initiative by brake

The Road to Recovery 2006 - supporting families when disaster strikes

A one day conference for professionals working with people traumatised by sudden death, serious injury or critical illness in the family
Organised by BrakeCare, a division of Brake, the UK road safety charity, with sponsorship from Irwin Mitchell Solicitors
Date of event: Thursday 16 November 2006

Conference summary
Copies of power point presentations are available for £10 by calling Brake on 01484 559909.
The below minutes represent a summary only of each speech.
The summary is written in the order the speeches were made, and are divided into the following sessions:

Section one: The trauma of disaster and Post Traumatic Stress Disorder (PTSD) - Sudden death - Professor David A. Alexander - The NICE Guidelines on PTSD - Stuart Turner
Section two: Keynote speech - Disaster support - policy developments - Gerry Sutcliffe, Victims’ Minister, Home Office
Section three: From the field - Supporting families bereaved in road crashes - Cathy Keeler, policy director at Brake and PC Ken Johnson, Deputy Family Liaison Coordinator, Thames Valley Police - The Tsunami Support Group and the London bombings: lessons learnt from major disasters - Rosie Murray, Chair of the Human Rights Aspects Group (emergency planning society) - Delivering counselling to victims of PTSD - Sheila Marston and Alan Penny, trauma therapists, ASSIST Trauma Care - Developing a Bereavement Strategy & Care Pathway: Best Practice for Families and Professionals - Tony Brookes, Bereavement Services Manager, University Hospital of North Staffordshire and Chairman of the Bereavement Services Association
Section four: Individual solutions for individuals in a crisis - Family breakdown in response to serious illness & injury - Ceri Bowen - Addiction and suicide risk - Dr. Ash Kahn, consultant psychiatrist, Woodbourne Priory Hospital - Religion and culture - Chris Swift, president, College of Healthcare Chaplains
Section five: Medium- to long-term practical support issues - Civil claims following fatal road traffic collisions - Phil Edwards, partner, Irwin Mitchell - Living with spinal injury - Paul Smith, director, Spinal Injuries Association - Living with brain injury - Lisa Turan, chief executive, Child Brain Injury Trust

Disclaimer: Brake is not responsible for errors in speeches as transcribed and advises readers to check the validity of any services, ideas or facts contained within speeches with the authors before acting upon their contents.

All queries about future BrakeCare conferences contact us on 01484 559909 or at

‘Sudden Death’ - Professor David A. Alexander MA(Hons), C.Psychol, PhD, FBPS, FRSM, (Hon) FRCPsych, Director, Aberdeen Centre for Trauma Research

Preface
If you work with people affected by trauma, it can be helpful to consider their body language. In particular, it is commonly the case that the bereaved will hide their faces, hold “themselves in”, or hug a symbol or representation of the bereaved.

It is very important not to “medicalise” perfectly normal reactions to bereavement. Grief is not an illness, and it is important not to treat it as such.

Normal reactions - Emotional
For example, envy is a common emotional response. It can be hard for the bereaved to accept why they have lost a loved one and others have not. Sometimes, of course, this envy is hard to express because the bereaved feel guilty about sounding envious. Similarly, the bereaved may also feel angry. They may be angry at the alleged perpetrator of an “accident” or they may be angry with the medical staff who have broken bad news, or they may be angry at the deceased for leaving them alone and helpless.

  • Behavioural
    Crying is a normal response to grief - and probably universal. However, it is not appropriate to “force” someone to cry. Such a circumstance may leave them embarrassed and unlikely to attend another counselling session.
  • Physical
    Bereavement is a common time for physical symptoms. Sometimes these will mimic the symptoms from which the deceased suffered. For example, in the middle 50s, the bereaved will commonly report cardio-vascular symptoms. Also, sleep problems, loss of appetite, and loss of energy are commonly reported by the bereaved.
  • Cognitive
    In the turmoil after a bereavement, the bereaved are not able to take in information as quickly and as effectively as they did prior to their loss. Thus, it is important to speak slower and not to “overload” the bereaved with too much information - keep it simple and short.

Perception
It is not uncommon for the bereaved to have a sense of “a presence”. They feel that the deceased is alongside them. For some - and probably most - this gives comfort, but it is important not to challenge this. It is not our role to challenge the concept of “ghosts” etc. It is important to reassure the bereaved that such an experience is a normal one, and it is not a sign of “going mad”.

Adjustment to bereavement
How individuals adjust to bereavement overtime naturally varies. On the other hand, there are general patterns. For example, there is a lowering of the intensity of grief over a two year period. The intensity peaks about two weeks after the event and then again at the anniversaries of the death. There may also be some peaks at around special events such as Christmas, birthdays, and wedding anniversaries. It is important to prepare the bereaved for such reactions, otherwise they may feel they are back to “square one” in terms of their adjustment to the loss.

Unfortunately, society is not generous with regard to how long people are “allowed” to grieve; it seems to be that six months is as long as society is prepared to give the bereaved to adjust to their loss. However, the period of adjustment, after a “normal bereavement”, is likely to be about two years, and in the case of a “traumatic bereavement”, this can take about four years.

“At risk” factors (ie, those factors which may adversely influence how the bereaved adjust to their grief)

  • Features of the death
    Sudden and/or unexpected and horrific deaths are more likely to cause problems of adjustment. Similarly, if the body was mutilated or not even recovered, this too can lead to problems of adjustment.
  • Features of the bereaved
    Those who are anxious, insecure and/or suffer from low self esteem may have a more difficult period of adjustment. Similarly, if the bereaved have had a period of psychiatric illness, this too is likely to cause problems of adjustment.
  • Features of the relationship
    It is hardest to adjust to the death of a child or a spouse. Also, if the bereaved were highly dependent on the deceased, this too can lead to problems of adjustment. (They just “lived for each other”.)
  • Circumstances of the bereaved
    Those who have few family and/or social supports are likely to have more difficulties. Similarly, those who are of “low” socio-economic status may have more problems (particularly because they are likely to have additional problems of living including problems of finance, accommodation and employment).
  • Pathological grief
    We distinguish “normal grief” from “pathological grief” by: - the intensity of the emotional and other reactions - the duration of the reactions - a delay in the onset of reactions - the extent to which the grief reactions compromise day to day functioning

Post-traumatic stress disorder (PTSD)
The essential features of this condition are: - intrusive experiences (eg, in the fashion of flashbacks and nightmares) - avoidance of reminders of the trauma - hyperarousal (and hypervigilance)

NB: These three symptoms must have endured for about a month after the trauma

PTSD is but one of a number of post-traumatic conditions which might occur after trauma

About 80% of patients with PTSD will also have other conditions, in particular, anxiety, depression, and substance abuse

Don’t: - over talk (it is usually better to listen rather than to talk) - be judgemental - swamp the bereaved with information - be afraid to use words such as “dead” - use clich?s (eg, “well you still have one healthy child at home”) - deceive or offer false promises (eg, you cannot pretend that you can take away all the pain of the bereaved) - do not sit in the “favourite” chair of the deceased if you visit the home

Summary and conclusions - Traumatic deaths can be devastating. - However, successful adjustment is still the norm. - Certain factors (eg, those relating to the death, the relationship and the circumstances of the bereaved) are associated with poorer adjustment - Lay personal support can do much (but do not be unrealistic!)

NB: It is important to look out for those signs which differentiate between those bereaved who do require additional and, perhaps, even professional help from those who just need to be left to grieve in peace in knowledge that there is support around.

The NICE Guidelines on PTSD
Stuart Turner MD BChir MA FRCP FRCPsych, Consultant Psychiatrist/President-Elect, International Society for Traumatic Stress studies.

It is important to remember that the NICE Guidelines on PTSD are specifically for that disorder ? they are not guidelines for disaster support in general. Most people affected by disaster suffer early distress symptoms, but these fade. Not everyone gets PTSD ? for example, after the July 7th bombings, it was anticipated that as many people would develop travel phobias as PTSD.

Existing practice
Majority treated with medication (in one US survey, 77% with PTSD alone and 89% if co-morbid with depression).

Increasing access to Cognitive Behavioural Therapy (CBT) in UK but in some services, limit on number of sessions. It’s not uncommon for people to have to wait 12 months to be treated, which is unacceptable.

Many psychotherapeutic modalities are in use. There are often long delays and gatekeepers before treatment can commence.

NICE Guidelines
Psychological treatments

Clinician Ratings
This graph shows the extent to which different types of psychological treatment affect the symptoms of PTSD.

PTSD Diagnosis
This graph shows that, for every two people who are treated with CBT, one will be PTSD-free after.

