she said. “My pediatrician has said that he would venture to say that Lucas will be A.D.H.D.”

Stephen and Jacob were Lucas’s age — 6 — when they were given their first prescriptions.

The F.D.A. requires drug makers to prove that their drugs work safely before the agency will approve them for sale in the United States. But doctors can prescribe and combine approved medicines as they see fit. Such mixing is common in medicine but rarely studied by drug makers.

Psychiatrists started mixing psychiatric medications because the drugs were only moderately effective and often caused terrible side effects, said Dr. Steven E. Hyman, the provost of Harvard University and former director of the National Institute of Mental Health. “None of these drugs by themselves do an adequate job of controlling symptoms,” Dr. Hyman said.

If one drug failed, many psychiatrists assumed that two or more drugs used together might succeed. For decades, no one studied whether this was accurate. But in recent years, a trickle of studies have examined the question, with mixed results.

[...]

Even for single drugs, the effectiveness of some psychiatric medications in younger patients is questionable: most trials of antidepressants in depressed children, for instance, fail to show any beneficial effect. But hardly any studies have examined the safety or the effectiveness of medicine combinations in children. A 2003 review in The American Journal of Psychiatry found only six controlled trials of two-drug combinations. Four of the six failed to show any benefit; in a fifth, the improvement was offset by greater side effects.

“No one has been able to show that the benefits of these combinations outweigh the risks in children,” said Dr. Daniel J. Safer, an associate professor of psychiatry at Johns Hopkins University and an author of the 2003 review.

If the evidence for two-drug combinations is minimal, for three-drug combinations it is nonexistent, several top experts said.

“The data is zip,” Dr. Hyman said.

Many psychiatrists said that they turned to drug cocktails only in desperate circumstances. “If you’ve got a 15-year-old who is cutting up her arms, you’ve got a barn on fire and what are you supposed to do?” asked Dr. Alexander Lerman, a child and adolescent psychiatrist in New York, who said he rarely prescribed combinations.

Billy and Jackie Igafo-Te’o of Jackson, Mich., are among the desperate. In the last seven years, their 12-year-old son, Michael, “has been on just about everything you can put a child on,” Mrs. Igafo-Te’o said. He is now taking four medications: an antipsychotic, an anticonvulsant, an antidepressant and a sleep medicine.

Despite the medications, Michael’s behavior has grown increasingly disruptive. He has kicked and punched holes in almost every wall of the Igafo-Te’o home. He wrenched the sink off the wall in the upstairs bathroom and pulled two bedroom doors off their hinges, damaging the frames. The family no longer fixes the damage.

During a recent visit, Michael and Mr. Igafo-Te’o were sitting on the living-room floor. Michael wanted the phone. His father held it out of reach to prevent Michael from playing with it. Michael became increasingly desperate. He cried. He cursed.

“That’s it, you have a timeout,” Mr. Igafo-Te’o said.

“No, no, no,” Michael answered. “You pimp!”

He slapped his father in the face, hard. Mr. Igafo-Te’o hustled Michael into the kitchen and forced him to sit for 20 minutes.

“What’s the purpose of all this medication if I still have to do that?” Mr. Igafo-Te’o asked.

He said he wanted to end Michael’s drug therapy. Among other side effects, the drugs have made Michael obese, which has led to asthma.

Mrs. Igafo-Te’o quietly disagreed. “I’m afraid he wouldn’t be able to focus,” she said. “I’m afraid he would regress socially.”

“Regress socially? Look at him!” her husband responded, motioning to their son, crying uncontrollably on the kitchen floor.

“I have to believe in something,” his wife mumbled and walked out of the room.

Mr. Igafo-Te’o watched her go and then smiled apologetically.

“We always debate meds,” he said.

[...]

On Again, Off Again

Andrew Darr of Caldwell, Idaho, whose sons took medications, said that he was opposed to it from the start. “When you come home from work and instead of getting them clawing at your feet and yelling, ‘Daddy, Daddy,’ you get a lethargic grunt, it just kills you,” Mr. Darr said.

His wife, Leslie Darr, eventually agreed to stop the medicines, but only after a family tragedy.

The Darrs have four children, Nicholas, 16, Nathan, 15, Becky, 12, and Benjamin, 9. At 3, Nicholas suffered a mild brain injury when undiagnosed appendicitis led him to suffer weeks of high fever, Mrs. Darr said.

Mrs. Darr said that she was pressured by school officials to give Nicholas a stimulant at age 6. Nathan soon followed.

Three years later, the boys had a traumatic weekend away with relatives. A month after that, Mrs. Darr said, both were hospitalized for a week and given a diagnosis of bipolar disorder and prescriptions for antipsychotic, antidepressant and sleeping medicines.

