A violent TBS prisoner flees from the mental health institution on the Vrederust Estate in Halsteren and kills a 75-year-old woman. Another escapes and is shot by the police after a long chase. The two cases are not only being investigated by the police, but also by the healthcare institution itself. An independent inspection service assesses the results and determines whether lessons can be learned. A spokesperson for the Healthcare and Youth Inspectorate (IGJ) confirms this.
Both TBS patients lived at Vrederust in De Mare, a so-called Forensic Psychiatric Department (FPA) with high fences, electric wire and intercom.
Healthcare providers such as the GGZ are not legally obliged to report violence such as that seen in Halsteren last week. But in the interest of good and safe care, the IGJ does recommend this. This can be read on the website of the inspectorate that supervises healthcare institutions.
“If there is a calamity, we ask a healthcare provider to report it,” says Frank Wassenaar of the inspection service. “They then conduct their own research or give an assignment to a researcher.”
Own mental health research
After violence by patients, healthcare institutions can follow an extensive inspection checklist. It contains all kinds of questions that need to be answered: about the place where it happened, staff who were present, protocols followed, medication, reporting, aftercare and the measures that were taken. “We expect them to write that down in all openness and honesty,” says Wassenaar.
When an investigation report is completed, it goes to the inspectorate. “We then receive that report and assess it. For example, we look at the independence of the investigation. It cannot be the case that those involved in the violence themselves investigate their own actions.” The healthcare institution will receive a message within four weeks after the notification.
Whether the outside world understands what exactly happened depends on the healthcare institution. “They are the client, not us. They write all kinds of medical and personal data in such a report. They must be able to do this in complete safety, so we do not publish such a report. It is up to the healthcare institution itself whether, for example, they provide a summary want to give to the media.”
Inspection visits
The inspectorate also makes site visits. The last visit to the De Mare clinic, where the suspected TBS patients lived, was on October 4, 2021. The inspectorate then visited 22 clinics and departments in the country, because there was a lot of fuss about it at the time. The aim was to see whether care at De Mare was good and safe.
The conclusion was that the clinic had everything in order. The only criticism was that the building was ‘dated’, but that a lot had been done ‘to make the spaces more cozy’.
De Mare is described as a ‘way station’ for people who are slowly returning to society but still need help to prevent relapse.
‘Unsuitable for people at risk of flight’
The report further states that FPA De Mare has security level 2. For comparison: a ‘real’ TBS clinic, a Forensic Psychiatric Center (FPC), is at level 4. That is the highest level.
The report also states that De Mare is unsuitable for people who are a flight risk or life-threatening situation. It is still unclear how both TBS patients were assessed and what ‘status’ they had.
READ ALSO: Murder and wild pursuit of a TBS prisoner: how could things go so wrong at Vrederust?