NICE on treating PTSD
All PTSD sufferers should be offered a course of trauma-focused Cognitive Behaviour Therapy (CBT) or Eye Movement Desensitization and Reprocessing (EMDR), normally on an individual out-patient basis.
Usually 8-12 sessions, some at 90 minutes.
May need to be longer than 12 sessions if multiple trauma, co-morbidity, traumatic bereavement?
Training and competence essential.

CBT approaches:
Prolonged Exposure - The therapist helps the PTSD sufferer to confront their traumatic memories (written or verbal narrative, detailed recounting of the traumatic experience, repetition). - In vivo repeated exposure to avoided and fear-evoking situations that are now safe but which are associated with the trauma.

Cognitive Therapy - Focus on the identification and modification of misinterpretations that lead the PTSD sufferer to overestimate current threat (fear). For example, the perception of risk involved in travelling in a car may be heightened. - Also focus on modification of beliefs related to other aspects of the experience and how the individual interprets their behaviour during the trauma (eg issues concerning guilt and shame).

EMDR
Standardised, trauma-focused, procedure with several elements, always involving the use of bilateral physical stimulation (eye movements, taps or tones), thought to stimulate the individual’s own information processing in order to help integrate the targeted event as an adaptive contextualised memory.

NICE on treating PTSD
If there is little or no improvement after one of these psychological treatments, consider;
An alternative trauma-focused psychological treatment
Augmentation with pharmacological treatment.
Consider treating the PTSD before a co-morbid depression (often helps both).

Drug treatments
We reviewed:
SSRI anti-depressants (of which two ? paroxetine and sertraline are licensed in the UK).
Other anti-depressants.
Atypical antipsychotics.
Other drugs are in use but no clinical trials, meeting the NICE criteria, are available.

There are differences between trials of drugs and trials of clinical practice. It is important to consider these:
Methodological differences from psychology trials ? better placebo control?
Assumption that placebo arm includes a lot of attentional input and is likely to have active treatment elements.
Inclusion of limited data from two unpublished trials of sertraline (one of the licensed SSRI antidepressants).

Self report ratings
This graph shows the extent to which different types of drugs treatment affect the symptoms of PTSD. Mirtrazapine, Amitriptyline and Phenelzine have only had single trials, meeting the inclusion criteria, so it is wise to interpret the results with caution.

It is best to use psychological treatment to treat PTSD where possible, but in reality, many drugs are given as the first line of treatment in many cases. More trained professionals are needed to deliver psychological treatment.

NICE on treating PTSD
Drug treatments for PTSD should not be used as a routine first-line treatment in preference to psychological treatments.
If a drug treatment is used, consider paroxetine or mirtazapine (for general use) or amitriptyline or phenelzine (specialist Mental Health supervision).
(Sertraline, which has a product licence, has had two unpublished large trials. Including limited data from these trials in the meta-analysis suggested that it lacked, statistically, evidence of efficacy, so its use should be approached with caution.)

Early Interventions
Meta-analysis of predictive factors (Brewin et al, 2000) for PTSD emphasises:
trauma severity;
lack of (peri-traumatic) social support;
subsequent life stress.

Guidelines:
Offer immediate practical, social and emotional support. Don’t debrief individuals.
Many with early PTSD symptoms will spontaneously recover & “watchful waiting” is reasonable for people with mild PTSD symptoms in the first month (NB arrange a follow-up).
Consider acute phase symptomatic pharmacological management.

Trauma-focused CBT is the only treatment with a reasonable evidence base for early (less than 3 months) interventions in PTSD. It should be offered to:
people with severe symptoms in first month;
all with PTSD in the first three months.

Treating children
Do not rely solely on information from the parent/guardian in any assessment ? ask the child or young person separately and directly about PTS symptoms. Children often try to protect their parents, so they could deny symptoms in front of them.~
Where there is treatment outcome evidence (more limited) it favours Trauma-focused CBT.
Drug treatments should not be routinely prescribed.

Implications for Disaster Planning
Ensure disaster plan contains provision for a fully coordinated psychosocial response.
Clear roles and responsibilities need to be agreed in advance.
Ensure provision of immediate practical help and means to support the affected communities in caring for those involved.
Ensure provision of specialist mental health assessment and treatment services.

Screening after disasters
NICE guideline found no evidence to support large population screening in general ? but made specific recommendations for high prevalence populations (eg those closely involved post-disaster) ? this included the importance of more research in this area.

Conclusions
The NICE Guidelines are evidence-based guidelines on treatment of PTSD (but after a disaster, there is also a common need to treat depression, substance abuse etc and this needs to be remembered).
There are some limitations to the guidelines but they are probably the best we have at present.
This is the standard for treatment and services will be judged by their consistency with the evidence.
There is a need for regular updating as more evidence accumulates.

Government support for road crash victims ? Gerry Sutcliffe MP, Victims Minister, Home Office

Good morning everyone. I am pleased to have the opportunity to talk to you today about what the Government is doing to support those who suffer when, as the title of this conference aptly states, disaster strikes. In particular when someone becomes a victim of crime or is bereaved by a road crash. I will also update you on the Government’s strategy for reducing road casualties and look at what more needs to be done.

Victims
Disaster is devastating because it is sudden, unexpected and traumatic. Families of road crash victims unfortunately know exactly what this feels like and the personal impact to their lives is immeasurable and should not be underestimated. Like all victims, those bereaved through road traffic offences require support, information and a voice to be heard. So what can we, the Government, and all of us here do to help these people through these difficult times and prevent incidents from happening in the first place?

To begin, the Government is working hard to rebalance the criminal justice system in favour of the law abiding majority. We know that reducing crime, bringing people who commit crimes to justice and dealing with cases promptly and efficiently are among the most important issues for the public. If someone is a victim of crime or a witness they want to be given help, support, advice and a voice. They want the system to deliver justice.

As many of you will know, in December 2005 the Government published far-reaching proposals to improve the support we provide to victims.

Victim Care Unit Pilots
One aspect of this was the provision of enhanced services to victims through Victim Care Units. After some months of planning and work between the Home Office and Victim Support, the Victim Care Unit pilots are now up and running in Salford, Nottingham and North Yorkshire. They are, providing immediate, practical support to victims tailored to their needs. Referrals are coming in on a daily basis and Victim Care Officers are contacting victims by phone within 24 hours of referral, conducting a needs assessment and, if necessary, arranging for services to be provided. These services include practical help such as the fitting of new locks or childcare, emotional support or counselling, installation of security devices and assistance with medical costs. I visited the Salford pilot a few weeks ago and was extremely impressed with the dedication and enthusiasm of the staff. They told me how great it was for them to really do something quickly and practical for victims. They felt they were making a real difference to people’s lives.

The pilots will run until the end of March next year where they will be evaluated to provide us with a much fuller picture of victims’ needs and the cost-effectiveness of meeting these needs. If successful, we are keen to roll Victim Care Units out nationally.

Victims’ Code of Practice
Another important step is the implementation of the Victims’ Code of Practice. As many of you know, the Code came into practice in April and it gives victims legal rights for the first time. It defines a minimum level of service and establishes the rights for families who feel they have not received satisfactory treatment by the police following a crime, including road traffic crashes, to complain to the Parliamentary Ombudsman. It also obliges every criminal justice agency to provide better information to victims at all key points of their case’s progress. Victims and, in particular, families of fatal road crash victims should not feel like an ‘afterthought’.

Eligibility for services under the Code is defined by whether you are a victim of an offence under the National Crime Recording Standard. For road traffic cases, this includes death by dangerous driving, dangerous driving and causing death by careless driving while under the influence. It is worth noting the original draft of the Code only included victims of road traffic offences where the offender intended to cause harm, but following consultation it was amended to include victims of all offences under the National Crime Recording Standard.

Government Funding
More generally, the Government makes major financial contributions to the support of victims of crime through ?200m a year to the Criminal Injuries Compensation Scheme and ?30m for, the national charity, Victim Support. Additionally the Victims’ Fund totalling £5.25m over 3 years has been used to fund a wide range of provisions, focusing efforts over those 3 years on victims of sexual violence. We are currently looking at how the Victims’ Fund can be expanded and, as you know, we have consulted on the question of extending it to road crash victims.

Strategy For Reducing Road Casualties
I would now like to talk about the Government’s progress on reducing road casualties.
Certainly recent figures have shown improvements:

  • killed and seriously injured down 6% on 2004, 33% on the 1994-98 baseline average; - and over the same period, children killed and seriously injured down 11% and 49%; - slight casualties down 3% and 23%.

