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The Journal of Forensic
Psychiatry
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Injustice in forensic
psychiatry: the Scott-
Moncrieff hypothesis
revisited
Philip Sugarman a & Ashmesh
Roychowdhury b
a Clinical Director, Kent Forensic
Psychiatry Service , Trevor Gibbens Unit ,
Hermitage Lane, Maidstone , Kent , ME16
9QQ
b Senior House Officer, Kent Forensic
Psychiatry Service , Trevor Gibbens Unit ,
Hermitage Lane, Maidstone , Kent , ME16
9QQ
Published online: 09 Dec 2010.
To cite this article: Philip Sugarman & Ashmesh Roychowdhury
(2000) Injustice in forensic psychiatry: the Scott-Moncrieff hypothesis
revisited, The Journal of Forensic Psychiatry, 11:2, 465-469, DOI:
10.1080/09585180050142660
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The Journal of Forensic Psychiatry Vol 11 No 2 September 2000 465–469
Injustice in forensic psychiatry:
the Scott-Moncrieff hypothesis
revisited
PHILIP SUGARMAN and ASHMESH
ROYCHOWDHURY
ABSTRACT Scott-Moncrieff (1993) argued that key decision-making in
forensic psychiatry may be biased against the individual by false or misleading
information presented in reports. We examined this by comparing accounts of
incidents and other problems in reports to the mental health review tribunal,
with contemporaneous records. In a regional secure unit a signiŽcant discrep-
ancy was found, particularly in the reporting of aggressive behaviour. The
authors argue that reliance on verbal accounts and inadequate contemporane-
ous notekeeping are more likely explanations than true bias, but accept Scott-
Moncrieff’s recommendation of proper investigation of incidents in hospital.
Keywords: mental health review tribunal, injustice, forensic psychiatry
In the pages of this journal a well-known mental health lawyer published an
account of inaccurate reports about several of her Special (high-security)
Hospital clients (Scott-Moncrieff, 1993). She alleged that some patients may
not be discharged because, at hearings of the mental health review tribunal
(MHRT), ‘considerations of safety, dangerousness and risks may well be
inuenced by information that is biased or wrong’. Concerned that internal
investigation of incidents may be unjust, she urged that ‘psychiatrists should
consider adopting some of the methods of investigation that are thought
appropriate when others in society are suspected of wrong doing’.
The Journal of Forensic Psychiatry
ISSN 0958-5184print/ISSN 1469-9478 online © 2000Taylor & Francis Ltd
http://www.tandf.co.uk/journals

466 JOURNAL OF FORENSIC PSYCHIATRY
Vol. 11 No. 2
It was decided to test the hypothesis of Scott-Moncrieff’s paper in a
medium secure setting by investigating whether behaviours of concern
observed in hospital are misrepresented to MHRTs.
METHOD
Medical and social work reports to MHRTs on inpatients at the Trevor
Gibbens Unit, the regional secure unit (RSU) for the county of Kent, were
examined, covering the years 1986 to 1998. The reports were rated using
Health of the Nation Outcome Scales (Wing
., 1998) in a format devel-
et al
oped for mentally disordered offenders (HoNOS-MDO – Sugarman and
Everest, 1999). Of the 13 scales, 5 were deemed relevant to the purpose, com-
prising: aggressive behaviour, self-harm, substance misuse, psychotic features
and depressive features. These scales of HoNOS-MDO differ little from
HoNOS, the reliability of which has been extensively investigated (Stein,
1999). The HoNOS four-point interval scales of severity are designed to be
scored for psychiatric symptoms and impairments in a set time period, typi-
cally 2 weeks. Scores can be compared and totalled as part of a programme
to measure progress toward Department of Health targets (Wing
., 1998).
et al
A 2-week period around notable incidents of disturbance was rated by one
of us (A. R.). Formal written reports to the MHRT by the responsible
medical ofŽcer (RMO) and social worker (SW) were examined. For com-
parison, medical and nursing notes, contemporary to the incidents in ques-
tion, were rated using the same instrument for the same time windows.
Records examined included hand-written notes, incident forms and weekly
ward-round notes. To avoid any inter-rater variation, only one rater was
used, who could not therefore be blind as to the content of MHRT reports.
Thirty-seven cases were found, of which 7 had to be rejected as medical
and nursing records could not be located. Analysis of paired data utilized t-
tests for normally distributed variables and McNemar’s test for non-normally
distributed variables.
RESULTS
The HoNOS-MDO ratings are shown in Table 1 (possible scores 0 to 3, 0 to
15 for the total). SigniŽcantly lower scores were found in contemporaneous
records, especially on the aggression scale. Restricting the analysis to a subset
of the 21 more recent cases, involving only patients of current consultant
staff, showed a similar statistically signiŽcant pattern, although less markedly
so. In 4 cases the incidents of concern were reported at tribunal hearings to
which the RMO and the SW were recommending discharge. The scores for

