Opening the doors: Critically examining the locked wards policy for public mental health inpatient units in Queensland Australia

Abstract

The Queensland Government issued a policy directive to lock all acute adult public mental health inpatient wards in 2013. Despite criticism from professional bodies and advocacy for an alternative, the policy has been retained to this day. A blanket directive to treat all psychiatric inpatients in a locked environment without individualised consideration of safety is inconsistent with least restrictive recovery-oriented care. It is against the principles of the United Nations Convention on the Rights of Persons with Disabilities, to which Australia is a signatory. It is also contrary to the main objects of the Mental Health Act 2016 (Qld). Queensland Health has reported a reduction in ‘absences without permission’ from psychiatric inpatient wards after the introduction of the locked wards policy; however, no in-depth analysis of the consequences of this policy has been conducted. It has been argued that patients returning late or not returning from approved leave is a more common event than patients ‘escaping’ from mental health wards, yet all may be counted as ‘absent without permission’ events. A review of the international literature found little evidence of reduced absconding from locked wards. Disadvantages for inpatients of locked wards include lowered self-esteem and autonomy, and a sense of exclusion, confinement and stigma. Locked wards are also associated with lower satisfaction with services and higher rates of medication refusal. On the contrary, there is significant international evidence that models of care like Safewards and having open door policies can improve the environment on inpatient units and may lead to less need for containment and restrictive practices. We recommend a review of the locked wards policy in light of human rights principles and international evidence.

Locked external doors on inpatient mental health units: A scoping review

“…Despite this lack of evidence, many mental health units persist in using this practice, creating a custodial environment in what should be a healthcare facility. Gill et al (2021) report community perceptions as potentially being at the root of these decisions, with mental health units being locked in response to societal perceptions that individuals with a mental illness are dangerous, with the community needing to be protected when they are unwell. These considerations lead to the practice of ‘defensive psychiatry’, where the mental health unit becomes focused on reducing every conceivable risk to avoid negative outcomes and their follow‐on effects, including adverse media coverage and legal issues.…”

“…This review has found that the situations caused by locking doors, such as aggression, and a lack of evidence for absconding and drug importation have remained since Van Der Merwe et al (2009) review. In fact, some jurisdictions have moved to a blanket policy of locking unit doors at all times for 'patient safety', despite the evidence that locked doors are ineffective at preventing common risks associated with inpatient mental health units (Gill et al, 2021).…”

“…However, there is a lack of consensus in the literature as to whether locking doors is considered a restrictive intervention, but there is an argument that a reduction of liberty, personal freedom to leave a hospital unit and confinement for treatment are by their very nature restrictive. There are arguments in the literature that locked units are in contravention of the Convention on the Rights of Persons with Disabilities (2008), where a reduction of liberties in order to treat psychosocial disability is considered counterproductive, detention on the grounds of impairment is detrimental to individual autonomy and liberty (Mezzina et al, 2019), and a fine balance exists between community expectations and the welfare of mental health staff and individuals (Ashmore, 2008; Gill et al, 2021).…”

Elimination of restrictive interventions: Is it achievable under the current mental healthcare landscape?

“…Many wards also operate in an environment that is by its very nature restrictive. For example, some Australian states have previously announced that all wards should lock their doors in response to the perceived risk of absconding, compounded by the community's fear of people with mental ill health who have been hospitalized (Gill et al, 2021). In our experience, several Victorian wards remain locked under local direction to prevent absconding, despite an absence of evidence that this reduces absconding in comparison to open wards (Searby et al, 2023).…”

Helpful encounters with mental health nurses in Australia: A survey of service users and their supporters

“…In Australian public mental health services, the nurse also has tasks related to containing people who are coerced into care and compelled to receive treatment. In the State of Queensland, all mental health units are required to be locked and nurses do not even have the discretion to unlock a door (Gill et al, 2021) which is emblematic of how entrenched coercion is in mental health services (Sashidharan et al, 2019). A common pathway to hospital in Australia is via involuntary transportation initiated by ambulance or police services (Clough et al, 2022) with those presenting to emergency departments with mental health problems more than 10 times more likely to be brought in by police than attendees with other health problems (Australian Institute of Health & Welfare, 2022).…”