Over the next three years, Nicholas’s weight ballooned to 140 pounds from 52. Nathan went to 115 pounds from 48. Neither boy got much taller, Mrs. Darr said. They did poorly in school.

Then Becky developed a brain tumor. A nurse practitioner gave Mrs. Darr free samples of an antipsychotic drug to help her cope. After starting it, she said, she could not sleep or think straight. She realized that she had been giving similar medicines to her sons for years and she decided to wean the boys off the pills.

Their behavior immediately worsened. At one point, Nicholas left the house during a blizzard wearing only boxer shorts, Mrs. Darr said. They found him in a tire swing saying, “Baaa.”

“There were several times that we almost gave up,” Mr. Darr said.

But after four months off medication, the boys’ behavior normalized, the Darrs said, and they were transferred out of special education and into regular classes. The Darrs recently allowed the boys to spend their first evening at a mall without supervision, and in July they gave both boys their first bicycles. “They’ve come a long way,” Mrs. Darr said.

In an interview, Nicholas said the drugs “were not cool.”

“You go to school and everybody thinks, ‘Look at that retard,’ ” he said.

[...]

This article has been edited for clarity and length

School Psychologist Accused of Faking Cases

As seen in this intro to the full report. The full news story is currently available to subscribers only, and will be available online in one month, during Christmas week. This news item seems to be taking palce in New York City.

A School Psychologist working with the Department of Education submitted 26 falsified Bilingual Psycho Educational Assessment Reports, collecting more than $10,000 on them, according to a report released by Special Commissioner of Investigation Richard J. Condon.

Oregon school psychologist arrested for ID theft

As seen here:

The Winston-Dillard School District has notified parents that an employee arrested on suspicion of identity theft and illegal possession of prescribed drugs has been placed on administrative leave and will not have access to confidential information while police are investigating.

The alleged crimes were not connected with the school. The district learned of the arrest after reading The News-Review's police log Nov. 13, Superintendent Duane Yecha said.

School psychologist Emily Lewis, 27, was arrested on suspicion of identity theft, a felony, and possession of illegal prescription drugs, which could be a misdemeanor or felony, depending on the drug, Roseburg Police Sgt. Aaron Dunbar said.

"Apparently she has an addiction to prescription pain killers," Dunbar said.

Lewis allegedly visited multiple urgent care centers, giving false names and dates of birth to get pain killers. A nurse at one of the centers recognized her and checked an earlier record, which had a photocopy of Lewis' driver's license, Dunbar said.

Police gave the school district a list of names Lewis allegedly used, and the investigation is continuing, Dunbar said.

And as reported here

A school psychologist has been placed on administrative leave following her arrest on suspicion of identity theft and possession of illegal prescription drugs, the Winston-Dillard School District said.

Emily Lewis, 27, also will not have access to confidential information during the police investigation, the district said in a notice to parents.

The district learned of the Nov. 13 arrest from the police log in the (Roseburg) News-Review, Superintendent Duane Yecha said.

Roseburg Police Sgt. Aaron Dunbar said Lewis visited multiple urgent care centers, giving false names and dates of birth to get pain killers.

A nurse at one of the centers recognized her and checked an earlier record, which had a photocopy of Lewis' driver's license, Dunbar said.

Police gave the school district a list of names Lewis allegedly used, and the investigation is continuing, Dunbar said.

NY State Considers Revisions to Aversion Therapy Regulations

As Seen here

Revised proposed regulations relating to Behavioral Interventions, including Aversive Interventions have been published in the State Register and are available for public comment. A two-page summary of the major revisions to the regulations that were adopted through emergency action in June 2006 is available to assist the public in its review of the revised proposed rules.

A full text of the revised proposed rule can be accessed at www.vesid.nysed.gov/specialed/behavioral/proposedterms1106.htm

Written comments on the proposed regulation must be received by December 15, 2006 and may be submitted to:

Rebecca H. Cort, Deputy Commissioner

VESID, New York State Education Department

Room 1606 One Commerce Plaza

Albany, New York 12234

Or by email to:

Attention: Comments: Behavioral Intervention Regulations vesidspe@mail.nysed.gov

You can see the Summary here

Among other things, The regulations were revised to prohibit, without exception, the following aversive interventions:

* ice applications; hitting; slapping; pinching; deep muscle squeezes;
* use of an automated aversive conditioning device;
* the combined simultaneous use of physical or mechanical restraints and the application of an aversive intervention;
* withholding of sleep, shelter, bedding or bathroom facilities;
* denial or unreasonable delays in providing regular meals to the student that would result in a student not receiving adequate nutrition;
* placing a student unsupervised or unobserved in a room from which the student cannot exit without assistance;
* or other stimuli or actions similar to these interventions at the discretion of the Commissioner.

