Source document: https://docs-lawep.s3.us-east-2.amazonaws.com/1694841154224.pdf (Malta)
“Combatting Stigma and Discrimination: Empowering stakeholders and tackling challenges together” Annual Report 2019 20th November 2020 Table of Contents Page Foreword Chapter 1: The Functions of the Office of the Commissioner Vision, Mission, Commitment Organisational set-up Vacancies as on 31st December 2019 in order of priority Management Committee Meetings The CMH Agenda up to end 2019 Monitoring of Patient Rights Flimkien għal Saħħa Mentali Aħjar (Together for Better Mental Health) World Mental Health Day 2019 The Development of Public Mental Health in Malta Parliamentary Debate of Annual Report 2018 Customer Care Curators Public Relations and Media Presence Mental Health Review Committee Influencing Legislation and Policy Working in Partnerships Meetings Participation in Conferences, Seminars, Workshops & other events Continuous Professional Development of Staff Involvement in Academic and Professional development of Others Chapter 2: Analysis of MHA Applications processed in 2019 The Involuntary Care System Acute Involuntary Care [MHA Schedules 2/13] Substance and Addictive Disorder Analysis 5 10 11 11 12 12 12 17 19 23 24 24 24 25 25 29 29 35 35 37 41 42 44 45 49 59 2 Acute Mental Health in Youth Analysis Suicide Inpatient Involuntary Treatment Orders [MHA Schedules 3/4/5] Community Treatment Orders [MHA Schedules 7/8] Comparing Persons in Involuntary Care (1) Acute (2) Inpatient (3) Community Conclusion Chapter 3: Report on Visits to Mental Health Licensed Facilities Section A: Mental Health Service Users’ Perspective Section B: Mental Health Service Providers’ Views Section C: Responsible Carer Telephone Interviews Section D: Assessments of the Care Environment Chapter 4: Analysis of Incident Reports ~~~ Appendix 1: Functions of the Commissioner Appendix 2: Visitation 2019 – Questionnaires and Template 60 61 63 65 68 69 70 72 128 171 174 184 213 215 Appendix 3: The Development of Public Mental Health in Malta (extract from Public Health in 231 Malta 1999-2019 – MAPHM 20th Anniversary Edition) 3 “Combatting Stigma and Discrimination: Empowering stakeholders and tackling challenges together” ...promoting and upholding the rights of people suffering from mental disorders ...li jinġiebu ‘l quddiem u jiġu rispettati d-drittijiet ta’ nies li jbatu minn diżordni mentali 4 Foreword – Combating Stigma and Discrimination: Empowering stakeholders and tackling challenges together The Office of the Commissioner for Mental Health presents its Annual Report for the year 2019 which is its eighth full year of operation.
This Office is indebted to the hundreds of patients, responsible carers and professional staff and to several entities, NGOs and other stakeholder organisations whose input and trust in our ability to advocate for better mental health and well-being in our society have provided us with the energy and the facts which we present in this report.

The Mental Health Strategy for Malta 2020-2030: Building Resilience, Transforming Services was launched by the Ministry for Health on 17th July 2019.
Through our advocacy and documentation throughout the past eight years, we have contributed heavily to the national evidence base that has been extensively utilised by the Mental Health Strategy Team of the Ministry of Health in compiling the strategy.

We note that close to 80% of the proposed actions within the strategy reflect recommendations that this Office has made over the years.

We welcome the unanimous approval of all stakeholders within the health sector and across parliamentary groups.
This is a positive and resilient cornerstone which certainly facilitates implementation and action.

Our Office will be monitoring and reporting regularly on the implementation of those aspects of the strategy that fall within the mandate and remit of the Office as determined by the Mental Health Act.

It is our duty to ensure that the voice of service users, families and providers are at the core of the policy making and strategy implementation process.
The various initiatives taken by our Office during 2019 build upon, strengthen grassroot insights and provider perspectives on the state of mental health and well-being in Malta and the outcome is an incredible richness of observations and recommendations that can be meaningfully utilised as robust indicators of the way forward.
The recommended pillars for effective mental health and well-being reform have in fact been extended to include the promotion of mental wellbeing across all age groups and life settings; active prevention including suicide prevention; and combating stigma and discrimination, in addition to mainstreaming mental health and well-being in all policies and services; moving the focus of care from institutions to the community; moving acute psychiatric care to the acute general hospital setting; supporting rehabilitation through specialised units preferably in the community; and providing long-term care in dignified facilities.
Transforming recommendations into action plans requires appropriate funding accompanied by sound human resource planning.

Bold management decisions must continue to be taken.

Clear and effective information to patients, families, and staff must bear the hallmark of continuous stakeholder involvement.

Robust and resilient leadership is fundamental to bring about the desired changes.
Through a multi-faceted approach, we strive to report factually and effectively on the state of the rights of persons suffering from mental disorders in Malta.

We are not the National Preventive Mechanism 5 for persons deprived of their liberty for reasons of mental disorder.

However, the Office operates within the guidelines established by the UN Subcommittee on Prevention of Torture and utilises the monitoring frameworks of the World Health Organisation.
We fully embrace and uphold the UN Convention on the Rights of Persons with Disabilities and actively collaborate for its wholesale implementation in the area of disabilities due to mental disorder.

Through a constructive climate with all stakeholders, we seek to find solutions and provide the best protection possible for persons suffering from mental disorders whether in detention or living in our communities.
Our monitoring of the involuntary care processes (Chapter 2) confirms that patients deprived of their liberty are being followed up on a regular basis by their respective caring teams within much shorter timeframes as established by the new law.

Length of stay in involuntary care has diminished and more patients are being discharged to community treatment orders rather than being left on “leave of absence” for years on end.
Community involuntary care is by far the preferred option of following up difficult cases (86% of long-term compulsory treatment cases), also because it includes as a care option the possibility of short inpatient admissions for observation and stabilisation care if the need arises.

It is noted that this shift has brought about renewed commitment which should now lead to further strengthening and focusing of community support services by robust and stable multidisciplinary teams.
58% of acute involuntary admissions are being followed by the newly established acute psychiatric specialists.

This is positive news in view of the future move of acute care away from the institutional setting.

The distribution of disease burden by specialisation confirms the validity of upholding and supporting an intensive acute service, reducing lengths of stay, avoiding institutionalisation and promoting further subspecialisation.
Other implications for service delivery that emerge from analysis of acute involuntary care admissions include: the heavy presence of young people aged less than 30 years (35% of all acute admissions) and adults aged 30-44 years (32% of all acute admissions); the impact of migratory flows from Africa and the Middle East with a 3.7 fold increase in relative risk; persons in residential care or detention facilities with a 2.9 fold increase in relative risk; the mental health needs of foreign workers contributing to the Maltese economy; the challenge of addictive disorders with 27% of acute admissions linked to addictive behaviours mainly illicit synthetic drug abuse; and the significant contribution of mood disorders and severe anxiety (almost 60% of all cases) in epidemiology of attempted suicide, suicidality and self-harm.
Investing in the mental health and well-being of our younger and middle-aged generations is a policy priority which needs holistic action between health, education, employment, social welfare, 6 workplaces and employers to address the core determinants of poor mental health and move to early intervention using available and targeted services in schools, in educational and training institutions, in all workplaces and in health and social care services.
The richness of data available to the Office through the annual structured visitation process presented in Chapter 3 of this report demonstrates our effort to faithfully capture and represent the thoughts, comments, opinion and recommendations of our stakeholders: patients, responsible carers, staff and care providers.

The Office feels that standards of care have to be better aligned to the patients’ experience and expectations, in order to improve the quality of care being provided.
Such standards should lead to less unwanted variations between services delivery settings and overall better care for patients.

Patients and responsible carers need to be better supported.

Staff members need to be more looked after.

The care environment should foster a continuous learning culture with services being effectively led, managed and resourced.

Services delivery environments must be safe, clean and comfortable at all times for patients, responsible carers and staff.
The huge disparity in the care environment among the wards at Mount Carmel Hospital is not acceptable.

An 80% improvement in the current abysmal situation can be achieved by targeting ward closure and relocation of the Maximum-Security Unit, Male Ward 8B, both Forensic wards, Male Intellectual Disability Unit, Male Ward 1and both Male and Female Secure Units.

It is recommended that the programme of ward improvement be aligned to address these wards as a matter of priority.
The CMH Office noted that in 2019, patients within Mount Carmel Hospital were moved to three vacated wards which were refurbished in order to provide better and more dignified care environments.

It is hoped that the ongoing planned refurbishment programme and its proposed timeframes are adhered to in the forthcoming months so that the meagre environmental assessment which this Office has repeatedly reported about and highlighted in the past 5 years, becomes history.
Whilst the inpatient unit at Mater Dei Hospital continues to be the gold standard for optimum care environment conditions, this report provides evidence that almost all commuity residential facilities provide better care environments than that available in most wards at Mount Carmel Hospital.

It is positive that some of these care environments are now providing care to several ex-MCH residents.

These improved care standards are obviously beneficial to patient welfare.
The notable exception is the child residential services temporarily housed in Hamrun.

All outpatient and day centre facilties are managed by public Mental Health Services.
There are issues with the standard of the care environments in all the Day Centres and in all the Mental Health Clinics housed in community centres.It is evident that as part of the upcoming implementation of the Mental Health Strategy with renewed focus and emphasis on multidisciplinary care within community settings, 7 investment in upgrading community care facilities must follow closely the refurbishment programme within Mount Carmel Hospital.
The number of patients which these services will be handling in the coming years requires welcoming environments that encourage persons in trouble to seek help early.

Defeating stigma and promoting early intervention requires infrastructural investment to support caring teams.

Environmental improvement is however not the only necessary action.
The current strengths and shortcomings highlighted by mental health service users, professional staff and responsible carers in the questionnaires, are primarily but not exclusively related to identifying and correcting bad practices, improving poor morale, tackling the unacceptable care environment and addressing resolving various management issues that have been festering for years.

The feedback, opinions and comments speak volumes.


Not addressing these concerns urgently would be a continuing disservice to patients and their responsible carers and constitutes a continuing fundamental breach of their right to quality care and protection of patient rights.

Continuing to ignore the staff cry for help on issues that remain untackled increases burnout and puts patient care at peril.
Culture change is not easy to achieve but is a vital building block necessary to shore up the current poor mental health service infrastructure.

Without an enlightened, empowered, decisive and adequately resourced management to lead the way, this change will not be delivered.

More investment needs to be made in the continued professional education of all healthcare professionals so that staff can offer the best possible care to the patient that is more sensitive to their needs.
Certain requirements by law which can be easily implemented such as consent taking and the appointment of a responsible carer, are still not being done ubiquitously.

Our random patient record analysis at Mount Carmel Hospital provides evidence that the caring consultant was not easily identifiable in about 20% of the files.

16% of cases, mainly third country nationals and involuntary admissions, had a formal multidisciplinary care plan registered.
75% of patients had a filled and signed treatment consent form.

Just under 50% of patients had a filled and signed appointment of responsible carer form.

It is worrying that appropriately filled records of any restraint /seclusion events could only be identified in 72% of cases with voluntary patients and third country nationals having a lower rate of such records.
The monitoring of the recorded time between the first medical exam in hospital and the patient review by a specialist in psychiatry revealed that 38% were seen by a specialist within 24 hours of admission, increasing to 56% within first 2 days.

Patient and responsible carer empowerment need to be strengthened through more information dissemination so that they are more aware of their rights and of where and how to seek existing forms of redress.
Our office is currently finishing the second edition of the handbook on the patient rights that are enshrined in the Mental Health Act and this should be available for dissemination in 2020.

8 We are once again this year providing an in-depth analysis of incident reports received by the Office (Chapter 4).

A considerable bias in incident reporting analysis is the subjective decision of the persons involved whether or not to file a report.
Apart from underreporting, improving the consistency in reporting practice by use of appropriate protocols and training decreases but does not eliminate this source of bias.

The number of incident reports has increased dramatically to 264 reports in 2019 compared to 74 incidents reported in 2014.

A small group of persons (28%) were involved in 57% of total incidents reported.
This is an area which merits further investigation to assess the causes of this behaviour with the aim of providing better care and support.

Almost all the reports were submitted by nursing staff, who rightly might consider this to be part of their duties, but this duty applies also to other health professionals who may need to be sensitised more to this need.
The type of incidents reported highlight the primary pressures on, and concerns felt by, front line mental health carers with regards to incidents involving aggressive behaviour, substance abuse, abscondment incidents and self-harm events.

Staff and patients are exposed to such incidents more in certain wards than in others and this has an impact on both staff morale and quality of patient care.
Of more importance is the action taken by management to investigate the contents of a report within a day or two of the incident and to address any potential shortcomings when indicated.

This includes timely management feedback to staff making the report.

In the absence of such interventions, incident reporting loses most of its potential as a tool to improve patient safety.

Finally, I thank the team at my Office who perform their duties commendably.
It is our resolve to continue to advocate for mental health and well-being mainstreaming within our society.

We have heightened awareness to mental health challenges among individuals, families, workplaces and in the media.

More persons are understanding the mental health challenges within our daily life.
Our target is to focus on the enormous goodwill to embrace and implement change that is also visibly evident in our encounters with patients and families, in our daily exchanges with staff, in the visitation exercise, and in most meetings, conferences, workshops, lectures and other events where members of my team and I have participated.

Our topmost priority is combatting stigma and discrimination by empowering stakeholders and tackling challenges together.
Dr John M. Cachia Commissioner 20th November 2020 9 10 CHAPTER 1 THE FUNCTIONS OF THE OFFICE OF THE COMMISSIONER FOR MENTAL HEALTH 2019 11 Vision, Mission, Commitment The vision of the Office of the Commissioner for Mental Health is that of an inclusive society that fully empowers persons with mental disorder to maximise their health potential and contribute actively to the community in all spheres of life, and that fully recognises positively enhancing and improving mental health and well-being for sustainable growth and prosperity of the community at large.
The mission of this Office is to promote and protect the rights and interests of persons with mental disorders, such that they and their caring others can benefit from a better quality of life through the maximisation of their potential as active participants in the care process and as valued members of society.
The Office strives to achieve this mission through the adoption of a person-centred approach, empowerment, advocacy, strategic leadership, influencing policy, monitoring relevant developments and best practice, fostering a quality improvement culture, and through working in partnerships and facilitating synergy within an all-inclusive society.

The core key commitments of this Office are: equal opportunities and equal treatment, the elimination of all forms of discrimination, and zero tolerance to abuse.
In all its work since it was set up in 2011, this Office has provided effective strategic leadership in ascertaining that the rights of persons with mental disorders are protected and upheld.

We live in a society in which the burden of mental disorder appears to continue to be on the rise.

Employment patterns and pressures on family structures are altering the caring options within society.

The challenges of economic dependencies and poverty risks associated with mental disorder are well known.
Organisational set-up The organisational set-up of the Office as on 31st December 2019 was as follows: Dr John M. Cachia, Commissioner Dr Miriam Camilleri, Consultant in Public Health Medicine, Head of Services Dr Jesmond Schembri, Officer in Grade 4, responsible for Customer Relations Ms Anna Debattista, Officer in Grade 4, responsible for Quality Dr Noel Vella, Consultant in Occupational Health, responsible for Workplace Mental Health and Patient Safety Ms Stephanie Chetcuti, Assistant Director 12 Dr Stephen Zammit, Legal Officer Ms Gertrude Buttigieg, Principal Speech & Language Pathologist, responsible for Communications Ms Mariella Maurin, Assistant Principal Ms Karen Turner, Senior Clerk Mr Emanuel Zammit, Messenger/Driver/Handyman Vacancies as on 31st December 2019 in order of priority Research Officer (Scale 10) – 1 position Management Committee Meetings Twelve regular Management Committee Meetings were held in 2019 as follows: 9 January, 14 February, 13 March, 9 April, 14 May, 11 June, 11 July, 8 August, 11 September, 16 October, 14 November, and 9 December 2019.
The CMH Agenda up to end 2019 Following the comprehensive review of its agenda and priorities for the years 2017-2019 in order to continue to be aligned with and respond to the needs and aspirations of those most at risk and vulnerable within our society, 2019 was the third and year of implementation this agenda.
The Office elaborated measurable deliverables linked to each action point and teams of staff members were assigned specific responsibilities for the various parts of the work required to implement this agenda.
Whilst recording satisfactory progress in most of the areas of attention and strategic priorities tackled in the first two years, adjustments, additions and deletions to the agreed action points were due to be undertaken in early 2019 in view of the alterations in staffing, particularly at Assistant Director level with a job description that re-introduced a stronger office maangement function and the improvements in available clerical / secretarial support.
The following is a brief summary of progress acheived: OBJECTIVE 1 – Pursue the obligations that emanate from the Mental Health Act EXPECTED OUTCOMES Patient awareness and understanding of their rights Patient empowerment to speak for their rights Dignity for patients Respect for privacy Respect for patients by professionals 13 Respect for professionals by patients Active support for the responsible carers Addressing legitimate complaints that are not seen to by service providers Use of schedules to improve quality of care Timeframes and schedules are respected Continuous monitoring, follow-up and after care to avoid deterioration Action against discrimination and stigma ACTION 1.1 Introduce an effective IT-based The system was fully functioning by end-2019.
monitoring system ACTION 1.2 Effective and comprehensive Further follow-up with MHS management is multidisciplinary care plans strongly indicated.

ACTION 1.3 Effective use of consent forms to No specific action initiated.

Visitation reports convey information on care continue to highlight discrepancies between signed consent forms and declared informed consent by patients and carers.
ACTION 1.4 Continue the dialogue with service The second course on patient rights has been users informing of their rights and delivered by staff of the Office in collaboration responsibilities with the Department of Mental Health, within the Faculty of Health Sciences of the University of Malta.
ACTION 1.5 Protect those who require social Ongoing activity by the Customer Care function care without the need to subject them to within the Office with the involvement of unnecessary restrictions relevant authorities within and outside Health.

ACTION 1.6 In-depth analysis of the Mental No specific action initiated.
Health Act OBJECTIVE 2 – Ensure continued accountability of public funds allocation and explore other funding routes beyond current central government funding arrangements EXPECTED OUTCOMES Better links between budget and operational performance More independence from direct Ministry funding ACTION 2.1 Develop internal operational and Internal financial arrangements reviewed and financial audit overhauled.
14 ACTION 2.2 Build a direct relation with the Further discussions with Ministry of Health and Ministry of Finance to secure support for the Budget Office to be taken in hand now that initiatives financial overhaul has been concluded.

ACTION 2.3 Develop specific expertise in Active membership of the Social Determinants applying for and managing EU funds, including Project at Ministry level.

Contacts with possible co-funding arrangements international partners have not materialised.
ACTION 2.4 Consider particular sponsorships To be discarded.

and partners for particular initiatives and events ACTION 2.5 Develop links with the Malta Regular contributions to the MFWS on various Foundation for the Wellbeing of Society themes.

Regular contributions to initiatives by (MFWS) and the University of Malta, particularly the Faculty of Health Sciences and the Faculty focusing on funding and implementation of of Social Wellbeing (University of Malta).
research initiatives Research initiatives not yet well developed.
OBJECTIVE 3 – Increase independence, public visibility and public awareness of the Office of the Commissioner EXPECTED OUTCOMES Become more a voice for patient rights and less a government department Obtain political commitment and goodwill for mental health and wellbeing at Ministry level Foster a Mental Health in All Policies approach Develop international cooperation ACTION 3.1 Work towards increasing the To be linked with Action 1.6 and included in independence of the Office proposed amendments to the MHA.
ACTION 3.2 Foster a mental public health Proceeded to a further re-print of 10,000 copies approach of the “10 Idejat Zbaljati” leaflet.

ACTION 3.3 Ensure representation of the Office Very significant contributions with multiple in relevant meetings, conferences, boards and stakeholders.

See specific sections in this committees report.

ACTION 3.4 Ensure invitations and participation Very significant contributions with multiple of the Office in relevant events and meetings stakeholders.
See specific sections in this report.

ACTION 3.5 Commence a Mental Health in All Very significant contributions with multiple Policies dialogue with relevant non-health stakeholders.

See specific sections in this departments, agencies and organisations report.

15 ACTION 3.6 Establish links with foreign A search for counterparts is still being agencies and authorities that work on the same conducted.
The bodies involved in authorisation agenda as our Office of involuntary care and regulatory organisations that oversee safeguarding of rights of persons with mental disorders are very disparate across continental Europe.
OBJECTIVE 4 – Provide strategic advocacy for change in mental health service delivery by entities in public health system EXPECTED OUTCOMES Persuade people in the health sector to be committed to mental health Health promotion in mental health Consolidation of community services Involvement family general practitioners Improvements of the physical environment where care is delivered Acute psychiatry from general hospital settings at par with all other acute conditions A functioning outreach service A functioning crisis intervention service ACTION 4.1 Set-up and chair a focus group with See Action 3.5 relevant invited stakeholders from within the health sector: health promotion, disease prevention, public and private primary care, general and specialised hospital care, rehabilitation, geriatrics ACTION 4.2 Dialogue with general No effective action initiated yet.
practitioners, primary care providers, and community pharmacists ACTION 4.3 Push for better mental health in The need for this service is felt at grassroots maternity services level.

Doctors and midwives are in tune and collaborative.
ACTION 4.4 Detailed review of the This area of work was overshadowed by the pharmaceutical prescribing of psychiatric and methylphenidate and the long-acting psychotropic medication at national level olanzapine issues 16 ACTION 4.5 Ensure that public mental health Ongoing pressure to implement mainstreaming services deliver the appropriate changes and of mental health with action on the four reform improvements pillars: improved community care, acute care in the acute hospital, specialised rehabilitation services and dignified long-term care.
OBJECTIVE 5 – Build alliances and work jointly with the various stakeholders including the non-health public sector, civil society and NGOs, the public at large, and the media EXPECTED OUTCOMES Bring together NGOs and work more with NGOs, building on the success of the Expo 2015 Better awareness to mental health among public service employees Effective partnership initiatives with education social security and social welfare employment Create a focus group for interested journalists from media houses and newspapers ACTION 5.1 Keep mental health and wellbeing The mental health issues linked to migration always on the agenda in all fora linked to social from Africa and war-torn areas in the Middle dialogue and integration East continue to present challenges that need to be tackled with the migrant communities themselves.
Foreign workers from EU countries and the Balkan states present added challenge for mental health issues.

To be tackled also with Action 5.3 as part of the workplace mental health agenda.

ACTION 5.2 Maintain a special focus on Collaborative initiatives with MFWS, FSWS, children, adolescents and youths (aged <30 Agenzija Zghazagh, Richmond Foundation, years) Education have continued.
ACTION 5.3 Widen the agenda for better Building on the Declaration on Mental Wellbeing mental health at the workplace and employment at the Workplace signed in October 2018, it is necessary to bring social partners to work together on effective examples of good practice leading to a Charter of Basic Principles for Mental Health at Work.

17 ACTION 5.4 Continue effective dialogue with To focus on individual cases that come to our social services and social welfare attention.
To continue to press for a holistic approach in drug addiction services between Sedqa, Health, Caritas and OASI.

ACTION 5.5 Create a focus group for interested To continue the constructive dialogue on the journalists from media houses and newspapers handling of suicide and suicidality on the media - written, radio, TV and social media.

In conclusion, this exercise served its original purpose and assisted the Office in focusing its actions on the priorities identified.
It is comforting to note that more than 80% of the targets have been reached.

With the publication of the Mental Health Strategy, the Office will now turn its attention to the monitoring of its implementation from a patient rights perspective.

An exercise will be undertaken to identify the action points that fall within the mandate of the Office and to report progress attained on a regular basis.
Monitoring of Patient Rights The Office adopts a multi-faceted approach to be able to report factually and effectively on the state of the rights of persons suffering from mental disorders in Malta.

Pursuant with its mandate and obligations emanating from the Mental Health Act, the Office has practically adopted the role and functions of the National Preventive Mechanism (although this role is not officially recognised) for persons deprived of their liberty for mental disorder reasons.
The Office operates within and utilises proactively the monitoring frameworks established by the UN Subcommittee on Prevention of Torture and the World Health Organisation.

We foster a constructive climate with all stakeholders that seeks to find solutions and to provide the best protection possible for persons in detention and for persons suffering from mental disorders living in our communities and their families.
Mental Health Act applications for restriction of patient rights The Mental Health Act has strict timeframes within which restriction of liberty for reasons of mental disorder can be done.

These timeframes are regulated by the Schedules attached to the Act itself.

This data presented in Chapter 2 of this report represents the fifth full year of implementation of the new Mental Health Act.

The involuntary care process is closely monitored, and trends are confirmed.
Patients are being followed up on a regular basis by their respective caring teams and within the much shorter timeframes.

Although not strictly comparable, length of stay in involuntary care has diminished radically.

Patients are being discharged from compulsory treatment orders or transferred to community treatment orders rather than being left on “leave of absence” for years on end.
Community involuntary care is now by far the preferred option of following up difficult cases (more than 91% of 18 long-term compulsory treatment cases), also because it includes as a care option the possibility of short admissions for observation and stabilisation care if the need arises.

This shift requires continued commitment to further strengthen community support services.

The quality of the information backing requests for involuntary detention of persons is improving.
Applications for involuntary care are progressively being better completed and they have allowed for deeper epidemiological analysis of complex issues such as suicide and self-harm, inpatients on involuntary treatment orders and community treatment orders.

The quality and detail of some care plans being submitted merit recognition, but other care plans can and should improve.

The issue of availability of human resources regularly features in feedback with care teams.
Greater involvement of patients and responsible carers in the care planning process should be better documented if it is indeed happening.

All these issues are dealt with in depth in the feedback and analysis of the findings of the Annual Visitation to Licensed Mental Health Facilities 2019 (see Chapter 3) and in the analysis of Incident Reports reported to our Office for 2019 (see Chapter 4).
Visitation of Licenced Mental Health Facilities The Office has carried out its Sixth Annual Inspection of 59 mental health facilities in the latter part of 2019.
The aims of the visits in 2019 were to (1) ensure that patients are being taken care of in a dignified manner by dedicated staff in a suitable environment; (2) explore whether service users are aware of their rights, participate in their care process and assess their care experience; and (3) assess the manner and extent of the organisation of medical records and their content, especially documentation required by the Mental Health Act.
During this inspection the team evaluated the level of adherence to these rights by providers, assessed the physical environment, the quality of care, and the available documentation such as consent forms, the appointment of responsible carer forms and the availability of multidisciplinary care plans, and appraised the patients’ experience with no less than 180 face-to-face interviews.

It also heard the concerns of the 153 staff members in both public and private mental health services.
The questionnaires with Responsible Carers were carried out through 24 detailed telephone interviews were held by the Office of the Commissioner for Mental Health.

The questionnaires / template utilized were (a) Service User Questionnaire; (b) Staff Questionnaire; (c) Responsible Carer Questionnaire and (d) Environmental Assessment Template.
These can be perused at Appendix 2 Analysis of Incident Reports A considerable bias in incident reporting analysis is the subjective decision of the persons involved whether or not to file a report.

Apart from underreporting, improving the consistency in reporting practice by use of appropriate protocols and training decreases but does not eliminate this source of bias.

The number of incident reports has increased dramatically to 264 reports in 2019 compared to 19 74 incidents reported in 2014.
A small group of persons (28%) were involved in 57% of total incidents reported.

This is an area which merits further investigation to assess the causes of this behaviour with the aim of providing better care and support.

Almost all the reports were submitted by nursing staff, who rightly might consider this to be part of their duties, but this duty applies also to other health professionals who may need to be sensitised more to this need.
The type of incidents reported highlight the primary pressures on, and concerns felt by, front line mental health carers with regards to incidents involving aggressive behaviour, substance abuse, abscondment incidents and self-harm events.

Staff and patients are exposed to such incidents more in certain wards than in others and this has an impact on both staff morale and quality of patient care.
Of more importance is the action taken by management to investigate the contents of a report within a day or two of the incident and to address any potential shortcomings when indicated.

This includes timely management feedback to staff making the report.

In the absence of such interventions, incident reporting loses most of its potential as a tool to improve patient safety.

Flimkien għal Saħħa Mentali Aħjar (Together for Better Mental Health) This national conference was organised by H.E.
Dr George Vella, President of Malta in collaboration with our Office on 9th September 2019 at Verdala Palace in Buskett.
Among those present there was bilateral representation from the Maltese Parliament; heads or representatives of departments and agencies within health, police, correctional services, detention services, employment, education, youth services; trade unions and employer associations; mental health professionals; academics and student organisations; and representatives from more than 20 non-governmental organisations.
The conference was extensively covered by all the national TV and radio news bulletins news portals on the day of the conference and by all the national newspapers the following morning.

Follow-up programmes and interviews by various media houses were organised in the days following the conference leading up to World Mental Health Day on 10th October 2019 where the focus was suicide prevention.
Address by HE the President - Inkeeping with the pledge made in his inauguration speech in April 2019 that mental health was a priority on the agenda his presidency, the President stated this national conference was being called primarily to combat stigma associated with mental health and to foster an open dialogue within Maltese society on this subject.
He expressd his belief that for a long time we have not paid proper attention to the mental health and dignity of those who suffer from problems of this nature.

The President believes that when we talked, we talked more about psychiatric illness or mental disorder instead of the need for better mental health and wellbeing in the daily lives of our citizens.

“So let’s shape a different agenda for better mental health.
The starting point must be the Mental Health Strategy for Malta 2020-2030, where it is clear that there is agreement by all on the 20 direction we should take,” the President said in his opening address.

He called for the need to understand that better mental health requires the full participation of the whole of society.

Political leadership - government and opposition - must be a living testament of intersectoral working and collaboration.
The conference will show in practice how health, education and employment policy and social policy and protection are linked.It will bring together the human, economic and social aspect for better mental health.

Children, adolescents, young people and the elderly need action focused on early awareness and timely interventions to prevent more serious illnesses.
Work pays homage and dignity to human beings, but extra pressure, inappropriate stress and inhumane conditions can turn the workplace into a serious challenge to the mental health of workers and families.
Malta needs to reflect on the mental health challenges in specific sectors such as substance abuse, immigration, refugees who have fled terrible situations in their home countries and sought refuge and comfort here, foreigners who are work among us, and many other realities in which citizens live in our communities and localities.

There is a need for concrete actions on social inclusion and true equality.
The environmental challenge and the development of our cities, towns and streets must be attentive to and provide more open spaces for outdoor activities such as exercise and sports, recreation and entertainment in clean air.

The President highlighted three areas that need more coordination between various organizations and services: prevention of substance dependence, gambling and the internet; self-harm and suicide prevention; and the prevention of all forms of violence and abuse.
There is a need for reflection on mental health in criminal justice systems and prisons.

We must recognize and uphold the added value of better mental health by taking an active part in cultural and popular activities, by creativity, by art and by drama, both as good use of free time and as therapy for those experiencing mental health challenges.
Today and in the years to come, the Presidency and the President personally will be insisting that everyone has a place and that everyone has duties to perform: politicians, public and private departments and entities, professionals, constituted bodies, patient associations and family members, non-governmental organizations, the organized media and all citizens.
We need, however, to respect everyone who has a role to play, to be coordinated, not to duplicate efforts and services, to work wisely, to build on each other's skills and develop new skills, to give everyone a chance, in one word - Together For Better Mental Health.

Interventions by Government Ministers and the Opposition – Hon.

Chris Fearne, Deputy Prime Minister and Minister for Health insisted that he was the one that was ultimately responsible for the mental health sector.
He stressed that work on the implementation of the 10-year plan for mental health was well underway.

He stated that this was an ambitious strategy, which has been costed, which has clear targets, and which was nothing short of revolution.

He acknowledged the problems 21 which continue to plague Mount Carmel Hospital, insisting however that work was underway to resolve the situation.
Close to 200 patients that did not need to be at Mount Carmel Hospital had already been relocated, with the hospital expected to be up to standard within two to three years.

Government believes in community-based care and would be looking to other services, including outpatient services at community health centres.

The remaining 300 or so people that cannot receive this sort of care would be moved to a new hospital at Mater Dei Hospital.
As regards prevention, the Minister for Health insisted that everyone was at risk and that after setting up clinics at the University of Malta and MCAST, the ministry would also be looking to have help available in secondary schools.

Hon.Evarist Bartolo, Education & Employment Minister stressed that policy makers cannot ignore their responsibility towards social wellbeing.

We need to have economic, social, environmental alignment, otherwise we will simply be solving one problem only to create another.
It is contradictory to talk about how many more psychiatrists we are going to need to employ in order to solve the problems that our system is creating.

He insisted that a holistic approach needed to be applied to policy-making, with an emphasis on the various aspects of the system.

We must ensure that we not a part of the problem but a part of the solution.
Society needed to be sensitized to issues of mental health, including in schools, where children often face very big pressures to perform, as well as the workplace, where more often than not people end up taking their work home.

Hon.

Michael Falzon, Social Solidarity Minister said it was estimated that one in four people were likely to experience some form of mental health problem in their lifetime.
In Malta, he said that 7% of the population will be affected by depression, which when taking about their family members, meant that a quarter of the population was being affected.

He stressed that depression often places people in a position where they were unable to maintain a job or relationships with others, leading them into a destructive vicious cycle.

One of government’s responsibilities was to identify what cases certain types of mental health issues.
We must ensure that we match economic advancement with steps forward in this field as well.

He too stressed that people needed to know that they can, and should, seek help.

The worst thing one can do is close up and see the things that once gave you pleasure cause you pain.

He emphasised that without a multi-disciplinary approach, authorities couldn not hope to help those suffering because of such conditions.

A visible consequence of problems going untreated were intergenerational vicious cycles.
You sometimes sign a care order for a child and notice that the child’s mother also had a care order issued in the past.