But we would all agree that we are still facing a huge task. We are still working hard to meet our casualty reduction targets as set out in our Road Safety Strategy by 2010 . We intend to publish a review document in early 2007 that updates the Strategy in line with new opportunities for reducing casualties to meet the 2010 targets and we will also be developing a timetable to develop a road safety strategy beyond 2010.

Children and Publicity
Focusing more specifically on children’s road safety, there has been a great deal of publicity about the new rules we have introduced on child safety seats, and only a short while ago we launched an updated version of the “Be Safe Be Seen” campaign, including a new sing-along version of the cinema advert. We will continue to implement a wide range of measures to reduce casualties, including more local safety schemes, development of safety camera programmes and greater promotion of safer road use by everyone under the THINK! Banner. Including the Christmas drink drive campaign which will provisionally be launched nationally on 1 December 2006.

Enforcement - the Police
The public want to be assured that the law will be enforced and that criminal and anti-social behaviour will not be tolerated. We have made it very clear that roads policing is important and makes a vital contribution to the work of the police overall. We have done this by increasing police numbers by over 14,000, but also through a number of specific measures, including:

  • the use of a hand-held mobile phone whilst driving is now a specific offence - in 2004 over 75,000 such offences were dealt with; - the police can put an immediate stop to some of the worst examples of anti-social driving by seizing the vehicles used; - the police can now require production of vehicle registration documents and there is a new offence of being the user of an incorrectly registered vehicle; - there is better access to information on the Motor Insurance Database, and the police can now seize immediately a vehicle being driven by someone who does not have insurance.

Road Safety Act
In line with these measures we have introduced the Road Safety Act. The Act, which received Royal Assent just last week, has a number of measures that will increase police powers and offences and, ultimately, serve as a deterrent to those who misuse the roads. The Act includes two new bad driving offences of: - Causing death by careless driving, with a maximum penalty of 5 years imprisonment, and - Causing death whilst driving unlicensed, disqualified or uninsured, with a maximum penalty of 2 years imprisonment - This responds to the concerns of families, victims, and road safety groups who have campaigned for these offences for some time. I believe these new offences strike the right balance between the level of criminal fault on the part of the bad driver and the devastation their actions can cause.

Other measures in the Act include: - a deposit system so that offenders without a UK address do not escape penalty; - arrangements for the endorsement of driving records for unlicensed and foreign drivers; - power to ban speed camera detection and interference devices; - power for the courts to give offenders the option of attending a retraining course that could result in a lower penalty; - higher penalties for careless and inconsiderate driving, using a vehicle in a dangerous condition, using a mobile phone whilst driving, failing to identify the driver of a vehicle and carrying a child not wearing a seat-belt in a car’s rear seat; - an offence of keeping a vehicle that does not meet insurance requirements.

Drink-Driving
Driving whilst impaired by drink or drugs is, rightly, an anathema to modern civil society; however it is still a menace that needs to be tackled. Therefore a combination of effective legislation and enforcement by the police is of the utmost importance. For instance, the Road Satefy Act includes provision for the development of an alcohol ignition interlock programme. This measure builds on steps we have already taken. It is now possible, for example, to take blood specimens from unconscious persons. Nurses and paramedics can also take blood specimens in police stations.

Conclusion
As we know, there is always more to be done. However I can assure you the Government will continue to work hard on all fronts to achieve our overriding goal of making our roads safer for all who use them and providing support, information and a voice to victims and families of road crash victims.

I want to thank all of you here for the hard work you continue to do in this area. I thank you for the opportunity to speak today and I welcome BrakeCare’s continual valuable contribution to road safety and supporting those affected by road crashes.

Questions and answers
To Gerry Sutcliffe

Cathy Keeler: As Victims’ minister, can you explain why the political agenda for support for road crash victims and their families seems to be slipping down the Government’s list of priorities? For example, the withdrawal of Home office funding for the BrakeCare Bereavement Guide, the fact that road crash victims cannot benefit from the Victims’ Fund or Victim Care Units and that there has still not been an evaluation of the face-to-face care pilots BrakeCare worked on.

Gerry Sutcliffe: With regards to the BrakeCare bereavement guide, there have been difficulties with the budget this time, but I want to find an alternative means of funding. There has been a lot of pressure on Home office budgets due to other issues, such as overcrowded prisons. I’m sad to hear you think road crash victims have slipped down the political agenda, as we are trying to put victims at the heart of what we are doing. We want to make sure our investments are effective, for example, that the services Victim Support is delivering are consistent across the UK. Lots is being done, but there is still room for improvement. We are currently looking at how the Victims’ Fund will be distributed for future years and there is also the possibility the BrakeCare guide could be funded through the Victims’ Fund in the future.

With regard to the evaluation of the face-to-face pilots, you are right that there has been a very long delay in the publication of the findings. I can give you my assurance an evaluation report will be published in the New Year.

Maggie Garside, Road Victims Trust: We support 6,000 people who have been affected by road death and we have always used the Brakecare bereavement guide and found it very useful. What offends us most about the withdrawal of the Home Office funding for the guide is that it sends out the message that the needs of people bereaved by road crashes isn’t even being considered. We started out as part of Victim support but left as we felt road crash victims were being overlooked I am not aware of any change for the better. We are still struggling for funds and there should be no question of support for the people we work with.

Gerry Sutcliffe: The funding for the Brake care bereavement guide has only been withdrawn from a specific budget - we are still looking for alternatives. I will continue to make the commitment to make sure the guide is available. It is important to consider how other Government departments can support it.

Richard Roberts, FLO from West Mercia Police: The BrakeCare bereavement guide is an incredibly useful resource. It saves us time and money. Wouldn’t it be a good idea to use the money raised from Safety Camera Partnerships to fund the guide?

Gerry Sutcliffe: I agree. I will make this point to the Department for Transport ministers.

FLO (name not recorded), Wiltshire Police: I feel like I have been listening to a party political broadcast. You say you are interested in preserving road policing, but we keep seeing officers being disbanded in favour of SCPs.

Gerry Sutcliffe: There has been an investment in police numbers, but you may disagree as to their priorities. This issue is high on my agenda. I hope to be able to come back next year and tell you what achievements we have made in this area.

Jackie Briscoe, Aftermath Support: We were involved in one of the face-to-face pilots and so far we have had no feedback or support from the Home Office. Why can’t some of the money being used in Victim Care Units benefit people affected by road crashes? We recently went to Luxembourg with the BBC, and while there we met a prominent Government minister who had lost two people close to him due to road crashes. The Government there did a lot more to support people affected by road crashes - it seems that we only recognise how important it is when we are directly affected. Locks on doors are no use to road crash victims.

Gerry Sutcliffe: Locks are important for victims of burglary, though. We don’t want victims of any aspect to feel left out in the cold. The Victim Care Unit pilots are providing immediate, practical and tailored support to all victims of crime. They are providing many valuable services that can directly support victims, for example counselling, transport, childcare, financial assistance. Again, the face-to-face evaluation report and feedback will be published in the New Year.

Representative (name not recorded) from Trauma Auditing Research Network (TARN): Injury kills and disables. In fact, injury causes more deaths than cancer and heart problems combined. It has a huge costs both emotionally and financially. In the NHS Development Fund, injury receives the least money - could the Minister please bring this up with his colleagues?

Gerry Sutcliffe: We need to make sure the bodies looking at funding raise the profile of road crash victims and we all need to make sure we communicate with each other and with the public so they understand why these issues are important.

FLO (name not recorded) West Midlands Police: A lot of money for road crash victims comes from the Motor Insurers Bureau we have the powers to deny criminals the use of the roads by seizing vehicles but there are loopholes in this system, - as they can get their vehicles back fairly quickly and at low cost. How will these powers be extended to ensure drivers have a fully fledged insurance policy in place before they get their vehicles back.

Gerry Sutcliffe: Secondary legislation could be used to close this loophole and I will come back to you when I have spoken to my colleagues about this. However, as you will know, in order to strengthen enforcement activity to tackle insurance evasion we introduced two new measures last year. Firstly, to give the police improved access to the Motor Insurers Database to enhance their capability to detect uninsured driving by using ANPR (Automatic Number Plate Recognition) equipment. Secondly powers to allow the police to seize vehicles being driven uninsured. Both these measures are proving effective with the police seizing nearly 600 uninsured vehicles each week. In addition the Road Safety Act, has powers for a new scheme of Continuous Insurance Enforcement. This scheme will mean that rather than having to rely on spotting an uninsured vehicle on the road we can identify, from the database, vehicles where insurance polices have lapsed and not been renewed.

