Forensic Brain Injury

The World Health Organization’s definition of acquired brain injury:

‘Damage to the brain, which occurs after birth and is not related to a congenital or a degenerative disease. These impairments may be temporary or permanent and cause partial or functional disability or psychosocial maladjustment’.

A brain injury may be caused by:

• External blows or jolts
• Penetrating wounds (also known as traumatic brain injury)
• Stroke
• Heart attack
• Infections
• Brain tumours
• Loss of consciousness
• Loss of oxygen to the brain from choking, near drowning or other anoxic conditions

At the present time 1.3 million people in the UK are living with the long term consequence of a brain injury.

Typical presenting needs of someone with a brain injury include:

• Executive functioning deficits
• Insight and awareness difficulties
• Perceptual disturbance
• Apathy
• Memory and attentions difficulties
• Emotional dysregulation
• Cognitive fatigue
• Occupational/vocational/social skills
• Communication and language difficulties
• Physical health needs following a brain injury including epilepsy
• Comorbid mental health difficulties
• Risk behaviours (violence, vulnerability, harm to others/self, impulse control and offending)

The service has the following admission criteria:

• Male, aged 18 or above
• Have personality, behavioural or emotional changes as a result of a brain injury and/or have mental illness as a result of a brain injury
• Are detained/detainable under the Mental Health Act - our current patients come from a variety of places including:
  • Prison
  • PICU
  • Other secure hospitals
  • Rarely, the community/step down setting, but would need to be detained under the Mental Health Act
• Suitable for secure services for example they have demonstrated a significant risk of harm to themselves or others or have a forensic history indicative of significant risk
• The brain injury has occurred more than three months earlier which allows for natural recovery from Post Traumatic Amnesia
• Their primary diagnosis is not a developmental disorder, learning disability or degenerative neurological disorder

If the admission criteria are met, the Forensic Brain Injury service will send out its own assessment team within two weeks if non-urgent. This is dependent on the receipt of suitable referral information, support documentation and geographical location.

Following assessment the assessing team discuss their findings with the Forensic Brain Injury team, who meet regularly and a decision is made about suitability for admission, security level, initial risk management plan, potential safeguarding concerns and a care pathway plan.

We also offer advice regarding referrals and signposting. We are aware that for many services they may not have considered or been aware of our service before. We are very happy to receive a quick phone call to sense check any of these areas – being an NHS provider we can offer an independent view of what may help your needs.

Every patient has a structured clinical assessment of risk as well as situational specific risk management plans. These are reviewed and updated regularly. Our service uses an electronic risk assessment tool that forms the basis for individualised Situational Specific Risk Procedures (SRSP).

Assessment of Cognitive Function

Each brain injury ward has an allocated psychologist. On admission, the psychology team commence a formal review and assessment of cognitive functioning.

The assessment is comprehensive and time intensive, however the results enable the care team to determine bespoke treatment and psychological programmes benefitting the individual’s cognitive profile.

Our occupational therapists and technical instructors complete functional assessments of independent living skills, including:

• Social skills
• Safety assessments
• Motor assessments

Should any communication or swallowing difficulties be identified, a referral can be sent to our speech and language therapist who will complete an assessment and make recommendations.

The assessment are completed within 16 weeks of admission, however this may vary depending on the severity of cognitive impairment and comorbidity e.g. epilepsy or mental illness which might affect the process

Mental Health Assessment

There are two responsible clinicians, a neuropsychiatrist and a forensic psychiatrist with specialism in neuropsychiatry. Each patient has assessments and regular reviews of their mental state. The consultants are responsible clinicians as per the Mental Health Act and therefore have responsibility to ensure detention in hospital is necessary and proportionate to the presenting risk.

Approximately 70% of patients are subject to part iii of the Mental Health Act 1983 including hospital orders as directed by the court. These can include individuals subject to the Ministry of Justice restrictions and those transferred from the prison estate.

Medication reviews are in collaboration with the Guild Lodge Pharmacy Team who provide invaluable support and contribute to care team meetings.

Physical Health Assessment

Every patient admitted to the service has a physical health examination, with a minimum yearly update. We encourage our patients to have routine blood screening and an ECG.

Patients with long term medical conditions are referred to the physical health care team. All patients are registered with the visiting GP. A nurse practitioner also holds weekly clinics. Support is offered to all patients for smoking cessation and weight management, focussing on adopting a healthy lifestyle through education and health promotion.

All patients with epilepsy have a comprehensive epilepsy care plan. NICE guidelines for epilepsy management are followed.

Further investigations for neurological conditions can be accessed at the local general hospital - Royal Preston Hospital.

Formulation

On completion of the assessment, a formulation meeting is held. The aims of the meeting are to identify and establish the following:

• Diagnosis- including comorbidities
• Neurobehavioral rehabilitation goals
• Cognitive rehabilitation goals
• Environmental support
• Educational needs
• Interventions (if required) including psychological, occupations, nursing and speech and language

Our activities are multipurpose- they assess and provide rehabilitation in engagement, cognitive functioning, social skills, motor skills and mental health; which in turn can lead to even more specific rehabilitation interventions for the individual patient.

Our activities include:

• Daily orientation and current affairs
• Art therapy
• Social skills
• Personal care
• Pet therapy
• Cooking
• Music therapy
• Physical exercise
• Vocational skills including woodwork, metalwork and bike maintenance
• Numeracy and literacy
• Basic computing

Short and long term recovery goals and targets are set in collaboration with the patient and are a key pillar of our care. Specific treatment interventions will largely fall into one of the following categories:

Maximise internal strategies

• Education
• Targeted psychology
• Occupational Interventions
• Medication

Optimise environment

• Compensatory aids
• Specialist nursing support

Psychological interventions

• Brain injury awareness education
• Reminiscence therapy
• Emotional coping skills
• Anger management
• Relaxation skills
• Drug and alcohol interventions
• Life minus violence (with modules for harmful sexual behaviour)
• Trauma therapy
• Cognitive behaviour therapy
• Personality assessment

All of these therapies have been adapted for individuals with a brain injury and can be provided to individuals as well as small groups. Given the variation in cognitive impairment of our patients, one to one provision is more common.