We often witness the same phenomenon with substance abuse.

Hon Stephen Spiteri, Spokesperson for Opposition on Health stated that Government has an obligation to provide the best care and services for mentally ill patients and this can only be done through long-term planning.
He recalled statistics that had recently been published showing that 20% of young people between the ages of 18 and 24 suffer from some form of depression.

In light of this, 22 increasing societal involvement is crucial to overcoming mental illness.

He emphasised the importance of early diagnosis and intervention, with priority being given to suicide prevention in schools.

From various studies, it has become clear that there is need better care to be given to patients in our country.
He stress the importance that Monte Carmel Hospital is rebuilt to be safe for both patients and workers as the environment of the place helps to heal.

It is ironic that we have advanced research which unfortunately cannot be used in the best possible way.

He added that rehabilitation leads to better healing and urged for social support in the workplace and for improved educational opportunities.
The Opposition would be working in Parliament not only to draw attention to Government’s failure in this area, but also to issue a number of proposals and suggestions which ensure that patients and their relatives are given the best possible life without any delay.

Technical presentations – The human face of mental health means supporting and sustaining families caring for people with mental health challenges.
When dealing with this topic, Ms. Connie Magro - a specialist nurse and mental health activist - stressed that families are an invaluable gift in a society that cares.

Families have a lot to offer but need help discovering their skills.

They need to be key partners in any care plan for their loved ones.

They need to be more involved in policy making and decision making.

We must also remember however that family members have another life beyond care.
A person’s skills are a key foundation for strong economic growth and better health for both the person and society.

Ms. Amanda Borg - an economist specializing in social investment - said that beyond cost-benefit calculations, the biggest economic gain comes from a holistic vision that focuses on health prevention and maintenance for better mental health instead of repairing damage that has already been done.
She cited the Happiness Index as an example which is being measured by the OECD and the United Nations as another indicator of how the economy is doing.

Promoters of new projects and initiatives in the UK and New Zealand are being asked to provide an assessment of the expected improvement in wellbeing and happiness in people's lives.
When dealing with the social determinants of mental wellbeing, the Commissioner for Mental Health focused on increased awreness of the challenges and opportunities required to achieve and maintain better mental health.

This can be acheived by a better understanding of what leads to mental health problems, of the need to seek help early and that there is nothing better than early treatment.

This also reduces stigma.


Better awareness comes from national and local educational campaigns combined with targeted interventions mainly in schools and workplaces.

Professionals need training to increase awareness and lead others to seek help.

There are also specific sectors in society that have special needs which need to be addressed either individually or in small groups.

23 World Mental Health Day 2019 The theme chosen for World Mental Health Day 2019 was Suicide Prevention.
In line with this theme, the main message was that Maltese society needs to acknowledge the reality of suicide and suicidal behaviour and be ready to speak about suicide.

Suicide Prevention needs all stakeholders to help share the experience and knowledge about this important and painful issue.

Suicide is the second leading cause of death among 15-29-year-olds.

Many children and young people engage in suicidal behaviour as a result of violence, sexual abuse, bullying and cyberbullying.
The WHO estimates that a death by suicide occurs every 40 seconds worldwide which means that an estimated 800,000 lost lives every year.

Local statistics reveal that, in Malta there were 2-3 deaths by suicide per month for the period 2013-2018.

86% of deaths were males.

Only 25% of recorded suicides had at least one contact with mental health services.

Almost two-thirds of all deaths were males aged between 30 and 59 years.

Among women 20% of deaths were aged 14 to 17 years.
Suicidal behaviour has existed throughout human history, but due to several complex factors in the past few decades, it has reached alarming statistical levels.

Suicide prevention is not just mental health challenge.

It deserves the attention of stakeholders in the fields of health, social policy, education, justice, scientific and professional organizations, universities and research institutes and organizations for mental health users and their families.
The role of traditional media and social media is of no less importance, since their participation can have both positive and negative effects, depending on how the subject of suicide is addressed.

We call for prevention that is trans-sectoral and interdisciplinary with all stakeholders involved.

Many within our society hold mistaken, prejudiced or stigmatised ideas about suicide.

It tends to be taboo until it hits someone whom we know.
Accepting suicide as a reality can help prevent an unnecessary death.

People need to talk about suicide to help the community to understand and identify the risk factors and learn to address them.

Suicide Prevention is possible, and suicide can therefore be avoided.

That is why efforts on suicide should focus on early identification and prevention.

People should not be left alone to suffer in silence.

People should not be afraid to seek help.


Those around them who suspect suicidal behaviour should not be afraid to ask the question, “Do you wish to die by suicide?” That may indeed be the important first step towards opening up to necessary assistance.

This is just one aspect of the subject.

Over the course of 2020, our Office intends to address other aspects of suicide prevention.
Our aim is to provide links to reliable reports, documents and tools not only to professionals but also to the community as a whole so that citizens are empowered and prepared to detect and address suicide behaviour.
24 The Development of Public Mental Health in Malta Dr Miriam Camilleri (as lead author), the Commissioner and Dr Antonella Sammut from Mental Health Services were asked to prepare an article highlighting 20 years of mental health developments in the Maltese health system as part of a series of articles for a special publication issue to commemorate the 20th anniversary of the Malta Association of Public Health Medicine (MAPHM).

The paper which was included in the special publication is at Appendix 3.
Parliamentary Debate on Annual Report for 2018 After couple of postponements in November 2019, the Annual Report 2018 was eventually discussed in a joint meeting of the Committee for Social Affairs and Committee for Health of the House of Representatives held in the Parliament building on 29th January 2020.

A total of 4 MPs (6% of the House) took part in the debate.
Customer Care Requests for assistance/information addressed to the Customer Relations unit appear to have stabilised at an average of 12 per week with the trend, highlighted in preceding years, that persons with mental health issues and/or their responsible carers appear more informed as to their rights under the Mental Health Act being confirmed.

This is particularly evident in patients of Mount Carmel Hospital, the majority of whom are assisted by ward staff in making such requests to this Office.
On the other hand, calls by concerned relatives of drug addicts who request the intervention of this Office to ensure the continued detention of family members at Mount Carmel Hospital – viewed as the only safe place available to them remains constant.

Whilst understanding the reasoning behind such requests, it is sometimes difficult to explain to these callers that one of the principal aims of this Office is diametrically opposed to their request, i.e.
it is the duty of the Commissioner to ensure that no-one is kept at Mount Carmel Hospital unless such hospitalisation is necessary for their care.

This trend also serves to highlight the lack of safe residential facilities for drug addicts that do not qualify for/are not interested in drug rehabilitation programmes.
In addition, anxious calls by neighbours of persons with mental health problems who consider such persons a nuisance at best and a danger at worst underlines the fact that society still has a long way to go in understanding the unique situation of person with mental health problems.
The stigma and pre-conceived opinions surrounding mental health are ever present and the fact that such concerned neighbours do not have a readily identifiable port of call (with the exception of the Police) exacerbates the problem.

25 The unit also provides advice to healthcare professionals within the Mental Health Service in dealing with particular cases and situations.
Such requests are invariably handled by the Customer Relations unit through telephone and email communications with some cases requiring face to face meetings.

Whilst requests for advice are received from the whole spectrum of health care professionals, social workers (both at Mount Carmel Hospital as well as in the community) are by far the largest customer base with queries mostly relating to social benefits, accommodation and issues with relatives.
Curators In terms of Article 26 of the Mental Health Act, curators are bound, inter alia, to submit to the Commissioner within three months of their appointment a register of assets belonging to the person lacking mental capacity and submit every six months an income and expenditure account of the said person.
Despite the best efforts of this Office to inform curators of their obligations at law and consequently to persuade them to bring themselves in line with such, compliance with the afore-mentioned Article is patchy and relatively poor.

This Office re-iterates its call that the Minister should make regulations in terms of Article 47 (3) (d) of the Mental Health Act to “establish a range of fines ….

for non- compliance with any provision or any requirement imposed under such provision”.
It is the hope of this Office that the threat to impose administrative fines would act as timely and effective reminder to curators to diligently go about their reporting duties as prescribed in the Mental Health Act.

Public Relations and Media Presence The Office has kept a regular presnce on all levels of media throughout 2019.

The Office regularly updated its Office website and Facebook pages, with sharing of news items from local and foreign sources of information.
This is done regularly according to material encountered on a local or internation level, thus ensuring a basic presence in the social media world.

There were 20 live radio and 6 live television particpations and numerous other recorded participations which centred mainly around topics such as stigma, patient rights and patient advocacy.

Presence in the written print was particularly intensive around World Mental Health Day and the publication of the Annual Report in October.
There were several instances where media houses requested the reaction of the Office to general news and current affairs items on the theme of mental health.

The Office considers prompt and clear responses to such requests as critical for keeping mental health on the national agenda.

A Round Table between Media representatives and Mental Health Specialists on reporting of Suicide on Media was orgaised by the Office June.
A selection of print media interventions on topical issues that arose throughout the year is reproduced hereunder: 26 Id-depressjoni mhix marda li tista tikkuraha fi ftit minuti (3 February 2019) Id-depressjoni teżisti u hi marda reali.

Skont l-Organizzazjoni Dinjija tas-Saħħa hemm diversi forom ta’ depressjoni iżda karaterristiċi komuni huma dwejjaq, li wieħed jitlef interess f’affarijiet li normalment kien iħobb, problemi bl-irqad, għejja, problemi biex wieħed jikkonċentra u bidla fl-aptit għall-ikel.
Id-depressjoni tista’ tkun ukoll minħabba ċirkostanzi li wieħed ikun għaddej jew għadda minnhom bħal problemi soċjali, problemi tas-saħħa, problemi ta’ xogħol eċċ.

Sfortunament minħabba li l-kundizzjoni ma tistax titkejjel b’mod li jidher, per eżempju permezz ta’ testijiet tad-demm jew kejl ieħor, jista’ jkun li l-persuna jew dawk ta’ madwarha ma jindunawx li qegħdin f’sitwazzjoni li tirrikjedi l-għajnuna.
Oħrajn jindunaw li għandhom bżonn l-għajnuna u ma jafux fejn se jsibuha u għaldaqstant huma ħafna li jfittxu għajnuna permezz tal-internet u l-media soċjali.

Waqt li xi informazzjoni tista’ tkun utli biex wieħed jagħmel l-ewwel passi neċessarji biex ifittex l-għajnuna mhux dak kollu li ssib fuq il-media soċjali huwa veru jew xjentifikament korrett.
Għalhekk wara diversi kuntatti li rċevjna bħala Ufficċju tal-Kummissarju għas-Saħħa Mentali u li ġew investigati, qed nagħtu parir li wieħed għandu jfittex pariri u servizzi mingħand entitajiet li huma reġistrati u rikonoxxuti fil-qasam tal-kura tas-saħħa mentali u mingħand professjonisti li huma liċenzjati u regolati biex joffru dawn is-servizzi.
Servizzi minn entitajiet jew individwi li mhux liċenzjati jew regolati biex jagħmlu dan ix-xogħol jistgħu ikunu ta’ dannu aktar milli ta’ ġid għal persuni vulnerabbli speċjalment jekk is-servizzi jiġu ppreżentati bħala ‘kura ta’ malajr u b’xejn’.

Strong appeal to public authorities for National Emergency Psychiatric Response Service (3 July 2019) The Commissioner for Mental Health advocates caution whenever claims are made about treatment which can bring about rapid changes in suicidal behaviour.
To our knowledge, transcranial magnetic stimulation (TMS) is currently not approved for use in reducing suicidal behaviour by leading international regulatory agencies such as the Food and Drug Administration (FDA) in the United States of America, the European Medicines Agency (EMA), and the United Kingdom National Institute for Health and Care Excellence (NICE).
Evidence-based treatment and care requires thorough scientific analysis of efficacy and safety studies that have been done or still need to be conducted.

Meanwhile it is incumbent upon local academia, professional organisations and national regulatory authorities to provide leadership, definitive results and direction.

Our people deserve this.

Published reliable scientific data indicates that TMS is only approved for use in the treatment of refractory depression.
This means TMS may be considered for use only in cases of severe depression that has not responded to other forms of standard treatment, such as medication or psychotherapy, 27 or where such forms of treatment may not be suitable.

More safety studies are needed to determine long term effects.
As Commissioner for Mental Health, I once again strongly appeal to the responsible public authorities to urgently implement the National Emergency Psychiatric Response Service, appropriately resourced and functioning in accordance with best practice.
Such a service should provide an adequate and timely response to persons and families experiencing a psychiatric emergency within the community, prevent unnecessary psychiatric hospital admissions, and provide follow-up to individuals and their families in their own homes or within their own communities.

Suwiċidju (20 August 2019) Mewt b’suwiċidju ħafna drabi ma tkunx ġrat minħabba sitwazzjoni waħda imma minħabba bosta affarijiet li jseħħu fil-ħajja tal-persuna.
Hu diffiċli li wieħed ikun jaf dak li għadda mill-moħħ tal-persuna meta jseħħ is-suwiċidju.

Mill-esperjenzi ta’ persuni fejn suwiċidju jfalli, dawn jiddeskrivu l-mument bħala waqt fejn id-diffikultajiet jarawhom kbar wisq.

Hemm bosta, speċjalment nisa, li jgħidu li ma jaslux għal suwiċidju minħabba uliedhom, oħrajn iqisu li forsi l-ħajja ta’ wliedhom tista’ tkun aħjar mingħajrhom.

Huma ħafna l-fatturi li jistgħu jwasslu lil persuna biex tiddeċidi li ma hemmx triq oħra ħlief is-suwiċidju.
Fost l-aktar komuni hemm depressjoni severa u mard mentali serju ieħor.

Studji juru li ħafna drabi jkun hemm fatturi soċjali oħra, fosthom problemi ta’ flus, livell baxx ta’ għarfien, nuqqas ta’ xogħol u każi ta’ vjolenza domestika.

Hu diffiċli li wieħed jiddetermina x’jiġi l-ewwel jekk hux il-mard mentali sever jew sitwazzjonijiet soċjali diffiċli - li hu żgur hu li meta dawn l-affarijijet jiltaqgħu flimkien jogħla ferm ir-riskju għas-suwiċidju.

X’jista’ jsir?
X’jista’ jsir?

Fuq livell personali, li wieħed jidentifika u jinduna li għandu diffikulta’ u li jista’ jfittex u jsib l-għajnuna huwa l-ewwel pass.

Mhux aċċettabli li persuna raġel jew mara taċċetta abbuż fiżiku, psikoloġiku jew emozzjonali minn persuna oħra.

Meta persuna tħossha li f’relazzjoni mhux qed tkun ittrattata sew hemm bżonn li tieħu azzjoni mill-ewwel.

Hu normali li hemm elementi ta’ biża u forsi anke ta’ mistħija.
Kultant dawk ta’ madwar il-persuna ma jirrejalizzawx id-diffikultajiet imma dan ma jfissirx li l-persuna m’għandiex raġun.

Il-mediċini mhux dejjem huma s-soluzzjoni.

Kultant wieħed irid jieħu deċiżjonijiet, ifittex soluzjonijiet u fejn hemm bżonn anke l-għajnuna ta’ professjonisti vari.

Fuq livell soċjali hu importanti li min jiltaqa’ ma dawn is-sitwazzjonijiet bħal pulizija u l-ħaddiema fl- oqsma soċjali, edukattivi u tas-saħħa ma jaħlqux għajnejhom.
Mhux dejjem li r-raġuni ewlenija tkun il-mard mentali.

Importanti li wieħed jeżamina s-sitwazzjoni sew biex flimkien noffru possiblita’ ta’ soluzjoni aħjar lil persuna minn mewt b’suwiċidju – kull persuna hija importanti!

28 Hu fattur dokumentat li persuni li jwettqu suwiċidju mhux neċessarjament għax riedu jmutu imma għax kien l-uniku mezz li raw biex ifitxu l-għajnuna.

B’hekk attentat ta’ suwiċidju hu talba għall-għajnuna biex iwasslu l-messaġġ li għaddejjin minn tbatija kbira.
Sfortunatment persentaġġ minn dawn il-każi jkunu fatali u l-persuni jaslu biex jitlifu ħajjithom.

Għalhekk l-enfasi trid tkun sistemi ta’ emerġenza f’posthom fejn persuni jsibu l-għajnuna meħtieġa f’waqtha, qabel ma jkun tard wisq.

Attivita’ fiżika bħala terapija (19 November 2019) Is-Saħħa Mentali ma għandhiex tiġi separata mis-saħħa sħiħa tal-bniedem.

Meta jirriżulta li persuna tkun qed tbati minn problemi ta' saħħa mentali u jidher li jkun hemm bżonn ta' mediċini, dawn jiġu rakkomandati.
Ma jfissirx li dan waħdu hu l-uniku mezz ta' kura għal dik il-problema.

Hemm uħud li jkollhom bżonn kura permezz ta' mediċini għal perjodu qasir ta' żmien u wara jkomplu b'forom oħra ta’ kura jew xejn.

Hemm oħrajn li minħabba li l-kundizzjoni tagħhom hi kronika jkollhom bżonn mediċini b'mod regolari.

Għalhekk wieħed ma jistax jirrakomanda li kulħadd jagħmel l-isports minflok jieħu l- mediċini.

Hu fatt magħruf li l-ġisem jipproduċi kimika differenti skond il-bżonn u l-mod kif ikun qed jaħdem.
Fost dawn il-kimiċi hemm l-ormoni li jirregolaw diversi funzjonijiet tal-ġisem fosthom il-moħħ u kif wieħed iħossu.

L-ormoni tat-tip 'Endorphins' għandhom il-funzjoni li jġiegħlu il-persuna tħossha tajba, pożittiva u b'iktar enerġija.

Permezz tal-‘Endorphins’ wieħed iħoss inqas uġigħ u l-burdata titjieb.

Il-ġisem jipproduċi l-'Endorphins' b'mod naturali.

F’ċirkostanzi fejn il-produzzjoni tonqos, il-ġisem jista' jerġa jistimola il-produzzjoni permezz ta' mediċini jew permezz ta' attivitajiet oħra.
Dawn jinkludu ikel bnin u frisk, attivita li tagħtik pjaċir bħal xi passatemp, kif ukoll attivita' fiżika bħall-isports, xi mixja jew xi għawma.

L-attivita' fiżika tgħin ukoll biex jitnaqqas l-effett tal-istress u l-anzjeta waqt li tista' tgħin biex wieħed jorqod aħjar.

Barra minn hekk kull attivita’ fiżika tgħin biex wieħed iżomm piż tajjeb jew inaqqas il-piż, itejjeb iċ-ċirkolazzjoni u dan jgħin fis-saħħa mentali u s-saħħa fiżika.
Bosta postijiet fejn tingħata kura lil pazjenti bi problemi ta' saħħa mentali huma mgħammra b'faċiliatjiet u spazji fejn wieħed jista' jeżerċita' ruħu.

Fattur interessanti li forsi ħafna jagħżlu li jinsew hu li l-binja tal-Isptar Monte Karmeli nbniet lejn l-aħħar tas-seklu 19 u kienet iddisijnata biex toffri spazju miftuh fejn wieħed seta' jgawdi mixja jew attivita' fil-kampanja waqt li jirċievi il-kura li kellu bżonn.
Li jkollok ukoll faċilita' bħal gym hija ħaġa tajba iżda wieħed m'għandux jieqaf biss fuq affarijiet fissi.

Tista' tagħmel mixja jew anke eżerċizju fuq tapit jew bi ftit mezzi sempliċi u li ma jiswewx wisq flus.

Importanti ferm biss li wieħed jara li jkun ingħata pariri jew ikollu l-gwida ta' professjonisti bħal fiżjoterapisti jew persuni kwalifikati fil-qasam tagħhom, dan biex wieħed jevita li jagħmel iktar ħsara milli ġid.
Id-Dipartimenti tal-Fiżjoterapija u tal-Occupational Therapy u xi swali ġo l-Isptar Monte Karmeli huma mgħammra b'apparat tal-eżerċizju li jintuża’ skond il-bżonn u d-diskrezzjoni tal-professjonisti.
Attivitajiet fiżiċi oħra jitmexxew ukoll mill-fiżjoterapisti fil-ġonna tal-isptar kif ukoll barra f'dak li jissejjaħ 'Psychotherpeutic-oriented physiotherapy approach' fejn permezz ta' attivitajiet fiżiċi l-pazjenti jkunu 29 ggwidati biex jiffurmaw esperjenzi pożittivi fuq livell psikoloġiku minflok ħsibijiet negattivi jew problemi li mhux dejjem wieħed jista' jsolvi imma jkollhom impatt fuq is-saħħa mentali tal-persuna.
Aħna dejjem ninkoraġġixxu li dak kollu possibli fil-prevenzjoni, kura u rijabilitazzjoni għandu ikun għad- disposizzjoni tal-pazjenti.

Biss fl-aħħar mill-aħħar id-deċiżjoni ta' x'servizzi jkunu offruti dejjem tiddependi mill-amministrazzjoni tal-isptar u d-direzzjoni li din tingħata.
Mental Health Review Committee The Mental Health Review Committee was set up within the Office for the handling of requests for reviews of cases either by the Minister for Justice or by the patients or their responsible carers in terms of the Mental Health Act.
The main function of this Mental Health Review Committee is to advise the Minister responsible for justice on leave applications (Schedule 15 of the Mental Health Act) on behalf of patients detained under Article 37 of the MHA (formerly known as CCJP patients) and in other situations whenever the Minister for justice feels that the advice of the Commissioner is required to arrive at a decision.

There were three referrals that were processed and advised upon in 2019.
Influencing Policy and Legislation A Mental Health Strategy for Malta 2020-2030 The launch of the strategy document Building Resilience Transforming Services by the Ministry of Health on 17 July 2019 was a milestone acheivement for mental health and wellbeing in Malta.
The strong recommendations made repeatedly by this Office since its inception have been vindicated in the strategy document itself where 75 of the 94 envisaged actions echo or reproduce recommendations made by this Office in successive reports and documents.

The evidence collected by this Office over the years underpins the proposals being put forward for the future development of mental health over the next decade.

Our reaction to the strategy is positive.


We support the approach of consensus and stakeholder involvement.

A major concern is that the setting out of the strategy in itself may provide a false sense of achievement which only serves to put on a back burner the addressing of various priority issues which are very pressing.

There are no alternatives to acute admission to Mount Carmel Hospital in severe cases requiring involuntary care.
We cannot continue to expose an already ill patient to further mental trauma.

The building of a new facility close to Mater Dei Hospital, whilst long overdue, is not by itself a solution.

The current shortcomings relating to bad practices, poor morale and management issues amongst others, must be tackled now and not carried over to the new facility at Mater Dei Hospital or to community care or residential facilities that are rolled out as part of implementation.
On behalf of patients whose rights we are legally bound to promote and protect, we re-iterate our resolve 30 to persue active monitoring of the strategy implementation process.

We have identified from within the strategy document itself, a number of issues that should not wait for 5 years or so to be addressed.

Failing to prioritise would signify a continuing disservice to patients and their relatives and represents a continuing breach of their fundamental right to quality care.
In our opinion, the areas for attention in the short and medium term i.e.

the next 3 years include (not in any priority order): • Resolution of issuesconcerning infrastructure, environment and maintenance.

Closure of the Dickensian parts of MCH.

• Various issues responsible for, or affecting, the current poor management of, communication and consultation within Mental Health Services need to be addressed.

It is useless to have new premises if management issues remain untackled.
• Empowerment of managers within the organisation.

• Emergency response services at national level needs to be set up.

• All referrals for acute psychiatric evaluation and eventual hospital admission to be channelled through the psychiatric team at Mater Dei Hospital A&E Department on a 24/7 basis.

• Referral of patients from MDH A&E to outpatient services needs better liaison.

• Observation ward in MDH urgently needed to complement the Psychiatric unit, at least in the interim.
• Operating protocols, particularly, admission and discharge protocols cannot wait to be addressed.

• Drug misusers abusing admission and using MCH as respite must be tackled through an upgraded substance misuse admissions policy and appropriate social support.
• Unacceptable infrastructure, poor environment and understaffing are causing demotivation and low morale in staff across professions This sense of overload is inevitably perceived by trainees and students during placements at MCH, with the result of extinguishing any interest that newly recruited graduates might have in psychiatry.

• Issues relating to long waiting lists and proper management of Psychiatric Outpatients need to be immediately sorted out.
In addition, the lack of one patient file containing all clinical notes including those related to psychiatry, further insulates quality of care.

• The custodial mentality which pervades MCH organisational culture needs to be countered.
• Properly functioning multidisciplinary care teams with an adequate number of psychologists, psychotherapists, social workers and occupational therapists • Better communication between different professionals, and between staff and patients • Proper patient care planing involving all members of MDT, patient and families shoulde be available for all patients admitted to MCH, whether voluntary or involuntary.
31 • A General Practitioner service should be available to cover the non-psychiatric care requirements of patients at MCH.

• Issues of polypharmacy and interactions / side effects of medications on patients require the continued in clinical pharmacists.

• Improving staff safety and support.

• Addressing patient idleness • Proper resourcing of and maximising use of community mental health teams both to prevent overload of acute services as well as to address long waiting times for specialist services.
• Community mental health services in Gozo are non-existent.

ILO – Work for a Brighter Future This is a broad overview of the foreseeable challenges facing the world of work from a global perspective, taking into consideration both existing problems and inequalities as well as expected future developments, whether threats or opportunities.

It is meant to stimulate discussions between the social partners on how these issues can be addressed in a cooperative manner.
As such the document is not meant to identify the innumerable factors affecting the goal of achieving decent work for all, or the strategies thereof; nor is it a stand-alone document.

Rather it is to be used as a tool to raise awareness of social partners and promote the need for a focused discussion on this topic.

In our view, the fact that ‘mental health’ is actually mentioned once in such a broad-based outlook is actually quite positive (there is also a reference to psychosocial risks).
The overview addresses several relevant Social Determinants of Mental Health and Well-Being.

The various challenges mentioned - equal pay, harassment and violence at work, working time, gender discrimination, unemployment, adequate living wage, social protection systems, decent work, etc, - all can influence on mental health.

Addressing these challenges will have profound positive effects on individual and societal mental well-being and on sustainable economic development.
A policy on inclusive education in schools General Comment - The 3 documents outline practices which to a certain extent have been tested over a considerable timespan.

However, no background or analytic evaluation of what has been achieved or what has failed over the past 20 years or so of ‘inclusion’ are outlined.
Future in the context of inclusive education needs to mean a productive future where the learning leads the individuals developing their full potential and to be equipped for challenges of life whatever these may be for the individual.
The teaching establishment should give individuals the necessary environment to belong as valued members through active participation and the elimination of the barriers limiting the participation and achievement of all learners, respect diverse needs, abilities and characteristics.

Continuous Professional Education should not be limited to educators but should be extended to all 32 professional staff working within Education.
Learners are all children who attend be Child Care Centre, Kindergartens, and institutions which offer educational settings for Compulsory Schooling.

Support structures and services should include a comprehensive diversity of support professionals who offer services within specific schools and in classes or ‘special’ classes according to the need.

Having school-based support services gives more continuity of services, more support to the educators.
Adequate evaluation of the necessary support services to meet the needs of children and families need to be studied with care in view of social context we are living, taking in consideration that even the parents of children in the most stable environment will need to juggle between work and accessing the necessary support services let alone the children coming from dysfunctional families where often taking a child for a Speech Therapy appointment or an Occupational Therapy session would be the last of the priorities on the parents’ mind if they are dealing with other issues.
Route to Quality Inclusion - Mental Health per se is not considered in the Diversity Wheel Categories provided in the ducument.

Mental health is included in the definition of disability in line with equal opportunities legislation.

However one then notes that intellectual disability is considered separately on its own under “Cognitive and Learning Diversity” whilst emotional and behavioural challenges are listed under “Physical and Psychological Diversity”.
Although one understands the need to categorise, it is hoped that children themselves will not be labelled according to the category under which their needs are assessed.

It is also to be remembered that a child can manifest more than one diversity issue which together provides a more complex picture and may need different management.
A National Inclusive Education Framework - The challenge is whether the educational system will develop and sustain the capacities to implement this framework effectively and across all the system, and the extent to which individual schools/classrooms will have the capacity and support to truly exert autonomy and flexibility to address their particular challenges in a timely and effective manner for the best interests of their learners.
Mental Health is specifically mentioned in the definition of disability and therefore we presume that all references to the term disability are therefore interpreted as also inclusive of mental disabilities.

Mental health is also indirectly being addressed wherever reference is made to cognitive, social, emotional, and behavioural difficulties/needs of learners.

Parents’ Guide - Parental empowerment should be emphasized.
Parents are to be active partners in the educational goals and future vision approach to meet their child’s needs and abilities.

Where unfortunately children are coming from dysfunctional families these need to be supported even more since a dysfunctional family will produce dysfunctional children and future dysfunctional society members.

We would have liked to see more commitment of the schools to promote mental health and well-being, also as a vehicle to address parental wellbeing issues.
Reform on Human Trafficking and Prostitution 33 Whilst this Office agrees with the Government’s aim to protect individuals, who are coerced, deceived and exploited into the complex webs of trafficking, we believe that the primary emphasis should be prevention of such occurrences in the first place.
Human trafficking should not only be limited to the context of prostitution but needs to be expanded to include any form of forced/unpaid/low paid work, degrading work conditions, slavery, extortion, and other forms of exploitation and dis-empowerment of human beings by others that increase their risk for poverty, homelessness, and create vicious cycles of vulnerability and dependency.
Hence, it is important to explore and establish the myriad of reasons which lead both women and men into prostitution and exploitation, and then to address these systematically and strategically.

Mental health constitutes one of these underlying reasons, but there is a whole interplay of socio-economic factors which can be at the root cause.
Hence addressing social dimensions or in other words the conditions in which people are born in, live, form relationships, study, work and eventually die in, is of the utmost importance if we really want to address prevention.

In addition, we strongly believe that in order to address issues related to prostitution, it is of utmost importance to strive to close the exploitation and vulnerability loops outlined above.
Human Trafficking - On the raising of awareness and on strengthening the prevention of human trafficking, we reiterate that the focus should be preventing the occurrence of circumstances that would make people vulnerable in the first place.

We believe that education is crucial in imparting the knowledge, skills, attitudes and values, that should focus on human dignity, human rights, empowerment, resilience, and so on.
Streamlined referral mechanisms are extremely important and we consider that the biggest hurdles here involve the identification of victims and the efficient sharing of meaningful information.
In our opinion these need to be addressed by (1) education of critical personnel (health, education, social welfare, disciplinary forces, judiciary, civil society etc) in how to increase index of suspicion, how to be able to identify, and to know what to do in such circumstances; and (2) having clear paths of information sharing between critical personnel.

We need to ascertain that sharing of information is not jeopardised by incompetent/convenient citation of GDPR and Data Protection Legislation.
Protection mechanisms should also be extended as appropriate to potential victims.

It is essential to work together across entities.

Mental health assessments, intervention and support should also be provided within this holistic approach.

Health (including mental health) and education sectors, amongst others, should also be included among entities to support enforcement and prevention strategies.

Anti-trafficking laws should also be extended to protect suspected and/or potential victims.
The judiciary must receive appropriate training.

Concerning regulation for “gentlemen’s clubs”, massage parlours and temporary work agencies, we consider it essential that once a massage parlour is licensed as such, there is effective monitoring to ensure that such parlours are being used only for massage by suitably qualified therapists.
As for the so-called “gentlemen’s clubs” or strip clubs, it is our opinion that these are by their very nature derogatory, exploitative and perverse settings which feed upon the vulnerability of human beings.

34 The Government aims to ensure through regulations that “these outlets are not used by criminals as a legitimate interface of human trafficking and sexual exploitation”.
We ask whether such outlets are actually registered/licensed, and if so for what specifically stated purpose; whether these are monitored, and what behaviour is deemed permissible/not permissible.

We are of the opinion, that strip clubs should be abolished.

Prostitution - We agree with removing punishment from those who “loiter for the purpose of prostitution” and that prostitutes are given appropriate health and psycho-social services and support.
However, this does not tackle the more important issue of primary prevention, i.e.

preventing entry into prostitution by identifying and tackling the root causes.

The law should deal harshly with persons who exploit prostitutes such as pimps and traffickers.

There should also be more effective police surveillance near well-known hotspots.

Prostitution is a result of a number of vulnerabilities that interact with each other.
Prostitutes are exploited and abused by the very fact that their services are sought after, even when it appears that they provide services out of their free will.

We therefore maintain that the most important interventions should be focused on addressing the various psychosocial and economic determinants that push persons into prostitution.

The various factors leading to entry into prostitution and exit from prostitution need to be adequately addressed before any other intervention.
We agree with public health interventions and access to health services but propose the specifice inclusion of access to mental health services in the title of this key legal and policy area.

We would like to specifically include the promotion of mental health and well-being of prostitutes and the provision of mental health and psychological services.

We agree in making punishments harsher when such coercion is used in relation to minors, or other vulnerable persons.
However here we open a Pandora’s box, since we believe that to some extent most (if not all) persons who “choose”/resort to prostitution are already vulnerable.

We fully agree that we need to listen to (and strive to understand) persons who have resorted to prostitution.
Social Regulatory Standards for Office-Based and Residential Services offered to Persons with Drugs, Alcohol and Gambling-related problems The 11th Edition of the WHO International Classification of Diseases (ICD-11) classifies diseases due to substance use or addictive behaviours as mental disorders.

As such therefore, persons suffering from drugs, alcohol and gambling-related problems are included in the definition of “mental disorder” as defined in the Mental Health Act (Cap 525 of the Laws of Malta).
The definition of “treatment” in the Mental Health Act also includes care of a social nature.