FLO (name not recorded) from West Midlands: I have an issue with the levels of sentencing given out for road offences leading to deaths the message these lenient sentences send out is wrong - we need to talk to judges to encourage them to up their sentences.

Gerry Sutcliffe: We have tried to look at and overhaul the system, but there are barriers to overcome. The public have got to have confidence in sentencing policy. The Road Safety Act has a new offence of causing death by careless driving with a maximum penalty of 5 years imprisonment and a new offence where a disqualified, unlicensed or uninsured driver is involved in a fatal incident with a maximum penalty of 2 years. Those who kill whilst driving are likely to receive harsher penalties following these new offences once they are implemented.

Stuart Turner: Can I please add that, since I got involved in this type of work in the 1980s, a lot has changed. It is important to press for change. The NHS needs to make more changes, but there have been some very important developments over the last 20 years. Victims’ needs and rights are recognised more than they used to be. It has to be a step in the right direction that we have a Victims’ Minister at all. There is a long way to go, but we are moving in the right direction.

Supporting families bereaved in road crashes - Cathy Keeler, policy director at Brake and PC Ken Johnson, Deputy Family Liaison Coordinator, Thames Valley Police

Levels of FLO - building up experience and expertise

Cathy Keeler: Tell us about the system of different levels of FLO you’ve introduced at Thames Valley Police - what is it?

Ken Johnson: There are three FLO levels that officers are trained to:

Level 1 - get an input on the patrol officers’ training course on the role of the FLO. Level 1s are rarely deployed on their own and if so, only in the simplest of cases.

Level 2 - get 2 days training on delivering death messages, recognising and dealing with stress, the role of the coroner, dealing with children. Level 2s may be deployed on their own in straightforward cases - normally not section 1s, police deaths or where there is a lot of press interest.

Level 3 - get the full national 5-day FLO training course. Can deal with all cases, but may be deployed in pairs or more for complicated cases.

CK: Why did the force decide to introduce this?

KJ: It helps develop experience and expertise at each level, officers can shadow the level above before deciding to apply for training to carry out the role.

Case studies on responding to different incidents

Case 1

Released on Friday, 09 July 2004 at 16:58:17.

Renewed appeal for information following double fatal yesterday Officers investigating a collision on the M4 yesterday in which two men died are renewing their appeal for information. Shortly before 5am yesterday (8/7), a silver Porsche Boxster was in collision with the back of a van on the slip road between junction 15 of the M25 and junction 4B of the M4. Two men, both passengers in the Porsche, died as a result of the collision. The van driver was taken to Wexham Park Hospital with chest injuries where he remains this afternoon. His condition is described as non-life threatening. As part of the ongoing investigation following yesterday’s crash, police are urging motorists or anyone with information who has not yet come forward to do so immediately. They are particularly keen to hear from anyone who saw the silver coloured Porsche Boxster, stolen from an address in London on June 28, being driven around the M4, M25, or local roads prior to the collision or since the date it was stolen. Sgt Andy Shearwood, investigating officer, said: “It is vital that people with any information, despite how trivial it may appear, come forward immediately.” The two men who died have not yet been formally identified. Anyone with information should contact Sgt Shearwood via the 24 hour Police Enquiry Centre on 0845 8 505 505 or call Crimestoppers anonymously on 0800 555 111. ?An 18-year-old man from Staines in Middlesex who was arrested on suspicion of causing death by dangerous driving following the incident remains in hospital this afternoon. He has yet to be interviewed by detectives.

Released on Monday, 22 November 2004 at 11:43:01.

Teenager sentenced for two counts of causing death by dangerous driving An 18-year-old Berkshire man has been sentenced to five years imprisonment for two counts of causing death by dangerous driving. Daniel Beldom, of Douglas Lane, Wraysbury, was sentenced at Reading Crown Court on Friday 19 November. At an earlier hearing he had pleaded guilty to causing the deaths of Ali Malik, aged 26, of Warpole Road, Old Windsor, and Ricky Loveridge, aged 25, of Ditton Road, in Datchet. Both died following a collision on the M25/M4 slip road near Colnbrook during the early hours of Thursday 8 July this year. Beldom, a provisional licence holder, was driving a stolen Porsche Boxster S on the slip road from the northbound M25 onto the westbound M4 with Ricky Loveridge and Ali Malik as passengers in the two seater car. He lost control of the car, which had a virtually bald tyre, and collided with a van which was temporarily parked on the hard shoulder. Mr Loveridge and Mr Malik died upon impact. Beldom left the scene but was arrested nearby. He sustained injuries as did the driver of the van. Both spent a number of days in hospital. Following Friday’s sentence, PC Mark Scully, one of the team of officers investigating, said: “No matter what the circumstances surrounding a fatal collision are, there is always a family who have lost a loved one. This has been no different. The Crown Court Judge has passed a sentence which falls within the guidelines available to her for this offence, taking into account factors including Beldom’s guilty plea, his age, his driving history and other factors surrounding the collision. He added: “When dealing with road deaths of any circumstances, no sentence of any length will bring a loved one back.” Note to editor: Please note that the following information has been prepared from police notes, not court proceedings.

KJ: This was a difficult case for several reasons. It involved a stolen vehicle, being used by two criminal families. It was also hard to identify the dead. The whole scene was contained immediately and officers dealt with the incident there and then. It took 12 hours to identify the bodies. Three FLOs were assigned to work with the families. They agreed to ensure they each used an approach consistent with each other. The deceased had been on the run for 18 months before the crash. There was a lot of anger toward the police from the families.

Case 2

Released on Sunday, 29 May 2005 at 10:56:58.

Three boys among collision dead - Oxford Thames Valley Police can this morning confirm that three of the males who died in last night’s collision in Oxford were aged between 12 and 13. The fourth person who has died as a result of the incident, on the A4142 Eastern Bypass, between the Green Road roundabout and Slade Road traffic lights, was a 21-year-old man. A difficult and complicated investigation was launched by Thames Valley Police’s roads policing department last night and officers have worked tirelessly throughout the night to try and identify those involved in the tragedy and contact their next of kin. The relatives of all involved were finally reached at 6am today. Five people remain in critical conditions with life-threatening injuries as a result of the collision. The female driver of the Citroen, a 45-year-old woman, was airlifted to the Great Western Hospital in Swindon where she is in intensive care and being treated for multiple injuries, including severe neck injuries. Four boys ? aged between 12 and 13 ? remain in critical conditions at the John Radcliffe II Hospital in Oxford. They all have life-threatening head injuries. Three other men taken to other hospitals in the area have been treated for minor injuries and all have been released. Experts continue to work this morning to determine exactly how this tragedy occurred. At this stage, it is believed the Citroen, driven by the 45-year-old woman and containing the seven young boys, was travelling southbound and, for reasons not yet ascertained, lost control and crossed the grass verge central reservation, colliding with a Honda Civic and two other vehicles in the northbound carriageway. The driver of the Honda died later in hospital. His passenger, a male, was treated for injuries that are not life-threatening. The male drivers of an Audi and Volkswagen also involved were also treated for minor injuries. A male motorcyclist who fell from his vehicle as he attempted to avoid the collision was also treated for minor injuries. Two of the young boys in the Citroen were pronounced dead at the scene. The third died in hospital. Police continue to work at the scene to investigate the incident and the road remains closed in both directions at this time. Motorists are urged to avoid the area. The road will re-open in stages as the scene investigation draws to a conclusion. We will keep the media informed of updates. The scene of the incident was carnage, with barely-recognisable vehicles and debris sprayed along the road for some half a mile. Due to the serious conditions of all those involved, police were presented with a large challenge in terms of determining which casualties came from which vehicles. The boys were all on an evening out together and it was difficult to identify them, as the driver of the Citroen, the only one with the facts about who was in her vehicle, has been unable to speak. Work to identify all seven boys and trace their parents was a challenging and distressing job, fulfilled by officers who worked throughout the night. An incident room has been formed to investigate the collision, manned by specially-trained officers and supervisors. Family liaison officers have been appointed to support the families of those who have died or are injured. Police are keen to speak to people who were in the area at the time who saw the collision, who have not yet come forward, to do so immediately. They are also keen to speak to people who may have information surrounding the vehicles involved prior to the collision. Those who can help can contact the incident room at Bicester roads policing via 0845 8 505 505. Note to editors: Supt Mick Doyle and Sgt Steve Capper will be at the scene from 11.30am for interviews and updates. Formal identification of all those who died is likely to take some time and until this process is complete, Thames Valley Police will not release details of names. They will also not confirm or comment on names put to them.