Meaning that these and other actions were previously permitted.

Please Take time to submit your comments.

Pennsylvania State AG investigating East Stroudsburg doctor

As Reported in the Pocono Record News

The state attorney general is investigating Dr. Harold J. Pascal, a psychologist with a practice in East Stroudsburg.

Pascal's office was searched recently for illegal drugs or signs of drug-related activity, according to court records.

Pascal has closed his practice, leaving patients with only a signed note on the door that says, "Please go to the emergency room or RedCo for treatment."

The closing follows a hearing in Monroe County court last week at which an attorney for Pascal requested the return of items seized in a law enforcement search of the doctor's office.

The record of the hearing has been sealed. A decision is expected later this week.

Pascal, saying he is retiring, resigned recently as the doctor who does psychiatric evaluations for the Stroudsburg Area School District.

Pascal's office is at 233 E. Brown St. [...]

Blaming Paxil for Financial Fraud

The side effects of Paxil have become well known enough that convicts are trying to use it as an excuse for their misdeeds. As seen in this report.

Patrick Henry Stewart, a mid level finance professional who stole $1.8-million from ex-employer Jabil Circuit and will be sentenced for wire fraud next week, is waging a last-minute bid to avoid prison time.

His angle? The Paxil made me do it.

Stewart, 42, pled guilty this fall to writing more than 100 company checks to himself and his creditors. In exchange for his cooperation, federal prosecutors agreed to recommend a reduction in the maximum prison term of 20 years.

But in motions filed this week, attorney Kevin Darken cited testimony from three psychiatrists who claim Stewart was suffering from an undiagnosed case of bipolar disorder when a doctor prescribed him the antidepressant Paxil in 2002. The interaction allegedly flipped a "manic switch" that caused Stewart to make bizarre and impulsive decisions throughout his two-year-long scam.

According to Darken, Stewart allegedly:

- Kept a parrot in his Jabil office even though it bit people; ate a bag of marijuana while in Amsterdam on a business trip; and drank so heavily at an Orlando conference for Jabil controllers that he cut his head open in the pool.

- Bought a 2.2-pound gold bar, a gold-plated Colt .45 pistol, mailboxes for seven of his Hunter's Green neighbors, $100,000 worth of coins, a solo ticket for a trip down the Amazon River and a John Deere lawn mower that he drove home from the store. He also donated more than $25,000 to the Tampa Bay Performing Arts Center. Daily shoplifting ventures culminated with his arrest outside a Publix grocery store.

"If this problem had been identified quickly and early ... I have no doubt that Stewart would not have suffered from this manic behavior and would not find himself in his current legal predicament," University of South Florida psychiatric research director David Sheehan said in a letter to the court. "This phenomenon of secondary mania has been well-documented in medical literature."

Stewart called his check-writing scheme compulsive and risky during a 2005 psychiatric evaluation.

"I didn't set up any shadow companies," he reportedly told Sheehan. "I just processed the checks ... (and) copied them on the copier in front of my colleagues and bosses."

Stewart kept each check under $50,000 so that he wouldn't need to obtain a second signature.

Stewart has repaid more than $1-million to Jabil. The federal government is reclaiming still more by seizing his home, cars and other assets.

Jabil spokeswoman Beth Walters said she was unaware of Stewart's last-minute gambit.

"We're confident the U.S. Attorneys' office will address the purported 'Paxil defense' during Monday's hearing," she said.

UPDATE: Apparently the Judge Agrees

A federal judge in Tampa is agreeing with the claim of a business executive who says the anti-depressant drug Paxil prompted him to embezzle one-point-eight million dollars from a former employer.

The judge granted a reduced sentence — sending Patrick Stewart to a year of home confinement and five years of probation. He did so partly because defense lawyers produced studies and experts that said the drug sometimes causes arrogant and uncontrollable behavior in people with bipolar disorder.

Prosecutors wanted Stewart to go to jail for at least three and a-half years.

The company he took the money from says the sentence sends "the wrong message.

"

Why can't the system cope?

As seen in the Observer A sad tale of the utter madness and incompetency of the mental care system as it currently exists in Britain.

A litany of failures was revealed last week in the mental care of John Barrett, the man who murdered a stranger in Richmond Park. The failures are not unique. In this brutally honest account, author and father Tim Salmon reveals the frustrations and confusion that have blighted his son's treatment as inadequate care services struggle to manage

I do not like to call my son mad. It seems such a final and unforgiving word for a person who for 17 years has struggled with the illness more commonly known as schizophrenia.