It is our considered opinion that services (whether Office-Based or Residential) licensed through these propoased regulatory standards are also facilities purporting to provide mental health services and therefore subjected to conform also to the requirements of Articles 40-42 of the Mental Health Act.
Article 6(k) of the Mental Health Act obliges the Commissioner for Mental Health to oversee the safeguarding of patient rights in all 35 licensed facilities purporting to provide services for persons suffering from mental disorders.

This Office therefore requested that the above is addressed and clarified to provide clear guidance to both service provider and regulatory entities.
We welcome the establishment of standards, guidelines and quality and performance indicators and we strongly recommend that these become applicable to Mental Health Services such as Psychiatric Outpatient services, community mental health clinics, outreach services, and rehabilitation centres (day centres) and inpatient and hostel residences all of which cater for a diversity of mental health conditions that definitely include persons with drug, alcohol and gambling related problems.
Working in Partnerships The Office of the Commissioner involved in building networks and working in partnership with key stakeholders from various sectors whether public, private, church or social, to facilitate synergistic action and identify ways for mutual collaboration.
This is done through requesting and accepting requests for meetings, fostering a culture of joint groups focused on multidisciplinary action, actively participating in conferences, seminars, workshops and other events, and working together with stakeholders on specific actions.
Meetings The following meetings were held at the request of the Office of the Commissioner: Introductory meeting with Ms Simone Azzopardi, the newly appointed Commissioner for Gender- Based and Domestic Violence Meetings with Council of Heads within the various colleges to discuss the relevance of mental health issues to the daily running of public educational institutions: • St Margaret College (Cottonera, Zabbar) • St Clare College (Sliema, Gzira, San Gwann, Pembroke, St Julians) • Maria Regina College (Mosta, St Paul’s Bay, Mellieha, Naxxar, Gharghur) • St Thomas More College (Zejtun, M’Xlokk, M’Scala, Fgura, Tarxien, Sta Lucia) Courtesy visit to His Excellency Dr George Vella, President of Malta on his appointment and to provide an update on the work of our Office.
Further meetings with the Office of the President were held in preparation for the National Conference which was held in September 2019.
Visit to HILA services (within CareMalta Group) in Sliema, Mosta and Rabat Regular meetings with Commissioner for the Rights of Persons with Disability and staff to coordinate action with a focus on mental health issues in disability and the disabling nature of mental disorders 36 Courtesy meeting with Dr Maria Vella on her appointment as Commissioner for Older Persons Meeting with Hon Clifton Grima, Parliamentary Secretary for Youth, Sport and Voluntary Organisations youth on mental health initiatives Courtesy meeting with Hon Chief Justice Joseph Azzopardi Introductory meeting with Mr Matthew Vella, CEO Social Care Standards Authority The following meetings were held at the request or invitation of other entities: Meeting of the Poverty and Social Exclusion Think Tank Working group on Disability Assessment Reform with the aim of unifying diability assessment procedures across various entities, including housing, social welfare, social security, employment.
Consultation Meeting with the Mental Health Strategy Team and its external advisers to discuss the draft of the strategy Meeting with ELSA Malta Social Policy Team on mental health legislation and policy Meetings with prospective candidates for the forthcoming elections of Members of the European Parliament: Dr Frank Psaila, Mr Felix Busuttil Meeting with the Malta Police Association Regular meetings with Richmond Foundation to coordinate action and to discuss pending matters and forthcoming initiatives Regular meetings of the joint Police/Mental Health Nursing Services team chaired by Dr Miriam Camilleri on a number of issues including (1) police assistance when called by the lay public to control aggressive behaviour of a person/s suggestive of either a mental illness and/or alcohol/drug intoxication; (2) Police assistance when patients abscond from MCH, or do not adhere to conditions of leave, or fail to abide by a CTO Care Plan; (3) Police Training Needs; (4) Dementia; (5) Liaison with Psychiatrists; and (6) emergency psychiatric response – a total of 5 formal team meetings and numerous informal interventions in 2019 Visit to MCAST Well-being Hub and meeting with MCAST management and staff of the hub Rountable with media houses on the reporting of deaths by suicide in the media Meeting with WHO experts on the drafting of the National Tobacco Control Strategy – the Office requested that action to address the severe smoking problems in persons with mental disorders be placed high on the agenda of the upcoming revised strategy.
37 Meeting with Victim Support Malta to illustrate SPOT - Suicide Prevention, Outreach and Therapeutic services project Meet Mr Dana Piillai from Humanity 2.0 Foundation on joint projects with the Malta Foundation for the Wellbeing of Society Regular meetings with CEO Agenzija Zghazagh to coordinate action and to discuss forthcoming initiatives Meeting with Crisis Resoultion Malta and Clinical Chair of the Deparment of Psychiatry on the future plans for emergency services Courtesy Call to the CMH Office by the United States Consul on the occasion of World Mental health Day 2019 Study Visit by a small delegation of professionals from Ireland to understand local online support service and other support services for youth Mental Health in Malta Participation in Conferences, Seminars, Workshops & other Events The Commissioner and senior members of the staff delivered presentations and participated in several conferences, seminars, workshops and events both locally and internationally.
These events are excellent opportunities for networking and disseminating the messages linked to the mandate of the Office.

Participation in Local Events Launch of “Hope in the Journey of Recovery” - a project by Arts Council Malta supported by Il-Premju tal-President għall-Kreattività focusing on teamwork and goal creation for patients at Mount Carmel Hospital through artistic expression.
National Sustainable Development Conference 2019 by the Ministry for the Environment, Sustainable Development and Climate Change, with the participation of the Commissioner in the panel of the workshop entitled Building a more resilient and inclusive labour market Homelessness The Hidden Scandal by President’s Foundation for the Wellbeing of Society Business Breakfast by the Malta Business Weekly in collaboration with the Malta Federation of professional Associations on the topic of “Sustainability Measures to Protect Employment” Violence in Our Society – Developing Evidence Based Practice Interventions Conference 2019 by the Commission on Gender-Based and Domestic Violence on quality improvement of interventions 38 Closing Conference of project entitled “Mental Health and Well-Being: Reaching Third Country Nationals at Risk” - a 2 year mental health community support programme for migrants by Foundation for shelter and Support to Migrants funded by the Malta Community Chest Fund Foundation (MCCF) Closing conference of Mental Health Project by Kunsill Nazzjonali taz-Zghazagh Strategic Development Forum for External Stakeholders by University if Malta Early School Leaving and Personal and Social Well-being: A Qualitative Study Soft Launch, at San Anton Palace, Attard, organised by the National Observatory for Living with Dignity, within the President of Malta’s Foundation of Social Wellbeing Conference ‘Ensuring social cohesion and wellbeing of people: Looking ahead to 2050’ by the Ministry for the Environment, Sustainable Development and Climate Change, with the participation of the Commissioner in the panel of the workshop entitled Building Healthy Communities ACAMH Conference on Neurodevelopmental Disorders Opening remarks in debate by CARE MALTA entitled ‘Mental Well-Being as we Age’ National Conference on the Wellbeing of Foreign Children in Malta presenting a research study by the Centre for Resilience and Socio-Emotional Health, University of Malta commissioned by the Commissioner for Children Opening
 remarks of the University of Malta Faculty of Health Sciences Conference Conference by the Embassy of the United States of America on Gender Based Violence, Mental Health and Migration – ‘Better Future’ One Year On: Seminar on Wellbeing at Work - Psychiology Day Conference ‘In My Words’ – a cultural evening by students and staff of the Department of Mental Health, Faculty of Health Sciences, University of Malta Meeting with Ms Sharon Cusens, Spring Productions International on various training initiatives on mental health and wellbeing Celebration of the 20th Anniversary of the Malta Association of Public Health Medicine ‘L-Irtokk’ by Benedittu productions – a reflective presentation on mental health and wellbeing by students of St Benedict College Conference by the Malta Foundation for the Wellbeing of Society to celebrate International Family Day 2019 39 Roundtable Conference on Maternal Health, organised by the Office of the President Emeritus Stakeholder Round Table meeting organised by the Faculty of Social Well-being Maltese Association of Psychiatry Conference 2019 on ‘Suicide Prevention and Self Harm Behaviours’, with a keynote presentation by the Commissioner on The Epidemiology of Suicide and Suicidality in Malta Celebration of the 50th Anniversary of the MCH Social & Culture Club Dr Maria Sciberras Memorial Lecture on recent developments in Addiction Medicine Celebration of the Feast of Our Lady of Mount Carmel, the Patron Saint of Mount Carmel Hospital Launch of the Admissions Policy and the Zero Tolerance to Violence Policy within Mental Health Services Launch of the Mental Health Strategy 2020 – 2030 by the Ministy for Health Address at the Launch of Mental Health Support and Care Course by CareMalta Group Consultation meeting with the Safeguarding Commission on the policy and procedures concerning the safeguarding of children and vulnerable adults within the Maltese Ecclesiastical Province Active participation in Parlament tan-Nanniet sessio Launch of the
 Malta Business Diability Forum PES / PL Event - Challenges and Opportunities for the Integration of Children in Migration Conference - Towards 100%: Advancing LGBTIQ equality in Malta and Globally by the SOGIGESC Unit within the Human Rights and Integration Directorate on the first year of implementation of the LGBTIQ Equality Strategy and Action Plan 2018-2022 Seminar on Reformative Justice by the Judicial Studies Committee with the participation of the Commissioner in the discussion on Mental Health and the Judiciary Launch of Youth Mental Health First Aid training courses for youth leaders organised by The Malta Foundation in ccollaboration with the National Youth Council Rock Concert to celebrate World Mental Health Day 2019 with the participation of MCH staff and residents from the Correction Service Agency undergoing rehabilitation programmes Launch event of the Malta Eye Study 40 Seminar on the Right to Disconnect by MEUCAC with the participation of the Commissioner in the discussion on mental health and wellbeing Consultation Seminar on the National Health Strategy 2020+ organised by the Ministry for Health and its external advisers Seminar - Involuntary Treatment in Mental Health co-organised by the Bioethics Research Programme of The Faculty of Medicine and Surgery of the University of Malta and the Bioethics Consultative Committee of the Office of the Deputy Prime Minister and Minister for Health to focus on the Additional Protocol to the Oviedo Convention, concerning the protection of human rights and dignity of persons with mental disorder with regard to involuntary treatment Gozo Mental Health Association Annual Conference on the theme of mental health and the workplace - “Is-Saħħa Mentali TIEGĦI fuq il-post tax-Xogħol” Richmond Foundation Annual Conference 2019 - Re-Member Without Suffering : Tackling Trauma – to raise public awareness about trauma and about Eye Movement Desensitisation and Reprocessing as a therapy to address the impact of Trauma and
 PTSD.
Mental Health Services OT Department Conference - #Talk: Mental health and Community Inclusion with keynote address by the Commissioner entitled Community Inclusion: the Social Determinants of Mental Wellbeing SMEs National Forum Malta 2019 – ‘Today’s Opportunities and Challenges in Employment for SMEs’ MAP-N Conference 2019 on the theme “Deinstitutionalization in the 21st Century” – the concluding panel discussion was chaired by Dr Miriam Camilleri on behalf of the Commissioner Public Lecture to the members of the Mental Health Association focusing on the new Mental Health Strategy Panel discussion on the movie SOLD organised by Soroptimist Malta, focusing on The Girl Child Trafficking and Mental Health Panel discussion on prostitution in Malta organised by Dar Hosea 2nd National Public Health Symposium organised by the Malta Association of Public Health Medicine Anti-Poverty Forum Conference on Il-Progress u l-Faqar 41 Participation in Overseas Conferences International conferences offer an opportunity to share experiences, views and strategies concerning persons with mental problems and to assist professionals within the Office to keep abreast with innovations and developments at EU and international level on subjects such as patient rights, public health and professional development.
During 2019 the Commissioner and other members of the staff participated in overseas conferences viz.
: 13th European Patients’ Rights Day, European Parliament, Brussels (9-10 April 2019) 5th Academy Meeting of the National Brain Councils – with a view to setting up a National Brain Council for Malta in the near future - Dubrovnik, Croatia (9-10 May 2019) Public Mental Health Conference in Jerusalem with the presentation of two papers on Building resilience in Adolescents and Youth and MHA 5 years – a reflection on the Mental Health Act (Malta) 2012 – EUPHA Public Mental Health Section and Israeli Association of Psychiatry (18-21 June 2019) Societal Impact of Pain (SIP) National Platforms meeting & 11th Congress of the European Pain Federation (EFIC) in Valencia (3-5 September 2019) Good Practice Services: Promoting Human Rights and Recovery in mental Health – International School Franca & Franco Basaglia – Trieste (22-26 September 2019) SIP Symposium, 2019 in Brussels (6-7 November 2019) European Public Health Conference 2019 in Marseille (19-23 November 2019) European Conference on Social Dialogue for the Future of Professionals at the European Parliament in Brussels (4 December 2019) Supporting Refugees' Mental Health – a Finnish Presidency discussing ways to support refugees’ mental health as well as integration – Helsinki (10-12 December 2019) Continuous Professional Development for Staff The Office is committed to the professional development of all staff and to their contribution to the professional development of others.
This is achieved by encouraging staff to participate in continuous professional development activities and by regularly involving staff in the academic and professional development of others.

This helps staff to improve their skills and expertise to implement the mandate of the Office and deliver a quality service.

42 Throughout the reporting period, several training initiatives were taken up by various staff members.
These included: Module on Strategic Management in Public Management Toolkit offered by the Institute of Public Administration Training Seminar Managing Challenging Behaviour organised by ASLP (Malta) Continuing Professional Development Programme of the Faculty of Public Health (UK) - two officers confirmed in good professional standing for CPD with the Faculty of Public Health, UK MAPHM CPD sessions Business Breakfast by Europe for Citizens – orientation on funding programmes available Suicide Prevention in Primary Care – CPD event organised by the Malta Association of Public Health Medicine and the Maltese Association of Psychiatry in collaboration with the Malta College of Family Doctors Training in the prevention of Sexual and Gender-Based Violence against minors -The definition of SGBV in the context of migration; Types of SGBV Harmful Traditional Practices; Legal aspects and the referral system; Working with a cultural mediator Social Determinants of Health awareness training session on mental health Training seminar organised by MEUSAC as part of the ESF-funded project ‘ENGAGE – enhancing stakeholder engagement in social dialogue’ Involvement in Academic and Professional Development of Others During the year under review, members of staff from the Office of the Commissioner were involved in academic and professional development of others as follows: CME updating sessions for staff at Mount Carmel Hospital Ethics in Mental Health seminar for Mental Health Nursing Students Co-ordination of the Organisation and Management module (PHL5127) of the MSc Public Health of the University of Malta.
The Office delivered this module with the revised curriculum whose content and assessment increased from 5 ECTS to 10 ECTS with effect from October 2018.

The Office provided oversight of the whole module, 60% of the entire academic content, examination coordination and publication of assessment results in February 2019.

All 5 trainees completed the module successfully.
43 Tutorial to Public Health Trainees on Mental Health and Well-Being – patient rights and advocacy Educational supervision of two second year foundation doctor (FY2) Two seminars on mental health rights for students following the MA in Bioethics course organised by the Faculty of Theology at the University of Malta (THL3168) Undergraduate MD 4th Year students on management and healthcare organisation challenges (MDS4017) Membership of the International Scientific Committee of the European Public Health Association.
Scoring of 45 single abstracts and 90 workshop abstracts submitted for EPH 2019 held in Marseille Provided input to several students of the University of Malta and MCAST as part of their projects, assignments, Masters and Ph.D. theses and other research Provided training supervision for one HST leading to the Exit assessment Delivery of several lectures on The Mental Health Act and mental health and wellbeing from various perspectives including basic and higher psychiatry specialist training, occupational therapists, support groups, students, NGOs, social welfare staff Three orientation sessions about the public health medicine component offered by the Office of the Commissioner for Mental Health CPD Course on Rights and Responsibilities in Mental Health Care (MNH4002) – delivery of 12 of the 14 sessions of the course was provided by the Office Lecture on the Mental Health Act and Minors addressed to the multidisciplinary teams working in child and adolescent mental health services Lecture on the Legal Aspects of Dementia in the Dementia Care Practice Module (LAS1102) Lecture on Mental Health First Aid aimed at pastoral workers – one of the training courses offered by the Vicariate for Parishes and the Clergy within the Archdiocese of Malta Lecture on Interdisciplinary Approaches to Mental Well-being (SWB5002) CPD Session on behalf of the English Language Training Council focusing on students with mental health issues attending English Training Schools 44 CHAPTER 2 Analysis of MHA Applications processed in 2019 15 July 2020 45 THE INVOLUNTARY CARE SYSTEM With the entry into force of the relevant sections of the Mental Health Act on 10th October 2014, this Office has been actively monitoring the process through which persons suffering from mental disorders have their rights restricted.
This involves the active follow-up of 13 of the 15 Schedules prescribed under the Act and through which the appropriate checks and balances of the restriction of rights and freedom for reasons of mental disorder are ascertained.

Since 2014, a total of 1857 persons have had at least one restriction of rights and these persons have been registered in the involuntary care system held at the Office of the CMH.
As can been seen from the table below the number of new registrations in the involuntary care system has stabilised at around 350 new cases per year.

New cases from 10th October 2014 to end 2014 New cases in 2015 New cases in 2016 New cases in 2017 New cases in 2018 New cases in 2019 TOTAL 40 410 379 358 332 338 1857 During the past 5 years, the Office utilised a number of Excel spreadsheets in parallel with the manual filing system in order to perform this monitoring function.
With the swelling of the numbers of new cases every year, the finalisation and commisioning of an electronic patient monitoring system is becoming an urgent priority.
In fact in the last six months of 2019, intensive work was undertaken with IMU-Health to provide this unit with the long-awaited temporary elctronic based solution that will ensure more accurate and detailed person identification and audited tracking of the daily processing of the Schedules through which the restriction of patient rights for mental health reasons is being carried out.

INVOLUNTARY CARE IN 2019 The Office received 1274 Mental Health Act Schedules for involuntary care in 2019.
There were 545 notifications (Schedules 2, 13) - the commonest being notifications of involuntary admission for observation (525).

8 notifications were invalid.

There were 729 applications which needed a decision from the Office.

Of these 718 were approved and 11 were refused or withdrawn.

497 were approvals of restriction of patient rights for treatment reasons (Schedules 3, 4, 5, 7) and 23 were approvals of restriction of communication (Schedule 1).
182 releases from treatment orders were granted (Schedules 6, 10).

15 persons were certified as lacking mental capacity (Schedule 11) with 1 person 46 subsequently released from certification as a person lacking mental capacity (Schedule 12).

No requests for shared GP Care in the Community (Schedule 8) or approvals for Irreversible Treatment (Schedule 14) under the Mental Health Act were made in 2019.
The detailed breakdown of this activity was as follows: Mental Health Act Schedule Definition Received Refused Approved Patients Schedule 1 - RFC (Restriction of Communication) 23 0 23 18 Schedule 2 - IAO (Involuntary Admission for 525 520 were valid 436 Observation) Schedule 3 - IATO (Involuntary Admission for 187 Treatment Order) Schedule 4 - EIATO (Extension of Involuntary 39 Admission for Treatment Order) Schedule 5 - CDO (Continuous Detention Order) 34 Schedule 6 - RTO (Release from Treatment Order) 121 Schedule 7 - CTO (Community Treatment Order) 245 Schedule 8 - GP Care in the Community Schedule 10 - RCTO (Release from Community Treatment Order) 0 62 Schedule 11 - CLMC (Certification of Lack of Mental 17 Capacity) Schedule 12 - RCLMC (Revocation of Certification 1 2 1 2 1 3 0 2 0 185 171 38 37 32 120 242 62 21 110 150 0 56 15 15 1 1 Not applicable of Lack of Mental Capacity) Schedule 13 - Admission of Minors Schedule 14 – IIT (Invasive or Irreversible Treatment) 20 0 17 were valid 0 0 16 0 When classified by type of MHA Schedules received, it transpired that the 1255 valid applications / notifications processed referred to a total of 1035 patients.
However, it must be remembered that the involuntary care process is dynamic, and the same person may require a number of different schedules throughout a single admission.

When pooled together, all the above activity was found to involve a total of 579 different persons.

Of these, 338 persons had their first encounter with the involuntary care system in 2019.

47 The table below summarises the total number of persons whose rights were restricted as on 31st December 2019.
This table suggests a prevalence of involuntary inpatient care of around 63 patients daily, with an average 114 persons per day receiving compulsory care in the community.
Mental Health Act Schedule Definition In Force Approved/Received Schedule 1 - RFC (Restriction of Communication) 2 23 approved Schedule 2 - IAO (Involuntary Admission for Observation) 13 520 valid received Schedule 3 - IATO (Involuntary Admission for Treatment 34 185 approved Order) Schedule 4 - EIATO (Extension of Involuntary Admission 5 38 approved for Treatment Order) Schedule 5 - CDO (Continuous Detention Order) 11 32 approved Schedule 6 - RTO (Release from Treatment Order) not applicable 120 approved Schedule 7 - CTO (Community Treatment Order) 114 242 approved Schedule 8 - GP Care in the Community not applicable 0 received Schedule 10 - RCTO (Release from Community not applicable 62 approved Treatment Order) Schedule 11 - CLMC (Certification of Lack of Mental 6 15 approved Capacity) Schedule 12 - RCLMC (Revocation of Certification of Lack 1 1 approved of Mental Capacity) Schedule 13 - Admission of Minors not applicable 17 valid received Schedule 14 – IIT (Invasive or Irreversible Treatment) 0 0 approved Compared to the trend in previous years, the shift towards compulsory care in the community seems to have stabilised with a further significant year on year increase in the total number of persons benefitting from compulsory care in the community: Date Inpatient Treatment Orders Community Treatment Orders TOTAL End 2014 (est.)
68 (97%) End 2015 50 (67%) End 2016 70 (58%) 2 (3%) 25 (33%) 50 (42%) 70 75 120 48 End 2017 68 (52%) End 2018 56 (36%) End 2019 63 (36%) 64 (48%) 100 (64%) 114 (64%) 132 156 177 The final outcomes for the 520 valid involuntary admissions for observation were: CLOSED EPISODES (90.0%) Involuntary hospital admission lasting 10 days or less 308 59.2% Involuntary hospital admission lasting up to 10 weeks or less 96 18.5% Involuntary hospital admission lasting up to 17 weeks or less Involuntary detention in hospital lasting more than 17 weeks Involuntary care in the community INCOMPLETE EPISODES (10.0%) Involuntary Admission Order on 31st December 2019 Involuntary Treatment Order on 31st December 2019 Extended Treatment Order on 31st December 2019 9 7 1.7% 1.4% 48 9.2% 13 34 5 2.5% 6.5% 1.0% 520 100% 59.2% of involuntary admissions were either discharged or continued to receive inpatient care on a voluntary basis whilst 21.5% required further inpatient treatment against their will and 9.2% were placed on a Community Treatment Order.
10% of cases had valid admission or treatment orders as at 31st December 2019 and therefore the final outcome of their applications could not be determined.

On 31st December 2019 there were 125 patients on long term treatment orders: 11 (8.8%) were hospital in-patients and 114 (91.2%) were living in the community on community treatment orders, a further encouraging 5.7% shift towards long term care in the community in 12 months.
58.4% of these cases were already on long term treatment orders at the end of 2018, 8 persons in hospital detention and 65 persons followed up in the community.

The net new burden of long-term care for 2019 was 20 cases (14 more cases being followed up in the community and 6 person less being cared for as an inpatient) which amounts to 16% of the total long-term care burden at end 2019.
The patient movements throughout 2019 were as follows: 49 Year Continuous Detention Order Community Treatment Order 31 December 2018 17 (14.5%) 100 (85.5%) Discharged Died Transfer to CTO Transfer to CDO New Cases in 2019 -8 -1 -1 0 +4 -35 0 +1 0 +48 31 December 2019 11 (8.8%) 114 (91.2%) ACUTE INVOLUNTARY CARE [MHA SCHEDULES 2/13] This section of the report deals with notifications of involuntary admission for observation.
These notifications are MHA Schedule 2 for all admissions which is accompanied by an MHA Schedule 13 when the acute admission concerns a minor.

Our Office received and processed 520 valid notifications of acute involuntary admission within licensed mental health institutions.

These were in respect of 436 different persons - 419 (96.1%) were adults and 17 (3.9%) were minors.

AGE AND GENDER - The gender ratio was 281 males (64.4%) and 155 (35.6%) females.
The gender distribution by age was as indicated below: Age Total 0-11 years 12-17 years 18-29 years 30-44 years 45-59 years >60 years 0 17 137 138 72 72 % 0 3.9% 31.4% 31.7% 16.5% 16.5% Male 0 13 94 90 42 42 % 0 4.6% 33.5% 32.0% 15.0% 15.0% Female 0 4 43 48 30 30 % 0 2.6% 27.7% 31.0% 19.4% 19.4% TOTAL 436 100% 281 100% 155 100% (chi-square = 4.4953; p-value = 0.343105; NOT significant at p < 0.05 / p < 0.1) 67% of admissions involved persons aged less than 45 years – 35.3% were adolescents and youth aged less than 30 years and 31.7% were adults aged 30-45 years, confirming the high burden of mental disorder in younger segments of society.
About one-sixth of admissions were persons aged 50 60 years or more.

There are small differences in age distribution by gender, but these are not statistically significant.

Age Total / 1000 Males /1000 Females / 1000 M : F 12-17 yrs.

0.674 (17/25210) 1.001 (13/12984) 0.327 (4/12226) 3.1 : 1 18-29 yrs.

1.608 (137/85196) 2.083 (94/45131) 1.073 (43/40065) 1.9 : 1 30-44 yrs.

1.185 (138/116465) 1.448 (90/62142) 0.884 (48/54323) 1.6 : 1 45-59 yrs.
0.810 (72/88867) 0.918 (42/45778) 0.696 (30/43089) 1.3 : 1 >60 yrs.

0.586 (72/122835) 0.732 (42/57393) 0.458 (30/65442) 1.6 : 1 >12 yrs.

0.994 (436/438573) 1.253 (280/223428) 0.725 (156/215145) 1.7 : 1 (NSO – Total Population by age at end 2018 as denominators) When analysing admission data by total population, the acute involuntary admission rate for the Maltese islands in 2019 was 1 per 1000 total population.
The analysis by age reveals a very strong gender bias at all ages with male admissions being more frequent than female admissions.

The data for youths under 30 years and adults aged between 30 and 44 years are being analysed separately below to identify in greater detail any possible reasons for such heavy gender bias and obtain indicative areas where further action is needed.

As can be seen by this detailed analysis, there is the substantial contribution of substance abuse to this gender bias.
NATIONALITY - 25.7% of all acute involuntary admissions were foreigners – 9.6% were non-Maltese European Union / European Economic Area (EU/EEA) citizens, 13.3% were persons from medium and less developed (MD / LD) countries and 2.8% were persons from very highly and highly (VHD / HD) developed countries.
Nationality Total % Male % Female % Maltese / Gozitan citizens 324 74.3% 205 72.9% 119 76.8% Non-Maltese EU/EEA citizens MD / LD Country Citizens VHD / HD Country Citizens 42 58 12 9.6% 13.3% 2.8% 21 51 4 7.5% 21 13.5% 18.2% 1.4% 7 8 4.5% 5.2% 436 100% 281 100.% 155 100% (Chi-square = 23.0522; P-value = 0.000039, significant at p < .01) Concerning the gender distribution by broad nationality categories of these involuntary admissions, the table above is highly statistically significant mainly due to the preponderance of males coming 51 from medium and less developed countries and the preponderance of females among non-Maltese EU/EEA citizens and females coming from very highly or highly developed countries.
Almost 44% of these foreigners had a Maltese ID Card with an “A” suffix, the rest were either temporary visitors or rejected asylum seekers.

Practically all foreigners coming from EU/EAA and very highly and highly developed countries provided an address on admission.
Among persons coming from medium and less developed countries, 40% provided an address, 22% were from initial reception or detention centres, 17% were from open centres, 16% had no fixed abode or said they were homeless and 5% were Correctional Facility (CCF) inmates.

GEOGRAPHICAL CONSIDERATIONS - Persons coming from other countries and who develop an acute mental health episode are often socially isolated within their own community.
Poor support and lack of networks cannot ensure safe return to the community.

We continue to emphasize the need for a more profound understanding of the cultural significance of mental disorder in different cultures and within different communities even among foreigners coming from the same country.
This situation also leads to justifiably lower thresholds for admission and higher thresholds for discharge, with clinical teams having to judge available support that is sometimes at best chaotic and in many cases non-existent.

ALL PERSONS No.
Rates/1000population Risk (MT=1) Maltese / Gozitan citizens 324 0.790 (324/410292) * Southern Harbour 63 0.817 (63/77113) * Northern Harbour 88 0.739 (88/119167) * South Eastern 52 0.827 (52/62920) * Western 33 0.717 (33/58305) * Northern 38 0.610 (38/62286) * Gozo/Comino 15 0.492 (15/30501) * Homeless 8 Not possible 1.0 1.0 0.9 1.1 0.9 0.8 0.6 Residential Care / Facility (27) 2.250 (27/12000) ** 2.9 Mental Health Elderly Intellectual Disability Adolescent/Youth facilities 7 8 5 2 52 Corradino Correctional Facility 5 Non-Maltese EU/EAA Citizens MD / LD Country Citizens 42 58 0.911 (42/46075) * 2.949 (58/19669) * 1.2 3.7 West Africa 25 East Africa 15 (includes 1 from CCF) North Africa 11 (includes 1 from CCF) Far East & Asia Other 4 3 VHD / HD Country Citizens 12 0.685 (12/17523) * 0.9 South America Balkans & East Europe Far East & Asia 3 7 2 *NSO data for end-2018 used as denominator; **Extrapolation from 2011 Census used as denominator For Maltese citizens, the above table classifies admissions by the last known address with 289 (89.2%) admissions from a private residence address, 27 (8.3%) admissions from various residential facilities and 8 (2.5%) admissions stating they had no fixed abode or were homeless.
This relative risk analysis by geographical address of residence for the native population is as accurate as the declared address on the application.

This analysis by geographical distribution shows marginal relative risk differences within the native population, with the exception of Gozo and the Northern Region which demonstrate lower overall risk levels.
The relative risk of acute involuntary admission was once again in 2019 much higher (RR=2.9) for Maltese citizens residents in institutions and the highest (RR=3.7) for foreigners coming medium and low developed countries.

The relative risk for acute involuntary admission for citizens of EU/EAA countries and citizens of very highly and highly developed countries was very close to the relative risk for the native population.
This data once again highlights the inherent risks of developing an acute psychiatric episode within a residential or institutional setting and the need to focus on the mental health challenges of foreigners coming from medium and less developed countries.

Relative risk due to geographical characteristics is further analysed by gender in the tables below: MALES No.
Rates/1000 population Risk (MT=1) Maltese / Gozitan citizens 205 1.006 (205/203703) * 1.0 53 Southern Harbour 42 1.099 (42/38230) * Northern Harbour 59 1.001 (59/58971) * South Eastern 34 1.079 (34/31504) * Western 17 0.587 (17/28987) * Northern 24 0.779 (24/30798) * 1.1 1.0 1.1 0.6 0.8 Gozo/Comino 10 0.657 (10/15213) * 0.65 Homeless 4 Not possible Residential Care / Facility 15 3.125 (15/4800) ** Non-Maltese EU/EEA Citizens MD / LD Country Citizens VHD / HD Country Citizens 21 51 4 0.793 (21/26492) * 4.397 (51/11598) * 0.398 (4/10043) * 3.1 0.8 4.4 0.4 *NSO data for 2018 used as denominator; **Extrapolation from 2011 Census used as denominator FEMALES No.
Rates/1000 population Risk (MT=1) Maltese / Gozitan citizens 119 0.576 (119/206589) * Southern Harbour 21 0.540 (21/38883) * Northern Harbour 29 0.482 (29/60196) * South Eastern 18 0.572 (18/31416) * Western 16 0.546 (16/29318) * Northern 14 0.445 (14/31488) * Gozo/Comino 5 0.327 (5/15288) * Homeless 4 Not possible Residential Care / Facility 12 1.667 (12/7200) ** Non-Maltese EU/EEA Citizens 21 1.072 (21/19583) * MD / LD Country Citizens VHD / HD Country Citizens 7 8 0.867 (7/8071) * 1.070 (8/7480) * 1.0 0.9 0.8 1.0 1.0 0.8 0.6 2.9 1.9 1.5 1.9 *NSO data for 2018 used as denominator; **Extrapolation from 2011 Census used as denominator 54 There are no gender differences in relative risk for acute admission for Maltese / Gozitan citizens across all geographical areas.
As expected however, relative risk is much higher for Maltese persons in residential care with a 3-fold higher risk for both males and females when compared with Maltese citizens living in the community.

There was a ratio of 6 males to 1 female for acute involuntary admissions from the Corradino Correctional Facility, whilst admissions from all other residential settings showed a gender balance.
Males coming from medium and least developed countries have a 3-fold risk (RR=4.4 for males and RR=1.5 for females).

The Relative Risk for all persons coming from very highly and highly developed countries and for non-Maltese EU and EEA citizens was equal to that of the local population.
The analysis for gender differences reveals however that females coming from non-Maltese EU and EEA countries also have a 2-fold risk compared to males whilst females from very highly and highly developed countries have an almost 5-fold risk compared to males.

This analysis brings to focus the largest risk groups by gender: CCF inmates and persons coming from for males and EU or EAA citizens and persons coming from very highly and highly developed countries for females.
The highest risk group by far is male CCF inmates from medium and least developed countries (RR=13.75).