Released on Friday, 03 June 2005 at 15:32:33.

Statement read by Insp Steve Bridges - Oxford fatal The tragic incident on the Oxford eastern bypass on Saturday (28/5) has touched the lives of many people and sent shockwaves through the community as a whole. Four of the boys who were in the Citroen Xsara remain in the JR2 Hospital. Two are still in a critical condition, another two have left the intensive care unit and are stable. They have been named as Conor Hunt, age 12, Jake Proper, age 13, Aiden Wood, age 13 and Anton Dublin age 13. Antony and Colette, Jake’s parents would like you to know: “Jake is showing signs of improvement and is hanging in there and being strong.” The 45-year-old woman remains in a critical condition in the Great Western Hospital in Swindon. None of the seriously injured people have been interviewed by police because they are all still too unwell. We have been holding daily meetings with our partner organisations to ensure that we are doing everything we can to help those affected in the wider community by this tragedy. Good progress is being made by the team which is working relentlessly to establish why the Citroen left the road and crossed the central reservation. At this stage we are still keeping an open mind about the cause of the crash. As with any serious collision we will look at all the possible contributory factors which include the road, the vehicles, the conditions and the events leading up to the crash. Detailed examinations of the cars involved have been completed and the evidence is now being collated and analysed. We are still taking witness statements and are responding to the calls we have received from members of the local community for which we are very grateful. A significant amount of forensic evidence has been obtained. The seven officers in the incident room, set up on Sunday (29/5) morning, have all been working in excess of 12 hour shifts and have already worked some 529 hours in the first five days. This does not include the 13 family liaison officers or other officers working on generated inquires outside of the room itself. We are still appealing for witnesses and would particularly like to speak to anyone who was behind the Citroen Xsara before the crash and any of the people who stopped to help who have not already given statements to police. Officers will be at the scene tomorrow (4/6), one week on, to carry out roadside checks between 6.30pm and 8.30pm. We will be speaking to drivers to establish if they were making the same journey this time last week and if they saw any of the vehicles involved in prior to the collision, or the incident itself, particularly in relation to the gold Citroen. Once again we would ask the media to respect the privacy of the families involved and to direct any queries to our media team.

Released on Friday, 03 June 2005 at 15:32:33.

Statement read by Insp Steve Bridges - Oxford fatal The tragic incident on the Oxford eastern bypass on Saturday (28/5) has touched the lives of many people and sent shockwaves through the community as a whole. Four of the boys who were in the Citroen Xsara remain in the JR2 Hospital. Two are still in a critical condition, another two have left the intensive care unit and are stable. They have been named as Conor Hunt, age 12, Jake Proper, age 13, Aiden Wood, age 13 and Anton Dublin age 13. Antony and Colette, Jake’s parents would like you to know: “Jake is showing signs of improvement and is hanging in there and being strong.” The 45-year-old woman remains in a critical condition in the Great Western Hospital in Swindon. None of the seriously injured people have been interviewed by police because they are all still too unwell. We have been holding daily meetings with our partner organisations to ensure that we are doing everything we can to help those affected in the wider community by this tragedy. Good progress is being made by the team which is working relentlessly to establish why the Citroen left the road and crossed the central reservation. At this stage we are still keeping an open mind about the cause of the crash. As with any serious collision we will look at all the possible contributory factors which include the road, the vehicles, the conditions and the events leading up to the crash. Detailed examinations of the cars involved have been completed and the evidence is now being collated and analysed. We are still taking witness statements and are responding to the calls we have received from members of the local community for which we are very grateful. A significant amount of forensic evidence has been obtained. The seven officers in the incident room, set up on Sunday (29/5) morning, have all been working in excess of 12 hour shifts and have already worked some 529 hours in the first five days. This does not include the 13 family liaison officers or other officers working on generated inquires outside of the room itself. We are still appealing for witnesses and would particularly like to speak to anyone who was behind the Citroen Xsara before the crash and any of the people who stopped to help who have not already given statements to police. Officers will be at the scene tomorrow (4/6), one week on, to carry out roadside checks between 6.30pm and 8.30pm. We will be speaking to drivers to establish if they were making the same journey this time last week and if they saw any of the vehicles involved in prior to the collision, or the incident itself, particularly in relation to the gold Citroen. Once again we would ask the media to respect the privacy of the families involved and to direct any queries to our media team.

KJ: In this case, there were seven young passengers involved. The whole city was shut off following the incident. The driver was taken to Banbury Hospital, which was miles away, and the victims to two other hospitals. We needed enough FLOs to cover each hospital. As the passengers were all children and the driver was hospitalised, there was no way of identifying the victims. The driver’s husband came to the hospital. The identity of his son was then ascertained because of his ethnic origin. The husband was then able to identify all the other dead victims and the FLOs took him to the houses belonging to their families.

CK: How many FLOs were used on this case and what level were they trained to?

KJ: Level 3 FLOs were used for every family. It proved quite difficult to find enough for every family, as it as a Saturday night. We also provided level 3 FLOs for each of the witnesses. The driver’s family was from a troubled estate and there was a lot of anger in the local community. The driver got a two-year sentence.

Breaking bad news - experienced FLO vs time delay

CK: How does the three-tier system work when it comes to call-outs?

KJ: Any roads policing officer should be able to pass on the death message if necessary and understand and explain the role of the FLO. There are always all levels of FLOs on duty.

System to manage workload and number of cases

CK: What systems have you got in place to manage FLOs’ workload and numbers of cases?

KJ: The force has tried to put a computer system in place, with the idea that FLO coordinators all have laptops and can access it from home. However, this is a bit of a work in progress ? it is not always easy to access or updated when it should be.

Selection de-selection process

CK: How else are you tightening up procedures in Thames Valley police force? What about making sure you’ve got the right people for the job?

We have a structured support system - with FLO managers, welfare, Occupational Health Unit.

Selection process - officers have to apply to move up a level in the FLO tier system, listing experience.

De-selection process - officers can be de-selected if not performing the job properly. Time for a chat if logs and/ or formal or informal conversation show they are overstepping their duties and getting too involved with the case.

The Tsunami Support Group and the London bombings: lessons learnt from major disasters - Rosie Murray, Chair of the Human Rights Aspects Group (emergency planning society)

Can I just start by saying that there are differences between a Tsunami and road crash, but similarities lie in the way we deal with them. It is important that Government departments work together properly when disaster strikes.

Disaster action - support
The following statement was made in 1990 by Disaster Action: “Our personal experience of disasters taught us that the immediate aftermath is often made more painful by professionals and institutions who are insensitive and unsympathetic to the rights and needs of bereaved families and survivors.” This doesn’t just apply to police, but other professionals. Local Authorities and the NHS may not have progressed in the way that police have in this area.

The History of Human Aspects

  • 1990 Allen Report
  • Dealing with disasters
  • 1995 Human Aspects Group
  • Responding to Disasters - the Human Aspects
  • Post 2001 - Vital Human Services

There were 5 major disasters during an 8 month period, from Dec 88 - Aug 89, which received a lot of publicity, but it is worth bearing in mind that they claimed less UK lives altogether than road crashes do annually. The disasters were the Clapham train crash, and Lockerbie (Dec 88), Kegworth (Jan 89), Hillsborough (April 89) and Marchioness (Aug 89)

Responding to Disasters

I worked with the British Red Cross to support the victims of the Boxing Day Tsunami. This involved:

  • Tsunami Support Line - Rosie was project co-ordinator. It wasn’t a helpline, but rather offered support and signposting
  • Tsunami Support Network coordinated by Dr Anne Eyre
  • Tsunami Memorial Support Line
  • Working with FCO, FLO co-ordinators and DCMS
  • Partnership working with ADSS

Findings of post tsunami research by Zito Trust (NAO)
These findings have been delayed, but are about to be published by the National Audit Office. They found:

  • The care offered in immediate aftermath was not effective - there was not enough and it wasn’t always of a high enough standard
  • 1 in 3 people involved in the Tsunami were not offered any support when returning to UK
  • Support at airports was effective once established
  • Fewer than 1 in 5 bereaved people were able to meet the coffins carrying their loved ones at the airport. The ability for bereaved people to do this is very important, and is an issue I have seen raised a lot in relation to families bereaved by road crashes occurring overseas. Not being able to meet the coffin in these circumstances can be extremely distressing. It also emerged there are also no facilities at airports, such as special waiting rooms, for people to use in these circumstances
  • Government agencies did not work together very well
  • Information not shared between them
  • There were Data Protection Issues
  • Problems accessing appropriate psychological interventions - it is important to be careful to refer those requiring psychological interventions to appropriately trauma-trained personnel
  • Financial problems - many people almost lost their homes. It was difficult explaining to UK residents affected by financial hardship as a result of the tsunami that they could not access any of the £100millions being held by the Disasters Emergency Committee.
  • Benefit and tax issues - many bereaved people suffered these - the Government should ensure this does not happen again.