Although the underlying condition does not go away, its worst manifestations are cyclical rather than continuous: periods of relative stability interrupted by crises, usually brought on by refusing medication. That is when 'madness' is certainly a much better description of what is happening than 'having issues', the phrase one mental health worker used to describe my son. It is obviously not an easy condition to treat. But once you get involved in this world of 'issues around mental health' - as parent, partner, sister, friend, the mad one himself - you could be forgiven for thinking that confusion reigns.

I am far from alone in my criticism of the care provided by the mental health services. And I know that many parents of sons and daughters with schizophrenia feel as I do - that there is a certain arrogance among the professional caring services, a presumption that they know better than we do what is good for our sick children. Most of us do not have to deal with situations as dramatic as that revealed in last week's damning report on the case of John Barrett, a schizophrenic who killed a stranger in Richmond Park, south west London, after he was released by the secure unit where he was staying. The report showed that many people working in mental health had put the 'rights' of John before the security of the public or even his own safety. It highlights in the starkest manner the possible consequences of focusing on the rights and liberties of the patient turned client.

There is supposed to be a 'seamless network of care'. It is supposed to cover the medical, social, housing and other needs of the mentally ill. But for various reasons it does not. Some of the reasons are financial, some organisational and some, paradoxically, have to do with the culture - to use a horrible jargon word - of the professional caring services and mental health charities whose genuinely held intention is to care for the mentally ill. A further reason - and far from the least important, as it probably behoves people like me who are critical of the system to remind themselves - is the intractable and messy nature of an illness whose distinguishing feature is loss of reason.

Not that you are allowed to say that, because it runs counter to the 'ethos of optimistic realism', probably promotes stigma and generally interferes with our modern desire to pretend that there are no inequalities or other unpalatable differences between people.

This extreme aversion on the part of the caring professions to calling things by their proper names is one of the most vexatious 'issues' I have encountered. The sick are no longer patients, but clients or service users and, by implication, considered capable of evaluating their own needs, entering into contractual relations with doctors and other agencies whose function is to deliver the chosen service or care package. If this seems a surprising way of approaching people who, when ill, are almost by definition 'not in their right minds', what are we to make of the recent 'best value' review of mental health services by Camden council in north London in which it proposes to give patients/clients direct payments from social services with which 'to organise and buy the services you need for yourself'? And this, when one of the most notorious symptoms of schizophrenia is an inability to understand your own situation.

When I suggested in a discussion about compulsory treatment that perhaps, just as we accept the notion of acting in loco parentis where children are concerned, it might be wise to accept a similar dispensation for people who are 'not in their right minds' - a condition that those of us who have observed schizophrenia at close range are all too familiar with - I was beset by cries of outrage from the spokesmen for civil liberties, advocacy services and pressure groups.

But these are the orthodoxies of the day. Even the National Schizophrenia Fellowship, founded 30 years ago by parents of schizophrenic children to campaign on their behalf, has succumbed. Under the influence of professional charity workers whose training and career prospects depend on their acceptance of these things, the organisation's name was changed to Rethink. Schizophrenia, they argue, is an alarming word: it stigmatises the sufferer and discourages donors to the charity. The group's literature is full of optimistic talk about recovering and positive outcomes, and full of smiling faces on pastel pages. It is not a view of the illness that tallies with my experience or that of the many other parents I have talked to over the years.

The doctors do not seem to have any difficulty in calling the illness by its name, but then it is hard in medicine to develop a treatment for a phenomenon you cannot bring yourself to identify. There was a revealing demonstration of the difference between these approaches at the fateful National Schizophrenia Fellowship annual meeting where the decision to change the name was taken. Professor Robin Murray from the Maudsley Hospital in south London gave an address in which he used the term schizophrenia frequently. He was followed to the podium by the fellowship's chief executive and architect of the name change who did not use the word once. Is the hope that all nastiness and discomfort will disappear if you call it by another name?

As all parents with mentally ill children will know, practical issues are as pressing as ethical debates. The most pressing for us is my son's homelessness. He was admitted to a hospital in north London in May 2005, under 'section' - that is, detained under the Mental Health Act. He is still there. Although his section was lifted in November 2005, he could not be discharged because he was officially homeless. Since he was considered well enough to leave, even though he could not, he no longer had his own bed.

Until he was sectioned again in July, the hospital shuffled him from bed to bed, ward to ward, building to building - including a hotel - in response to the pressures of demand from patients considered to be in more urgent need. It is not a regime calculated to promote the good health of anyone, least of all a person with a history like my son's and was, moreover, in direct contradiction of the doctors' instructions.