DISEASE BURDEN – Disease burden analysis is based on the primary diagnosis declared on applications for involuntary care by specialists in psychiatry who in accordance with the requirements of the Mental Health Act are obliged to examine and confirm the need for involuntary care within 24 hours of admission for observation.

Disease Category No.
% Per 1000 population Neuro-developmental disorders 23 5.3% 0.052 Schizophrenia / psychotic disorders 115 26.4% 0.262 Mood disorders 106 24.3% 0.242 Anxiety, obsessive and stress-related disorders 45 10.3% 0.103 Substance and addictive disorders 105 24.1% 0.239 Impulse-control and disturbed behaviour disorders Neurocognitive and organic mental disorders TOTAL 16 26 3.7% 0.037 6.0% 0.059 436 100.% 0.994 Schizophrenia, addictive disorders and mood disorders represent close to 75% of the total acute disease burden.
In 12 cases where the primary diagnosis was not addictive disorders, specialists 55 nonetheless reported the concurrent abuse of alcohol and/or psychoactive substances, pushing up the addictive disorder burden by a further 2.8%.
Age distribution by gender for the different disease categories was as follows: Disease Category Age 12 to 17 Gender years 18 to 30 to 45 to 29 44 59 years years years 60 years or more Total Neuro- Developmental Schizophrenia Mood Anxiety / OCD / Stress Substance Abuse Impulse / Behaviour Neurocognitive / Organic Total Admission rates by gender for the different disease categories were as follows: Disease Category Neuro-developmental disorders Schizophrenia / psychotic disorders Mood disorders Anxiety / obsessive / stress disorders Male Female Gender Per 1000 Per 1000 population population 0.058 0.313 0.255 0.152 0.047 0.209 0.228 0.051 Ratio M : F 1.2:1 1.5:1 1.1:1 3.0:1 56 Substance and addictive disorders Impulse-control / behaviour disorders Neurocognitive / organic disorders ALL CAUSES 0.376 0.031 0.067 1.253 0.098 0.042 0.051 0.725 3.8:1 1:1.4 1.3:1 1.7:1 Whilst mood disorders were almost equally distributed among males and females, there are notable differences in the distribution by gender for all other disease categories.
It is important to note that admissions for substance and addictive disorders were 3.8 times more common among males than females.

Anxiety-related disorders were thrice more common among males compared to females.

All- cause morbidity was 1.7 times more common among males.

RESPONSIBLE SPECIALISTS - The acute disease burden was distributed among the various responsible specialist firms as follows: Specialisation Acute Psychiatry (3 consultants) General Adult incl.
Forensic (5 consultants) Rehabilitation (2 consultants) Addiction (2 consultants) Child / Adolescent / Youth (2 consultants) Learning Disability (1 consultant) No.

252 59 54 43 17 11 % 57.8% 13.5% 12.4% 9.9% 3.9% 2.5% TOTAL 436 100% 58% of acute admissions are being followed by the newly established acute psychiatric specialists.

This is positive news in view of the future move of acute care away from the institutional setting.
The distribution of disease burden by specialisation confirms the validity of upholding and supporting an intensive acute service, reducing lengths of stay, avoiding institutionalisation and promoting further subspecialisation.
57 Disease Category L A T O T e t u c A Neuro-developmental disorders 23 6 Schizophrenia / psychotic disorders 115 76 Mood disorders 106 64 t l u d a l a r e n e G 2 16 21 Anxiety / obsessive / stress disorders 45 36 3 n o i t a t i l i b a h e R 2 19 16 2 n o i t c d d A i 0 2 3 1 Substance and addictive disorders 105 45 11 12 35 Impulse-control / behaviour disorders Neurocognitive / organic disorders 16 26 6 19 Disease Category / .
l o d A / h C h t u o Y / .

l o d A / h C 5 2 0 3 2 5 0 .

i b a s D g n n r a e L i .
i b a s D g n n r a e L i 8 0 2 0 0 1 0 Neuro-developmental disorders 26% 9% 9% 0 22% 35% Schizophrenia / psychotic disorders 66% 14% 17% 2% 2% 0 Mood disorders 60% 20% 15% 3% 0 2% Anxiety / obsessive / stress disorders 80% 7% 4% 2% 7% Substance and addictive disorders 43% 11% 11% 33% 2% 0 0 Impulse-control / behaviour disorders 38% 6% 13% 6% 32% 6% Neurocognitive / organic disorders 73% 19% 4% 4% 0 0 RE-ADMISSIONS - Re-admissions provide insight into the quality of care particularly concerning the risk assessment prior to discharge by caring teams.
In this analysis re-admissions were defined as persons re-admitted in acute involuntary care within 3 months of a previous acute involuntary 58 admission.

This would not include cases of involuntary care with a previous voluntary admission or involuntary admissions that are followed by a voluntary admission.
Re-admissions for 2019 were sub- divided as follows: Type 1 Admission Persons Admissions 369 persons 369 admissions 1 Admission + 1 Re-admission* 56 persons 112 admissions 1 Admission + 2 Re-admissions* 6 persons 18 admissions 1 Admission + >2 Re-admissions* 5 persons 21 admissions Total 436 persons 520 admissions *within less than 3 months of previous admission date This data represents a re-admission risk of 15% within 3 months from the previous date of admission.
49.2% of re-admissions were under the care of acute psychiatry consultants.

The gender and age distribution for these re-admissions were as follows: Age Total % Male % Female % <18 years 18-29 years 30-44 years 45-59 years >60 years TOTAL (Chi-square = 1.7195.

P-value = 0.632607.
P-value = 0.632607.

The result is not significant at p < .05) Of the 67 persons (65 adults, 2 minors) with at least one re-admission, 45 (67.2%) were males, 22 (32.8%) were females.

49 were Maltese citizens (47 adults, 2 minors), 7 were non-Maltese EU adult citizens and 11 were adults from countries outside the EU.

Adult males aged 18-44 years and adult females aged 45-59 years had a slightly higher risk of re-admission, though the differences are not statistically significant.
Disease Category by primary diagnosis Neuro-developmental disorders Percentage 6.0% 59 Schizophrenia / psychotic disorders Mood disorders Anxiety, obsessive and stress-related disorders Substance and addictive disorders Impulse-control and disturbed behaviour disorders Neurocognitive and organic mental disorders 23.9% 23.9% 6.0% 35.8% 4.5% 0 36% of re-admissions had a primary diagnosis of substance and addictive disorders 24% were suffering from schizophrenia / psychotic disorders and another 24% had mood disorders.
These rates roughly reflect reasons for acute admission, except for addictive disorders (+10%), anxiety and related disorders (-4%) and organic brain conditions (-6%) SUBSTANCE AND ADDICTIVE DISORDER ANALYSIS - The 117 acute involuntary admissions with either a primary diagnosis of drug abuse (n=83) or alcohol abuse (n=22) or those for whom alcohol/drug abuse was indicated alongside other diagnostic groups (n=12) were analysed to identify possible trends and risk categories, compared with prevailing total for all diagnostic groups was as follows: Male Female 12-17 years 18-29 years 30-44 years 45-59 years >60 years Non-Maltese EU/EEA citizens MD / LD Country Citizens VHD / HD Country Citizens Acute psychiatry specialists Addiction specialists Suicide attempt / risk and DSH All cases % Addictive Disorder % 64.4% 35.6% 3.9% 31.4% 31.7% 16.5% 16.5% 9.6% 13.3% 2.8% 57.8% 9.9% 27.3% 77.8% 22.2% 0.9% 29.9% 50.4% 13.7% 5.1% 7.7% 10.3% 1.7% 43.6% 31.6% 23.9% 60 Acute admissions for substance and addictive disorders are confirmed as being more common among males (77.8%).
Those aged 18-44 years constitute 80.3% of acute psychiatric admissions linked directly or indirectly to substance abuse.

Maltese citizens are more frequently represented (+6%) with 8 Maltese citizens with addictive disorders (4 males, 4 females) declaring that they are homeless.
ACUTE MENTAL HEALTH IN YOUTH ANALYSIS - The situation prevailing in 2019 concerning 154 acute involuntary admissions young people aged less than 30 years presents an important perspective with regards to priorities that apply to this important sector within society.

35.3% of acute involuntary admissions were young people.
Gender distribution All cases % Young People % Male Female 64.4% 35.6% 69.5% 30.5% Geographical distribution All cases % Young People % Maltese / Gozitan citizens Non-Maltese EU/EEA citizens MD / LD Country Citizens VHD / HD Country Citizens 74.3% 9.6% 13.3% 2.8% 64.9% 10.4% 20.8% 3.9% Maltese / Gozitan citizens All cases % Young People % Southern Harbour Northern Harbour South Eastern Western Northern Gozo/Comino Residential Care / Facility Homeless Disease Category Neuro-developmental disorders Schizophrenia / psychotic disorders Mood disorders Anxiety / stress-related disorders Substance / addictive disorders 19.4% 27.2% 16.1% 10.2% 11.7% 4.6% 8.3% 2.5% 16.0% 33.0% 19.0% 8.0% 11.0% 6.0% 4.0% 3.0% All cases % Young people % 5.3% 26.4% 24.3% 10.3% 24.1% 7.8% 25.3% 22.7% 16.9% 18.8% 61 Impulse-control / behaviour disorders Neurocognitive / organic disorders 3.7% 6.0% 8.5% 0% Males are more frequently represented with 69.5% of admissions compared to 30.5% of female admissions.
Persons coming from medium and less developed countries were 1.5 times more frequently represented with regards to geographical distribution with a correspondent substantial decrease (-9.4%) among Maltese citizens.

The shifts by area of residence among Maltese citizens are minimal compared to the distribution of all cases, with fluctutations ranging between +5% and - 3%.

Important differences can be seen for the declared primary diagnosis among acutely ill young people.
As expected for this age group, neuro-developmental disorders and impulse-control and disturbed behaviour disorders are more heavily represented.

Mood disorders and schizophrenia are equally represented.

There is an increased incidence of anxiety disorders (+6.6%) and a decreased incidence of admissions for addictive disorders (-5.3%).

Organic mental disorders are absent.


SUICIDE – The epidemiological analysis of suicidal behaviour introduced in the 2018 Annual Report was received with interest by clinicians, policy makers, the media and other stakeholders.
The analysis for 2019 shows that there were 119 acute involuntary admission notifications in which the referring doctor and / or the specialist in psychiatry confirming involuntary admission mentioned either suicide or overdose or deliberate self-harm or suicide intent alongside the disease category indicated as the primary diagnosis.

This represents around 27.3% of all acute involuntary admissions.
This should not be considered as a suicide incidence statistic; it merely reflects the number of times that suicide was mentioned in admission documentation notified to this Office.

The recorded events can be classified as follows: Event described in IAO Suicide attempt – overdose Suicide attempt - hanging Suicide attempt - jumping Suicide attempt – other methods / undisclosed Deliberate self-harm Suicide ideation / intent Total No.
25 15 11 12 13 43 % 21% 13% 9% 10% 11% 36% 119 100% Males and persons aged between 18-29 years are more commonly represented when compared to overall data for all involuntary admissions.
62 All cases % Suicide % Male Female 12-17 years 18-29 years 30-44 years 45-59 years >60 years Maltese / Gozitan citizens Non-Maltese EU/EEA citizens MD / LD Country Citizens VHD / HD Country Citizens 64.4% 35.6% 3.9% 31.4% 31.7% 16.5% 16.5% 74.3% 9.6% 13.3% 2.8% 68.1% 31.9% 5.0% 37.0% 29.4% 17.7% 10.9% 68.9% 12.6% 15.1% 3.4% All foreigners are more frequently represented with more than 31% of cases of documented suicide attempts or expressed intent being citizens of EU/EAA countries (+3%), medium/least developed countries (+1.8%) and very highly/highly developed countries (+0.6%).
As expected, the highest burden of care is offered by the acute psychiatrists: Specialisation All cases % Suicide % Acute Psychiatry (3 consultants) General Adult incl.
Forensic (5 consultants) Rehabilitation (2 consultants) Addiction (2 consultants) Child / Adolescent / Youth (2 consultants) Learning Disability (1 consultant) TOTAL 57.8% 13.5% 12.4% 9.9% 3.9% 2.5% 100% 67.2% 8.4% 11.8% 6.7% 5.1% 0.8% 100% The various disease categories indicated as the primary diagnosis along with declared suicide attempts or expressed intent were noted to be distributed as follows: Disease Category All cases % Suicide % Neuro-developmental disorders Schizophrenia / psychotic disorders 5.3% 26.4% 5.0% 9.3% 63 Mood disorders Anxiety / stress-related disorders Substance / addictive disorders Impulse-control / behaviour disorders Neurocognitive / organic disorders 24.3% 10.3% 24.1% 3.7% 6.0% 29.4% 28.6% 15.1% 8.4% 4.2% This data indicates that mood disorders are the most commonly represented disease category within the group of persons with documented suicide attempts or expressed intent.
Anxiety related disorders whilst being the second most common disease category would seem to carry an even higher risk and at almost three times the frequency when compared to all cases.

More in-depth analysis is certainly needed but data of this nature is certainly indicative of the possible risk scenarios that may be prevalent in the local context.

INPATIENT INVOLUNTARY TREATMENT ORDERS [MHA SCHEDULES 3/4/5] This section of the report deals with approvals of involuntary inpatient treatment.
MHA Schedules 3/4/5 are received processed and approved in accordance with the provisions of the MHA, including independent psychiatrist advice prior to approval for MHA Schedules 3 and 5 and a thorough discussion with the responsible specialist when MHA Schedule 4 is submitted for approval.

Our Office received and processed 255 valid applications.

Since the inpatient involuntary treatment process is dynamic, the same person may require a number of different schedules during a single admission.
When pooled together, all the above applications were found to involve a total of 187 different persons of whom, 182 (97.3%) were adults and 5 (2.7%) were minors aged less than 18 years.

AGE AND GENDER - The gender ratio was 118 males (63.1%) and 69 (36.9%) females.
The gender distribution by age was as indicated below: Age Total 0-11 years 12-17 years 18-29 years 30-44 years 45-59 years >60 years TOTAL % 0 2.7% 32.1% 33.2% 16.0% 16.0% Male 0 4 43 36 15 20 % 0 3.4% 36.4% 30.5% 12.7% 17.0% 0 5 60 62 30 30 187 100% 118 100% Female 0 1 17 26 15 10 69 % 0 1.5% 24.6% 37.7% 21.7% 14.5% 100% (chi-square = 5.5547; p-value = 0.234961; NOT significant at p < 0.05 / p < 0.1) 64 68% of admissions involved persons aged less than 45 years – 34.8% were adolescents and youth aged less than 30 years and 33.2% were adults aged 30-45 years, confirming once again the high burden of mental disorder in younger segments of society, and its impact on inpatient treatment facilities.
About one-sixth of admissions were persons aged 60 years or more.

There are minor differences in age distribution by gender, but these are not statistically significant.

NATIONALITY – 20.3% of patients receiving inpatient involuntary treatment were foreigners – 7.5% were non-Maltese European Union / European Economic Area (EU/EEA) citizens and 12.3% were persons from medium and less developed (MD / LD) countries.
Nationality Total % Male % Female % Maltese / Gozitan citizens 149 79.7% 89 75.4% 60 87.0% Non-Maltese EU/EEA citizens MD / LD Country Citizens VHD / HD Country Citizens 14 23 1 7.5% 7 5.9% 12.3% 21 17.8% 0.5% 1 0.9% 7 2 0 10.1% 2.9% 0% 187 100% 118 100.% 69 100% (Chi-square = 9.5916; P-value = 0.008264, significant at p < .01) Concerning the gender distribution by broad nationality categories of these patients, the table above is highly statistically significant mainly due to the preponderance of males coming from medium and less developed countries.
DISEASE BURDEN – Disease burden analysis is based on the diagnosis declared on applications for inpatient involuntary treatment by the responsible psychiatrist.

Almost all these applications are reviewed by an independent specialist in psychiatry appointed by the Office to confirm that the legal and clinical requirements of the Mental Health Act for involuntary treatment as inpatients are in place.
It is only after evaluating such independent advice that the Office approves involuntary inpatient treatment.

Disease Category Neuro-developmental disorders Schizophrenia / psychotic disorders Mood disorders Anxiety, obsessive and stress-related disorders Substance and addictive disorders No.
8 65 40 9 55 % 4.3% 34.8% 21.4% 4.8% 29.4% 65 Impulse-control and disturbed behaviour disorders Neurocognitive and organic mental disorders TOTAL 4 6 187 2.1% 3.2% 100% Schizophrenia, addictive disorders and mood disorders represent close to 85.6% of the total burden of involuntary inpatient treatment.

acute disease burden.


In a further 6 cases where the primary diagnosis was not addictive disorders, responsible specialists nonetheless reported the concurrent abuse of psychoactive substances, pushing up the addictive disorder burden by a further 3.2%.

RESPONSIBLE SPECIALISTS - The distribution of the inpatient involuntary treatment burden among the various responsible specialist firms was as follows: Specialisation Acute Psychiatry (3 consultants) General Adult incl.
Forensic (5 consultants) Rehabilitation (2 consultants) Addiction (2 consultants) Child / Adolescent / Youth (2 consultants) Learning Disability (1 consultant) TOTAL No.

89 23 31 33 6 5 187 % 47.6% 12.3% 16.6% 17.6% 3.2% 2.7% 100% COMMUNITY TREATMENT ORDERS [MHA SCHEDULES 7/8] This section of the report deals with approvals of involuntary community treatment.
The Community Treatment Order (CTO) was intended to replace the practice of retaining cases of inpatient involuntary care on the books of the inpatient care facility whilst placing such patients “on leave” from the institution.

It was introduced amidst widespread scepticism due to failure of similar arrangements in foreign metal health systems.
MHA Schedules 7/8 are received processed and approved in accordance with the provisions of the MHA, particularly concerning the identification of the key healthcare professional tasked with the monitoring of the patient on behalf of the caring team.

It is positive to note that the community outreach service provided by the public Mental Health Service is backbone of the regular monitoring of patients.

Our Office received and processed 242 valid applications for community involuntary treatment.
No Schedule 8 applications for shared care with 66 primary care physicians or family doctors were received.

It is most unfortunate that the possibility of joint care is not being utilised.

Most beneficiaries from CTOs are persons suffering from chronic mental disorders who live in the community.

Since a CTO is valid for six months, most patients will have two different CTO applications in one calendar year.
All the above applications were found to involve a total of 150 different persons of whom, of whom 148 (98.7%) were adults and 2 were minors aged less than 18 years.

AGE AND GENDER - The gender ratio was 99 males (66%) and 51 (34%) females.
The gender distribution by age was as indicated below: Age Total 0-11 years 12-17 years 18-29 years 30-44 years 45-59 years >60 years 0 2 34 50 40 24 % 0 1.3% 22.7% 33.3% 26.7% 16.0% TOTAL 150 100% Male 0 2 27 35 21 14 99 % 0 2.0% 27.3% 35.4% 21.2% 14.1% 100% Female 0 0 7 15 19 10 51 % 0 0 13.7% 29.4% 37.3% 19.6% 100% (chi-square = 6.9007; p-value = 0.075131; NOT significant at p < 0.05, SIGNIFICANT at p < 0.1) 60% of persons on CTO were aged 30-59 years, confirming the high burden of chronic mental disorder among adults within the working population segments of society, and its impact on ability to engage in employment, disposable income and issues around poverty.
About one-sixth were persons aged 60 years or more.

Differences in age distribution by gender were statistically significant at p<0.1.

NATIONALITY & GEOGRAPHICAL DISTRIBUTION – 94.6% of patients on CTOs were Maltese / Gozitan citizens.

A very small number of foreign patients benefitted from this modality of treatment.
Nationality Total % Male % Female % Maltese / Gozitan citizens 142 94.6% 95 96.0% 48 94.1% Non-Maltese EU/EEA citizens MD / LD Country Citizens VHD / HD Country Citizens 1 6 1 0.7% 4.0% 0.7% 1 3 0 1.0% 3.0% 0% 0 3 0 0% 5.9% 0% 150 100% 99 100.% 51 100% 67 Concerning the geographical distribution of the Maltese / Gozitan citizens, the table below shows that the burden of patients on CTOs is uniformly spread across all regions in Malta but the rate for Gozo is halved.
Location N % Rates/1000 population Maltese / Gozitan citizens 142 100% 0.346 (142/410292) * Southern Harbour Northern Harbour South Eastern Western Northern Gozo/Comino Homeless 31 40 19 23 23 5 1 21.8% 0.402 (31/77113) * 28.2% 0.336 (40/119167) * 13.4% 0.302 (19/62920) * 16.2% 0.395 (23/58305) * 16.2% 0.369 (23/62286) * 3.5% 0.164 (5/30501) * 0.7% Not possible *NSO data for end-2018 used as denominator DISEASE BURDEN – Disease burden analysis is based on the diagnosis declared on applications for community treatment by the responsible psychiatrist.
Almost 70% of these applications included an identified responsible carer.

No CTO applications are processed unless a key healthcare professional and a care plan are submitted.

Disease Category Neuro-developmental disorders Schizophrenia / psychotic disorders Mood disorders Anxiety, obsessive and stress-related disorders Substance and addictive disorders Impulse-control and disturbed behaviour disorders Neurocognitive and organic mental disorders TOTAL No.
4 77 25 1 37 4 2 150 % 2.7% 51.2% 16.7% 0.7% 24.7% 2.7% 1.3% 100% 68 Schizophrenia, addictive disorders and mood disorders represent close to 92.6% of the total burden of involuntary inpatient treatment.

acute disease burden.

This data would confirm that CTOs are a useful tool in the control of chronic mental disorder, avoiding unnecessary institutionalisation and allowing for short inpatient admissions as necessary.
RESPONSIBLE SPECIALISTS - The distribution of the community treatment burden among the various responsible specialist firms was as follows: Specialisation Acute Psychiatry (3 consultants) General Adult incl.

Forensic (5 consultants) Community-based (4 consultants) Addiction (2 consultants) Child / Adolescent / Youth (2 consultants) Learning Disability (1 consultant) TOTAL No.
12 31 68 30 2 7 150 % 8.0% 20.7% 45.3% 20.0% 1.3% 4.7% 100% COMPARING PERSONS IN INVOLUNTARY CARE (1) ACUTE (2) INPATIENT (3) COMMUNITY The overall observation when comparing acute care; inpatient involuntary treatment; and community treatment orders is that there are very minimal differences in the demographic and clinical characteristics of the persons receiving such care: larger prevalence among males (M:F=2:1); two- thirds of inpatients were persons aged less than 45 years and 20-25% were foreigners; more than 90% of patients on community treatment order were Maltese citizens.
The burden of substance abuse at around 25% of all cases, is uniform across all three scenarios.

The comparative data confirms the increasing burden of schizophrenia in community-based services whilst mood disorders and anxiety are more represented in acute and inpatient settings.

The shifts in workloads among the various specialisations are starting to reflect more evidently the changes introduced to provide more focused acute and community psychiatric services.
Disease Category Acute% IATO / CDO% CTO % Neuro-developmental disorders 5.3% 4.3% 2.7% 69 Schizophrenia / psychotic disorders 26.4% Mood disorders Anxiety / stress-related disorders Substance / addictive disorders Impulse-control / behaviour disorders Neurocognitive / organic disorders 24.3% 10.3% 24.1% 3.7% 6.0% 34.8% 21.4% 4.8% 29.4% 2.1% 3.2% 51.2% 16.7% 0.7% 24.7% 2.7% 1.3% Specialisation Acute% IATO / CDO% CTO % Acute Psychiatry (3 consultants) 57.8% 47.6% 8.0% General Adult incl.
Forensic (5 consultants) 13.5% 12.3% 20.7% Rehabilitation / Community (4 consultants) 12.4% 16.6% 45.3% Addiction (2 consultants) Child / Adolescent / Youth (2 consultants) Learning Disability (1 consultant) 9.9% 3.9% 2.5% 17.6% 20.0% 3.2% 2.7% 1.3% 4.7% CONCLUSION This data represents the fifth full year of implementation of the new Mental Health Act.

Certain trends are now very clearly established.

The involuntary care process is being closely monitored.
Patients are being followed up on a regular basis by their respective caring teams and within the much shorter timeframes.

Although not strictly comparable, length of stay in involuntary care has diminished radically.

Patients are being discharged from compulsory treatment orders or transferred to community treatment orders rather than being left on “leave of absence” for years on end.
Community involuntary care is now by far the preferred option of following up difficult cases (more than 91% of long-term compulsory treatment cases), also because it includes as a care option the possibility of short admissions for observation and stabilisation care if the need arises.

This shift requires continued commitment to further strengthen community support services.
70 CHAPTER 3 Report on Visits to Mental Health Licensed Facilities Conducted in 2019 http://commissionermentalhealth.gov.mt 21st October 2020 71 Visitation Report 2019 The Office has carried out its Fifth Annual Inspection of all mental health facilities in the latter part of 2019.
The aims of the visits in 2019 were to (1) ensure that patients are being taken care of in a dignified manner by dedicated staff in a suitable environment; (2) explore whether service users are aware of their rights, participate in their care process and assess their care experience; and (3) assess the manner and extent of the organisation of medical records and their content, especially documentation required by the Mental Health Act.
During this inspection the team evaluated the level of adherence to these rights by providers, assessed the physical environment, the quality of care, and the available documentation such as consent forms, the appointment of responsible carer forms and the availability of multidisciplinary care plans, and appraised the patients’ experience.

It also heard the concerns of the staff.


The report with the findings and recommendations will be forwarded to the Ministry and relevant senior management for their information and consideration.

The questionnaires with Responsible Carers were carried out through detailed telephone interviews were held by the Office of the Commissioner for Mental Health.
During the year 2019, the questionnaires / template utilized were as follows: • Mental Health Service User Questionnaire • Staff Questionnaire • Responsible Carer Questionnaire • Environmental Assessment Template The full version of the relative questionnaires / template is at Appendix 2 of the Annual Report.

The full report of the findings of the visits is at Sections A, B, C and D below.
72 SECTION A: MENTAL HEALTH SERVICE USERS’ PERSPECTIVE [N=180] Objective The aim of this exercise was to obtain a snapshot of the current situation in the provision of mental health care in Malta as seen by clients of the service, with the ultimate objective being the provision of better-quality care for, and promotion of their rights.

Questions dealt primarily with their experiences as patients and the exercise of their rights.
It also allowed patients and residents an added opportunity to voice their concerns and suggestions on mental health care in general.

The questionnaire also included a section which was completed after a review of the patient’s file.

Method A randomly chosen sample of patients and residents in a number of licensed mental health care facilities were asked to reply to a questionnaire.

These were carried out by OCMH staff in the last 3 months of 2019 during a number of inspections of these facilities.
These facilities, both public and private, were located in both Malta and Gozo.

The OCMH greatly appreciates the feedback given by the participants.

Demographic data There were 180 patients and residents who were asked to take part in this exercise which was performed in both publicly and privately funded licensed mental health facilities.
These facilities were grouped into (a) in-patient wards (hereafter referred to as ‘hospital’), (b) Psychiatric out-patient /community mental health clinic / day centres (hereafter referred to as ‘clinics’) and (c) community residential facilities (hereafter referred to as ‘residences’).

Fig.

1 shows a breakdown of the participants by gender (one client did not identify as male or female but chose to participate).
They were of different nationalities (Maltese, European Union or European Economic Area, and Third Country nationals) (Fig 2) and were seen in a number of different clinical settings (Fig 3).

47% of participants were in the 50-69-year age groups (Fig 4).

Out of 180 persons who were asked to take part in this study, 11 had memory issues and 4 refused to participate.
The nationality of participants varied with clinical setting (Fig 5), with practically no EU/EEA or TCNs in the OP/ Clinic or residential settings samples.

Gender of participants also varied when nationality was considered (Fig 6).

73 Whilst the majority of participants were voluntary patients, it was worrying to note that 11% did not know what their status was (Fig 7).

This was proportionately higher among TCNs (Fig 8) and in the OP/ clinic setting (Fig 9).
The highest proportion of involuntary patients was in the hospital setting, with the residential clients being voluntary in their majority (Fig 9).

Fig 1.

Gender of participants Participants by gender % (n=179) accepted refused 84 93 16 7 Males - 106 Females - 73 Fig 2.

Participants by nationality Nationality ( n=180) EU/EEA 4% TCN 8% MT 88% 74 Fig 3.

Participants by clinical setting Location of patient (n=165) Hospital OP/ Day centre community 23% 14% 63% Fig 4.
Age distribution of participants Age distribution of participants (n=165) <18 18-29 30-39 40-49 50-59 60-69 70-79 11% 5% 21% 26% 13% 11% 13% Fig 5.

Nationality by type of unit Nationality of participants by clinical setting % (n=165) MT EU /EEA TCN 100 97 80 13 7 0 0 3 0 Hospital - 104 OP/ Clinic / DC - 25 Residence - 36 75 Fig 6.

Participants’ gender by nationality Gender distribution in different national cohorts % (n=165) M F Other 86 75 58 41 25 1 0 14 0 MT - 143 EU/EEA - 8 TCN - 14 Fig 7.
Participants’ declared status Particpants' self- declared status (n=165) don't know 11% involuntary 20% voluntary 69% Fig 8.

Participants’ status and nationality Pt status and nationality (n=165) Vol Invol ?

71 10 19 MT 63 37 50 29 21 0 EU/EEA TCN 76 Fig 9.

Participants’ status and clinical setting Pt status by unit (n=165) vol invol ?

92 63 57 28 9 39 4 8 0 hospital op/clinic residence Main findings 1.
11% of respondents did not know what their status was, and this was more likely to happen in the TCN cohort and in the clinic setting.

2.

14% of voluntary patients stated they could not leave hospital (a further 8% not knowing) whilst 21% of involuntary patients thought that they could leave the hospital if they wanted to.

3.
3.

47% of all respondents stated that they had given written consent for care and treatment received; 29% stated that they had not, whilst the remaining 24% stated that they did not know.

Respondents who were female or of EU/EEA origin were more likely to report not having given written consent.

4.
4.

84% of all respondents said that quality of care was good or very good, with differences in outlook noted by nationality (TCNs highest, EU/EEA lowest), gender (males higher), clinical setting (residential setting highest, clinics lowest) and status (voluntary higher).

5.
5.

73% of respondents felt that their involvement in decisions about their care was good or very good with differences in declared perception by nationality (EU/EEA lowest), gender (males higher), clinical setting (clinics highest, hospital lowest), perceived quality of care (QoC) and status (involuntary poorer) 6.
2/3 of respondents from the clinic cohort reported having appointed a responsible carer, a proportion which fell to just over a half in the hospital and residence groups with further differences by nationality (EU/EEA lowest, MT highest), gender (females higher), clinical setting clinics highest), and status (involuntary lower) 7.

Of the 39% of hospital respondents who declared that they did not have a responsible carer, only 40% claimed that they had been asked to appoint one.

77 8.
77 8.

Of the hospital respondents who had claimed that they had appointed a responsible carer, only 64% were found to have a properly filled Responsible Carer Form on reviewing the patient’s clinical file; at the same time, 17% of patients claiming that they had not appointed a responsible carer had a properly filled Responsible Carer Form in their file.

9.

82% stated that the appointment of a responsible carer was useful.

10.
10.

13% and 6% of hospital and residence respondents reported feeling unsafe, with clients who were female, on involuntary status, EU/ EEA nationals, had reported complaints or were unhappy with how a staff member had treated them being more likely to feel unsafe.

11.
11.

84% reported that they did not feel a difference in treatment when compared to other patients, but EU/ EEA clients, clients who felt unsafe, clients who reported complaints or who felt unhappy with how staff members treated them were more likely to perceive being treated differently.

12.
12.

44% of respondents in hospitals and 25% in residences had complaints about aspects of stay or treatment, with respondents who were female, on involuntary status or from an EU/EEA country or having reported being unhappy with how a member of staff had acted towards them in the previous month being more likely to register complaints with interviewers.

13.

98% had no issues with freedom to practise religion.

14.
14.

Whilst 76% of voluntary hospital patients claimed they had someone who would support their recovery when not in the hospital, this figure dropped to about half for involuntary hospital clients.

Support was noted to be less for TCNs and residential clients.

15.
15.

18% of respondents reported feeling unhappy with the way a member of staff acted towards them in the previous month with clients who were female, of EU/EEA nationality, on involuntary status, being treated in a clinic/Out-Patients, and having a poor perception about QOC being more likely to express unhappiness.

16.

80% of patients reported that they were always or almost always treated in a way that strengthens their sense of dignity.
Clients who were female, from EU/EEA origin, in a hospital setting, on involuntary status and having poor perceptions about QoC were more likely to have poor perceptions about being treated in a way that strengthened their sense of dignity.

17.

93% of respondents felt that staff always or almost always gave sufficient consideration to their feelings, wishes and rights.
Clients who were from EU/EEA origin, in a hospital setting, on involuntary status and having poor perceptions about QoC were more likely to feel that staff did not give sufficient consideration to their feelings, wishes and rights.

18.

File review of hospital participants showed that: a. the patient’s caring consultant was easily identifiable in 81% of cases; b.
16% of files had a formal multidisciplinary care plan registered; c. 73% of patients had a filled and signed treatment consent form in file; d. 47% of participants had a filled and signed appointment of responsible carer form; 78 e. 72% of cases had an appropriately filled record of restraint /seclusion events with voluntary patients and TCNs having a lower rate of such records.
f. 38% of patients were seen by a specialist in psychiatry (resident specialist or consultant) within 24 hours from the time when the admitting physician had examined the patient, with a further 18% being reviewed by a specialist in the second day post admission.