7 July bombings

  • A Family Assistance Centre was set up to support victims’ families
  • London Bombings Screen and Treat Mental Health Programme - to provide support. This was the first time this has been done.
  • NHS Trauma Response Screening Team - long term follow up.

Report on 7 July bombings showed:

  • Government contact was slow
  • Organisations did not work together to share info, so joined up services were lacking
  • There were problems contacting Police Casualty Bureau
  • It was difficult to get information regarding survivors in hospitals
  • There were concerns regarding the time it took to identify those who had died
  • Information was not passed to families through identification process
  • The Family Assistance Centre was not promoted enough
  • Only the most severely injured received support
  • There could have been better facilities for survivors to contact each other through internet or support groups
  • Contact details could have been better shared between organisations
  • More could have been done to advise employers on how to treat staff after a disaster ? the effects can be very long-term as we know.

Developments post tsunami and 7/7

  • Critical Incident Response Advisory Team (CIRAG)
  • National Aftercare Group (NAG)
  • National Training Standards Group
  • DCMS Humanitarian Assistance Unit

Guidance documents

  • The Humanitarian Assistance Document
  • The Home Office Guidance on dealing with Mass Fatalities
  • NICE Guidelines on PTSD
  • Literature and best practice review and assessment ? produced by Dr Anne Eyre for DCMS

Conclusions

  • Lessons have been learned - but slowly. We need to ensure these lessons are followed up for the future
  • Support is available in immediate aftermath
  • Medium/Long term needs are less likely to be met
  • Response needs to be more ‘joined up’ and ‘seamless’.

Lesson Learned from 7July

“and a crucial lesson we have drawn is that the quality of help received in the first few hours and days can determine for years to come people’s reaction to a terrible event of this sort”

Tessa Jowell Secretary of State Dept of Culture, Media and Sport.

Timeline of needs / reactions following a critical incident

GRAPH

Tsunami:

Died: 150

Injured: 800

Affected: approx9,000

Approx 25% affected will go on to suffer PTSD

Road Collisions:

Fatal: 3,336

Serious injuries: 30,027 serious

Slight injuries: 245,813

Queue-jumping for support services for the Tsunami victims did occur, but obviously we don’t want that to disadvantage road crash victims.

Delivering counselling to victims of PTSD ? Sheila Marston and Alan Penny, trauma therapists, ASSIST Trauma Care

This presentation will cover:

  • ASSIST Trauma Care
  • Trauma Treatment
  • Outcomes

ASSIST exists to offer help and support to individuals and families who have experienced trauma, and to provide professional, evidence-based therapies where appropriate.

ASSIST Trauma Care - Therapeutic Services

  • Early Intervention
  • PTSD Assessment
  • Single Incident Trauma:
  • Trauma-focused cognitive behavioural therapy (CBT)
  • Eye Movement Desensitisation and Reprocessing (EMDR)
  • Children affected by trauma
  • Type II or Complex Trauma
  • Group work
  • Telephone Support - Helpline

Early Intervention
We work to the NICE guidelines and find they are effective.

First 4 weeks “Watchful Waiting”:

  • Information. Immediately after the traumatic event, we take time to explain how mind and body reacts to a trauma and symptoms that may be experienced. This makes it easier for sufferers to understand what’s happening to them, and that it’s ok not to feel ok.
  • Practical and emotional support. Some people won’t have this available (e.g. from a family), so we will meet this need. It’s important to listen.

4?6 weeks after the traumatic event if psychological symptoms continuing:

  • Trauma-focused CBT. By this stage, sufferers are already used to talking to about their trauma, so it can be an easier process for them to then go into the therapy and the number of sessions is often minimal.

A PTSD assessment is made, looking at:

  • Full client history. (ASSIST treat sufferers from all over the UK, with referrals coming from a number of different sources, including GPs There is a need to increase GPs understanding of PTSD so they are better equipped to identify the symptoms and refer on.)
  • Current problems
  • Psychological tests and measures, e.g.

  • Horowitz ? Impact of Events (IES): intrusion and avoidance (client rates their experience over the last seven days, and so can be used even a long time after the trauma occurred.

DSM-IV Post Traumatic Stress Disorder Symptom Checklist:

re-experience phenomena; avoidance/numbing; increased arousal using a Yes/No indicator

  • Brief description of the traumatic event
  • Maintaining factors ? what are they doing in life/extending
  • Impact on life
  • Treatment and legal issues

Treatment: NICE Guidelines

Course of trauma-focused CBT:

  • 8-12 sessions, 1-11/2 hours
  • Therapeutic relationship
  • Schemas and beliefs
  • Exposure therapy ? taped
  • Hotspots
  • Cognitive restructuring
  • Review and Ending
  • Feedback - immediate and after 4 months

Avoidance is often a high maintenance factor with PTSD sufferers. It is often necessary to relive the trauma to enable them to identify the worst parts ? the meaning and the emotions. After 6-7 sessions a review and reassessment is carried out, and this is then repeated at the end of therapy.

Case study: Fireman - driver

Activating Event:

13 January 1996 - on the way to answering an emergency call, he was involved in road crash. It resulted in the fatality of the female driver of the other vehicle. Mike (his name has been changed) attempted to keep her alive, but she later died.

Consequences:

2000 - Mike diagnosed with PTSD. Between this and 2005, he was on various waiting lists, had various referrals and treatments, none of which were evidence-based trauma treatments and proved unsuccessful.

2005 - Self-referred to ASSIST Trauma Care.

Treatment began 1 September 2005

Treatment ended 23 November 2005.

  • Mike was encouraged to discuss all his concerns. Trust and honesty were paramount to his relationship with the ASSIST counsellors.
  • It was also important that compassion was exercised, as it enabled any irrational belief systems he had to be normalised.
  • ASSIST also checked if he was on any medication.
  • His main concerns were: lack of concentration; anger; guilt; fear of being violent and nightmares.
  • He summarised what happened when the crash occurred, his flashbacks and concerns.
  • After the first session, he started to explore his feelings and emotions. Time was always taken at the end of the session to ensure Mike was safe to drive home (as the journey home was often traumatic for him. This agreement was particularly important when he underwent the ‘exposure’ element of the therapy).
  • Exposure session: Mike was asked if he was ready to continue (if he wasn’t, this was ok, but a discussion would take place as to why he wasn’t ready). The first stage involved him making a 1 hour audio tape of his traumatic event, whilst making this his body language and reaction were monitored.
  • At the next stage, Mike took the tape home, to encourage him to take control. He was encouraged to listen it as much as he wanted, and to be aware of ‘hotspots’ (parts of the tape that affected him most).
  • At session 5/6, we discussed the tape. Then a re-evaluation took place.
  • Using the PTSD checklists showed he had improved a lot, he had had no nightmares in two weeks and a lot less anger.

Between 1 August 2005 - 31 July 2006, ASSIST saw 54 new clients:

53 had ‘Type 1’ Trauma

1 had ‘Type 2’ Trauma - 13 already being treated on an ongoing basis.

The most common causes of PTSD among the ‘Type 1’ sufferers were:

  1. Domestic Abuse
  2. Attack
  3. Bereavement
  4. Road crashes
  5. Work-related

They were given an average 14 hours’ therapy, all receiving trauma-focused CBT and one who received EMDR.

Change in symptoms - example

The following table shows changes in symptoms achievable through the therapy.

IES = Impact of Event Scale

DSM-IV = Diagnostic and Statistical Manual of Mental Disorders - IV

Start End
IES
Intrusion 35 out of 35 3 out of 35
Aviodance 32 out of 40 1 out of 40
DSM-IV PTSD
Re-experience 5 out of 5 0 out of 5
Avoidance 5 out of 7 0 out of 7
Increased arousal 4 out of 4 0 out of 4

Clients’ comments at the end of therapy

  • “My life has taken a definite turn for the better. My immediate family express their gratitude for giving me the opportunity to improve my quality of life. My son now has a father ??..”
  • “I am now able to cope with life and plan my future.”
  • “You gave me back control of my mind and also gave my husband’s wife back, and my beautiful daughter the mother she deserves.”