And why is my son still homeless after more than 18 months when already, on admission to hospital, everyone knew that accommodation would have to be found for him? The same thing happened in 2003. There does not seem to be a very clear reason, other than bureaucratic inertia and the apparent inability of right hands to know what left hands are doing, a situation compounded by my son's status as 'a client' and 'free agent'. For, when a voluntary agency was finally engaged to help him, he refused them and they withdrew - a decision that I am glad to say has now been reversed, but it was not one that my son should be congratulated for having taken in the first place. Yet, as a client, a customer, who is to say that he does not know best?

I - foolishly, it turned out - had assumed that the local authority, in our case, Camden, would have a stock of accommodation deemed suitable for vulnerable people like my son. But no, that is not how it works: your need is assessed and you are awarded points accordingly. You consult the Camden New Journal week by week, identify the accommodation that your score of points might qualify you for, and bid for it, over the phone, in competition with others in search of a home - ex-offenders, foreign asylum seekers, you name it. Priority, as a 40-year resident of Camden, disabled by schizophrenia? You do not see the property, you do not speak to another human being, you are not interviewed by anyone from the council. It is hard to imagine a less humane way of doing things.

And all the while my son is stuck in hospital, at considerable cost to the public purse. The room he used to occupy, in a hostel run by the charity Mind, to which he does not wish to return and to which he cannot return because Mind does not want him back, remains empty and cannot be given to anyone else until he is rehoused. Where is the logic in that?

And how did he end up in a hostel run by Mind? Because he could not return to his flat following an episode with a neighbour which came about because he had not taken his medication for several weeks. Why? Because, suffering from a kind of agoraphobia, he was afraid to leave the house and walk the 15 or 20 minutes to the surgery to renew his prescription. Why the surgery did not have a way of noticing that such a vulnerable patient had not collected his prescription, I cannot say.

And as for the social services, they had long since given up on him. If you say no often enough, they just stop bothering. You are a free agent, after all, free to act against your best interests until you are found roaring and naked in the street at Mornington Crescent at 3am or shouting abuse at a blank wall in Stoke Newington at lunchtime... or worse. Then you are detained and sectioned.

Last Christmas I was alarmed to discover that there would be no staff at the hostel where my son was staying for four or five days. I spoke to my local paper, which ran an article. I also wrote to my MP, Glenda Jackson, who rang me and told me off for going to the press, repeating Mind's sales pitch about empowerment. When I said I thought this language was hardly appropriate where an illness like schizophrenia was concerned, she accused me of wanting to go back to the days of long-stay asylums.

On one occasion my son was threatened with eviction for being difficult. I intervened and said I thought Mind's position contradictory: on the one hand it accepted residents with a difficult psychiatric history and on the other treated them as if they were normal tenants in breach of their lease. A social worker called a couple of days later to tell me that a meeting was to be convened to review my son's situation. 'That's good,' I said. 'What time?' He refused to tell me, without my son's written permission. I told him that we had seen countless social workers come and go over the years, that the only constant support in my son's life came from his family. He still would not tell me. This is common practice. The Camden and Islington Mental Health Trust would not even reply to my written complaint about my son's current situation at hospital without his written permission.

Shortly after the threatened eviction, encouraged by the social worker to find some kind of occupation, my son signed up for a language course. In Toulouse. And off he went, although he had been more than a month without medication. This, in spite of the fact that his medication had been changed from pill form to fortnightly injection so that people looking after him could keep better track of it. Because, however, my son and all those like him are clients, when he says no, there is nothing anyone can do.

My son is brave and determined, still fighting for his independence and dignity after 17 years. He got to Toulouse, but two days later dad had to set off on a rescue mission - four days of unrelenting and sleepless anxiety. ('Don't say that, dad. We had a really nice holiday together!')

Within a few days of returning home, the police picked him up in the street and took him to hospital. The social worker who had refused to give me any information wrote to say that he was himself going away on a course and would no longer be working with my son. Was he the 31st or the 42nd? I have lost count.

Can anyone explain to me wherein lies the value of the freedom to refuse medication, go round the bend and end up detained in hospital? Yet a coalition of mental health charities, Rethink and Mind among them, are opposing the compulsory treatment laid down in the government's draft mental health bill published on Friday.

I heard Paul Farmer, former Rethink and Mental Health Alliance spokesman on these matters, speaking of 'sections' on Channel 4 news not long ago as if they were routinely used as a tool of repression by a malevolent 'regime'; he made them sound like the old Soviet practice of confining dissidents to psychiatric hospitals. Yet I firmly believe being sectioned has saved my son's life more than once - and the lives of many like him. But then Rethink also apparently looks forward to a time when 'building-based care' will be a thing of the past. Perhaps they have some insider tip on the imminent collapse of the NHS.