79 Replies to specific questions in Questionnaire Q 7.

When did you first seek help from a healthcare professional (in public or private services) about your mental health condition?
The majority of respondents reported that their first contact with a health care professional regarding mental health had been longer than 10 years before the date of interview (Fig 10).
When their responses were stratified by clinical setting, the majority of respondents in hospitals (53%) and in residences (70%) had had their first contact more than 10 years previously, which differed from the situation in out-patients were the majority of patients had had their first contact between 1 and 5 years previously Fig 11).
The majority of both voluntary (63%) and involuntary patients (60%) reported having first sought help from a mental health care professional more than 10 year previously (Fig 12).

When results were analysed by nationality, it was noted that TCNs were the only cohort where there was a slight majority were the first encounter had occurred less than 5 years previously.

(Fig 13).

Fig 10.
(Fig 13).

Fig 10.

First encounter with health care professional Time since first encounter with health professional regarding mental health % (n=165) 32 27 20 10 7 <1yr 1-5yr >5-10yr 10-20yr >20yr 4 ?

Fig 11.

Respondents’ reported first encounter with health professional in different clinical settings Duration from time when pt first sought help by unit % (n=158) <1yr 1-5yr >5-10yr >10-20yr >20yr 60 24 16 34 23 15 19 9 41 29 18 9 0 0 3 Hosp -104 Outpatient - 25 Residence - 36 80 Fig 12.
Respondents’ reported first encounter with health professional and status Duration from time when pt first sought help by status % (n=158) <1yr 1-5yr >5-10yr >10-20yr >20yr 35 28 21 10 6 Vol - 113 40 20 27 13 0 Invol -33 37 32 11 16 5 ?

-19 Fig 13.
-19 Fig 13.

Respondents’ reported first encounter with health professional and nationality Duration from time pt first sought help by nationality % (n=158) <1yr 1-5yr >5-10yr >10-20yr >20yr 57 38 28 20 9 6 38 23 23 14 14 14 0 15 0 MT -143 EU / EEA - 8 TCN - 14 Freedom to leave facility Q 10.

Can you leave the hospital /residence if you don’t want to stay here anymore?
Respondents in general showed a degree of confusion when answering this question, with 14% of voluntary patients thinking they could not leave hospital (a further 8% not knowing) whilst 21% of involuntary patients thought that they could leave the hospital if they wanted to (Fig 14).

The situation with regards to replies from respondents in residences was worse (Fig 15).

81 Fig 14.

Leaving hospital by status.

Client repsonses to ability to leave hospital by status (%) (n=94) can leave cannot leave ?
77 79 15 8 21 0 vol - 65 invol - 29 Fig 15.

Leaving residence by status Client responses to ability to leave residence by status % (n=36) can leave cannot leave ?

73 24 3 67 33 0 vol - 33 invol - 3 Granting of Consent Q 11.

Have you given written consent for the care and treatment you are receiving?

Less than half of respondents stated that they had given written consent for care and treatment received.
This becomes more worrying when coupled with a further 24% of respondents who stated that they did not know (Fig 16).

There was no data for 7 clinic patients.

The majority of females (61%) reported not giving consent or not knowing if they had given consent, more so then their male counterparts (Fig 17).

TCNs were the only group having a strong majority reporting that they had given written consent (Fig 18).

82 Fig 16.

Granting of consent Pts giving written consent (n=158) 47 29 24 Yes % no % ?
% Fig 17.

Granting of consent by gender Pts giving written consent by gender (n=157) Yes % no % ?

% 53 15 32 M- 93 39 36 25 F - 64 Fig 18.

Granting of consent by nationality Pts giving written consent by nationality (n=158) Yes % no % ?

% 79 46 50 29 25 25 25 21 0 MT - 136 EU/EEA- 8 TCN - 14 83 It was only in a hospital setting that an absolute majority of respondents reported having granted written consent (Fig 19), with the smallest proportion being in persons in residential care.
The majority of voluntary patients reported giving written consent, compared to less than quarter of involuntary patients (Fig 20).

Fig 19.

Granting of consent by clinical setting Pt giving written consent by unit (n=158) Yes % no % ?

% 53 31 16 42 44 33 25 28 28 Hosp - 104 clinic - 18 Residence - 36 Fig 20.

Granting of consent by status Pts giving written consent by pt status (n=145) Yes % no % ?

% 54 51 26 20 23 10 vol - 112 Invol - 33 84 Perceived Quality of Care Q 12.
How would you describe the quality of the care being provided to you?

84% of respondents said that this was good or very good (Fig 21).

This was highest in TCNs followed by Maltese respondents (Fig 22), with females more likely to report poor quality of care (QoC) than males (Fig 23).

The residential cohort had the most favourable outlook on the quality of care provided, and although at its lowest, more than 3/4 of respondents from a clinic / OP setting said that this was good or very good.

(Fig 24).
(Fig 24).

Fig 21.

Perception of Quality of Care Patient perception (%) of QoC provided (n=165) 54 30 12 2 1 v good good fair poor v poor 1 ?

Fig 22.

Perception of Quality of Care by nationality of responder Perception of QoC provided by Nationality % (n=163) V good / good fair poor / v poor 93 85 63 25 12 EU/EEA 2 13 MT 0 7 TCN 85 Fig 23.

Perception of Quality of Care by gender Perception of QoC by Gender % (n=163) v good / good fair poor/ v poor 87 82 100 12 1 12 6 M - 97 F - 65 0 0 O - 1 Fig 24.
Perception of Quality of Care by clinical setting Perception of Qoc by Unit % (n=163) v good fair poor 94 83 78 13 5 22 0 6 0 Inpt - 104 outpt - 23 Residential - 36 Respondents on voluntary status were much more likely to perceive a better QoC than those on involuntary status (Fig 25).
There was no difference in perceptions about QOC between clients voicing complaints with the interviewers in different clinical settings (Fig 26), a situation which was quite different in respondents not voicing complaints with the interviewers, where the perception of QoC was less favourable in respondents from a hospital setting when compared with that of clients in a residential setting (Fig 27).This would appear to indicate that failure to raise complaints does not equate with a higher perceived level of QoC.
86 Fig 25.

Perception of Quality of Care by status Pt perception of QoC by status % (n=163) v good / good fair poor / v poor 90 84 67 9 1 21 12 16 0 Vol - 111 Invol - 33 ?

- 19 Fig 26.

Perception of Quality of Care of respondents who voiced complaints by clinical setting Pt having complaints and perceived QoC in Hospital/ residences % v good / good fair poor/ v poor 69 67 22 9 22 11 hospital - 45 Residence - 9 Fig 27.
Perception of Quality of Care of respondents who did not voice complaints by clinical setting Pts not having any complaints and perceived QoC in hospital/ residences % v good / good fair poor/ v poor 70 61 32 7 24 6 hospital -59 Residence - 17 87 Involvement in Decision making Q 13.

How would you describe your involvement in decisions taken about your care?

Overall, almost ¾ of respondents felt that their involvement in decisions about their care was good or very good (Fig 28).
This was at its highest in the clinic setting (92%) and lowest in the hospital setting (68%).

It was in the latter setting that the highest proportion of clients felt that involvement was poor or very poor (16%) (Fig 29).
Fig 28 Respondents’ perceptions about their involvement in care decisions Perception of involvement of pt in decisions about their care % (n=164) 47 26 15 10 2 v good good fair poor v poor Fig 29 Respondents’ perceptions about their involvement in care decisions by clinical setting Involvement in care decisions by Unit % (n=164) v good / good fair poor / v poor 92 74 68 15 16 4 4 20 6 Hosp - 104 Clinic - 25 Residence - 35 88 Males expressed a more favourable outlook on involvement than females (Fig 30), and EU/ EEA nationals less favourable views about their involvement in care decisions, with 38% stating this was poor or very poor (Fig 31).
This perception about involvement did not appear to vary with status (Fig 32) but appeared to be correlated with granting of consent to treatment in the hospital cohort (Fig 33) with respondents who reported not having given consent also reporting less involvement in decision making.
Fig 30 Respondents’ perceptions about their involvement in care decisions by gender Involvement in care decisions by gender % (n=164) v good fair poor 100 80 64 9 11 M - 96 22 13 F - 67 0 0 O- 1 Fig 31 Respondents’ perceptions about their involvement in care decisions by nationality Involvement in care decisions by nationality % (n=164) v good fair poor 74 71 50 38 15 11 12 14 14 MT- 142 EU / EEA - 8 TCN - 16 89 Fig 32 Respondents’ perceptions about their involvement in care decisions by status Involvement in care decisions by status % (n=164) v good fair poor 73 70 74 19 8 24 6 16 10 Vol - 112 Invol - 33 ?
- 19 Fig 33 Respondents’ perceptions about their involvement in care decisions and granting of consent to treatment Hospital patients perceived involvement in decisions and granting of consent % (n=87) v good/good fair poor / v poor 78 67 13 9 24 9 consent given - 54 no consent given - 33 Respondents who reported being involved in care decisions were more likely to express favourable views on QOC.

This was found to be the case across all clinical settings (Fig 34- 36).

90 Fig 34.
90 Fig 34.

Perception of Quality of Care by perceived patient involvement in hospital setting.

Perception of Qoc by perceived involvement in hospital setting (n=104) QoC vgood QoC fair QoC poor / v poor 3 11 86 6 22 72 15 7 77 Involvement v good / good - 73 Involvement Fair - 18 Involvement poor / v poor - 13 Fig 35.
Perception of Quality of Care by perceived patient involvement in Clinic/OP setting Perception of QoC by perceived involvement in outpatient setting (n=25) QoC vgood QoC fair QoC poor / v poor 0 18 82 0 100 0 0 0 0 Involvement v good / good- 22 Involvement Fair - 2 Involvement poor / v poor - 0 Fig 36.
Perception of Quality of Care by perceived patient involvement in residential setting Perception of QoC by perceived involvement in residence setting (n=33) QoC vgood QoC fair QoC poor / v poor 0 0 100 0 0 100 0 33 67 Involvement v good / good - 24 Involvement Fair - 6 Involvement poor / v poor - 3 91 Responsible carer Q 14.

Have you appointed a responsible carer (family member or friend) to be involved in care decisions?
2/3 of respondents from the clinic cohort reported having appointed a responsible carer, a proportion which fell to just over a half in the hospital and residence groups (Fig 37).

Foreign nationals were much less likely to appoint a responsible carer (Fig 38).

Females were more likely to have a responsible carer (fig 39), as were patients on voluntary status (fig 40).

The latter was particularly so in the hospital setting (Fig 41).
With regards to hospital respondents, 3/5 stated that they had a responsible carer (Fig 42), and of the 39% who did not have a responsible carer, only 40% claimed that they had been asked to appoint one (Fig 43).

Fig 37.

Patients’ reporting appointment of responsible carer by clinical setting Pts reporting having appointed a responsible carer by clinical setting (n=165) Yes % no % ?

% 68 55 34 11 24 8 53 22 25 Hosp - 104 Clinic - 25 Residence - 35 Fig 38.
Appointment of responsible carer and nationality Appointment of responsible carer in different nationality cohorts (n=165) Yes No ?

75 61 24 15 25 64 29 0 7 MT EU/ EEA TCN 92 Fig 39.

Appointment of responsible carer by gender Pts appointing a responsible carer by gender (n=165) Yes % no % ?

% 63 52 34 14 24 13 M- 97 F - 67 Fig 40.

Appointment of responsible carer and status Pts appointing a responsible carer by status (n=145) Yes % no % ?

% 57 29 14 52 42 6 vol - 112 Invol - 33 Fig 41.


Appointment of responsible carer by hospital patients and status Hospital patients stating that they had appointed a RC by status % (n=94) Yes No ?

62 31 7 45 48 7 vol - 65 involuntary -29 93 Fig 42.

Reported appointment of responsible carer by hospital patients Hospital patients' declaration re RC % (n=93) 61 39 yes no Fig 43.

Hospital respondents who stated they had not appointed a RC and whether requested to do so.
Were you asked to appoint a responsible carer?

(ward cohort) (n=36) 40 34 26 Yes No ?

When the clinical files of the hospital respondents who claimed that they had appointed a responsible carer were checked, it was found that only 64% had a properly filled Responsible Carer Form (Fig 44).

By contrast, 17% of patients claiming that they had not appointed a responsible carer had a properly filled Responsible carer Form in their file (Fig 45).

94 Fig 44.
94 Fig 44.

Actual situation on appointment of responsible carer by hospital patients who had reported appointing one.

Hospital patients who said they had a RC and presence of appropriately filled RC form % (n=57) 64 36 yes no Fig 45.

Actual situation on appointment of responsible carer by hospital patients who had reported not having appointed one.
Hospital patients who reported not having a RC and presence of approopriately filled RC form % (n=39) 83 17 yes no When the results of the respondents who had reported having appointed a responsible carer were analysed, a considerable majority of respondents (82%) stated that the appointment of a responsible carer was useful (Fig 46).
Completeness of documentation was variable when client files were reviewed to ascertain if proper documentation regarding appointment of responsible carer was complete (Fig 47).

95 Fig 46 Appointment of responsible carer and assistance provided Has appointment of responsible carer helped you (in- patients) (n=56) 82 Yes 4 No 14 ?

Fig 47.
Fig 47.

Appropriately filled responsible carer documentation by ward of patient Proper RC documentation by ward (n=103) 100100100100100100 75 60 50 50 50 50 50 50 50 40 36 33 25 0 0 0 0 0 2 - 2 w F 2 - A 3 w F 2 - 7 w F 1 - 8 w F 2 - H W H 8 - U P 4 - u d d f 0 1 - F W A M 0 1 - 1 W M 2 - E 1 w m 2 - 2 W M 2 - 7 W M 5 - B 8 W M 2 - u p y 4 - G W S S 1 1 - 1 W F 9 - M W A M 4 - U D D M 2 - S K D 4 - G W S L 2 - U S M 2 - A 3 W M 2 - U S 0 1 - c i s n e r o F Perception of safety in facility Q 17.
Do you feel safe in the unit?

Whilst none of the Clinic clients reported feeling unsafe, 13% and 6% of hospital and residence respondents reported feeling unsafe (Fig 48).

Patients were more likely to report feeling unsafe if they were female (Fig 49), had involuntary status (Fig 50), were EU/ EEA nationals (Fig 51), reported 96 complaints (Fig 52), perception of different treatment (Fig 53) and being unhappy with how a staff member had treated them (Fig 54).

Fig 48.
Fig 48.

Respondents’ perception of safety Perceived safety in different clinical settings % 87 13 safe unsafe 100 94 0 6 hospitals clinics residences Fig 49.

Respondents’ perception of safety by gender Proportion of pts feeling unsafe by gender (n=16) 15 6 Fig 50.

Respondents’ perception of safety by status male female Proportion of patients feeling unsafe by status (n=16) 21 8 vol invol 97 Fig 51.
Respondents’ perception of safety by nationality Proportion of patients feeling unsafe by nationality (n=16) 25 10 MT EU/EEA Fig 52.

Respondents’ perception of safety and registering of complaints Patients feeling unsafe as a proportion of patients having complaints (n=16) 17 5 had complaints no complaints Fig 53.
Respondents’ perception of safety and perception of different treatment Patients feeling unsafe as a proportion of patients saying they were being treated differently (n=16) 16 7 treated differently not treated differently 98 Fig 54.

Respondents’ perception of safety and perception of treatment by staff Patients feeling unsafe as a proportion of patients being unhappy with how staff treated them (n=16) 33 4 unhappy not unhappy Perceptions of different treatment Q 20.
Do you feel you are treated differently than other patients?

A large majority reported that they did not feel treated differently compared to other patients (Fig 55), with little difference between various clinical settings (Fig 56), gender (Fig 57) or status (Fig 58).

EU/ EEA clients , clients who felt unsafe or clients who reported complaints or who felt unhappy with how staff members treated them were more likely to perceive being treated differently (Fig 59 - 62).

Fig 55.
Fig 55.

Perceived difference in treatment Pt perception of difference in treatment % (n=165) 84 14 yes no 2 ?

99 Fig 56.

Perceived difference in treatment by clinical setting Proportion of clients having perception of being treated differently by clinical setting (n=25) 15% 12% 17% hospital -104 clinic - 25 residence - 36 Fig 57.

Perceived difference in treatment by gender Proportion of clients having perception of being treated differently by gender (n=25) 16% 13% male - 97 female -67 Fig 58.
Perceived difference in treatment by status Proportion of clients having perception of being treated differently by status (n=25) 17% 12% vol - 113 invol - 33 100 Fig 59.

Perceived difference in treatment by nationality Proportion of clients having perception of being treated differently by nationality (n=25) 38% 21% 13% MT - 143 EU/EEA - 8 TCN - 14 Fig 60.
Perceived difference in treatment and perceptions of safety Proportion of clients having perception of being treated differently by perceptions of safety in unit (n=25) 25% 14% safe - 148 not safe - 16 Fig 61.

Perceived difference in treatment and reports of complaints Proportion of clients having perception of being treated differently by reports of complaints (n=25) 20% 12% had complaint - 66 no complaint - 99 101 Fig 62.
Perceived difference in treatment and unhappiness with how staff treated them Proportion of clients being treated differently by unhappiness with treatment by staff (n=25) 43% 9% unhappy - 30 not unhappy - 135 Complaints Q21.

Do you have any complaints about aspects of your stay or treatment in the hospital / residence?
A considerable proportion of respondents in both hospitals and residences had complaints about aspects of stay or treatment, with hospital clients being almost twice as likely to have complaints (Fig 63).

Hospital patients detained involuntarily were more likely to have complaints than voluntary patients (Fig 64).

Fig 63.
Fig 63.

Respondents in hospitals and residences reporting complaints Complaints about stay in hospital / residences complaints no complaints 56 44 75 25 hospital - 104 residence - 36 102 Fig 64.

Status of respondents in hospitals and residences reporting complaints Pt complaints by status in hospital / residential setting % (n=130) complaint no complaint 60 40 55 45 73 27 100 0 Hosp Vol-65 Hosp Invol - 29 Res Vol- 33 Res Invol - 3 10 hospital pts were unaware of their status (4 had complaint, 6 did not).
Female respondents voiced more complaints than their male counterparts in both hospitals and residences (Fig 65) and a majority of hospital clients from EU/ EEA countries voiced complaints, with hospital clients of third country origin reporting half as much complaints (Fig 66).

Age did not appear to be related to complaints made whether in hospitals or residences (Fig 67, 68).

Fig 65.
Fig 65.

Respondents in hospitals and residences reporting complaints by gender Pt complaints by gender in hospital / residential setting % (n=139) complaint no complaint 86 59 41 53 47 62 38 14 Hosp M - 61 Hosp F - 43 Res M - 22 Res F - 13 (1 gender O pt not included) 103 Fig 66.
Respondents in hospitals and residences reporting complaints by nationality Pt complaints by nationality in hospital / residential setting % (n=140) complaint no complaint 54 46 57 43 73 74 27 26 100 0 Hosp MT - 83 Hosp EU/EEA - Hosp TCN - 14 Res MT -35 Res EU/EEA - 1 7 Fig 67.
Respondents in hospitals reporting complaints by age Pt complaints by age in hospital setting % (n=104) complaint no complaint 50 50 53 47 47 53 67 61 64 67 43 39 36 33 H <19 (4) H 20-29 (17) H 30-39 ( 19) H 40-49 (14) H 50-59 (23) H 60-69 (18) H 70-79 - (9) Fig 68.
Respondents in residences reporting complaints by age Pt complaints by age in residential setting % (n-36) Series1 Series2 100 100 67 67 33 33 62 38 40 20 0 0 17 12 R <19 (3) R 20-29 (3) R 30-39 (1) R 40-49 (2) R 50-59 R 60-69 (8) R 70-79 (5) (14) 104 In both hospitals and residences, clients registering a complaint with the interviewers were more likely to report being unhappy with how a member of staff had acted towards them in the previous month (Fig 69, 70).

Fig 69.
Fig 69.

Respondents in hospital registering of complaints and perceptions of being unhappy with their treatment by staff.

Hospital clients perceptions about manner in which staff members acted & reporting of complaints % unhappy not unhappy 90 67 33 10 complaints - 21 no complaints - 83 Fig 70.

Respondents in residences registering of complaints and perceptions of being unhappy with their treatment by staff.
Residence clients unhappy about manner in which staff member acted towards them by reporting of complaints % Unhappy not unhappy 67 33 93 7 Residence pts reporting complaints - 9 Residence pts not reporting complaints - 27 Religious freedom Q 19.

Are you allowed to freely practise your religion here (in-patients /residents)?

There did not appear to be any issues with freedom to practise religion.

(Fig 71).
(Fig 71).

105 Fig 71 Freedom to practise religion Freedom to practise religion % (n=139) yes no 98 2 yes no Support Q 22.

Is there anyone who is supporting /will support your recovery when you are not in hospital/ residence?

Patient support plays a crucial part in improving mental wellbeing and efforts to integrate an individual beck into society.
Data obtained from the clients in different settings was worrying as whilst ¾ of voluntary hospital patients claimed they had some support, this figure dropped to about half for involuntary hospital clients.

Figures for residential clients were somewhat worse (Fig 72, 73).

Support for TCN hospital patients was the lowest when the hospital cohort was stratified by nationality (Fig 74).
The number of patients in residences did not permit analysis by nationality (Fig 75) as there were no EU/EEA or TCNs in the samples obtained.

Perceived support outside hospital or residences did not appear to be related with duration of stay (Fig 76, 77) or with gender (Fig 78).

Fig 72.

Hospital clients’ perception of support by status Support outside hospital by Status (n=91) support no support 76 55 45 23 Vol - 62 Invol - 29 106 Fig 73.
Residence clients’ perception of support by status Support outside residence by status % (n=33) YES NO 52 48 50 50 VOL - 31 INVOL - 2 Fig 74 Hospital clients’ perception of support by nationality Support outside hospital by nationality (n=100) support no support 86 71 29 57 43 14 MT - 79 EU/EEA - 7 TCN - 14 Fig 75 Residence clients’ perception of support by nationality Support outside residences by nationality (n=31) support no support 100 50 50 MT - 30 EU/EEA -1 0 0 0 TCN - 0 107 Fig 76 Hospital clients’ perception of support by length of stay Perceived support (%) outside hospital by length of stay (n=100) support no support 43 57 22 78 19 81 43 57 0 100 37 62 Fig 77.
Residence clients’ perception of support by length of stay Perceived support outside residence by length of stay in residence (n=28) support no support 40 60 50 50 25 75 20 80 67 33 0 0 Fig 78.

Hospital & Residence Clients’ perception of support by gender Support outside hospital / residences by pt gender % Support No support 31 69 29 71 50 50 50 50 Hosp M - 59 Hosp F - 43 Res M- 20 Res F - 10 108 Treatment by staff members Q 23.
In the last month, were there instances when you felt unhappy with the way a member of staff* acted towards you?

(*actions which border on verbal, mental, physical or sexual abuse).

Overall, 18% of respondents reported feeling unhappy with the way a member of staff acted towards them in the previous month (Fig 79), with the proportion of clinic respondents being slightly higher than hospital respondents and twice as much as residence clients (Fig 80).
Female respondents were twice as likely to express unhappiness with staff treatment in their regards when compared to their male counterparts (Fig 81).

Whilst the proportion of MT and TCN respondents who were unhappy was similar, this was considerably less than that of EU/EEA clients (Fig 82).

Patients on involuntary status were twice as likely to report being unhappy than others on voluntary status (Fig 83).
Unhappiness with staff appeared to be correlated to perceptions of lower QoC (Fig 84) and of being treated with less dignity (Fig 85).

Fig 79.

Proportion of patients feeling unhappy with way staff members acted towards them % of patients unhappy with way staff member acted towards them (n=165) Yes 18% No 82% 109 Fig 80.
Proportion of patients feeling unhappy with way staff members acted towards them by unit Pts unhappy with way member of staff acted towards them by unit % (n=165) 81 yes no 78 90 19 22 10 hosp clinic residence Fig 81.
Proportion of patients feeling unhappy with way staff members acted towards them by gender Pts unhappy by treatment by staff by gender %(n=165) 88 12 M Y N 75 25 F 0 1 O Fig 82 Proportion of patients feeling unhappy with way staff members acted towards them by nationality Pts unhappy with treatment by staff by nationality % (n=165) 84 Y N 50 50 86 16 14 MT EU/EEA TCN 110 Fig 83.
Proportion of patients feeling unhappy with way staff members acted towards them by status Patients unhappy with treatment by staff according to status % (n=165) Y N 70 30 85 15 vol invol 90 10 ?

Fig 84.

Proportion of patients feeling unhappy with way staff members acted towards them by perceived QoC.

Clients unhappy with treatment by staff and perceived QoC % (n=163) v good / good fair poor / v poor 75 54 32 14 7 1 Unhappy- 28 Happy - 135 Fig 85.
Respondents in hospital / residences unhappy with their treatment by staff and their perception on being treated with dignity.
Clients' views on being unhappy with treatment by staff and perception of being treated with dignity al always / usually sometimes rarely / al never 45 30 25 83 15 2 60 40 94 0 6 0 Hosp Unhappy - 20 Hosp not unhappy - 81 Residences unhappy - 5 Residences not unhappy - 31 111 Perceptions regarding strengthening of dignity Q 24 Do you feel that you are being treated in a way that strengthens your sense of dignity?
A large majority of patients reported that they were always or almost always treated in a way that strengthens their sense of dignity (Fig 86), with males being slightly more likely to think so than females (Fig 87).

When gender was stratified by clinical setting, there did not appear to be much gender difference in the hospital cohort but in the residence cohort, females were less likely to report being treated with dignity than their male counterparts (Fig 88).

Fig 86.
Fig 86.

Respondents views on being treated in a way that strengthened their sense of dignity Respondents views on being treated in a way which strengthens dignity (n=162) 80% 13% 7% al always / usually sometimes rarely / al never Fig 87.

Perceptions of treatment with dignity by gender Pt perception of treatment with dignity by gender % (n=162) al always / usually sometimes rarely / al never 82 77 100 10 8 17 6 0 M - 96 F - 65 O - 1 112 Fig 88.
Gender cohort views on being treated in a way that strengthened their sense of dignity by clinical setting Client views (%) on treatment with dignity in hosp / residences by gender al always / usually sometimes rarely / al never 72 70 95 79 15 13 20 10 5 0 21 0 hospital males hospital females Residences males Residences females Nationality affected outlook.

Clients from EU/EEA states were the least likely to state that they were always or almost always treated with dignity, (Fig 89).
The same picture was obtained when the hospital client cohort was stratified by nationality (Fig 90).

Fig 89.

Respondents views on being treated in a way that strengthened their sense of dignity by nationality Client views on treatment with dignity by nationality % al always / usually sometimes rarely / al never 84 9 7 50 25 25 71 22 7 MT -135 EU/EEA - 8 TCN - 14 113 Fig 90 Hospital respondents’ views on being treated in a way that strengthened their sense of dignity by nationality.
Client views on treatment with dignity in hospital cohort by nationality % al always / usually sometimes rarely / al never 74 71 43 29 29 15 11 21 7 MT Hosp - 83 EU/EEA Hosp -7 TCN Hosp - 14 There were also considerable variations in outlook on perceived treatment with a sense of dignity by clinical setting.

All clinic clients said that they were always or almost always treated with a sense of dignity (Fig 91).
Of the 13% of all respondents (Fig 86) who said that they were sometimes treated with dignity the majority were hospital clients.

Hospital clients were the group with the lowest proportion of respondents agreeing that they were always or almost always treated with dignity (71%) when compared to clinic or residence clients.

Only patients in hospital stated that they were rarely or almost never treated with a sense of dignity and this amounted to 12% of hospital patients (Fig 91).

Fig 91.
Respondents views on being treated in a way that strengthened their sense of dignity in different clinical settings Client views (%) on treatment in a way which strenghthens dignity by clinical setting al always / usually sometimes rarely / al never 100 89 71 17 12 0 0 11 0 hospital - 101 clinics - 25 Residences - 26 114 Patients who said they were on involuntary status were less likely to report being treated in a way that strengthened their sense of dignity than their voluntary counterparts (Fig 92).
Fig 92.

Perceptions of treatment with dignity by status Pt perception of treatment with dignity by status % (n=162) al always / usually sometimes rarely / al never 84 88 64 12 4 21 15 VOL - 112 INVOL - 33 12 ?

- 17 0 Perception of treatment with dignity was also negatively affected by reporting of complaints with the interviewers in both hospital and residential settings (Fig 93, 94), and to perceptions of poor QOC (Fig 95).

Fig 93.
Fig 93.

Hospital pts’ views on being treated with dignity by reporting of complaints Hospital clients perception of treatment with digniity by reporting of complaints % al always / usually sometimes rarely / al never 60 20 20 82 14 4 Hosp Pt had complaints - 45 Hosp pts not having complaints - 56 115 Fig 94.
Residence client views on being treated with dignity by reporting of complaints Residence clients' perception of treatment with dignity by reporting of complaints % al always / usually sometimes rarely / al never 67 22 11 93 7 0 Residence clients with complaints - 9 Residence clients with no complaints - 27 Fig 95.
Perceptions of treatment with dignity by perceived QoC Pt perception of treatment with dignity by perceived QoC (n=161) al always / usually sometimes rarely /al never 87 11 2 58 21 21 67 33 0 QoC v good / good - 136 QoC fair - 19 QoC poor / v poor -6 Q25.

Do you feel that staff give sufficient consideration to your feelings, wishes and rights?
Whilst overall a very large majority (93%) of respondents felt that staff always or almost always gave sufficient consideration to their feelings, wishes and rights (Fig 96), this perception was reduced somewhat in the hospital cohort (Fig 97) and in clients on involuntary status (Fig 98).
Gender of respondents did not appear to affect this perception (Fig 99) but nationality did appear to have a considerable effect with only a fourth of EU/EEA responders agreeing that that staff always or almost always gave sufficient consideration to their feelings (Fig 100).

A perception that staff always or almost always gave sufficient consideration to patients’ feelings appeared to be correlated to positive perceptions of QoC (Fig 101).

116 Fig 96.
116 Fig 96.

Client perception about staff giving sufficient consideration to client’s feelings, wishes and rights Perception % of staff consideration to feelings & wishes (n=165) 42 41 10 3 4 al always usually sometimes rarely al never Fig 97.
Client perception about staff giving sufficient consideration to client’s feelings, wishes and rights by unit Patient perception of staff consideration by unit % (n=161) al always / usually - 137 sometimes - 15 rarely / al never - 9 78 96 97 13 9 4 0 3 0 hospital clinic residence Fig 98.

Client perception about staff giving sufficient consideration to client’s feelings, wishes and rights by unit.
Patient perception of consideration by staff by status % (n=161) al always / usually sometimes rarely / al never 94 88 70 7 5 18 12 5 0 VOL - 111 INVOL - 33 ?

- 17 117 Fig 99.

Client perception about staff giving sufficient consideration to client’s feelings, wishes and rights by gender Patient perception of staff consideration by gender % (n=161) al always / usually sometimes rarely / al never 86 84 100 8 5 9 6 0 0 M - 96 F - 64 O - 1 Fig 100.
Client perception about staff giving sufficient consideration to client’s feelings, wishes and rights by nationality Patient perception of staff consideration by nationality % (n=161) al always / usuallys sometimes rarely / al never 88 93 50 25 25 9 3 7 0 MT - 139 EU/EEA - 8 TCN - 14 Fig 101.
Client perception about staff giving sufficient consideration to client’s feelings, wishes and rights by perceived QoC Patient perception of staff consideration by perceived QoC % (n=159) QoC v good /good QoC fair QoC poor / v poor 90 10 0 53 33 13 56 33 11 al always / usually - 135 sometimes - 15 rarely / al never - 9 118 File Review The medical files of participating hospital clients were analysed to see if: 1. the caring consultant was easily identifiable: in about 1/5 of files the caring consultant was not easily identifiable(Fig 102); 2. whether the patient had a formal multidisciplinary care plan registered – this was the case in only 16% of cases (Fig 103); TCNs and involuntary patients were more likely to have such a plan (Fig 104,105); 3. whether the patient had a filled and signed treatment consent form – this was the case in about ¾ of patients (Fig 106): MT nationals were more likely to have a completed form as were voluntary patients (Fig 107, 108); 4. whether the patient had a filled and signed appointment of responsible carer form – this was the case in less than half the cases (Fig 109); TCNs and involuntary patients had lower rate of such appointments (Fig 110,111); 5. whether there was an appropriately filled record of any restraint /seclusion events - this was the situation in 72% of cases (Fig 112); voluntary patients and TCNs had a lower rate of such records (Fig 113, 114).
6. the time between the first medical exam in the hospital and the patient review by a specialist in psychiatry - 38% were seen within 24 hours, increasing to 56% within first 2 days (Fig 115).

Fig 102.

Proportion of patient files having easily identifiable responsible consultant Hospital File review - Consultant identifiable % (n-103) 81 Yes 19 No 119 Fig 103.

Proportion of patient files having a formal multidisciplinary care plan Hospital File Review - Formal MDCP plan % (n=100) 84 No 16 Yes Fig 104.
Proportion of patient files having a formal multidisciplinary care plan by nationality File review - presence of MDCP by nationality % MDCP - Yes MDCP - No 87 86 71 29 13 14 MT - 83 EU/EEA - 7 TCN - 14 Fig 105.

Proportion of patient files having a formal multidisciplinary care plan by nationality File Review - presence of MDCP by status MDCP - Yes MDCP - No 89 11 64 26 vol - 63 invol - 28 120 Fig 106.
Proportion of patient files having a filled and signed treatment consent form Hospital File Review - filled & signed treatment consent form % (n=101) 73 yes 27 no Fig 107.