Questions and answers:

Chris Osborne, Metropolitan Police: I am surprised that not all your FLOs are fully trained. All our FLOs that deal with fatal cases have attended the full week course.
KJ: Money is a bit of an issue, but there are now only a few left to train up to this level. It does provide a stop-gap, as not all families require the highest level FLO. But our ultimate aim is to have them all trained up.
CK: I imagine it also avoids throwing some FLOs in at the deep end.

KJ: Yes. We also have some level 2 FLOs who deal with more difficult cases while being observed by level 3s.

Delegate, name not recorded, Cruse: One of our counsellors went into the schools involved in that last case study and saw that the officers had done a lot of good work there.

Delegate, name not recorded, Greater Manchester Police: How soon do FLOs get deployed and how do you assess what level is needed?
KJ: The co-ordinator on duty gets the first call (there is one on duty 24/7). They look at the details of the collision and the families and make a basic risk assessment. If they know it is a ‘Death by dangerous driving’ or ‘death by careless driving while under the influence of drink or drugs’ offence, then they will choose a level 3 FLO automatically. If it is a single vehicle motorbike crash, for example, a level 2 might be used. The system is flexible though.

Delegate, name not recorded: Is there much of a delay in getting the FLO to deliver the death message?
KJ: It can be hard. Some Investigating Officers say they don’t want to deal with this task, but because they have all now had the level 1 training, they can deliver the message when it is difficult to get a higher level FLO to the family in time, and the higher level FLO can then be assigned first thing in the morning.

CK: What are the challenges relating to call-outs in your force?

KJ: It is a big geographical force, with an uneven distribution of fatal and serious crashes (e.g. lots of motorcycle casualties in Oxford/ Abingdon in Summer). The South-East-based officers tend to be overworked and the North-West-based tend to be overworked. But this has been identified and we are looking at redressing the balance.

CK: Have any other forces got good systems in place or face similar challenges?
Phil L, Staffordshire Police: I think the Level 1 system is a good one. My only concern is with the level 2s and 3s ? whatever the dynamics of the crash, there will always be bereaved families to deal with. I’m also surprised you only have 44 FLOs for roads policing, as we have 70. We have a system for deployment that seems to work quite well, and we have used for three years. Each FLO gets mandatory welfare visits. I am quite concerned that FLO systems are different across the UK as well.

KJ: With reference to your concerns about using lvele 2s and 3s for road deaths, we work very hard to ensure the same level of service is delivered to the family across the board and a family can always ask for extra support if needed.

Bryn Majid, Cheshire Police: The Thames Valley system seems good. However, there has been no mention of officer welfare. We use convalescent homes and hold 3-4 weekend sessions for officer welfare every year.

KJ: We do have a structure in place - we have a welfare officer and a deselection process.

Family breakdown in response to serious illness & injury - Ceri Bowen, International Fellow, Working with Families, Royal Hospital for Neuro-disability, London

In this presentation, I will look at:

  1. The concept of ‘brain injured families’
  2. Family trauma & personal grief
  3. Breaking bad news
  4. Family dynamics
  5. Marital relations
  6. Common misunderstandings
  7. Goal-setting and the limits of rehabilitation
  8. Optimizing rehabilitation, involving the family and ongoing need
  9. Treatment options: 10 levels of intervention
  10. Family Systems-Illness Model

The concept of ‘brain injured families’ - The family system is always affected by illness and injury but the extent and the way will depend on members’ ability or inability to support each other - It will also depend on the professional help received - The immediate response for relatives is most likely to be a grief response (shock, denial, anger, acceptance, readjustment) - The process of grieving will vary for each person.

Family trauma: factors determining the nature of personal grief - Individual factors: relationship to the injured party, involvement in the accident or illness, likelihood of being the main carer, implications in terms of long-term care & life choices - Family factors: communication patterns within the family, flexibility of role relations, the ability to manage closeness / distance for individuals, space for feelings, problem-solving capabilities, previous experiences of coping as a family - Community factors: wider social support, extra financial support.

Breaking bad news (see Brewin 1996) - Giving information does not always equate to it being received ? feel free to follow up difficult conversations with a phone-call - To clarify matters it may be worth asking the person/family you are working with, ‘if a friend asked you what was said today, what would you say?’ - After speaking to a relative, why not end the conversation by going over to the injured party / patient and include them - It may be helpful to mention that trauma reactions are common and so individuals may become preoccupied by intrusions (e.g. flashbacks) and avoidance (e.g. staying away from the scene of the accident). - Try not to avoid mourners, the same applies to those dying - Be careful about terminology - let ‘dying’ refer to those who are expected to live 2-3 weeks or less, ‘terminal’ for those with 2-3 months of life - Remain optimistic and hopeful without losing your honesty - It may be helpful to prepare the family for any confusion that their loved one may experience nearing death.

Family dynamics - Pre-existing interpersonal conflicts may resurface - Uncontained anger needs managing or at the very least, individuals need to feel that it can be managed ? for example, an injured party may feel anger toward a family member who sets the boundaries on their lifestyle, or, if they were injured young, they may want to assert their independence which can cause anger on both sides - Individuals may be vulnerable to a perceived loss of meaning / purpose to life - Responsibility for day-to-day matters may move from a shared activity to being carried out single-handedly (super-parent) - Impaired brain functioning may lead to generalized neglect over dependents.

Marital relations - Relatives may oscillate between sympathy and frustration with the patient - Ambivalent feelings are very common - Loss of intimacy - Sexual dysfunction - Mood swings especially difficult to cope with - Relatives often report it is like ‘living with a stranger’, that the person is not the person they married.

Common misunderstandings that can lead to family breakdown

All of the following may have some neurological basis:

  • Impairment in the ability to initiate may be seen by the family as laziness - Impairment of concentration may be perceived as disinterest or inconsiderateness - Memory impairments may be misinterpreted as denial or resistance- for example if the inured forgets to take their medication, it can be seen as them not wanting to get better - Increased impulsivity may be seen as wilfulness, being stubborn or reflecting a ‘difficult’ personality.

Goal-setting and the limits of rehabilitation - There may be a need for families to modify their ideas of recovery - Goals need to be SMART ? specific, measurable, attainable, relevant, and timed - Processes of denial may be as common in relatives as in patients ? it can be hard for families to give up the idea that the injured person will never be the same again. - There may be a feeling that more is better, when it is equally important to think about pacing and building breaks into any rehabilitation - It is important for carers and families to allow their relative sufficient time and space to find their own way of expressing his or her views, beliefs and needs.

Optimizing rehabilitation, involving the family and ongoing need - In rehabilitation settings the patients with the most successful outcomes tend to have extensive family support ? people should be given choice in becoming a carer - Make a point of inviting relatives to meetings and try to pre-empt questions and problems before they arise - Most injured patients leave hospital and the family then becomes the rehabilitation team - There may be an ongoing need for respite care and group support in the case of survivors - In the case of death, relatives may show some ongoing attachment to people and professionals during their grief (e.g. the patient representative committee)

Treatment options: 10 levels of intervention
1. Information booklets / education / use of media
2. Biblio-therapy
3. Respite care
4. Involvement in rehabilitation / case conferences
5. Cognitive-neuro-behavioural support
6. Informal or peer support groups
7. Formal support groups (e.g. Headway)
8. Individual psychotherapy for relatives
9. Marital therapy
10. Family therapy

The last two tend to be separate clinics, often isolated from the rehabilitation clinics, and may not have good access for wheelchair users.

Family Systems-Illness Model (Roland, 1999): factors in perceived loss & strain - A key task for any therapist is to map out the incidence of predisposing vulnerability factors for family members - Psychosocial dimensions to the illness (type of onset, course or progression, predicted outcome, level of incapacitation, uncertainty) - Time-stage (crisis or diagnostic period, chronic or terminal stage) - Key family life cycle issues (e.g. are children involved / living at home? Parent or spouse?).