INJUSTICE IN PSYCHIATRY 467
Table 1
HoNOS – MDO
Scale
Mean rating
––––––––––––––––––––––––
Comparison of means
–––––––––––––––––––
SigniŽcance of
difference
MHRT
reports
Case-sheet
1 Aggressive behaviour
2 Self-harm
3 Substance misuse
6 Psychosis
7 Depression
2.73
0.90
1.10
1.33
1.50
7.57
2.13
0.90
0.87
1.03
1.10
6.03
p < 0.005*
not signiŽcant#
not signiŽcant#
p < 0.05#
p < 0.05#
Total score
p < 0.001#
Key: *t-test
#McNemar’s test
these 4 cases were on average slightly more divergent between MHRT reports
and case-sheets than was the case for the other 26, suggesting no trend
towards an association between recommendations against discharge and dis-
crepant reporting of incidents.
DISCUSSION
The expectation of the authors of this study had been that reports to MHRTs
in an RSU setting would have been, if anything, prone to underplay incidents.
These unexpected Žndings show that the authors’ preconceptions did not
inuence the study. The Žndings appear to support Scott-Moncrieff’s
hypothesis. We took some comfort in the suggestion of less discrepancy in
the more recent reports and that the discrepancy did not relate to reports’
recommendations. Interestingly there was no discrepancy in reporting self-
harm. However, we cannot disprove the idea that adverse reports of aggres-
sion and psychiatric symptoms might be unjustly elaborated as part of an
argument against discharge.
A scientiŽc hypothesis can be refuted by opposing data, but cannot be
deŽnitively veriŽed by supportive evidence (Popper, 1963). It is important to
consider other hypotheses to explain these Žndings. Medical and social work
staff at the Trevor Gibbens Unit were frankly surprised by these results, the
notion of unjust and exaggerated reports to tribunals being quite at odds with
the service ethos. Discussions took place on how to understand the Žndings.
The rater felt that, despite the highly detailed case-assessments demonstrated
in current multi-service audit (Sugarman and Everest, 1999), speciŽc details
of important incidents were often lacking in both medical and nursing notes,
and in incident forms too (numerous administrative changes in recent years

468 JOURNAL OF FORENSIC PSYCHIATRY
Vol. 11 No. 2
had dismantled a previously detailed incident-reporting system). Medical and
nursing staff were prone to use general terms such as ‘behaved aggressively’
or ‘agitated’, in fact just the ‘psychiatric jargon’ which Scott-Moncrieff (1993)
Žnds used extensively in psychiatric records. Such general terms tend to score
lower on HoNOS-MDO which prompts higher ratings most easily with
speciŽc details.
We take the view that something a little different from the Scott-Moncrieff
account has been happening in our service, or at least a benign version of it.
In a small RSU incidents of note are often discussed and rehearsed. The SW
and the psychiatrist will often have listened carefully to one or more Žrst-
hand eye-witness descriptions, which are later detailed in a typed case-
conference report or MHRT report. Sometimes, however, second-hand
versions are relied upon, when witnesses are off duty, on sickness leave, or
not at hand. Contemporaneous notes typically do not play a direct role in the
construction of reports, such that inadequate record-keeping can go unno-
ticed. Something of a two-tier record system has developed, between daily
hand-written ward records and detailed, periodic typed reports. Anecdotally
we are aware of inaccurate versions of incidents being promulgated, although
it seems that these often underplay the seriousness of incidents. Thus the
measured discrepancy might be an artefact of inadequate record-keeping but
it might reect elaboration through unreliable verbal relay.
It is certainly unsatisfactory that verbal reports should be the basis on
which important decisions are made, with contemporaneous notes playing a
secondary role. This study has prompted renewed efforts to raise the stan-
dard of note-keeping in the service. A clinical governance programme has
been implemented, with peer review of the quality of records of this kind,
open feedback and cyclical audit. To avoid the kind of injustice described by
Scott-Moncrieff we intend to follow her advice and assiduously record eye-
witness accounts, taking statements in criminal justice style, to incorporate
into routine record-keeping and reports (see the appendix). These accounts
will be made directly available at MHRTs. We hope to be able to show, on
the basis of careful recording of an investigative process, that justice is done
and to refute any suspicion of bias.
Philip Sugarman, MB, ChB, MSc, MRCPsych, clinical director, Kent Forensic Psychiatry
Service, Trevor Gibbens Unit, Hermitage Lane, Maidstone, Kent ME16 9QQ
Ashmesh Roychowdhury, MB, ChB, MRCPsych, senior house ofŽcer, Kent Forensic Psychiatry
Service, Trevor Gibbens Unit, Hermitage Lane, Maidstone, Kent ME16 9QQ
Correspondence to Dr Sugarman

INJUSTICE IN PSYCHIATRY 469
REFERENCES
Popper, K. (1963) Conjectures and Refutations: the Growth of ScientiŽc Knowledge.
London: Routledge & Kegan Paul.
Scott-Moncrieff, L. (1993) ‘Injustice in Forensic Psychiatry’. Journal of Forensic
Psychiatry 4: 97–108.
Stein, G. S. (1999) ‘Usefulness of the Health of the Nation Outcome Scales’. British
Journal of Psychiatry 174: 375–7.
Sugarman, P. and Everest, H. (1999) An Audit of Five Regional Secure Psychiatric
Services. South Thames NHS Multi-Authority Clinical Audit Group (available
from the authors).
Wing, J. K., Beevor, A. S., Curtis, R. H., Park, S. B. G., Hadden, S. and Burns, A.
(1998) ‘Health of the Nation Outcome Scales (HoNOS): Research and Develop-
ment’. British Journal of Psychiatry 172: 11–18.
APPENDIX: HEADING FOR INCIDENT FORM
It is the responsibility of the ward manager to arrange for statements to be
taken from witnesses as soon as practicable after any serious incident or alle-
gation. Include any aggressive or irresponsible behaviour, such as assaults,
threats, Žre-setting or damage to property, drugs or alcohol, weapons,
attempts to abscond – or any other disputed incident.
Detailed verbatim
by an experienced member of staff not
accounts should be taken impartially
immediately involved, and preferably from another part of the service. Indi-
viduals should be encouraged to bear witness, as their duty, and to give honest
accounts, whether they be patients or staff, victim, perpetrators or by-
standers. Witnesses should be prompted step by step to recall what happened,
including what was said. If possible a minimum of four witnesses should be
consulted, when available, including patients and staff.