Proportion of patient files having a filled and signed treatment consent form by nationality File review - presence of treatment consent form by nationality % treatment consent form - Yes treatment consent form - No 75 25 50 50 54 46 MT - 84 EU/EEA - 6 TCN - 13 Fig 108.
Proportion of patient files having a filled and signed treatment consent form by status File review - presence of treatment consent form by status % treatment consent form - Yes treatment consent form - No 75 25 67 33 vol - 64 invol - 29 121 Fig 109.

Proportion of patient files having a filled and signed treatment responsible carer form Hospital file review - filled & signed Responsible carer form % (n=103) 53 no 47 yes Fig 110.
Proportion of patient files having a filled and signed responsible carer form by nationality File review - presence of responsible carer form by nationality % responsible carer form - yes responsible carer form - no 53 47 75 85 25 15 MT - 83 EU/EEA - 8 TCN - 13 Fig 111.
Proportion of patient files having a filled and signed responsible carer form by status File review - presence of responsible carer form by status responsible carer form - yes responsible carer form - no 53 47 59 41 vol - 64 invol - 29 122 Fig 112.

Proportion of patient files having an appropriately filled recorded of restraint /seclusion event File review - appropriate record of restraint / seclusion events in hospital cohort % 72 28 record 23 no record - 9 Fig 113.
Proportion of patient files having an appropriately filled recorded of restraint /seclusion event by nationality File review - record of restraint / seclusion events by nationality % record no record 80 75 20 25 67 33 MT - 20 EU/EEA - 4 TCN - 6 Fig 114.

Proportion of patient files having an appropriately filled recorded of restraint /seclusion event by status File review - appropriate record of restraint / seclusion events by status % record no record 100 62 38 0 vol - 21 invol - 9 123 Fig 115.
Time between the first medical exam in the hospital and the patient review by a specialist in psychiatry Time between initial MO exam on admission and specialist exam % (n=79) 32 6 18 15 13 5 3 1 0 1 6 124 Conclusions Mental health care delivery depends on various factors and is affected by considerable variables.

This study provided a snapshot of the perceptions of patients in licensed mental health facilities in late 2019.
Apart from gauging patients’ experiences relating to use of mental health care services and perceptions on service delivery, data obtained can help inform decisions on where improvements to the service delivery may be required.

Further detailed analysis of specific issues and influencing factors needs to be carried out and concrete measures implemented to address deficiencies.
The main issues under investigation were patient awareness of their status, consent to care and involvement in decisions about care, appointment of responsible carers, patient status, gender, nationality, treatment setting, perceptions on QOC, patient safety, dignity and support.

Awareness of status There was a degree of confusion with regards to patients’ perception about their status.
As was to be expected, the majority of involuntary patients were in the hospital cohort, but what was surprising was that 39% of patients in the clinic cohort were uncertain about their status.
Better communication with patients could reduce this uncertainty, especially as this would also address issues relating to freedom to leave the facility, where 15% of patients who said that they were on voluntary status reported that they could not leave the facility whilst 21% of patients claiming that they were on involuntary status stating that they could leave the facility if they did not want to stay there anymore.

This is clearly of concern from the patient rights point of view.
It raises the issue whether the current level of communication between, and information transmitted by, staff and patient on these and other relevant issues can be improved.

Consent to care and involvement in decisions Less than half of respondents stated that they had given written consent for care and treatment received and a further 24% of respondents stated that they did not know if they had done so.
This was at variance with the actual situation obtained on reviewing each respondent’s clinical file which actually showed that 73% of patients had a completed treatment consent form and had given written consent for care and treatment; MT nationals and voluntary patients were found to be more likely to have a completed treatment consent form.

This could indicate either that the patient did not know what they were signing when they did so or that they did not remember.
A majority of females reported not giving consent or not knowing if they had given consent, more so then their male counterparts.

TCNs were the only group reporting in their majority that said they had given written consent.

The majority of voluntary patients reported giving written consent, compared to less than quarter of involuntary patients.
It was only in the hospital setting that a majority of 125 respondents reported having granted written consent with the smallest proportion being in persons in residential care.

Patient involvement in decisions about their care is not just a right but is an intrinsic and crucial part of the healing process.

More needs be done to see why clients of the female gender, from a hospital setting, of EU/ EEA Nationality and on involuntary status felt less involved in this process.
Responsible carer With regards to appointment of responsible carer, responses varied with nationality (EU/EEA lowest, MT highest), gender (females higher), treatment setting (clinics highest), and status (involuntary lower).

Whilst overall 82% stated that the appointment of a responsible carer was useful, on a review of patient files it was found that less than half of participants had filled and signed an appointment of responsible carer form.
Of the hospital respondents who had claimed that they had appointed a responsible carer, only 64% were found to have a properly filled Responsible Carer Form on reviewing the patient’s clinical file; at the same time, 17% of patients claiming that they had not appointed a responsible carer had a properly filled Responsible Carer Form in their file.

This again indicates that some patients are either unaware of what they had agreed to or might have forgotten.
This again raises the issue of the importance of proper communication.

The finding that of the 39% of hospital respondents who declared that they did not have a responsible carer, only 40% claimed that they had been asked to appoint one needs to be looked at further.

Involuntary patients Admission to a psychiatric hospital, while necessary in certain situations, can be an unpleasant experience.
The study showed that involuntary patients were more likely to express being treated without a sense of dignity, being unhappy with treatment by staff, having more complaints, less support outside hospital, having negative perceptions about their safety in the facility, about QoC and about staff giving sufficient consideration to their feelings, wishes and rights.
Female participants Female participants were more likely to express feelings of being treated without a sense of dignity, being unhappy with treatment by staff, having more complaints, not having given written consent and having negative perceptions about safety in their facility and about QoC.
126 Nationality Nationality also influenced outlook with EU /EEA nationals being more likely to express being treated without a sense of dignity, being treated differently than other patients, being unhappy with treatment by staff, not having appointed a responsible carer, not having given written consent, not being sufficiently involved in decisions about their care, having more complaints and having negative perceptions about safety in their facility, about QoC and about staff giving sufficient consideration to their feelings, wishes and rights.
This raises the query whether such perceptions are influenced in part by the degree of social and economic support, or lack thereof, that TCNs, in particular, have.

In contrast, it was interesting to find that TCNs were more likely to have a good or very good perception of QoC, not being aware of their status and having less support outside hospital.
Treatment setting Clinic patients were more likely not to know their status, have a poorer perception of QoC, of being treated without a sense of dignity and being unhappy with treatment by staff.

This was somewhat at odds with their reporting that staff gave sufficient consideration to their feelings, wishes and rights.

Unfortunately, the questionnaire did not enter the merits of which staff cohort they were referring to.

They were the cohort most likely to report having appointed a responsible carer.
This might indicate that clinic patients possibly have greater expectations with regards to their rights and freedoms.

QoC A large majority of patients reported that they were always or almost always treated in a way that strengthens their sense of dignity.

Clients who were female, from EU/EEA origin, in a hospital setting, on involuntary status and having poor perceptions about QoC were more likely to have poor perceptions about being treated in a way that strengthened their sense of dignity.
File review showed that only 16% of hospital patients had a formal multidisciplinary care plan registered in their files.

It also showed that only 56% of patients were seen by a specialist in psychiatry within 48 hours post admission into hospital.

Only 72% of cases had an appropriately filled record of restraint /seclusion events with voluntary patients and TCNs having a lower rate of such records.

This is of concern.
This is of concern.

Perceptions on staff 93% of respondents felt that staff always or almost always gave sufficient consideration to their feelings, wishes and rights.

Clients who were from EU/EEA origin, in a hospital setting, on involuntary status and 127 having poor perceptions about QoC were more likely to feel that staff did not give sufficient consideration to their feelings, wishes and rights.
84% reported that they did not feel a difference in treatment when compared to other patients, but EU/ EEA clients, clients who felt unsafe, clients who reported complaints or who felt unhappy with how staff members treated them were more likely to perceive being treated differently.
18% of respondents reported feeling unhappy with the way a member of staff acted towards them in the previous month with clients who were female, of EU/EEA nationality, on involuntary status, being treated in a clinic/Out-Patients, and having a poor perception about QOC being more likely to express unhappiness.

80% of patients reported that they were always or almost always treated in a way that strengthens their sense of dignity.
Clients who were female, from EU/EEA origin, in a hospital setting, on involuntary status and having poor perceptions about QoC were more likely to have poor perceptions about being treated in a way that strengthened their sense of dignity.

Perceptions on support Patient support is an essential part of the holistic healing process and possibly helps in reducing relapses.
It was worrying to note that 76% of voluntary hospital patients claimed they had someone who would support their recovery when not in the hospital, but that this figure dropped to about half for involuntary hospital clients.

Support was noted to be less for TCNs and residential clients.
Complaints & safety 44% of respondents in hospitals and 25% in residences had complaints about aspects of stay or treatment, with respondents who were female, on involuntary status or from an EU/EEA country or having reported being unhappy with how a member of staff had acted towards them in the previous month being more likely to register complaints with the interviewer.
13% and 6% of hospital and residence respondents reported feeling unsafe, with clients who were female, on involuntary status, EU/ EEA nationals, had reported complaints with the interviewer or were unhappy with how a staff member had treated them being more likely to feel unsafe.
Action is required to appropriately communicate to staff and patients alike the complaints procedure to be followed, promote the reporting of client complaints when this is considered necessary by a client, ensuring their early investigation and that such clients do not suffer any negative repercussions.

Timely remedial action, if so warranted, is to be seen to be implemented.
128 SECTION B: MENTAL HEALTH SERVICE PROVIDERS’ VIEWS [N=153] Objective The aim of this exercise was to obtain a snapshot of the current situation in the provision of mental health care in Malta as seen by frontline personnel, i.e.

different groups of health professionals working in both government and private licensed mental health care facilities.

The focus was on aspects of patient care and mental health care delivery, training needs, and relationship with patients and other staff.
Method Various meetings with different groups of health professionals working in both government and private licensed mental health care facilities were carried out in October and November 2019 as part of the annual exercise carried out by the Office of the Commissioner for Mental Health further to the Mental Health Act.
Apart from being given the chance to voice their concerns, aspirations, views and suggestions on mental health care in general and the specific issues faced by their profession at their particular workplace, these members of staff were also asked to complete a written self-administered questionnaire.

The OCMH appreciates the feedback given by these professionals as part of a process which has the aim to provide better quality care for patients and to safeguard and support the wellbeing of their carers.
Demographic data There were 153 employees of various professions working in publicly funded and private licensed mental health facilities who participated in this exercise.

Fig.

1 shows a breakdown of the participants providing services by clinical setting, i.e.
wards in licensed mental health facilities (hereafter referred to as ‘hospitals’), psychiatric out-patients, mental health clinics and Day centres (hereafter referred to as ‘clinics’), and residential facilities (hereafter referred to as ‘residences’) (Fig.

1).

Some staff worked in a mixture of clinical settings (Mix).

They were of different nationalities, grouped as Maltese (MT), European Union (EU/EEA) and third country nationals (TCNs) (Fig 2, 3) and gender (Fig.
4) and professional grouping (fig 5-9).

TCNs interviewed worked mostly in wards and no TCNs were interviewed in Clinics or found to be working in a mix of units (Fig 3).

The highest proportion of EU/EEA nationals who were interviewed worked in the residential setting.

The highest proportion of MT nationals worked in clinics, with the lowest being in wards.

129 Most of the respondents were females across all clinical settings (Fig 4).
The majority of participants were in the nursing profession (59%) (Fig 5).

Fig 1.

Staff by workplace Staff by workplace (n=153) hospitals clinics residences mix 6% 19% 19% 56% Fig 2.

Staff nationality Staff nationality (n=152) MT EU/EEA TCN 10% 9% 81% 130 Fig 3.

Staff nationality by workplace Staff nationality % by workplace (n=152) MT EU/EEA TCN 92 83 93 75 18 7 8 0 17 0 7 0 Hosp - 84 Clinic - 24 Residence - 29 Mix - 15 Fig4.
Staff gender by workplace Staff gender by workplace % (n=152) M F 83 83 90 56 42 17 17 10 Hosp - 85 Clinic -29 Residence - 29 Mix - 10 Fig 5.

Participants’ profession Profession of participants % (n=153) Dr general nurse psych nurse psychologist sw AHCP other 6% 8% 10% 1% 16% 16% 43% 131 When respondents were divided by the clinical setting in which they provided a service, most of the respondents working in a hospital environment in all nationality cohorts were nursing professionals (Fig 6).
In clinics, the largest group of respondents who participated in the questionnaire were nursing professionals in the MT cohort (33%): there were no EU/EEA or TCN nursing professionals in this clinical setting who participated (Fig 7).

In the residential care setting, the majority of respondents who were TCNs were nursing professionals and there were no EU/EEA participants (Fig 8).

Fig 6.
Fig 6.

Hospital Staff by profession & nationality Hospital staff by profession and nationality % (n=84) Dr general nurse psych nurse psychologist sw AHCP other 6 4 8 2 23 55 2 0 17 0 0 0 83 0 0 7 0 0 13 80 0 Hosp MT - 63 Hosp EU/EEA - 6 Hosp TCN - 15 Fig 7.
Clinic Staff by profession & nationality Clinic staff by profession and nationality % (n=29) Dr general nurse psych nurse psychologist sw AHCP other 19 11 7 7 22 33 0 50 50 0 0 0 0 0 0 0 0 0 0 0 0 Clinic MT - 27 Clinic EU/EEA - 2 Clinic TCN - 0 132 Fig 8.

Residence Staff by profession & nationality Residence staff by profession and nationality % (n=29) Dr general nurse psych nurse psychologist sw AHCP other 54 4 12 26 0 4 0 0 0 0 0 0 0 0 40 0 0 0 0 60 0 Res MT Res EU/ EEA Res TCN Fig 9.
Participants’ profession by place of work Participants' profession (%) by place of work (n=153) Dr general nurse psych nurse psychologist sw AHCP other 5 5 5 1 21 62 1 21 13 7 7 21 31 0 52 3 10 21 0 14 0 0 0 40 60 0 0 0 Hosp -85 Clinic - 29 Residence - 29 Mix - 10 Main findings 1.

Less than half of respondents said that patients they cared for in hospitals always or usually had a written MDCP and of these just under 2/3 of them stated that its implementation was either good or very good.
Clinic respondents thought that implementation of the MDCPs was slightly better in the clinic setting.

2.

Only just over half of all hospital respondents knew who was involved in the formulation of a MDCP.

3.

82% of the nurse cohort in a hospital setting stated that consent to treatment was usually or always obtained, dropping to 55% in the clinic cohort.

133 4.

57% of hospital respondents felt that patient’s awareness of their rights was either good or very good: this dropped to 43% in clinic cohort.
5.

92% of hospital staff and 80% of clinic staff thought that QoC in their setting was good or very good.

6.

90% of all respondents felt that patients are almost always or usually treated in a way that strengthened or restored their sense of dignity.

7.

94% of all respondents felt that staff almost always or usually gave sufficient consideration to patient’s feelings, wishes and rights.

8.
8.

82% of all respondents reported that they felt that their knowledge of the Mental Health Act was good or very good.

9.

70% of general nurses and AHCPs and about 50% of psychologists and social workers felt they needed training in mental health care.

EU/EEA staff felt most need for mental health care training when compared to other national groups.

10.

56% of nurses felt that there was a need for further training in general medical/ nursing care.

11.
11.

59% of respondents felt that there was a need for training on patient’s rights with differences by nationality and professional cohort.

12.

49% of respondents felt that there was a need for de-escalation training with differences noted between genders, nationality and professional grouping.

13.

85% of respondents stated that the liaison between respondent and individual members of care team was good or very good.

14.
14.

64% of all respondents were aware of mental health staff support structures with considerable variation by country of origin cohorts.

15.

59% of all respondents agreed or strongly agreed that the quality of mental health care delivery had improved in the previous year with differences by clinical setting and professional category.

16.

28% of all respondents reporting being unhappy with how other staff members acted towards them with differences noted between different genders and clinical setting.
17.

28% of all respondents were unhappy with how patients acted towards them in the previous month with differences noted between nationality of respondent, clinical setting and professional category.

18.

14% of all respondents reported being unhappy with how another member of staff acted towards a patient under their care with differences in responses by national cohorts, clinical setting and professional category.

134 Specific Questions 8.


Do patients you care for have a written multidisciplinary care plan (MDCP)?

Only 29% of professional hospital staff stated that hospital patients always had a MDCP.

Although this proportion increased to just under half of respondents if one had to add the cohort saying that patients usually had a care plan, 43% stated that this was not the case (sometimes, rarely, never) and another 9% stated that they did not know (Fig 10).

Fig 10.
Fig 10.

Professional hospital staff feedback on MDCP Professsional hospital staff on whether pts in hospital have written MDCP % (n=85) 29 32 19 6 5 always usually sometimes rarely never 9. Who is involved in drawing up the MDCP?

9 ?

Fig 11.
9 ?

Fig 11.

Professional hospital staff feedback on who is involved in drawing up MDCP Hosp professional staff and knowledge of who is involved in drawing up MDCP % (n=85) Yes No 49% 51% 135 Just over half of all respondents in hospitals (Fig 11) knew who was involved in the formulation of a MDCP, possibly indicating a lack of knowledge about, or experience in, MDCP formulation and use.

10.

How do you describe the way the MDCPs are implemented ?
Of the staff who reported that patients had an MDCP, 2/3 of professional hospital and clinic staff thought that the implementation of MDCPs was good or very good (Fig 12).

When general nurses’ views were compared with those of psychiatric nurses, psychiatric nurses appeared to be less satisfied with MDCP implementation in both hospital and clinic setting.
Whilst there were no particular differences between views of hospital and clinic general nurses, clinic psychiatric nurses appeared to view MDCP implementation more favourably in the clinic setting than in the hospital setting (Fig 13).

Fig 12.

Hospital nursing staff feedback on implementation of MDCP Nurses' description of MDCP implementation in hospitals and clinics where patients they care for have a written MDCP (n=86) 48 16 20 12 2 2 v good good fair poor v poor ?

Fig 13.
Fig 13.

Nurses (hospital & Clinics) feedback on implementation of MDCP Nurse cohorts' decription of MDCP inplementation in hospitals and clinics % v good good fair poor v poor 67 20 11 2 0 56 25 6 6 6 50 38 12 60 40 0 0 0 0 0 hosp GN - 45 Hosp PN - 16 clinic GN - 8 clinic PN - 5 136 11.

Do patients admitted voluntarily in a ward or residence give written consent prior to being given the required care and treatment?

Consent to treatment is a fundamental patient right.
Whilst only 56% of nurse cohort in a hospital setting stated that this was always the case, the figure increased to 82% when the ‘usually’ group was included (Fig 14).

The corresponding figures from the clinic nursing cohort were less, with proportion of nurse respondents in a clinic setting stating that this was always the case falling to 1/3 and the figure increasing to just over a half when the ‘usually’ group was included (Fig 15).

More needs to be done to safeguard this right.


When the replies given by different nurse cohorts in hospitals were compared to each other, there were some differences (Fig 16).

Fig 14.

Hospital nurses’ feedback on patient consent Hosp nurses on whether voluntary patients give written consent prior to treatment in hospitals (n=62) always usually sometimes rarely never ?
56 26 6 3 5 3 Fig 15 Clinic nurses’ feedback on patient consent Clinic nurses on whether voluntary patients give written consent prior to treatment in clinics (n=9) always usually sometimes rarely never ?

33 22 22 11 11 0 137 Fig 16.

General and psychiatric nurses’ feedback on patient consent in hospital Voluntary pts giving written consent prior to treatment in hospitals by diff nurse cohorts % (n=60) general nurse psych nurse 69 55 32 12 19 2 4 0 7 0 always usually sometimes rarely never 12.
How do you describe the patients’ level of awareness of their rights as patients?

Overall, just over half of all respondents felt that patients’ awareness of their rights was either good or very good (Fig 17).

When this data was analysed by setting, this figure remained the same in the hospital setting (Fig 18), falling to 1/3 of respondents in the clinic setting, but increased to more than 2/3 in the residential setting.
Fig 17 Feedback on awareness of patient rights Respondents' description of pts' awareness of their rights % (n=148) 39 28 15 11 7 v good good fair poor v poor 138 Fig 18 Feedback on awareness of patient rights by setting Respondents' description of pts' awareness of their rights by setting % v good good fair poor v poor 10 13 20 39 18 0 8 58 30 4 3 7 17 56 17 7 11 28 39 15 hosp - 84 clinics - 24 res - 29 mix - 11 When general nurses’ and psychiatric nurses’ views on patient awareness was considered, psychiatric nurses were more likely to have a favourable view about the level of patient awareness than general nurses (74% & 51% respectively) (Fig 19).
Fig 19 Nurses’ feedback on awareness of patient rights Nurses' description of patients' awareness of their rights % v good good fair poor v poor 47 27 37 23 14 15 11 17 7 3 gen nurses - 65 psych nurses -30 139 A quarter of hospital nurses described patients’ awareness of their rights as being poor or very poor, with the majority of clinic respondents saying that this was fair.

Views of the residence cohort were much more favourable (Fig 20).
Fig 20 Nurses’ feedback on awareness of patient rights by setting Nurses' description of pt awareness of their rights by setting % v good / good fair poor / v poor 80 59 25 16 53 40 7 10 10 Hosp - 70 clinics- 15 Res - 10 13.

How do you describe the quality of care being provided to patients in your unit during the last year?
Fig 21 Respondents views on Quality of Care Respondents description of QoC % (n=146) v good good fair poor v poor 1 1 25 13 60 Overall, 85% of respondents thought the QoC provided in their units was good or very good (Fig 21).

When respondents were stratified by unit, 92% of hospital staff and 80% of clinic staff thought QoC 140 in their setting was good or very good, while this dropped to 72% in respondents at residences.

In the latter, 10% felt that QoC was poor or very poor (Fig 22).
Fig 22 Respondents views on Quality of Care by setting Respondents' description of QoC in different settings % v good good fair poor v poor 65 27 55 42 38 8 0 0 20 17 17 0 0 7 3 Hosp - 83 Clinic - 24 Res - 29 When general nurses’ perception of QOC was compared with that of psychiatric nurses, general nurses were less likely to think that QOC was better in comparison with psych nurses (v good: 29% vs 37%, good 57% vs 60%) (Fig 23).
Fig 23 Different nursing cohorts’ views on Quality of Care Description of QoC by general nurses and psych nurses % v good good fair poor v poor 57 29 60 37 12 2 0 3 0 0 General nurse - 65 Psych nurse - 30 141 15.

Do you feel that patients are treated in a way that strengthens or restores their sense of dignity?

Overall, 90% of respondents felt that patients are almost always or usually treated in a way that strengthens or restores their sense of dignity (Fig 24).
Fig 24 Respondents views on treatment with dignity Pts treated with dignity (n=152) always usually sometimes rarely never 1% 0% 9% 34% 56% 16.

Do you feel that staff give sufficient consideration to patients’ feelings, wishes and rights?

Overall, 94% of all respondents felt that staff almost always or usually gave sufficient consideration to patient’s feelings, wishes and rights (Fig 25).

This is in keeping with the staff’s views about whether patients were being treated with dignity.
Fig 25 Respondents views on consideration to patients’ feelings wishes & rights Consideration to pts' feelings, wishes & rights by staff (n=151) always usually sometimes rarely never 4% 2% 0% 40% 54% 142 17.

How do you rate the level of your knowledge of the Mental Health Act (various orders, issues related to mental capacity, minors, rights of users and carers)?
82% of professionals in all clinical settings reported that they felt that their knowledge of the Mental Health Act was good or very good (Fig 26).

When staff were stratified by type of unit, all clinic staff said that this was good or very good, whilst about 20% each of respondents in hospitals and in residences felt that their knowledge was fair or poor (Fig 27).
Fig 26 Professionals rating of own knowledge of Mental Health Act Professionals' rating of their knowledge of Mental Health Act (n=126) 62 20 15 v good good fair poor v poor 2 1 Fig 27 Professionals rating of own knowledge of Mental Health Act by setting Professionals rating of their knowledge of Mental Health Act by Unit % v good/good fair poor / vpoor 100 80 79 16 4 0 0 21 0 hosp - 80 clinic - 21 residence - 14 143 18.
Need for training in mental health care A majority (59%) of all respondents stated that they felt the need for training in mental health care (Fig 28).

Mental health care is the core function of their service and should be followed up as necessary by management.

When this data was analysed by professional groupings, around 70% of general nurses and AHCPs, and about 50% of psychologists and social workers felt there was such a need.

Only 28% of psychiatric nurses thought this would help them (Fig 29).
Fig 28 Professionals views on own need for training in mental health care Respondents ' views on need for training in mental health care (n=151) yes no 41% 59% Fig 29 Views on own need for training in mental health care by professional cohort Professional group and need for training in mental health care (%) yes 67 53 46 71 28 GN - 65 PN - 25 Psych - 15 sw - 13 AHCP - 9 144 Overall, EU/EEA staff felt most need for mental health care training when compared to other national groups (78%)(Fig 30).
When hospital general nurses were stratified by nationality, the findings also reflected this (Fig 31).

Nursing respondents in clinics and residences were practically all Maltese nationals.
Fig 30 Respondents views on own need for training in mental health care by nationality Respondents (%) feeling the need for training in mental health by nationality MT -122 EU / EEA - 9 TCN - 20 78 60 50 MT -122 EU / EEA - 9 TCN - 20 Fig 31 Hospital nursing professionals’ views on own need for training in mental health care by nationality Hospital general nurses views on mental health care training by nationality GN hosp MT - 35 GN Hosp EU - 5 GN Hosp TCN - 12 74 80 58 GN hosp MT - 35 GN Hosp EU - 5 GN Hosp TCN - 12 145 Whilst the majority of hospital general nurses were in favour of mental health care training irrespective of years of working in mental health services (Fig 32), only psychiatric nurses with more than 20 years mental health care work experience expressed, in their majority, a need for further training (Fig 33).
Fig 32 General Nurses’ views on need for training in mental health care by time spent working in mental health care General nurses perceived need of mental health care training by years of service % <1yr 1-5yr >5-10yr >10-20yr >20yr 100 73 62 67 64 38 33 36 27 0 GN yes - 47 GN no - 19 Fig 33 Psychiatric Nurses’ views on need for training in mental health care by time spent working in mental health care Psychiatric nurses perceived need for mental health care training by years of service % <1yr 1-5yr >5-10yr >10-20yr >20yr 100 100 80 83 60 40 20 17 0 0 PN yes - 6 PN no - 18 146 19.
Need for training in general medical / surgical care A small majority of nurses felt that there was a need for further training in general medical/ nursing care (Fig 34).

Nationality did not appear to affect outlook, at least in general nurses (Fig 35).

Clinic nurses, both general nurses and psychiatric nurses, appeared to feel the need for such training more than their hospital counterparts.
At the same time, psychiatric nurses appeared to feel the need for such training much more than general nurses, both in the hospital as well as in the clinic settings (Fig 36).
Fig 34 Nursing Professionals views on need for training in general medical / surgical care Nurse cohort and need for training on general medical / surgical care % (n=89) yes no 44% 56% Fig 35 Nurses’ views on need for training in general medical / surgical care by nationality Nurses perceived need for training in medical/ surgical care by nationality (%) MT GN - 45 EU GN - 5 TCN GN - 15 MT PN - 20 EU PN - 0 TCN PN - 2 60 41 40 33 MT GN - 45 EU GN - 5 TCN GN - 15 MT PN - 20 EU PN - 0 TCN PN - 2 0 0 147 Fig 36 Nurses’ views on need for training in general medical / surgical care by setting Nurses perceived need for training in medical / nursing care by unit (%) Hosp GN - 51 clinic GN - 9 Hosp PN - 18 Clinic PN - 5 80 39 44 50 Hosp GN - 51 clinic GN - 9 Hosp PN - 18 Clinic PN - 5 Fig 37 Nurses’ views on own need for training in general medical / surgical care by gender Nurses perceiving a need for medical / surgical training by gender % M GN - 24 F GN - 40 M PN - 10 F PN - 13 70 42 38 40 M GN - 24 F GN - 40 M PN - 10 F PN - 13 Gender appeared to have a slight effect on general nurses’ perceived need for medical / surgical nursing care: however, there was a considerable difference in gender when psychiatric nurses’ responses were analysed by gender (M: F= 40%: 70%) (Fig 37).
There was no apparent relationship between nurses’ perceived need for training in general medical / surgical nursing care with number of years working as a health care professional.

148 20.

Need for training on patient rights Overall, 59% of respondents felt that there was a need for training on patient’s rights (Fig 38), with only a minor difference between males and females (Fig 39).
There was however a considerable difference in perceived need for training on patient rights, when one considered nationality, with EU/EEA nationals being less likely to express such a need than the MT and TCN colleagues (Fig 40), and amongst the different professional cohorts, with the majority of AHCPs, psychologists and general nurses expressing such a need (Fig 41).
No relationship was observed between nurses’ perceived need for training in patient rights and number of years working as a health care professional.

Fig 38.

Respondents perceived need for training on patient rights Proportion of staff needing training on patient rights (n=150) yes no 41% 59% Fig 39.

Respondents perceived need for training on patient rights by gender Proportion of respondents needing training on patients' rights by gender % (n=150) M - 46 F - 104 55 60 M - 46 F - 104 149 Fig 40.
Respondents perceived need for training on patient rights by nationality Staff needing training on patient rights by nationality % (n=150) MT - 121 EU / EEA - 9 TCN - 20 60 55 44 MT - 121 EU / EEA - 9 TCN - 20 Fig 41.

Different professional cohorts perceived need for training on patient rights Perceived need for training on patient rights by different professional cohorts (%) yes 67 100 46 58 38 GN - 65 PN - 25 Psych - 15 sw - 13 AHCP - 9 21.
Need for training in de-escalation Just over half the respondents felt that there was a need for de-escalation training (Fig 42), with the proportion of males being slightly higher than females (Fig 43).

There was a considerable difference between nationality grouping of respondents with both EU/ EEA staff feeling a greater need than their Maltese counterparts (Fig 44).
Different professionals had a different outlook on the need for de-escalation training, with psychiatric nurses feeling the greatest need (71%), followed by general nurses and social workers (58%, 57%), 150 and the least need being felt by psychologists (36%)(Fig 45).

In this regard, the difference between general nurses based at a hospital or in clinics place of work was minor (52% vs 47%) (Fig 46).
However when one considered years of service of hospital general nurses and perceived need for de-escalation training, it was noted that less experience correlated well with greater perceived need for training until years of service exceeded 5 years, with a marked increase in perceived need after 20 years’ service.

This was not the situation with clinic general nurses (Fig 47).

Fig 42.
Fig 42.

Respondents perceived need for training on de-escalation techniques Staff requesting training on deescalation techniques (n=149) yes no 49% 51% Fig 43.

Respondents perceived need for training on de-escalation techniques by gender Training on deescalation techniques by gender (n=149) M - 45 F - 104 56 49 60 50 40 30 20 10 0 M - 45 F - 104 151 Fig 44.
Respondents perceived need for training on de-escalation techniques by nationality Training on de-escalation techniques by nationality (n=149) MT EU / EEA TCN 67 65 48 MT EU / EEA TCN Fig 45.

Perceived need for training on de-escalation techniques by professional cohort Need for training in de-escalation techniques by professional cohort % yes 71 58 57 36 general nurse - 64 psych nurse - 24 psychologist - 15 sw - 13 Fig 46.
Perceived need for training on de-escalation techniques by nurses in hospitals and clinics Nurses in hospitals and clinics and need for training in deescalation techniques Yes % No % 52 53 48 47 all hosp nurses - 69 all clinic nurses - 15 152 Fig 47.
Nurses’ perceived need for training on de-escalation techniques by years working in mental health services Perceived need by nurses in hospitals and clinics for training in de- escalation techniques by years working in mental health services % Hosp Yes Clinic Yes 100 67 50 50 50 50 31 25 46 33 <1yr (n=5,2) 1-5yr (n=27,2) >5-10yrs (n=16,4) >10-20yrs (n=8,4) >20yrs (n=13,3) 23.

How do you rate the liaison between you and the individual members of the care team involved in a patient’s management?
Whilst overall 85% of respondents stated that the liaison between respondent and individual members of care team was good or very good (Fig 48), residence staff had a lower favourable perception when compared to hospital and clinic staff (73%, 89% and 87% respectively) (Fig 49).

Fig 48.

Rating of inter-professional liaison Rating of liaison between staff and members of care team % (n=148) 55 30 10 3 2 v good good fair poor v poor 153 Fig 49.
Rating of inter-professional liaison by clinical setting Rating of liaison between staff and members of care team by unit % v good good fair poor v poor 60 29 52 35 45 28 21 5 4 2 9 4 0 7 0 Hosp - 85 clinic - 23 Res - 29 When grouped by country of origin, TCNs reported a better liaison rating than other cohorts (95% compared to 84% for Maltese staff and 78% for EU/EEA staff) (Fig 50).
Males reported better perceptions about this issue than females with 91% and 81% respectively claiming this was good or very good (Fig 51).

Fig 50.

Rating of interprofessional liaison by nationality Rating of liaison between staff and members of care team by nationality of respondents % v good good fair poor v poor 55 56 29 22 57 38 11 3 2 11 11 0 5 0 0 MT 119 EU / EEA - 9 TCN - 21 154 Fig 51.
Rating of inter-professional liaison by gender Rating of liaison between staff and members of care team by gender % M - 47 F - 102 57 54 34 27 12 4 fair 5 0 4 2 poor v poor v good good 24.

Are you aware of any support structures available to help support staff members suffering from mental health issues?
Whilst almost two thirds of all respondents were aware of mental health staff support structures (Fig 52), there was considerable variation in results when analysed by country of origin cohorts, with TCNs reporting least awareness (50%) (Fig 53).

Respondents from the clinic cohort and particularly clinic psychiatric nurses were most aware about their existence (Fig 54, 55).