During the debate about changing the National Schizophrenia Fellowship's name to Rethink, I received the following explanation from the chairwoman about why she felt the change was necessary: '[It is the fellowship's] wish to move away from the idea that severe illness is the sum total of an individual who has such an illness, to seeing the whole individual who "happens" to have such an illness and, instead of writing him off, considering his abilities, his strengths and weaknesses... All this without losing a sense of realism, that some will not manage much of this, their steps may be very small, recognising that we are concerned with a very real and devastating illness... I am convinced the charity must move to the prevention of the past repeating itself.'

In promoting the case for the three new names proposed - Reason, Thought Works and Rethink - Farmer said: 'We need to develop a strapline, a visual identity and images to ensure that all aspects are addressed. As part of this, it is likely we will develop identities for local activities within the overall image... Rethink has extensive potential for visual identity scheme'. To say nothing of the 'ethos of optimistic realism' and much else in this vein.

In the face of this sort of nonsense and of the confusion that reigns in the mental health 'system' - lack of funds, shortage of beds, absence of suitable accommodation outside hospital, the failure of agencies to co-ordinate activities - it is hard to see who is rooting for people like my son, many of whom end up killing themselves and none of whom, in my experience, ends up with lovely smiles and careers, as Rethink would have us believe.

Government discovers Psychiatrists in Apathy about Patient Suicide

As Seen in this Australian Report

The [Queensland] State Government will consider new safety measures for psychiatric patients in care after a Coroner hit out at a "fatalistic professional attitude" to the risk of suicide.


Helen Jeffrey, 30, suffocated herself with a plastic bag provided by Nambour General Hospital staff on March 24 last year.

She had been admitted to the psychiatric intensive care unit after attempting suicide and became the second sectioned psychiatric patient in two years in Queensland to end her life using a plastic bag.

Maroochydore Coroner Ken Taylor last week made nine recommendations over Ms Jeffrey's death to Health Minister Stephen Robertson – expressing surprise that hospital staff had not identified plastic bags as a potential suicide aid.

"I have felt somewhat uneasy about what I shall, for the sake of convenience, term a fatalistic professional attitude towards suicide risk," Mr Taylor wrote.

A spokesman for Mr Robertson said the Minister was awaiting a copy of the recommendations which include a call to remove all objects "not uncommonly used as a means of suicide or attempted suicide".

Mr Taylor also recommended that Mr Robertson examine the feasibility of fitting remote pulse-monitoring wrist bands to all psychiatric patients held in state care.

Staff psychiatrist Keith Muir told the inquest that, in 35 years of clinical experience, he had never encountered such a death.

Asked by Mr Taylor if he was alarmed by the presence of plastic bags in psychiatric units, Dr Muir said: "Yes and no."

"The fact is that people who are determined to kill themselves . . . you know, that old expression, 'Where there is a will, there is a way'," Dr Muir said.

Mr Taylor said it was with a "considerable degree of incredulity" that he received the evidence that plastic bags had not been identified as a potential suicide aid before Ms Jeffrey's death.

Although Ms Jeffrey's family was entitled to be disappointed, the Coroner made no criticism of the standard of care.

"I am satisfied there was no wilful neglect," he said.

The Health Minister's office said plastic bags were already being removed "where ever practical" from psychiatric wards in line with precautions triggered by Ms Jeffrey's death.

But the spokesman said it would be difficult to eliminate their presence because plastic bags were necessary to line "communal" bins for potentially infectious or unhygienic waste.

Madhouse: A Tragic Tale of Megalomania and Modern Medicine

An excellent review of the book "Madhouse: A Tragic Tale of Megalomania and Modern Medicine" (Yale University Press, $30). Here's a snippet:

Lobotomy

Psychiatric patients were unusually vulnerable to medical experimentation. (Remember Jack Nicholson in "One Flew Over the Cuckoo's Nest"?)

The lobotomy started in Portugal in 1935 and was revamped in the United States by Drs. Walter Freeman and James Watts. They began the surgery in 1936, drilling holes in the skull and inserting a knife-like object, severing the frontal portions of the brain. This was supposed to dramatically relieve symptoms of mental illness, although the brain damage it caused was permanent. Some patients lost spontaneity or became a bit slaphappy.

To find out when to end the operation, Freeman would put patients under local anesthesia and talk them through the operation, asking simple questions to make sure they were still in touch. He asked one patient, "What's going through your mind?" The reply: "A knife." The doctors later refined their procedure, using an instrument similar to an ice pick, inserting it in tear ducts. Freeman and Watts claimed that 52 percent of their first 623 surgeries were "good," but they did not define what they considered good.

