1. Fire Risk Reduction Programme Dr Lauren Richards Consultant Clinical and Forensic Psychologist Ardenleigh Women’s Forensic Mental Health Service Bill Ruston Trust Fire Safety Advisor Birmingham & Solihull Mental Health NHS Foundation Trust

2. Fire Deaths in Healthcare Historically – many multi-fatality healthcare fires have occurred in Mental Healthcare settings : Shelton Hospital, Shrewsbury - 24 deaths Coldharbour Hospital, Dorset - 30 deaths Fairfield, Nottinghamshire - 18 deaths Clacton, Essex - 9 deaths St Crispin’s Hospital, Northants - 6 deaths Warlingham Park Hospital - 7 deaths

3. Healthcare Fire Statistics 1994-2004 (HTM 05-03 Part L “NHS Fire Statistics” Deliberately started fires = most common cause Waste was commonly first material ignited - More fires in Acute Trusts - Mental Health next most common 17 fatalities in Healthcare – (10 = Mental Healthcare) Ignition of “clothing on the person” most common

4. Injuries & Evacuation Total of 651 Injuries (344 were staff) – smoke inhalation most common cause 4769 fires in the ten year period caused the successful evacuation of 111,295 people 12,064 were rescued from the room of origin.

5. Traditionally, fire setting was often seen as part of the overall mental health condition of the client – it was rarely addressed on its own. It is often difficult to distinguish between a match accidentally dropped into rubbish and one deliberately dropped.

6. Context and Challenge Current provision : 30 medium secure beds at Ardenleigh and gate-way assessment function Referral summary : 41 % FS history; more frequently diagnosed with PD, more likely to be detained under part 3 of the MH act, higher levels of sexual abuse, DSH, and substance misuse indicated. No developed programme for fire-setting risk for women in secure settings

7. Clinical Picture Model of care : 3 R’s “Risk Reduction and Recovery” Co morbidity Chronicity Institutional Inertia

8. Self Harm Aggression Arson Psychosis Drugs and alcohol Medication Physical Health Purposeful activity Compassionate Care Trauma/ Psychotherapy Support with family/ practical issues Emotional Instability Risk Reduction Programme Women’s Forensic Mental Health Programme

9. Examples of two specific users MS, aged 41, MI/PD Criminality (arson) from adolescence onwards 7 convictions for arson culminating in a discretionally life sentence in 1996 Set fires to home, public buildings and prison areas 4 years in Ashworth Ardenleigh : Dec, 2003 DW, aged 50, MI/PD 29 years incarceration Half of which in Broadmoor Ardenleigh :June 2006 Set Fires : flat, shop, prison, psychiatric units Extreme violence and DSH, including burning using a cigarette

10. Characteristics of mentally disordered fire-setters Diverse Chaotic and abusive family backgrounds – socially, financially and educationally deprived Drug/alcohol abuse Difficulty in decision making skills, impulse control, communication and emotional regulation In-patient studies report mean age between 30-38 Self-harm

11. Women and Fire-setting (1) Few studies completed Descriptive in nature Tend not to be focused on service user perspective Across the general population men commit arson on a ratio of 6:1 (Stewart, 1993) In general mental health services fire setting equally distributed across the genders (Geller and Bertsch, 1985) In secure services in Birmingham there is a higher incidence of fire setting amongst women than men at a ratio of 4:1 (Beasley unpublished, 2003)

12. Women and Fire-setting (2) In Birmingham, largest sub group of all women admitted 1987-2005 (n=127) are those with a history of, or conviction for, fire setting (n=52) Thirteen of the 52 women do not self-harm 34 of the 127 women admitted do not self-harm or engage in fire setting behaviour Mean age of women who set fires = 32 years Majority of women are of White ethnicity (87%)

13. Women and Fire-setting in Birmingham Long term users of services Complex and challenging High physical morbidity Poor social health resulting from deprived and abusive backgrounds Weak attachments Little or no structure or resources in their lives Dysfunctional social cognition and social context High incidence of substance misuse

14. Fire-setting Programme - Preparation Nationally available programmes Interviewing the women –Early themes emerging – control, communication, isolation, regulation of emotion, revenge –Women who self-harm and set fires – SH started first and then there was an escalation in behaviour –Women who set fires but don’t SH – the fire was for a specific reason e.g. concealing a crime, ‘heroism’, accident, psychotic beliefs (e.g. delusions, paranoia) Variety of assessment tools –tools to measure FS fairly poor

15. The Fire-setting Programme Based on the qualitative and quantitative analysis conducted In house + existing research evidence 1st group – pilot, 2 nd group amended version Programme divided into 3 modules: - Psycho-education - Social skills - Anger Necessary for MHRT and discharge from hospital to show reduction in risk and increase in insight

16. The Programme Modules Psycho-education around fire-setting -Facts and figures around fires and their cost -Emotions (vulnerabilities, protective and problem solving) -Session with Fire Safety Officer with a view to beginning to increase empathy and address minimisation and denial -Social networks -Substance misuse -Insight, denial, empathy and motivation -Risk formulation, relapse prevention

17. The Programme Modules Social Skills: -Non/verbal communication- conversation skills -Listening skills -Passive/aggressive behaviour -Assertiveness skills -Problem solving skills

18. The Programme Modules Anger: -Function of emotions -Anger triggers and expression -Primary and secondary emotions -Controlling and coping with anger (emotions, physiology, cognitions) -Anger formulation, risk and relapse prevention

19. Outcomes MS Successfully completed all components of risk reduction programme Successful tribunal Successful appeal to parole board Currently residing in supported accommodation in community Ardenleigh follow-up MD Moved from HDU, to acute unit and on to rehab unit Completed risk programme and now engaged in recovery oriented work Referred to supported accommodation in community

20. How the programme has developed Increase in sessions focusing on risk formulation and empathy Adapted Social skills module – module was not intensive enough Stand alone anger programme – very little gender sensitive material available

21. Reflections and Lessons Learnt The programme to date – continued development and data collection Developing pro-social behaviour Cost of care (without succeeding in the 3 R’s)…………………………£7 million plus for two women Consideration of out-reach?

22. Fire Safety in Mental Healthcare Our interests are very much the same as those of the Fire Service It’s the Fires we want to Fight!