Fig 52.
Fig 52.

Awareness of staff support structures Respondents' awareness of MH staff support structures % (n=120) 64 36 yes no 155 Fig 53 Awareness of staff support structures by nationality Responders awareness of MH staff support structures by staff nationality % (n=120) 65 35 Yes No 78 22 50 50 MT --97 EU/EEA - 9 TCN - 14 Fig 54.

Respondent’s awareness of support structures by clinical setting.
Respondents' awareness of support structures by clinical setting (%) 60 40 Yes no 79 21 60 40 hosp - 83 clinics - 18 residences - 29 Fig 55.

Awareness of support structures in different nurse cohorts in hospital wards and clinics.

Awareness of staff support structures in different nurse cohorts in hospital and clinics % Yes no 63 37 50 50 56 44 83 17 hosp GN - 52 hosp PN - 18 clinic GN - 9 clinic PN - 6 156 25.

How do you rate these support structures?


The majority of respondents who were aware of the existence of support structures rated them as being good or very good by different majorities in the various cohorts, the least being in the hospital group (Fig 56).

This was again the situation when country of origin of respondents was analysed, the lowest majority being in the MT group (Fig 57).

Fig 56.

Rating of support structures by staff who were aware of their existence by clinical setting.
Rating of support structures by staff who were aware of their existence by clinical setting % (n=101) good/v good fair poor/v poor ?

54 18 22 6 75 83 64 19 6 0 13 4 0 18 18 0 hosp - 50 clinic - 16 residences - 24 mixed - 11 Fig 57 Rating of staff support structures by staff who were aware of their existence by nationality Rating of support structures by staff who were aware of their existence by nationality % (n=101) good/v good fair poor/v poor ?
64 72 73 16 16 4 MT -83 14 14 0 EU -7 18 9 0 TCN-11 157 26.

Do you think that there has been an improvement in the quality of mental health care delivery in the last year?

The majority of respondents (59%) agreed or strongly agreed that the quality of mental health care delivery had improved in the previous year (Fig 58).

However, when grouped by setting, this perception increased to about two thirds in the hospital and residence cohorts but decreased to 41% in clinic staff replies (Fig 59).
There were minor differences in replies when country of origin was considered (Fig 60).

Fig 58 Respondents’ views on mental health care delivery Respondents views on improvement in mental health care delivery % (n=153) 46 28 13 strongly agree 4 1 agree neutral disagree strongly disagree 8 ?
Fig 59 Respondents’ views on mental health care delivery by clinical setting Respondents views on improvement in mental health care delivery by setting (% within cohort) strongly agree agree neutral disagree strongly disagree ?
55 26 46 33 38 28 12 4 2 0 8 8 4 0 17 17 0 0 hosp -85 clinics - 24 res - 29 158 Fig 60 Respondents’ views on mental health care delivery by nationality Respondents views on improvement of mental health care delivery by nationality strongly agree agree neutral disagree strongly disagree ?
47 30 11 6 5 1 67 33 30 30 15 25 0 0 0 0 0 0 MT - 123 EU/EEA - 9 TCN - 20 When respondents were grouped in particular professional categories and by professional setting, it was noted that general nurses had a better perception about improvements to mental health care in previous year than psychiatric nurses, whether the setting was hospitals or clinics, whilst hospital staff gave better ratings than clinic staff, whether they were general or psychiatric nurses (Fig 61).
There appeared to be a positive relationship between hospital general nurses perceived improvement in mental health care delivery in the previous year with respondent’s increasing years of service (Fig 62).

This was not evident in the replies given by the psychiatric nurses’ cohort (Fig 63).

Fig 61.
Fig 61.

Hospital nurses’ views on mental health care delivery by clinical setting Nurse cohorts on improvement of mental health care delivery by hospital and clinic setting % strongly agree agree neutral disagree strongly disagree ?
53 25 15 45 33 22 50 33 50 33 17 6 2 0 0 0 0 6 6 6 0 0 0 0 Hosp gen nurse - 53 Clinic gen nurse - 18 Hosp psych nurse - 9 Clinic psych nurse - 6 159 Fig 62 Hospital general nurses’ views on mental health care delivery by years worked in mental health care by years of service Hospital general nurses' views on improvement in MHC delivery in previous year by years of service (n=51) stro agree agree neutral disagree str disagree 50 35 15 57 29 14 67 33 0 0 0 0 0 0 0 50 30 10 10 0 1-5yrs - 26 >5-10yrs - 7 >10-20yrs - 6 >20yrs - 10 Fig 63 Hospital psychiatric nurses’ views on mental health care delivery by years worked in mental health care by years of service Hospital psychiatric nurses' views on improvement in MHC delivery in previous year by years of service (n=17) stro agre agree neutral disagree str disagree 100 56 67 33 33 50 50 0 0 0 0 0 11 0 0 0 0 0 0 0 1-5yrs >5-10yrs >10-20yrs >20yrs 27.
In the last month, were there instances when you felt unhappy with the way a member of staff acted towards you?

(actions which border on verbal, mental, physical or sexual abuse) Overall, a substantial minority of respondents reporting being unhappy with how other staff members acted towards them (Fig 64).

160 Fig 64 Respondents being unhappy with other staff members’ action towards them.
Respondents reporting being unhappy with how other staff member acted towards them in previous month % (n=153) Yes No 28% 72% There was a considerable variation by nationality with the proportions of Maltese and EU/EEA respondents being thrice and twice as unhappy as that of TCNs (Fig 65).
Fig 65 Respondents being unhappy with other staff members’ action towards them by nationality Respondents being unhappy with how other staff members acted towards them in previous month by nationality % yes no 88 90 22 10 69 31 MT - 123 EU / EEA - 9 TCN - 21 The proportion of female staff being unhappy was almost 50% higher than that of their male colleagues (Fig 66).
The residential staff cohort was the lowest to express being unhappy and was less than half that of their hospital and clinic colleagues Fig 67).

Clinic nurses were more unhappy with their colleagues’ actions (40%) than hospital nurses (31%) (Fig 68).
Of note was the finding that hospital psychiatric nurses were almost thrice as likely to report being unhappy with a staff members action towards them than hospital general nurses (Fig 69), a different situation to that between clinic general nurses and clinic Psychiatric nurses.

161 Fig 66 Respondents unhappy with other staff members’ action towards them by gender.
Respondents being unhappy with how other staff members acted towards them in previous month by gender % yes no 79 69 21 31 M - 47 F - 106 Fig 67 Respondents unhappy with other staff members’ action towards them by clinical setting Repondents being unhappy with how other staff members acted towards them in previous month by unit % YES NO 71 29 67 33 86 14 Hosp - 85 clinic - 24 Res - 29 Fig 68.

Nursing cohorts’ unhappy with other staff members’ action towards them by clinical setting.
Nurses in hospitals and clinics unhappy with how member of staff acted towards them Yes % No % 69 31 60 40 all hosp nurses - 71 all clinic nurses - 15 162 Fig 69.

Reported unhappiness of different nurse cohorts with other staff members’ action towards other staff in different clinical settings.
Proportion of nurse cohorts in hospitals and clinics unhappy with how member of staff acted towards other staff Hosp GN - 53 Hosp PN - 18 Clinic GN - 9 Clinic PN - 6 61 21 44 33 Hosp GN - 53 Hosp PN - 18 Clinic GN - 9 Clinic PN - 6 28.

In the last month, were there instances when you felt unhappy with the way a patient acted towards you?
(actions which border on verbal, mental, physical or sexual abuse) More than a quarter of respondents were unhappy with how patients acted towards them in the previous month (Fig 70).

There was no gender difference (Fig 71), but considerable differences were noted when results were analysed by nationality with a majority of EU/ EEA staff (56%) being unhappy compared to over a third of TCNs and a quarter of Maltese respondents (Fig 72).
Fig 70 Respondents being unhappy with patient’s action towards them Staff unhappy with way patient acted towards them in past month (%) (n=153) Yes No 28% 72% 163 Fig 71 Respondents being unhappy with patient’s action towards them by gender Staff unhappy with how patients acted towards them in past month by gender % yes no 72 72 28 28 M - 47 F - 106 Fig 72 Respondents being unhappy with patient’s action towards them by nationality Staff unhappy with how patients acted towards them in previous month by nationality % Yes No 56 44 62 38 76 24 MT - 123 EU / EEA - 9 TCN - 21 Staff working in hospitals and in residences were substantially more likely to report an unpleasant patient episode than those in Clinics (Fig 73).
This was also the finding when the responses of all nurses working in these institutions were analysed (Fig 74).
However, when these cohorts were divided into general and psychiatric nurses, it was noted that the proportion of general nurses unhappy with patients was practically the same (1/3) in both hospitals and clinics, whilst the proportion of hospital psychiatric nurses who reported being unhappy with patients was much higher than that of hospital general nurses as well as when compared with clinic psychiatric nurses (Fig 75).
164 Fig 73 Respondents being unhappy with patient’s action towards them by clinical setting Staff unhappy with how patients treated them in previous month by unit % 35 Yes 17 28 Hosp - 85 clinic - 24 Res - 29 Fig 74 Nurses’ unhappiness with patient’s action towards them by clinical setting Nurses in hospitals and clinics unhappy with how a patient acted towards them Yes % No % 63 37 80 20 all hosp nurses - 71 all clinic nurses - 15 Fig 75 Nurse cohorts’ unhappiness with patient’s action towards them by clinical setting Proportion of nurse cohorts in hospitals and clinics unhappy with how a patient acted towards them Yes % 50 32 33 Hosp GN - 53 Hosp PN - 18 Clinic GN - 9 Clinic PN - 6 0 165 29.
In the last month, were there instances when you felt unhappy with the way a member of staff acted towards a patient under his/her care?

14% of respondents reported being unhappy with how another member of staff acted towards a patient under their care (Fig 76).

There was considerable variation in responses by national cohorts, with only 5% of TCNs reporting such actions, compared to twice that by EU/EEA and thrice that by Maltese staff (Fig 77).
There was no particular gender difference in outlook (Fig 78).
Fig 76 Respondents’ unhappiness with how another member of staff acted towards a patient Staff unhappy with how other member of staff acted towards a patient under his care % (n=153) Yes No 86 14 Yes No Fig 77 Respondents’ unhappiness with how another member of staff acted towards a patient by nationality Staff unhappy with how other member of staff acted towards a patient in their care by nationality % 16 11 5 MT - 123 EU / EEA - 9 TCN - 21 166 Fig 78 Respondents’ unhappiness with how another member of staff acted towards a patient by gender.
Staff unhappy with how other member of staff acted towards a patient under their care by gender% M - 47 F - 106 15 14 M - 47 F - 106 The lowest proportion (7%) of reported unhappiness was expressed by staff in residences with the highest by clinic staff (20%) (Fig 79).

When results were analysed by nursing professions in hospitals and clinics, the proportion of hospital nurses reporting being unhappy was slightly higher than for those working in clinics (Fig 80).
Fig 79 Respondents’ unhappiness with how another member of staff acted towards a patient by clinical setting.
Staff unhappy with how other member of staff acted towards a patient under their care by unit % 20 16 7 Hosp - 85 clinic - 24 Res - 29 167 Fig 80 Nurses reporting unhappiness with how another member of staff acted towards a patient by clinical setting Nurses in hopsitals and clinics unhappy with how a member of staff acted towards a patient Yes % No % 83 87 17 13 all hosp nurses - 71 all clinic nurses - 15 However, when these cohorts were divided into general and psychiatric nurses, it was noted that the proportion of general nurses unhappy with patients in hospitals was half that in clinics, whilst the proportion of hospital psychiatric nurses who reported being unhappy with patients was much higher than that of hospital general nurses as well as when compared with clinic psychiatric nurses (Fig 81).
Fig 81.

Reported unhappiness of different nurse cohorts with other staff members’ action towards a patient in different clinical settings.

Proportion of nurse cohorts in hospitals and clinics unhappy with how a staff member acted towards a patient Yes % 33 22 11 Hosp GN - 53 Hosp PN - 18 Clinic GN - 9 Clinic PN - 6 0 168 Conclusions Mental health staff play a major role in, and exert a huge influence on, the delivery of mental health care.
Their appropriate training, support and well-being have a considerable impact on the quality of care given to patients entrusted to them.

Their perspectives on the bread and butter issues they face every day are therefore of significant importance in any analysis of patient rights and quality of care being given.

This study provided a snapshot of staff views on these of issues related to patient rights and their care of in licensed mental health facilities in late 2019.
Gauging their views as service providers on service delivery should be useful in identifying any lacunae and implementing strategies to give better support and training to providers and improved service to clients.

The main issues under investigation were perceptions about MDCPs, patient consent and patient dignity, QoC, staff training and staff support and relationships with patients and other staff.
MDCPs MDCPs play a crucial role in setting out the various interventions required to address the patient’s holistic needs, expected outcomes, responsibilities and timeframes and will necessarily vary over time.

This directly impacts QoC.

Additionally, the formulation of a MDCP has also been a legal requirement for all patients since 2014.
It is of concern that less than a third of professional hospital staff said that hospital patients always had a care plan, with just 51% of hospital staff knowing who was involved in their formulation.

This possibly indicates either a lack of awareness of the need for such plans, or of the relevant legal requirements or a lackadaisical approach by those who should know better.
Just under 2/3 of all respondents who had stated that patients they cared for in hospitals had a written MDCP stated that its implementation was either good or very good (Fig 12).

Although this is a positive finding, in order to put this finding in a proper context, one has to remember that less than half of the respondents had stated that their patients usually or always had a written MDCP.
It would appear that psychiatric nurses had a more critical outlook then general nurses with regards to implementation of MDCP, possibly because of their specialised training, whilst there appeared to be agreement that implementation of MDCP was slightly better in the clinic setting.

Although the number of respondents was low, this might be a positive indication of better community based mental health services.
Patient consent and awareness of rights 169 It would appear from staff responses that patient consent is given in most cases in hospitals and somewhat less in clinics.

This is positive but some more effort is required.

With regards to patient’s awareness of their rights, there appeared to be a different outlook by staff depending on the care setting.
The Clinic staff group had the lowest (34%) proportion that thought that this was good or very good when compared to the cohorts of their hospital and residence colleagues.

However, ¼ of hospital staff thought that this was poor or very poor.

This is of concern.

Although there may be a number of factors affecting this result, this might in part be a reflection of the contact with, and time spent by, the health professionals with the patient.
QoC, dignity and consideration to patient’s feelings Staff had positive perspectives on QoC with the proportion of staff stating that this was good or very good being high (lowest figure (72%) in resident respondents).

Psychiatric nurses were somewhat more likely to have a good or very good perspective on QoC compared to the general nurse cohort.
A very large majority of staff (90%) felt that care was being delivered in a way that strengthened the patient’s dignity and gave sufficient consideration to their feelings.

With regards to mental health care delivery, this was seen as being positive in both the hospital and clinic setting where a majority of respondents felt that this had improved in the previous year, whilst only a minority of residence staff expressed this.
The proportion of general nurses who agreed that delivery had improved was less than that in psychiatric nurses’ cohort.

Staff training The majority of all staff felt a need for training on mental health care, patient rights and de-escalation techniques.

Unsurprisingly, psychiatric nurses were the cohort with the lowest proportion of respondents stating that they felt a need for mental health care training and for training on patient rights.
However, when compared to general nurses, female psychiatric nurses expressed a greater need for training in general medical / surgical care, being almost twice more likely to state this.

Furthermore, they were the group feeling the greatest need for training in de-escalation techniques.
Of note was the finding that a very large majority of hospital nurses with less than 5 years’ work experience in mental health services expressed a need for training in de-escalation techniques, possibly indicating a need for training and support to build their confidence in the initial period of work in mental health services.
Staff unhappiness A major factor affecting mental health at the workplace is how staff members get on with each other More than a quarter of respondents reported being unhappy with how a staff member acted towards 170 them in the previous month with the largest cohort being MT, female, working in clinics or in a ward setting.

Hospital psychiatric nurses were almost 3 times more likely to report this compared to hospital general nurses.
The way that clients are perceived to act with service providers affects service providers.

More than a quarter of respondents reported being unhappy with how a patient had acted towards them in the previous month with the largest cohort being of EU/EEA nationality, in hospital setting.

Also, Hospital psychiatric nurses were more likely to report this compared to hospital general nurses.
On the other hand, the way a service provider cares for a patient has an incalculable effect on the patient’s path to better mental wellbeing.

A small proportion of staff reported being unhappy with how a staff member acted towards a patient under their care in the previous month with the largest cohort being of MT nationality.

Hospital nurses were more likely to report this than clinic nurses and hospital psychiatric nurses were 3 times more likely to report this compared to hospital general nurses.
This might be an area were staff should be encouraged further and better empowered to report to management any perceived shortcomings to allow proper investigation of any incidents and appropriate addressing of any findings.

This would hopefully reduce such incidents, assist in improving staff morale, and improve safeguarding of patient rights.

Support structures Care provision, particularly in the mental health setting, can be extremely stressful.
The finding that over a third of all respondents reported being unaware of staff mental health support structures is worrying.

Hospital psychiatric nurses were almost 3 times more likely to report this compared to hospital general nurses.

TCNs and MT nationals were less likely to know of them than their EU/EEA counterparts.

However, the staff rating of these structures appeared to be quite positive.
It is positive that management is supportive of staff by providing the necessary support services for them.

However, staff providing services in a mental health facility can hardly access such available services if they are unaware of their existence.

It is a system failure if management fails to advertise these services properly or facilitate their uptake.
Like any other individual, such persons may have worries relating to confidentiality, stigma and negative consequences if they attempt to seek assistance.

Particular attention needs to be given to allay such understandable anxieties.

171 SECTION C: RESPONSIBLE CARER TELEPHONE INTERVIEWS [N=24] DEMOGRAPHIC DATA 50% of Responsible Carers were Female and 50% were Males .

The average age of the Responsible Carers interviewed was 52 years.

All interviewed Responsible Carers were Maltese.


QUESTIONNAIRE FINDINGS 33.3% have been the Responsible Carer for less than 1 year whilst another 25% have been Responsible Carers for 10-20 years.

75% of Carers know who the members of the care team are.

All the Responsible Carers interviewed were responsible for patients being taken care of on in- patient basis.

50% of Responsible Carers stated that the patients they are responsible for cannot leave the hospital/residence that they are residing in.
50% of the Responsible Carers stated that they gave a written consent to act as the patient’s responsible carer.

91.7% of the Responsible Carers stated that they know what their role entails.

33.3% of Responsible Carers stated that during the last month before the interview, members of the caring teams had asked to speak to them only twice; whilst another 25% stated that during the last month they were never asked to be spoken to.
50% of Responsible Carers stated that the quality of care provided to the patient is good.

33.33% of Responsible Carers stated that the environment of the facility where the patient is being treated is only fair; whilst an equivalent 33.3% stated that their involvement in decisions taken about the patient’s care was only fair.

33.33% of Responsible Carers describe their involvement in decisions taken about the patient’s care as fair.
58.3% of Responsible Carers describe their relationship with the caring team as good.

172 Whilst 25% of Responsible Carers never asked to speak with members of the care team in the last month prior to the interview, another 25% did so once a week and 25% did so twice a week.

41.7% of Responsible Carers describe the relationship between the patient and the caring team as fair.

67% of Responsible Carers feel that their appointment as RC has helped the patient.
The main activities which these RC described as being beneficial to the patient are daily visits; ensuring that the patient has clean clothes and enough food and also speaking to the patient regularly.

75% of Responsible Carers stated that they do not experience any difficulties in performing their role as RC.

The Responsible Carers who stated that they have problems listed the following as being their main grievances: 1.

Not being given any information on the patient’s status.

2.
2.

There are instances where they wanted to take the patient out and the Carer on duty did not want to help the RC to move the wheelchair and Oxygen Cylinder.

3.

Language barrier in respect of several foreign Carers.

4.

Some Carers do not clean the feeding tubes and around the mouth of patients needing feeding assistance.

83% of Responsible Carers think that the patient feels safe at the facility.

92% of Responsible Carers do not feel the patient is treated differently compared to other patients.
66.66% of Responsible Carers do not have any complaints about aspects of the patient’s stay or treatment; with the remaining RC listing the complaints hereunder: 1.

When patient does not eat solids, liquid feeds are to be provided.

2.

Treatment.

3.

Food variety and quality.

4.

More activities are necessary, for example, cooking classes for long stay patients.

5.

Dignity.

6.

Lack of facilities.

7.

Quality of cleaning.


In the last month, there were no instances when the Responsible Carers felt unhappy with the way a member of staff acted towards them; whereas 16.66% of Responsible Carers felt unhappy with the 173 way a member of staff acted towards the patient; to cite one specific example given – when staff are transferred from one ward to another they should both leave an adequate handing over regarding the patients to their substitutes.
83.3% of Responsible Carers feel that the patient is being treated in a way that strengthens his/her sense of dignity.

58.3% of Responsible Carers feel that the care team give sufficient consideration to their feelings, wishes and rights as Responsible Carers.

COMMENTS/RECOMMENDATIONS BY RESPONSIBLE CARERS DURING THE TELEPHONE INTERVIEWS • Patients are to be motivated and not just institutionalised.
• Service given depends on Staff, with some Responsible Carers stating that Maltese Staff give a better service than foreigners.

• Part-time Carers are to be more well versed on the specific patients’ data and needs.

• For patients requiring assistance to bath there is no privacy.

• A change in environment is required - MCH environment needs immediate upgrading in many areas.

• There is no food variety-always the same.


• More flexible visiting hours are necessary in respect of Responsible Carers who work.

• For patients in residences, the Responsible Carer needs to go arrange specific matters in respect of the Service user during office hours, thus necessitating taking vacation leave every time.

• Service Users require more dignity – they are being left in a prison-like environment.
• The pension of retired Responsible Carers is not enough especially if it needs to cater for medicines not provided for via the NHS.

• More help is required in order to help patients find a job when not at MCH.

• Guidance and assistance are required in cases wherein an involuntary patient at MCH wishes to grant a power of attorney to the RC.

174 SECTION D: ASSESSMENTS OF THE CARE ENVIRONMENT 59 Environment Assessment visits were carried out during the last quarter of year 2019 by CMH Staff.
Units were scored according to the nature of the service delivered.

Inpatients and residential units were scored out of a maximum of 120 points.

Outpatient clinics and day care services were scored out of a maximum of 80 points.
The average scores attained were distributed as follows: Mater Dei Hospital (MDH) IN PATIENTS [n=27] Gozo General Hospital (GGH) Units Average Score % Score 1 2 105 / 120 87.5 82.50 / 120 68.8 Mount Carmel Hospital (MCH) 24 59.75 / 120 49.8 RESIDENCES [n=19] Dar Kenn Ghal Sahhtek Casa Hope SVPR Casa Maria St Thomas Community Living Suret il-Bniedem Richmond Foundation (Adult) Richmond Foundation (KIDS) Centru Tommaso Chetcuti CYPS (SLH) OUTPATIENT AND DAY CARE SERVICES [n=13] Psychiatric Out-Patients (MDH) Day Centres Mental Health Clinics 1 1 6 1 1 3 5 1 1 1 1 5 5 97 / 120 93 / 120 80.8 77.5 91.5 / 120 76.3 88 / 120 88 / 120 86 / 120 73.3 73.3 71.7 79.8 / 120 66.5 51 / 120 66 / 80 53 / 80 50 / 80 42.8 / 80 39.8 / 80 42.5 82.5 66.3 62.5 53.5 49.8 The assessment score for Mater Dei Hospital Psychiatric Unit was close to double the average score attained by the Mount Carmel Hospital wards grouped together.
The huge disparity in the care environment among the wards at Mount Carmel Hospital is tackled in more detail below.

The above table indicates also that there are also inadequate standards in the care environment in the temporary 175 Child and Youth residential service offered by Richmond Foundation and in the five mental health clinics housed in community centres.
ENVIRONMENTAL ASSESSMENT OF MOUNT CARMEL HOSPITAL WARDS The average score attained in the environmental assessment for the 24 inpatient wards at Mount Carmel Hospital grouped together was as follows: No Criterion (0 means worst – 5 or 10 means excellent) Weight Score % Upkeep of place Light Airiness Noise (very noisy=0) Cleanliness Unpleasant odours (foul smell=0) Smoking area available 0-5 2.29 45.8 0-5 3.17 63.4 0-5 2.63 52.6 0-5 4.04 80.8 0-5 2.96 59.2 0-5 2.96 59.2 0-5 2.58 51.6 Smoking area well insulated and no smell of cigarettes 0-5 2.33 46.6 flows to other areas Measures are in place to protect people against injury 0-5 2.42 48.4 through fire (fire doors, fire extinguishers, fire exit) Evidence of regular maintenance 0-5 2.54 50.8 The facility is accessible for people with physical 0-5 2.21 44.2 disabilities (ramps, lifts, adjustable beds, hoists) 12 There is an adequate area specifically designated as a 0-5 1.96 39.2 leisure area for service users 13 There are activities (e.g.
billiard table, board / card games, 0-5 1.29 25.8 gym, crafts, books etc) available for use by service users 14 There are ample furnishings, and they are comfortable and 0-5 2.25 45.0 in good condition 15 The toilet facilities are accessible, clean and working 0-5 2.79 55.8 properly 176 16 17 18 19 The toilet facilities allow privacy 0-5 2.67 53.4 The bathing facilities are clean and working properly 0-5 2.75 55.0 The bathing facilities allow privacy 0-5 2.88 57.6 The bathing needs of service users who have impaired 0-5 1.29 25.8 mobility or other physical disabilities are accommodated 20 The sleeping quarters provide sufficient space per service 0-5 2.42 48.4 user and are not overcrowded 21 22 23 24 The sleeping quarters allow for the privacy of service users 0-5 1.92 38.4 Bed linen is clean 0-5 2.96 59.2 Adequate bed space per bed for each patient 0-5 2.38 47.6 Service users can keep personal belongings and have 0-5 2.08 41.6 adequate lockable space to store them TOTAL 0-120 59.75 49.50 As may be seen from the above score sheet, Mount Carmel Hospital scored poorly on all the 24 environment aspects which were assessed by the Office of the CMH during the year 2019.
The ‘highest’ average scores were 4.04 [out of a maximum of 5] in respect of noisiness within caring environments, 3.17 [out of a maximum of 5] in respect of light and 2.96 [out of a maximum of 5] in respect of three other parameters – cleanliness in wards, cleanliness of bed linen and levels of unpleasant odours.
When looking at the total scores attained in the environmental assessment of the 24 individual wards, a huge disparity among wards is immediately evident, as can be seen from the following table: WARD FEMALE WARD 3A FEMALE DUAL DIAGNOSIS UNIT YOUTH RESIDENCE FEMALE WARD 22 FEMALE WARD 7 MIXED ADMISSION WARD - FEMALE Score (out of 120) % 95 88 88 85 85 83 79.2 73.3 73.3 70.8 70.8 69.2 177 MALE WARD 2 MIXED ADMISSION WARD - MALE HALF-WAY HOUSE FEMALE WARD 8 FEMALE WARD 1 MALE WARD 7 MALE DUAL DIAGNOSIS UNIT 83 81 72 63 62 60 60 MOUNT CARMEL HOSPOITAL AVERAGE 59.75 TEMPORARY MALE WARD 1 @ YOUTH RES.
SECURE UNIT - MALE FORENSIC UNIT – MALE SECURE UNIT - FEMALE MALE WARD 1 MALE INTELLECTUAL DISABILITY UNIT FORENSIC UNIT - FEMALE MALE WARD 3A ** MALE WARD 3B ** MALE WARD 8B MAXIMUM SECURITY UNIT - MALE ** closed between date of inspection and date of compilation of report It is pertinent to point out that between the date of inspection and the date of compilation of this report, two of the worst scoring wards (Male Ward 3A and Male Ward 3B) were finally closed down with most patients relocated in residential care outside Mount Carmel Hospital.
The closure of these two wards had been advocated by this Office in every annual report since the year 2015.

Further closures were being programmed for early 2020.

In the chart below, the scores attained by the individual MCH wards (in dark blue) are compared to the scores attained by the Psychiatric Unit at Mater Dei Hospital (in red), the two wards at Gozo General Hospital (in green) and the average score for all MCH wards together (in yellow).

Male Wards 3A and 3B have been removed from this chart.
178 This scenario is far from acceptable.

The physical environment forms an integral part of the patient and caring staff wellbeing.

It is not acceptable that the mental health patients residing at MCH are living in such an environment.
The Pareto curve shows that 80% improvement in the current abysmal situation can be achieved by targeting ward closure and relocation of the Maximum-Security Unit, Male Ward 8B, both Forensic wards, Male Intellectual Disability Unit, Male Ward 1and both Male and Female Secure Units.

It is recommended that the programme of ward improvement be aligned to address these wards as a matter of priority.
The CMH Office notes that in 2019, patients within Mount Carmel Hospital were moved to three vacated wards which were refurbished in order to provide better and more dignified care environments.

Some teething problems were witnessed by our team during the visitation and action was taken to bring these issues to the attention of management.
It is hoped that the ongoing planned refurbishment programme and its proposed timeframes are adhered to in the forthcoming months so that the meagre environmental assessment which this Office has repeatedly reported about and highlighted in the past 5 years, becomes history.
179 ENVIRONMENTAL ASSESSMENT OF COMMUNITY RESIDENTIAL FACILITIES Whilst the inpatient unit at Mater Dei Hospital continues to provide the gold standard for this comparative analysis, it is evident that almost all commuity residential facilities provide better care environments than that available in most wards at Mount Carmel Hospital.

It is positive that some of these care environments are now providing care to several ex-MCH residents.
The improved care standards are obviously beneficial to patient welfare which will be assessed in forthcoming visitations.

The notable exceptions are the temporary residential facility for the KIDS programme in Fra Diegu Home in Hamrun and to a certain extent the Paola and the Attard hostels, all of which are managed by Richmond Foundation.
In the adult hostels we have observed the tendency to allow residents to replicate some of the institutional habits that they were accustomed to within Mount Carmel Hospital.
For completeness, the overall scores obtained by each of the 19 residential facilities can be seen in the following table: 180 RESIDENCE Score (out of 120) % RICHMOND FOUNDATION (ADULT) - Average 79.8 MOSTA HOSTEL VILLA CHELSEA -B'KARA QORMI HOSTEL PAOLA HOSTEL ATTARD HOSTEL KIDS FRA DIEGU 91 87 80 71 70 51 SVPR DEMENTIA UNITS - Average 91.5 ST.JOSEPH WARD 7 ST JOSEPH WARD 10 JP2-FEMALE WARD 1 ST.JOSEPH WARD 8 JP2-MALE WARD 2 ST JOSEPH WARD 11 SURET IL-BNIEDEM UNITS - Average DAR IMELDA B'KARA DAR FRANGISK DAR VICTORIA OTHER UNITS DAR KENN GHAL SAHHTEK CASA HOPE PAOLA CASA MARIA ST. THOMAS COMMUNITY LIVING.
ENVIRONMENTAL ASSESSMENT OF OUTPATIENT AND DAY SERVICES All outpatient and day centre facilties are managed by public Mental Health Services.
The above chart indicates that there are issues with the standard of the care environments in the Day Centres and in the Mental Health Clinics housed in community centres.It is evident that as part of the upcoming implementation of the Mental Health Strategy with renewed focus and emphasis on multidisciplinary care within community settings, investment in upgrading community care facilities must follow closely the refurbishment programme within Mount Carmel Hospital.
The number of patients which these services will be handling in the coming years requires welcoming environments that encourage persons in trouble to seek help early.

Defeating stigma and promoting early intervention requires infrastructural investment to support caring teams.
For completeness, the overall scores obtained by each of the 13 Outpatient / day centre facilities can be seen in the following table: FACILITY Score (out of 80) % TOMMASO CHETCUTI - MCH CYPS - SLH 66 53 82.5 66.3 182 PSYCHIATRIC OP - MDH 50 62.5 DAY CENTRES PAOLA ZEJTUN COSPICUA QORMI FLORIANA MENTAL HEALTH CLINICS MTARFA COSPICUA QORMI PAOLA FLORIANA 42.8 56 50 41 39 28 39.8 48 45 39 39 28 53.5 70.0 62.5 51.3 48.8 35.0 49.8 60.0 56.3 48.8 48.8 35.0 SELF-REPORTED YEAR-ON-YEAR IMPROVEMENTS IN CARE UNITS The CMH team also requested inpatient unit and residence managers to physically indicate areas of improvement in their care environment in the previous 12 months.
Out of 24 visits carried out at MCH inpatient wards, only 9 wards [37.5%] registered that any improvements in the environment had been carried out within the relevant ward within the preceding 12 months.

2 out of the 5 Richmond Foundation sites visited, registered environmental improvements during the preceding 12 months.

However one site had just been opened on 13 September 2019.

50% of SVPR Wards [3 out of the 6 wards visited] registered environmental improvements.
Hereunder are listed the improvements in the environment as stated by the relevant Personnel in respect of MCH wards: Plastering; Architects drew up a report on ceilings status [Female WARD 1] 183 Isolation rooms plastered [Female Secure Unit] Bigger ward now [Female 2 is now ex-San Gorg Preca] New beds arrived [Female Ward 3A] New ward during the last quarter of Year 2019 [Female 7 - ex-Jean Antide Ward] Plastering [Female Ward 8] Air conditioning installed but not working during time of inspection; Roofing ‘repaired’ but danger still there and leaking roofs [Male Ward 1] Lockers for each patient; separate smoking area [Male Ward 7] Moved from old ward to new place but no improvements were done- dangerous plugs; disconnected nurse calls; white washing needed and no isolation unit [Male Ward 2].
184 CHAPTER 4 Analysis of Mental Health Services Incident Reports received at OCMH for 2019 November 2019 185 Analysis of Mental Health Services Incident Reports received at OCMH for 2019 Introduction Incident reporting is a legal requirement emanating from the Mental Health Act with the obligation placed on the CEO of the licensed mental health facility to send such reports at least on a monthly basis.
Aim The aim of this study was to analyse the reports received from Mental Health Services for the year 2019.