Mental hospital

Scull's book, "Madhouse," recounts the story of Dr. Henry Cotton, a psychiatrist who was in charge of the state mental hospital in Trenton, N.J., from 1907 to 1930. Cotton assumed mental illness was the product of overlooked infections that fed toxins to the brain. His solution was to search for sources of infection and remove them.

Because teeth are close to the brain, Cotton had his patients' teeth pulled. Some of them recovered, a powerful placebo effect. Many did not, so Cotton looked elsewhere for infection. (Or did he wait too long to pull teeth?) He started removing tonsils. Again, no remedy.

Next, he removed colons and other organs, often on unwilling patients, ratcheting up his mortality rate. He had critics, but many followers, too. Cotton was investigated to determine whether his claims of an 85 percent cure rate were true. A report concluded that he was killing his patients, but the report was suppressed. His practices continued until a heart attack killed him in 1933. Long before he died, he had his two sons' teeth removed. They grew up and killed themselves.

Further punishment for shamed and disgraced psychiatrist

As seen here

A psychiatrist who harassed a nurse at the QEII Hospital in Welwyn Garden City by asking to check her pulse to see if she was happily married has been suspended for another year to protect the public.

Dr Idowu Otote was banned for 12 months after he was found guilty of serious professional misconduct in 2003 for his shameful festive frolics at another hospital in Devon where he groped a nurse's breasts and bottom after a hospital Christmas party.

The 41-year-old was allowed to work again providing he kept to certain conditions after he promised the General Medical Council (GMC) he had taken steps to improve his skills.

In October 2005 he was told he could still work provided he stayed within the NHS, practised under a consultant and avoided private locum work.

But the GMC decided last week that he should be suspended for another year, ruling he had failed to keep his skills up to date and had no insight into his conduct.

Otote started working for East and North Herts NHS Trust, which runs the QEII Hospital, in 2000 after resigning from South Devon Healthcare following the Christmas party incident.

However, as well as harassing the nurse there in August 2000, he also verbally abused another nurse a month later at the QEII-based Hollybush Day Hospital mental health unit when she explained she could not leave a ward to help him as she was the only nurse on duty.

On the same day he tried to pass off another nurse as a doctor and then he struggled to take a patient's blood pressure.

Otote also failed to examine physically three patients at the hospital when they were admitted.

Otote, from Southall, west London, trained as a medical officer in Nigeria.

GMC chairman Dr Kevin Dalton said the panel had decided that "it is necessary for the protection of members of the public and in the public interest" to suspend his registration for 12 months.

Otote will have to return to the GMC in a year with proof he has maintained his skills before the panel decides if he is fit to return to practice.

Psychiatrist defends electric shock treatment in New South Wales

Anothe mad doctor who beleives in the theraputic values of high voltage brain damage, as seen in this report

The chief psychiatrist in New South Wales has defended the use of electric shock therapy in the state's hospitals.

Government figures show the use of electric shock therapy has doubled in NSW in the past decade and more than a dozen children under the age of 14 have been given the treatment.

But Associate Professor John Basson says the perceived increase is not accurate because records of electric shock therapy were not reliable a decade ago and did not reflect the true number of cases.

He says there is no recorded cases of children receiving the treatment in the past two years, but his colleagues would not support a ban on the practice.

"Across the board they wouldn't wish to lose it as a possible treatment in very, very rare and unusual cases where the life of the child was put at risk," he said.

"This would be a treatment of extremely last resort.

"Recently we've been very much more scrupulous and that plays a part.

"You've got to be careful that we're not comparing apples with oranges. We've got to compare apples with apples and we are now in a situation where we can compare.

"I don't see that sort of increase that would cause us concern or would cause us to question."

Vermont State Supreme Court Clarifies State Regulations on Forced Psychiatric Drugging of Patients

As reported by WCAX TV

Friday the Vermont State Supreme Court clarified the rules on when the state can force patients at the Vermont State Hospital to take medications against their will, recognizing the patients' right to refuse the drugs.

"As long as patient can understand the consequences of refusing medication, the statute permits him to do so, even if refusing medication will be to his detriment," Justice Denise Johnson said for the unanimous court. "In other words, a person who is competent to make a medication decision within the meaning of the statute has the same right as any other person to refuse beneficial medication."

The issue of forcing mental health patients to take medications, even if they don't want to, has been an emotional one. The Legislature, after an passionate debate, approved a law in 1998 permitting involuntary medication for mental health patients.

Friday's case involving a 64-year-old man suffering from bipolar disorder and alcoholism was the first time the Supreme Court has decided one of the involuntary medication disputes. The justices overturned Family Court Judge Matthew Katz's decision ordering the medication, directing that he hear the case again.