References - Brewin, T. (1996) Relating to the Relatives: Breaking bad news communication and support. Oxford: Radcliffe Medical Press. - Rolland, J. S. (1999), Parental illness and disability: a family systems framework. Journal of Family Therapy, 21, 242-266

Addiction and suicide risk - Dr. Ash Kahn, consultant psychiatrist, Woodbourne Priory Hospital

Bereavement - emotions felt at different stages:

  • Numbness - Disbelief - Acute Grief - Depression & Despair - Resolution

Complicated Grief

  • Death of fully grown child - Sudden death - Suicide - An ambivalent relationship before death

Psychiatric Associations

  • Increased morbidity from stress related conditions - Hypochondriasis - Phobias - Alcoholism - Depression

Substance Misuse & Suicide

  • 20% of suicides are alcoholic - Alcohol is often involved in attempts - Depression secondary to alcoholism is probably a significant factor

Alcohol is a Dirty Drug

  • Acts on a variety of receptor sites - Opioid receptors - like heroin - GABA receptors - like valium / anxiety - 5 HT receptors - depression

Substance Use & Bereavement

  • Part of a normal cultural response to bereavement - Develops into a coping strategy - Reduces the anxiety - Blocks out the feelings of loss, depression, sense of isolation

Spectrum disorder:

Social use of alcohol/drugs can develop into problematic use (use to block out problems), and problematic use can then develop into dependence.

Dependence
Experimental substance use, casual substance use or circumstantial substance use can lead to regular substance use and this can lead to compulsive use.

Childhood experiences that can affect whether someone develops an addiction:

  • Birth Trauma - ADHD - Abandonment by parents - Death of parent/sibling - Over-gratification or deprivation - Sexual or Emotional Abuse

Adolescent experiences that can affect whether someone develops an addiction:

  • Adolescent Experiences - Learning or Conduct Disorder - Family structure breakdown - Poor parent / child relationship - Lack of Values / religion - Substance misusing peers - Inadequate coping skills / knowledge

Environmental factors that can affect whether someone develops an addiction:

  • Economic availability - Social availability - Physical availability - Employment - Stress - Loss events - Peers

Dependence syndrome

  • Salience - user spends all their time thinking about and using the substance - Tolerance - keep needing to take more - Impaired Control - Compulsion - to use, despite awareness of the problems - Withdrawal Syndrome - Relief Use - Reinstatement - the user is back to square one.

Biopsychosocial components

The factors that influence whether someone develops a substance addiction are biological, psychological and social.

Click here for a graph which explains ‘adaptation to alcohol as basis for withdrawal syndrome’.

Stages in the treatment of alcohol dependence

  • Acute Interventions - Detoxification / Withdrawal - Evaluation & Assessment followed by Appropriate Intervention ( Psycho- Social Intervention) - Abstinence Maintainence - Aftercare / Relapse Prevention

The Odyssey

“Helen slipped a drug that had the power of robbing grief and anger of their sting and banishing all painful memories. No one who swallowed this dissolved in wine will shed a tear that day even for the death of his mother or father.”

Depression and suicide - theories and treatment through the ages

Hippocrates 400BC - “The Nature of Man”

Melancholia - black bile, mania was due to excess of yellow bile

Over centuries mentally ill looked after by monasteries ? depression due to magical possession

1950’s psychosocial theories of depression

Symptoms of depression:

  • Low mood - worse in morning - No sense of pleasure - Sleep disturbance - early morning waking - Agitation - Loss of Appetite and loss of weight - Weeping for no reason - Loss of energy - Loss of Motivation

Assessing suicide risk - things to look out for:

  • Wishing they were dead - Major loss event - Having recurrent thoughts of ending their life - They see it as the ‘logical option’ - Planning the act - Planning the events after - for example wills, funeral - Increasing isolation from family, peers society - Having the tools to do the act. - Feelings of depression, worthlessness, hopelessness - Feeling that life is not worth living - Wanting to die - Acts of self harm - Violent methods - Detailed planning - Leaving a note - No future

Treatment of depression

-Treatment of acute episode - Continuation Therapy after acute episode - Maintenance treatment ( prophylaxis)

Drug treatment of depression:

Antidepressant medication

a) SSRI - Prozac

b) Tricyclic - amitriptyline, dosulepin

c) Others - Venlafaxine,

Psychotherapeutic interventions

a)Supportive psychotherapy

b) Brief therapy

c) Interpersonal therapy

d) Cognitive Behaviour Therapy ( CBT)

Electropexy

Question and answers
Delegate (name not recorded): In Ulster, we have seen an increase in the suicide rate. Can you suggest what the cause of this might be?

Ash Kahn: I’m not sure. It is possible it is related to the Troubles, but I couldn’t say for sure. One the whole, suicide rates are falling in Great Britain, especially among women. The older people get, the less likely they are to commit suicide. However, self-harm cases seem to be going up. In terms of addictions, more people are getting into debt these days and people are drinking more. Also, medication is weaker these days ? a lot of it used to be lethal when combined with alcohol, but not any more.

Religion and culture on the road to recovery - Chris Swift, president, College of Healthcare Chaplains

Can I just start by saying that the BBC website has some good quality information on a lot of the issues relating to different cultures and faiths.

Religion and culture: the difference
This is a huge topic of current debate: - The limits of diversity within a single nation - Serious stuff - issue of identity & feeling

These are very personal issues and at the core of may people’s identity. They arealso important in the context of loss.

  • A challenge to professionals: how to get it ‘right’ - or at least not get it wrong - What is religion? It can be summarised as a recognisable community of belief. The belief could relate to a historic text such as The Bible or The Koran, or have some other reference point - What is culture? It can be summarized as a recognised community of practice - ways of being is society.

Religion: Sociologists and anthropologists see religion as an abstract set of ideas, values, or experiences developed as part of a cultural matrix.

Culture: “culture should be regarded as the set of distinctive spiritual, material, intellectual and emotional features of society or a social group, and that it encompasses, in addition to art and literature, lifestyles, ways of living together, value systems, traditions and beliefs.” (UNESCO 2002)

There can be lasting as well as immediate consequences for giving good and bad care to people suffering trauma.

The danger of knowledge: - Deciding what the person ‘ought’ to be doing ? this can feel an insult to the person/family involved. - Not letting the person inform you - Using knowledge as more than a framework

Don’t just take a piece of knowledge about a religion and faith and apply it, but be perceptive in how to apply the knowledge to the situation. This is particularly important as there are increasing numbers of interfaith marriages/families. For example, a compassionate agreement may need to reached on a burial process in an interfaith marriage.

Examples of good care for people of different religion and culture in trauma: - Listening - Thinking ‘outside the box’ - helping meet families’ needs and using imagination - Knowing someone who knows - there are representatives for a diverse range of faiths throughout the healthcare profession - Diversity & choice - don’t treat everyone the same - Compassion - Time - dealing with the death by change the way grief is expressed over time.

A role for chaplains - Network of knowledge - Not needing to speak or ‘do’ - Spending time - Community links - Part of debate - Educating & training

Final thoughts: - Use sensitivity and honesty - Don’t be afraid to say ‘I don’t know’ - If you don’t know, find out - use the internet

Living with brain injury - Lisa Turan, chief executive, Child Brain Injury Trust

A story to tell: “No one can tell what the future will bring?and it’s probably just as well”

Every year, 25,000 children survive with acquired brain injury. Let me tell you about one particular case as an example:

Matthew was knocked down as a child. He was from a single parent family ? his father was a widower. The doctors said he wouldn’t live through the night. The family started to make arrangements for his death - organising an undertaker and so on. He was in an Intensive Care Unit for 5-6 days and then transferred to a main ward.

Six months later, he came home in a wheelchair. His father struggled to find information on acquired brain injury that could help him support his son. The systems weren’t there. Families affected by this type of injury need an introduction to brain injury as soon as the child is in hospital, to explain initially about what support is available and to signpost. Issues that he now faces include:

  • Will he be able to work? - Will he be ok at school? every child needs friends - He will need support for the rest of his life.

Matthew’s story is not an uncommon story.

The Child Brain Injury Trust is here for: - Parents - Children & young people - Other family members - Teachers - Health professionals - Other professionals who have an interest in acquired brain injury

“CBIT sees the person not the disability”

Child and family support: what it is and how it works
The CBIT can help the child and family with: - Hospital - Education - Social services - Returning home - Friends and social life - Community teams - Providing a break for all

Support at the earliest opportunity - Contact for family - make sure they have at least one person they can contact - Contact for staff - Immediate information

Long-term advocacy - acquired brain injury lasts a lifetime and affects the whole family - To help with understanding - To help with planning - To have representation - To feel supported

Child and family support at work new ways of working - Working together with health, education, social services - Developing support around the child and family - Listening - Communication

Child and family support - Faces reality with the child and family - Support at the earliest opportunity - this really takes a key priority - Support for life - Long term advocacy - Increasing understanding

CBIT offers training - ‘Don’t judge a book by its cover: supporting a child with an acquired brain injury at school’ - one day workshop. Child Brain Injury Trust, Unit 1, The Great Barn, Baynards Green Farm, Near Bicester, Oxfordshire, OX27 7SG