Method Incident reports forwarded on a monthly basis by Mental Health Services (MHS) for the calendar year 2019 were analysed.

Results 1.

Demographic data A total of 264 incident reports were forwarded to OCMH from MHS for 2019.

These incidents were caused by 158 persons.


Incidents were reported above the average (23) for the months of March, April, May and July, with January and February being the lowest (Fig 1).

The majority of reports involved voluntary patients and patients who were of Maltese nationality (Fig 2-4).

Overall, gender distribution was practically equal, but when patients were stratified by nationality, Maltese females and foreign males were in a majority.
(Fig 5- 6) Incident reports by month (n=264) 29 27 27 32 23 23 23 20 17 17 16 10 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Fig.

1 186 Incident reports by patient status % (n=264) 63 37 Vol invol Incident reports by nationality % (n=263) 86 14 MT Foreign Incident reports by patient nationality and status % (n=263) MT Foreign 63 62 37 38 vol Invol 187 Fig.2 Fig.
3 Fig 4 Incident reports and gender (n=264) 131 133 M F Incident reports by nationality and gender % (n=263) M F 89 43 57 11 MT Foreign Fig 5 Fig.

6 The largest proportion of patients was in the 20-39-year age cohorts (Fig.

7).

Only Maltese patients were represented in the cohorts below 20 and above 60 (Fig 8).

Incident reports by patient age (n=260) 66 61 39 20 31 24 13 6 10 19 20-29 30-39 40-49 50-59 60-69 70-79 >80 Fig.
7 188 Age by nationality (n=260) MT F 58 43 29 23 10 20 0 31 23 13 3 1 0 0 6 0 10 19 20-29 30-39 40-49 50-59 60-69 70-79 >80 Fig.

8 2.

Type of incidents Type of incidents % 46 17 10 9 7 5 5 1 Fig.

9 Just below 50% of all reports (Fig 13) involved aggressive behaviour (46%) whilst self-harm accounted for a further 17% together accounting for almost 2/3 of all reports.

Reports of falls were marginally higher than reports related to substance abuse (10%, 9%).
It was more common for reports of incidents involving aggressive behaviour (50% vs 39%) and self-harm (20% vs 13%) to involve females whilst conversely more incidents related to absconding (8% vs 5%) and substance abuse issues (17%vs 3%) were reported for males (Fig.

10) 189 Type of incidents by gender % M F 50 39 8 5 17 6 6 3 5 0 20 13 12 8 5 4 Fig.

10 In male patient wards, reports from MW8B, MSU and MAW accounted for 50% of all incident reports, with MW1 and MFU contributing to another 21% (Fig 11).
There was a similar pattern with regards to reports involving females (Fig.

12) with FW1 and FDDU, together accounting for 61% of all reports involving females .

Incident reports involving males by Unit (n=131) 25 21 19 17 11 Fig.

11 190 incident reports involving females by Unit (n=133) 49 29 16 10 8 7 6 2 1 1 1 1 1 1 Fig.
12 When the data was stratified by unit and type of incident, 75% of reports from MW7, involved aggressive behaviour, This also accounted for 71% of reports from MSU and 60% of reports from MW8B.

Self-harm reports accounted for 64% of incident reports sent in by MFU, while 42% of reports from MAWM related to illicit substances.

In FW2, 6 of the eight reports received involved aggressive behaviour (75%), whilst in FWI, 18 out of 29 reports also involved aggressive behaviour (63%).
With regards to FDDU, 24% of reports involved self- harm whilst aggressive behaviour accounted for a further 62%.

It was noted that there was a markedly different profile of incident reporting when nationality was considered with almost half of all incidents involving Maltese nationals being related to aggressive behaviour (48% vs 28%), whilst the proportion of reported self-harm incidents was considerably higher in foreign nationals (39% vs 14%) (Fig.

13).
13).

Type of incident by nationality % abs agg subst use med inc unresp fall self harm other 48 39 28 18 5 5 2 2 2 Foreign 14 11 6 11 4 5 0 MT Fig.

13 191 The largest proportion of incidents occurred in the 1600 to 2000hrs period, while as expected, the majority occurred between 0800 and 2000hrs (Fig.

14).

Time of incidents % 30 23 21 17 9 0 0001-0400 0401-0800 0801-1200 1201- 1600 1601-2000 2001-2400 Fig.

14 3.
14 3.

Aggressive behaviour The largest proportion of incident reports involving aggressive behaviour was for the second trimester, followed by those in the third trimester (44% and 36% respectively) (Fig.

15).

Reports of aggressive behaviour by month (n=131) 17 14 13 19 12 13 9 6 5 11 10 2 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Fig.
15 192 Reports of aggressive behaviour by Unit (n=131) 31 18 15 15 11 Aggressive behaviour by gender (n=131) 59 72 M F Aggressive behaviour by nationality (n=131) 121 10 MT Foreign Fig.

16 Fig.

17 Fig.

18 193 Reports of aggressive behaviour by patient status (n=131) 83 48 Vol Invol Fig.
19 The largest number of reports related to aggression involved patients suffering from mental and behavioural disorders due to psychoactive substance use (Fig 20), and the majority of aggression incidents were reported to have occurred between 1200 and 2000hrs (Fig 21).

Aggressive behaviour by ICD-10 diagnosis (n=131) 57 2 26 18 10 6 1 1 1 9 1.1 1.2 1.3 1.4 1.7 1.8 1.9 1.1 1.11 ?

Fig.
Fig.

20 194 Timing of incidents involving aggression % agg to pt agg to staff agg other pt ass by pt threatening beh 0001-0400 0401-0800 0801-1200 1201- 1600 1601-2000 2001-2400 Fig.

21 25% of the incident reports involving aggression involved patients aged 50 or above, and a further 10% were aged less than 20 (Fig 22).
Age and aggressive incidents (n=130) 37 28 19 13 16 11 4 2 10 19 20-29 30-39 40-49 50-59 60-69 70-79 >80 Fig.

22 4.

Abscondment incidents Males (Fig 23), involuntary patients (Fig 24), and Maltese nationals (Fig 25) were reportedly more involved in abscondment incidents than their females, voluntary and foreign counterparts.

Almost the majority of such incidents occurred from wards (Fig 26), occurred between 0801 and 1200hrs (Fig 27A).

ICD 1.2 was the commoner diagnosis in absconders (40%) (Fig 29).
Three fourths of absconders were aged less than 40 (Fig 30).

195 Abscondment by gender (n=20) 12 8 12 Males Females Status of abscondee (n=20) 8 Vol Invol Nationality of abscondees (n=20) 13 7 MT Foreign Fig.

23 Fig.

24 Fig.
23 Fig.

24 Fig.

25 196 Site of abscondment (n= 20) M F 5 4 3 2 0 0 5 1 abs W absMG Abs MDH abs other Time of abscondment incidents (n=20) 9 5 3 3 1 0401- 0800 0801-1200 1201-1600 1601-2000 2001-2400 Time of different types of abscondment incidents % abs W absMG Abs MDH abs other 100 83 67 44 0 0 0 0 11 0 0 0 0 0 22 0 0 11 0 0 11 0 33 17 Fig.

26 Fig 27A Fig.
26 Fig 27A Fig.

27B 197 Unit where abscondee was being treated (n=20) 5 5 3 2 2 1 1 1 MW1 FW1 HWH MAW YPU MW7 MIDU FDDU ICD-10 diagnosis of abscondee (n=20) 8 5 3 1 1 2 0 0 0 0 0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 1.9 110 ?

Age of abscondees (n=20) 9 5 1 2 1 1 0 0 10 19 20-29 30-39 40-49 50-59 60-69 70-79 >80 Fig.

28 Fig.

29 Fig.

30 198 5.

Treatment incidents These involved giving wrong medication to patients (40%), patients stealing or refusing to ingest medication (40%).
Majority of incidents involved Maltese nationals (Fig 31) Treatment incidents by nationality (n=15) 13 2 MT F Treatment incidents by patient status (n=15) 9 6 Vol invol Fig.

31 Fig.

32 199 Time of medical incident (n=15) 6 3 3 2 1 0401-0800 0801-1200 1201-1600 1601-2000 2001-2400 Patient age and medical incidents (n=15) 6 2 2 2 1 1 1 0 10 19 20-29 30-39 40-49 50-59 60-69 70-79 >80 Unit reporting medical incident (n=15) 3 2 2 2 2 1 1 1 1 CTC FW8 FDDU MSU MFU FW3A MW8B FW1 YPU Fig.

33 Fig.

34 Fig.
33 Fig.

34 Fig.

35 200 6.

Falls As was to be expected, falls were reported in older cohorts and in wards were such patients are kept (Fig 36, 37).

Reports involving females were 50% higher than those related to males (Fig 38), whilst reports involving Maltese nationals were the overwhelming majority (Fig 39).

A spike in incident reports involving falls was noted for the 0401-0800hrs time period (Fig 40).

Reporting of falls by Unit (n=30) 6 5 5 4 3 1 1 1 1 1 1 1 Fig.

36 Fig.
36 Fig.

37 Reports of falls by age (n=30) 10 7 5 2 1 1 0 3 1 10 19 20-29 30-39 40-49 50-59 60-69 70-79 >80 ?

201 Reports of falls and gender (n=30) 12 18 M F Reports of falls and nationality (n=30) 29 1 MT F Reports of falls and time of day (n=30) 11 6 5 4 3 1 0001hrs - 0400 0401-0800 0801-1200 1201-1600 1601-2000 2001-2400 202 Fig.

38 Fig.

39 Fig.

40 Reports of falls by month (n=30) 4 4 4 3 3 3 2 2 2 1 1 1 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Fig.

41 7.
41 7.

Self-harm The spike noted in last year’s incident reports where the risk of self-harm in forensic patients was greater than for other groups was not evident in this year’s reports, with the largest proportion of patients involved in self-harm incidents being in FW1 (Fig 42).

Almost 50% of reported incidents involved persons in the cohort aged 20-29 years (Fig 43).

Foreign nationals accounted for 30% of such incident reports (Fig 45).
Females were 50% more likely to be the subject of such reports than male individuals (Fig 46).

Unit reporting self harm event (n=50) 18 8 7 7 2 2 1 1 1 1 1 1 Fig.

42 203 Self harm incidents and age (n=50) 23 9 7 4 4 1 0 0 2 10 19 20-29 30-39 40-49 50-59 60-69 70-79 >80 ?

Patient status and self-harm incidents (n=50) 28 22 Vol invol Self harm incidents and nationality (n=50) 35 15 MT F 204 Fig.

43 Fig.

44 Fig.

45 Self-harm inicdents and gender (n=50) 30 20 M F Fig.
46 Patients with a primary diagnosis of substance abuse and disorders of adult personality and behaviour accounted for more than a third of self-harm reports each.

(Fig 47).

Self harm incidents and patient diagnosis (n=50) 17 17 8 0 2 1 0 3 1 1 0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 1.9 110 ?

Fig.
Fig.

47 40% of self-harm incidents occurred in the 1600 -2000hrs time period, and the second half of the day accounted for 84% of such reports (Fig 48), with 68% of incidents occurring during the April to September semester (Fig 49).

205 Time of self-harm incidents (n=50) 20 12 10 7 1 0401-0800 0801-1200 1201-1600 1601-2000 2001-2400 Self harm reports by month (n=50) 10 7 7 5 4 3 1 2 1 1 6 3 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Fig.

48 Fig.

49 8.
48 Fig.

49 8.

Substance abuse Male (Fig 50), Maltese (fig 51), voluntary patients (Fig 52) younger than 40 (Fig 53) were more likely to be involved in substance abuse incidents than their female, foreign, involuntary older counterparts.

Majority of incidents occurred between 0800 and 1600hrs (Fig 54,55).
206 Gender and reports of substance abuse incidents (n=25) 21 4 M F Nationality and substance abuse reports (n=25) 23 2 MT F Status of patients involved in substance abuse incidents (n=25) 13 8 Vol Invol 207 Fig.

50 Fig.

51 Fig.
50 Fig.

51 Fig.

52 Reports on substance abuse and age (n=25) 7 7 5 3 2 1 0 0 10 19 20-29 30-39 40-49 50-59 60-69 70-79 >80 Time of substance abuse incident (n=25) 8 7 4 4 2 0401-0800 0801-1200 1201-1600 1601-2000 2001-2400 Timing of different types of substance abuse incidents (n=25) Drug use Drug poss drug smuggling 5 1 1 2 0 0 3 3 2 2 2 3 1 0 0 0401-0800 0801-1200 1201-1600 1601-2000 2001-2400 Fig.

53 Fig.

54 Fig.

55 208 9.


Multiple incidents 44 patients were involved in a total of 150 incidents (57% of total incidents reported) (Fig.

56).

The intervals between reports of incidents related to the same patient showed that 18% of repeat incidents occurred within one day, and repeat incidents within one week accounted for 33% of reports (Fig 57).
Patients involved in multiple incidents reports (n=44) 23 5 6 3 3 1 2 1 two three four five six seven eight nine Interval between incident reports of same patient (n=105) 41 19 7 9 17 12 1 day 2-3days 4-7 days 1-2 weeks 3-4 weeks >4weeks Fig.

56 Fig.

57 209 Gender of patients involved in multiple incident reports (n=44) 23 21 M F Nationality of patients involved in multiple incidents (n=44) 38 6 MT F Status of patients involved in multiple incidents in each reported event (n=150) 88 62 vol Invol 210 Fig.
58 Fig.

59 Fig.

60 Age of patients involved in multiple incidents (n=44) 12 13 8 3 5 1 2 0 10 19 20-29 30-39 40-49 50-59 60-69 70-79 >80 Multiple incident events by reporting Unit (n=150) 36 23 8 1 S P Y C U D D F 1 W F 2 W F 5 5 8 W F H W H 3 A 3 W F 10 M W A M 2 F W A M 16 11 13 Fig.

61 Fig.
61 Fig.

62 Aggressive behaviour and self-harm were the most common incidents reported in patients having multiple incident reports (Fig 63) with a number of these patients being involved in repeated episodes of the same type of incident (abscondment: 2 patients - 4 incidents, self-harm: 5 patients -22 incidents, aggressive behaviour: 18 patients - 69 episodes, drug use: 2 patients -4 incidents, falls: 1 patient - 2 incidents).

211 Type of incident in patients with multiple reports 79 25 10 9 8 2 9 37 Fig.
63 Patients with a diagnosis of mental and behavioural disorders due to psychoactive substance use accounted for 44% of involvement in multiple incident reports (Fig.

64).

Patient diagnosis in each reported incident (n=150) 66 32 9 27 1 0 0 3 1 7 4 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 1.9 110 ?

Fig.

64 212 Conclusions A considerable problem in any incident reporting analysis is the subjective decision of the person involved whether or not to file a report.
This should include both events which have caused serious harm to patient, staff, public or environment as well as those that through appropriate intervention or pure luck result in the avoidance of such harm or damage.

Apart from underreporting, improving the consistency in reporting practice by use of appropriate protocols and training decreases but does not eliminate this source of bias.

The number of incident reports has increased from the 241 incidents reported in 2018.
Almost all the reports were submitted by nursing staff, who rightly might consider this to be part of their duties, but this duty applies also to other health professionals who may need to be sensitised more to this need.

Of more importance is the action taken by management to investigate the contents of a report within a one or two days of the occurrence of the incident and to address any potential shortcomings when indicated.

This includes timely management feedback to staff making the report.
In the absence of such interventions, incident reporting loses most of its potential as a tool to improve patient safety.

The type of incidents reported highlight the primary pressures on, and concerns felt by, front line mental health carers with regards to incidents involving aggressive behaviour, substance abuse, abscondment incidents and self-harm events.
Staff and patients are exposed to such incidents more in certain wards than in others and this has an impact on both staff morale and quality of patient care.

A small group of persons (28%) were involved in 57% of total incidents reported.

This is an area which merits further investigation to assess the causes of this behaviour with the aim of providing better care and support.
It is always challenging to provide quality care in a background of aggressive behaviour, substance abuse and fear of patient abscondment and its potential repercussions.

Measures to reduce such behaviour will doubtless improve both the patient’s lot, and that of the staff entrusted to care for them.

213 214 APPENDIX 1 Functions of the Commissioner (Article 6 (1) of the Mental Health Act – Cap.
525) The Commissioner shall: (a) promote and safeguard the rights of persons suffering from a mental disorder and their carers; (b) review any policies and make such recommendations to any competent authority to safeguard or to enhance the rights of such persons and to facilitate their social inclusion and wellbeing; (c) review, grant and extend any Order issued in terms of this Act and for this purpose it shall be the duty of any person to appear before the Commissioner when so requested; (d) ensure that patients are not held in the licensed facility for longer than is necessary; (e) monitor any person duly certified as lacking mental capacity and is under curatorship or tutorship; (f) authorise or prohibit special treatments, clinical trials or other medical or scientific research on persons under the provisions of this Act; (g) review all patient incident reports and death records received from licensed mental health facilities; (h) ensure that guidelines and protocols for minimising restrictive care are established; (i) investigate any complaint alleging breach of patient’s rights and take any subsequent action or make recommendations which may be required to protect the welfare of that person; (j) investigate any complaint about any aspect of care and treatment provided by a licensed facility or a healthcare professional and take any decisions or make any recommendations that are required; (k) conduct regular inspections, at least annually, of all licensed facilities to ascertain that the rights of patients and all the provisions of this Act are being upheld.
During such visits he shall have unrestricted access to all parts of the licensed facility and patient medical records as well as the right to interview any patient in such facility in private; 215 (l) report any case amounting to a breach of human rights within a licensed facility to the appropriate competent authority recommending the rectification of such a breach and take any other proportional action he deems appropriate; (m) report to the appropriate competent authority any healthcare professional for breach of human rights or for contravening any provision of this Act and this without prejudice to any other proportional action that he may deem necessary to take; (n) present to the Minister an annual report of his activity which shall be placed on the Table of the House of Representatives by the Minister and shall be discussed in the Permanent Committee for Social Affairs within two months of receipt; and (o) any other function which the Minister may prescribe by regulations under this Act.
216 APPENDIX 2 OFFICE OF THE COMMISSIONER FOR MENTAL HEALTH Visitation 2019 Service User Questionnaire 217 SERVICE USER QUESTIONNAIRE 2019 1.

Name of patient ____________________________________________ 2.

UNIT: 1  in-patient ward 2  OP Clinic / Mental HC / DC 3  community residential facility i.e.

____________________________________________________________ 3.

Gender 1  Male 2  Female 3  Other ______________________ 5.

Nationality 1  Maltese 2*  EU / EAA 3*  TCN *i.e.
__________________________________ 4.

Age : 6.

Residing in: 7.

When did you first seek help from a healthcare professional (in public or private services) about your mental health condition?

1  <1yr 2  1-5yrs 3  >5-10yrs 4 >10-20yrs 5  >20yrs 6 ?

8.

How long have you been cared for in this unit?

(use current admission length for in-patient /resident) 1  <1wk 2  1-4wks 3  >4wks-3m 4 >3-6m 5  >6-12m 6 >1yr 9.

Your status as a patient is currently:  voluntary 2 involuntary 3 ?

10.
10.

Can you leave the hospital /residence if you don’t want to stay here anymore?

1 yes 2 No 3 ?

11.

Have you given written consent for the care and treatment you are receiving?

1 yes 2 No 3 ?

12.

How would you describe the quality of the care being provided to you?

1  v good 4  poor 2 good 3  fair 5  v poor 6 ?

13.

How would you describe your involvement in decisions taken about your care?

1  v good 2 good 3  fair 4  poor 5  v poor 14.
Have you appointed a responsible carer (family member or friend) to be involved in care decisions?

1 yes 2 No 3 ?

15.

If not, were you asked to appoint a responsible carer?

3 ?

1 yes 2 No 4n/a?

16.

If you have a responsible carer, do you feel that the appointment of a responsible carer has helped you?

1 yes 2 No 3 ?

4n/a?

218 17.

Do you feel safe in the unit?

18.

If not, why?


1  yes 2 No ______________________________________________ _____________________________________ __________________________________________________________________________ _________ 19.

Are you allowed to freely practise your religion here (in-patients /residents)?

1  yes 2 No 3 ?

4 n/a 20.

Do you feel you are treated differently than other patients?

1  yes If yes, why?


2 No _____________________________________________________________________________ _____________________________________________________________________________ __________________ 21.

Do you have any complaints about aspects of your stay or treatment in the hosp/residence?

1  yes If Yes, 2 No what?________________________________________________________________________ __________________________________________________________________________ ________ 22.
Is there anyone who is supporting /will support your recovery when you are not in hospital/ residence?

1  yes 2 No 1  ?

23.

In the last month, were there instances when you felt unhappy with the way a member of staff* acted towards you?

(actions which border on verbal, mental, physical or sexual abuse) 1  yes 2 No If Yes, what happened?
_____________________________________________________________________________ _____________________________________________________________________________ __________________ Did you do anything about it?

_____________________________________________________________________________ _____________________________________________________________________________ __________________ 24.

Do you feel that you are being treated in a way that strengthens your sense of dignity?
(al: almost) 1  always 2 usually 3  sometimes 4  rarely 5  al never 6  ?

25.

Do you feel that staff give sufficient consideration to your feelings, wishes and rights?

3  sometimes 1  always 2 usually 4  rarely 5  al never 6  ?

219 26.

Is there anything you wish to add about your experience as a client of MHS?
(possibly expand on 21, 24, 25) _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ FILE REVIEW (Hospital patients only) 27.
Is the consultant responsible for current treatment easily identified?

1 yes 28.

Is there a formal MDCP plan for the current admission?

1 yes 2 No 2 No Is there an appropriately filled and signed: 29. treatment consent form?

30. responsible carer form?

1 yes 2 No 1 yes 2 No 31.

Are there appropriate records of restraint / seclusion events?

1 yes 2 No 3  n/a Current admission - date & time of first exam by: 32.

Junior MO i.c.w.
Junior MO i.c.w.

hospital admission _________________________________________________ 33.

Specialist** post hospital admission _________________________________________________ *member of staff: any grade, whether medical, nursing, AHCP or other.

**Specialist : resident specialist or consultant grade only 220 OFFICE OF THE COMMISSIONER FOR MENTAL HEALTH Visitation 2019 Staff Questionnaire 221 * staff: any grade, whether medical, nursing, AHCP or other.

STAFF* QUESTIONNAIRE 2019 1.


Name of staff member____________________________________________ 2.

Current place of work 1  An in-patient ward 2  OP Clinic / Mental HC / DC 3  community residential facility Address: _____________________________________________________________________________ 3.

Gender 1  Male 2  Female 3  Other ______________________ 4.

Age : ____________ 5.

Nationality 1  Maltese 2  EU / EAA 3  TCN 6.

To which profession do you belong?


1  A doctor in the grade of ___________________________________ 2  A general nurse (SN / EN) 3  A psychiatric nurse 4  A psychologist / psychotherapist / counsellor 5 A social worker 6  An allied healthcare professional i.e.

___________________________________ 7  Other (specify) 7.

How long have you been working as a healthcare professional with either public or private mental health services?

1  <1yr 2  1-5yrs 3  >5-10yrs 4 >10-20yrs 5  >20yrs 8.
Do patients you care for have a written multidisciplinary care plan (MDCP)?

1  always 2 usually 3  sometimes 4  rarely 5  never 6  ?

9. Who is involved in drawing up the MDCP?

____________________________________________________ 10.

How do you describe the way the MDCPs are implemented ?

1  v good 2 good 3  fair 4  poor 5  v poor 6  ?

11.

Do patients admitted voluntarily in a ward or residence give written consent prior to being given the required care and treatment?
1  always 2 usually 3  sometimes 4  rarely 5  never 6  ?

7 n/a 12.

How do you describe the patients’ level of awareness of their rights as patients?

3  fair 1  v good 4  poor 2 good 5  v poor 13.

How do you describe the quality of care being provided to patients in your unit during the last year?

1  v good 2 good 3  fair 4  poor 5  v poor 222 14.

What do you think are the main barriers to further improve quality of care in your unit?
__________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ 15.

Do you feel that patients are treated in a way that strengthens or restores their sense of dignity?

1  always 2 usually 3  sometimes 4  rarely 5  al never 6  ?

16.

Do you feel that staff give sufficient consideration to patients’ feelings, wishes and rights?
1  always 2 usually 3  sometimes 4  rarely 5  never 6  ?

17.

How do you rate the level of your knowledge of the Mental Health Act (various orders, issues related to mental capacity, minors, rights of users and carers)?

1  v good 4  poor 2 good 3  fair 5  v poor Do you think you need training in the following areas: 18.

Mental health care?

19.

General medical/ surgical nursing care?

(nurses only) 20.

Patient rights?

21.

De-escalation techniques?

22.

Other area?


1  yes 1  yes 1  yes 1  yes 1  yes 2 No 2 No 2 No 2 No 2 No 3n/a WHICH?___________________________________________________________________ 23.

How do you rate the liaison between you and the individual members of the care team involved in a patient’s management?

1  v good 2 good 3  fair 4  poor 5  v poor 24.

Are you aware of any support structures available to help support staff members suffering from mental health issues ?
1  yes 2 No 3  ?

25.

How do you rate these support structures?

3  fair 1  v good 2 good 4  poor 5  v poor 6 ?

26.

Do you think that there has been an improvement in the quality of mental health care delivery in the last year?

1  Strongly agree 2 agree 3  neutral 4  disagree 5  strongly disagree 6  ?

27.

In the last month, were there instances when you felt unhappy with the way a member of staff acted towards you?
(actions which border on verbal, mental, physical or sexual abuse) 1  yes 2 No If Yes, what happened?

_____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ 223 Did you do anything about it?
_____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ 28.

In the last month, were there instances when you felt unhappy with the way a patient acted towards you?

(actions which border on verbal, mental, physical or sexual abuse) 1  yes 2 No If Yes, what happened?
_____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ Did you do anything about it?

_____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ 29.
In the last month, were there instances when you felt unhappy with the way a member of staff acted towards a patient under his/her care?

1  yes 2 No If Yes, what happened?

_____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ Did you do anything about it?
_____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ 224 COMMENTS What issues do you feel require urgent addressing or decisions to improve the A. quality of patient care provided in your ward / clinic / facility?

B. mental health services offered in Malta and Gozo?

C. Any other comments?


THANK YOU 225 OFFICE OF THE COMMISSIONER FOR MENTAL HEALTH Visitation 2019 Responsible Carer Questionnaire 226 RC QUESTIONNAIRE 2019 1.

Name of Responsible carer ____________________________________________ 2.

Gender 1  Male 2  Female 3  Other ______________________ 4.

Nationality 1  Maltese 2*  EU / EAA 3*  TCN *i.e.

__________________________________ 3.

Age : 5.

Residing in: 6.


Relationship to service user 1  Husband / Wife / Civil Union / Co-habitant / Partner / In a relationship 2  Son / Daughter 3 Mother / Father 4  Other relative i.e.

_____________________ 5  Close Friend 6  Appointed as Curator / Tutor / Guardian (for care decisions only) 7  Appointed by the Commissioner 7.

How long have you been the patient’s responsible carer?

1  <1yr 2  1-5yrs 3  >5-10yrs 4 >10-20yrs 5  >20yrs 6 ?

8.
8.

Do you know who are the members of the care team are?

1 yes 2 No If yes, who?

__________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ 9.

Name of patient ____________________________________________ 10.

UNIT: 1  in-patient ward 2  OP Clinic / Mental HC / DC 3  community residential facility i.e.
____________________________________________________________ 11.

Gender 1  Male 2  Female 3  Other ______________________ 13.

Nationality 1  Maltese 2*  EU / EAA 3*  TCN *i.e.

__________________________________ 12.

Age : 14.

Residing in: 15.

Current patient status:  voluntary 2 involuntary 3 ?

When did patient first seek help from a healthcare professional (in public or private services) about the mental health condition?

2  1-5yrs 1  <1yr 3  >5-10yrs 4 >10-20yrs 5  >20yrs 6 ?
227 16.

Can patient leave hosp / residence if he/she doesn’t want to stay there anymore?

[hospital /residence ONLY] 1 yes 2 No 3 ?

17. Who asked you to act as a responsible carer of the patient?

1 staff 2 patient 3 ?

3 other______________________ 18.

Have you given written consent to act as patient’s responsible carer?

3 ?

1 yes 2 No 19.

Do you know what the role of the responsible carer is?

2 No 1 yes 3 ?
2 No 1 yes 3 ?

If yes, explain ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ 20.

In the last month, how many times have members of the caring team asked to speak with you?

1  twice/wk 2  once/wk 3  twice 4 once 5  never 6 ?

21.
21.

How would you describe the quality of the care being provided to the patient?

1  v good 2 good 3  fair 4  poor 5  v poor 6 ?

22.

How would you describe the environment of the facility where the patient receives treatment?

1  v good 2 good 3  fair 4  poor 5  v poor 6 ?

23.

How would you describe your involvement in decisions taken about the patient’s care?

1  v good 2 good 3  fair 4  poor 5  v poor 24.

How do you describe the relationship between you and the caring team?
5  v poor 3  fair 1  v good 4  poor 2 good 25.

In the last month, how many times have you asked to speak with members of the care team?

1  twice/wk 2  once/wk 3  twice 4 once 5  never 6 ?

26.

How do you describe the relationship between the patient and the caring team?

1  v good 2 good 3  fair 4  poor 5  v poor 27.

Do you feel that your appointment as a responsible carer has helped the patient?

1 yes 2 No 3 ?

4n/a?

228 28.

Why?


________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 29.

Have you experienced any difficulties in performing your role as responsible carer ?

1 yes 2 No 3 ?

4n/a?


If yes, explain __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ 30.

Do you think the patient feels safe at the facility?

1  yes 2 No 3 ?

If not, why?


__________________________________________________________________________ __________________________________________________________________________ 31.

Do you feel the patient is treated differently compared to other patients?

1  yes If yes, why?

2 No _____________________________________________________________________________ _____________________________________________________________________________ 32.
Do you have any complaints about aspects of the patient’s stay or treatment in the hosp/residence?

1  yes 2 No If Yes, what?

__________________________________________________________________________ __________________________________________________________________________ 33.

In the last month, were there instances when you felt unhappy with the way a member of staff* acted towards you?

(actions which border on verbal, mental, physical or sexual abuse) 1  yes 2 No If Yes, what happened?
_____________________________________________________________________________ _____________________________________________________________________________ Did you do anything about it?

_____________________________________________________________________________ _____________________________________________________________________________ 34.

In the last month, were there instances when you felt unhappy with the way a member of staff* acted towards a patient?
(actions which border on verbal, mental, physical or sexual abuse) 1  yes 2 No 229 If Yes, what happened?

_____________________________________________________________________________ _____________________________________________________________________________ Did you do anything about it?

_____________________________________________________________________________ _____________________________________________________________________________ 35.
Do you think that the patient is being treated in a way that strengthens his sense of dignity?

(al: almost) 1  always 2 usually 3  sometimes 4  rarely 5  al never 6  ?

36.

Do you feel that the care team give sufficient consideration to your feelings, wishes and rights as a RC?

1  always 2 usually 3  sometimes 4  rarely 5  al never 6  ?

37.

Is there anything you wish to add about your experience as a responsible carer?
_____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ 230 OFFICE OF THE COMMISSIONER FOR MENTAL HEALTH Visitation 2019 Environmental Assessment This environmental assessment refers to (Cross ONE box only) 1  An in-patient ward i.e.
_____________________ 2  An out-patient / mental health clinic / day centre i.e.

_____________________ 3  A residential facility in the community i.e.

_____________________ (To be asked to the person in charge of the facility at the time of the assessment) In the last year, have there been any improvements in the environment of this facility?
1  Yes 2  No If yes, please list the improvements made __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ ____________________________________________ 231 No Criterion (0 means worst – 5) means excellent) Weighting Score Upkeep of place Light Airiness Noise (very noisy=0) Cleanliness Unpleasant odours (foul smell=0) Is a Smoking Room/Area available?
If Yes, is the smoking room/area well insulated from rest of place so as to ensure that no smell of cigarettes flows to other areas?

Are measures in place to protect people against injury through [fire exits, fire doors, fire sensors, fire extinguishers, fire blankets]?

If Yes, is there evidence that regular maintenance/checks [as applicable] are effected/carried out?
The facility is accessible for people with physical disabilities (ramps, lifts, adjustable beds, hoists) There is an adequate area specifically designated as a leisure area for service users There are activities (e.g.
billiard table, board / card games, gym, crafts, books etc) available for use by service users There are ample furnishings, and they are comfortable and in good condition The toilet facilities are accessible, clean and working properly The toilet facilities allow privacy TOTAL (for all facilities) The bathing facilities are clean and working properly The bathing facilities allow privacy The bathing needs of service users who have impaired mobility or other physical disabilities are accommodated The sleeping quarters provide sufficient space per service user and are not overcrowded The sleeping quarters allow for the privacy of service users Bed linen is clean Is there adequate space per bed for each patient?
Is there adequate space for service users where they can keep their personal belongings?

0-5 0-5 0-5 0-5 0-5 0-5 0-5 0-5 0-5 0-5 0-5 0-5 0-5 0-5 0-5 0-5 0-80 0-5 0-5 0-5 0-5 0-5 0-5 0-5 0-5 TOTAL (only for in-patient wards and residential facilities) 0-120 232 APPENDIX 3 233 234 235 236 237 238 239