The court said trial court judges must consider whether a patient is competent to decline medication, something that did not happen in the case involving a patient identified in the decision only as "L.A."

"The statute requires only that (a) patient appreciate those consequences, not that he make the best decision in light of those consequences, or that he agree with his psychiatrist," Johnson wrote.

Jack McCullough, who represented the patient on behalf of Vermont Legal Aid, said the decision was an important one because it would guide the 25 to 30 cases of involuntary medication Legal Aid handles each year.

"It's very significant," McCullough said. "Ever since we started,, the state essentially has argued whenever the patient doesn't agree with the hospital psychiatrist, that proves that they can't make a decision. The Supreme Court specifically says that's not the case. The state has to show something more than just disagreeing with your doctor to show you incompetent to make a decision."

Assistant Attorney General David Bond said he believed the court merely was saying to the Family Court that its findings in the case "were not sufficient on the issue of competency" and did not signify a broader policy decision.

The state recognizes there are some patients with mental illness who have such significant physical side effects to medications that they can rationally refuse medication, Bond said. "That would be the kind of thing that might support a medication refusal," he said.

Although Bond said he believed the court "overstates what we argued," the justices acknowledged that the requirements of the law makes decisions more difficult, but that was as the Legislature intended.

"The Family Court and the commissioner appear to assume that there is only one competent choice patient could make _ to follow his doctor's advice and accept medication," Johnson wrote. "Neither the court nor the commissioner attempt to discern what patient perceives as the consequences of his decision to refuse medication. If patient's disagreement with his psychiatrist were sufficient to find him incompetent, the Family Court would have to grant every petition for involuntary medication filed by the commissioner."

On the Net:

http://dol.state.vt.us/gopher_root3/supct/current/2005-368.op

Psychiatric Clinic Ordered Closed in Aftermath of Park Murder

As seen in this report

A damning report into the case of a psychiatric patient who knifed to death a cyclist has ordered the closure of the unit responsible for his care.

The report on how paranoid schizophrenic John Barrett walked out of the secure unit at Springfield Hospital, Tooting, London in September 2004 and attacked Denis Finnegan as he cycled through Richmond Park, reveals a catalogue of blunders.

Barrett, 42, from Putney, was jailed for life at the Old Bailey last year after he was convicted of the manslaughter of 50-year-old Mr Finnegan, a retired banker.

Despite a long history of mental illness and violence, Barrett had been given "ground leave" from the hospital.

Doctors had no power to keep him against his will and he was allowed to wander the hospital complex unaccompanied on the understanding that he would return to the clinic. Instead he walked out and killed Mr Finnegan.

The 422-page report severely criticised South West London and St George's Mental Health Trust, which is responsible for Springfield.

It singles out and names individuals - including the psychiatrist who treated Barrett - doctors and social workers involved in Barrett's care.

Former trust chief executive Nigel Fisher is also believed to be mentioned in the highly critical findings.

The key recommendation in the report is to close the Shafesbury Unit pending an external audit by an independent-team. The clinic is the special-medium-secure facility in the hospital which treated Barrett.

The report stated the inquiry panel has doubts about managerial abilities and this had "serious implications for the safe delivery of patient care".

Mr Finnegan's brother John, 49, of Doncaster, who has read the report with his family, was shocked by its conclusions.

He said: "The contents of the report are a disgrace. The findings are a complete tragedy. They are worse than what we imagined. Every aspect of the mental health unit has been criticised."

Other cases at the hospital have included schizophrenic Jason Cann who beat to death nurse Eshan Chattun in 2003 and two dangerous patients going on the run in September of last year.

Two months later another patient, paranoid schizophrenic Sean Perry, was sent to Broadmoor Hospital after admitting the murder of 22-year-old Matthew Carter. The Finnegan family, including Mr Finnegan's two sisters and three brothers, said they are convinced that if the right procedures were taken their brother would still be alive.

With the backing of the mental health charity the Zito Trust, John Finnegan has put repeated pressure on the trust, the Strategic Health Authority - now NHS London - and the Government to discover the truth behind the circumstances into his brother's death.

The inquiry was undertaken by three leading experts including mental health lawyer, Robert Robinson, who chaired the committee. They were commissioned by the Strategic Health Authority and followed an internal report by the trust.

Mr Finnegan said: "This report confirmed my suspicions that the internal report was a waste of time. I was shocked at its frankness and the two years of doubt have been relieved."

Mr Finnegan's sister Annie Guest, 41, added: "It has taken the death of a fabulous person like Denis to make this happen. Denis was the heartbeat of this family. He was loved by everyone and desperately missed."

A Home Office spokesman said improvements have been made for monitoring systems for restricted patients.