Dangerosité des patients : nouveau rapport des inspections générales

Prise en charge des patients susceptibles d’être dangereux : un rapport supplémentaire

Le rapport de l’Inspection Générale de l’Administration (IGA), de l’Inspection Générale de l’Action Sociale (IGAS) et de l’Inspection Générale des Services Judiciaires (IGSJ) de février 2006 relatif à « La prise en charge des patients susceptibles d’être dangereux », concluant à la nécessité de clarifier l’organisation des soins en psychiatrie dans le but de mieux prévenir et gérer leur éventuelle dangerosité, recommande une nouvelle loi sur la prise en charge des patients présentant des troubles mentaux permettant de réformer certaines pratiques mais aussi la diffusion de circulaires, l’élaboration de protocoles et le lancement de recherches. Il s’agit du quatrième rapport sur le sujet rendu en deux ans et demi, après le rapport IGA-IGPN-IGN sur les problèmes de sécurité liés aux régimes d’hospitalisation sans consentement (mai 2004), le rapport IGAS-IGSJ sur la réforme de la loi du 27 juin 1990 (mai 2005) et le rapport de la commission Burgelin santé-justice « santé, justice et dangerosité, pour une meilleure prévention de la récidive » (juillet 2005).

Le rapport confirme aussi certaines recommandations des précédents rapports et recommande notamment des changements législatifs qui ont été intégrés dans le projet de loi sur la prévention de la délinquance, notamment réserver l’indication de troubles à l’ordre public pour les hospitalisations d’office (HO) et une meilleure information de la justice sur le devenir des personnes déclarées irresponsables pénalement pour des actes délictueux ou criminels et hospitalisées en psychiatrie. Dans la partie « état des lieux » du rapport, les inspecteurs dressent un constat alarmant pour le système de soins : hôpitaux en « surchauffe », conduisant à des sorties d’hospitalisation « prématurées » ; ratio personnel/malade en diminution ; professionnels en situation de « fragilité », avec une moindre cohésion des équipes, une mise en cause de la formation des infirmiers diplômés d’Etat en psychiatrie ; cadre d’exercice des soignants « instable » à cause d’une « incertitude sur l’avenir du secteur psychiatrique » et d’un « flottement sur le plan de la théorie et des pratiques ».

Le même constat de surchauffe est établi pour les prisons, ce qui rend difficile le repérage et surtout la prise en charge adaptée des détenus dangereux ou susceptibles de l’être.

Pour mieux organiser les soins, le rapport recommande de redéfinir, par voie législative, la sectorisation psychiatrique, c’est-à-dire ses fonctions et les modalités de mise en oeuvre.

Pour clarifier les pratiques, le rapport préconise d’organiser des conférences de consensus sur la prise en charge des états d’agitation et sur l’intervention en urgence des équipes psychiatriques au domicile d’un patient. Il demande aussi de développer des recherches sur les tests biologiques permettant d’assurer le dépistage d’un usage de toxiques, sur les nouvelles molécules à effet sédatif, sur les principes d’emploi des associations médicamenteuses, sur « le mélange de pathologies dans les unités de soins » et sur les courtes hospitalisations répétées. L’Agence nationale de la recherche (ANR), le Programme hospitalier de recherche clinique (PHRC) et les laboratoires pharmaceutiques doivent être sollicités sur ces sujets. Pour établir « des perspectives de gestion claire », les inspections estiment qu’il faut moduler l’arrêt de la fermeture des lits en psychiatrie en fonction des besoins, concevoir un financement des établissements assurant une « juste rémunération » des activités de psychiatrie et adopter une stratégie face à l’évolution démographique à la baisse des psychiatres. Sur ce dernier point, il suggère notamment d’engager une réflexion sur les transferts de compétence vers les psychologues. Le rapport insiste aussi sur la conception architecturale des bâtiments de psychiatrie en suggérant un appel d’offres du ministère de la santé auprès des architectes pour des unités types et un audit conduit par les ARH sur les solutions les plus efficaces d’évolution des centres hospitaliers spécialisés et sur la mise en elle-même d’un accueil adapté aux urgences générales.

Constatant que la dangerosité est une notion floue, le rapport estime d’abord qu’il faut mieux l’évaluer, en développant les observatoires de la violence dans les établissements et en étudiant les outils d’évaluation de la dangerosité qui existent mais qui ont des limites. Il préconise aussi de mieux encadrer l’usage de la contention et de la mise en chambre d’isolement, en recourant à des protocoles -à élaborer par la Haute autorité de santé-, pour le recours aux sédatifs, le recours aux liens physiques et le recours à la chambre d’isolement. Il insiste sur les conditions de sécurité à respecter ainsi que le respect de la dignité humaine dans ces pratiques. Le rapport estime qu’il ne faut pas encourager la spécialisation de structures ou d’équipes dans la prise en charge de la violence, car cela risquerait de laisser désarmés les soignants dans les autres services.

Il se prononce aussi pour le respect de la liberté d’aller et venir des patients en HL, ce qui nécessitera parfois de créer des espaces spécifiques pour les patients en hospitalisation sous contrainte. La création d’une obligation de soins en ambulatoire, décidée par le préfet ou sur demande d’un tiers, déjà préconisée dans les rapports précédant, est jugée urgente. Pour améliorer l’expertise judiciaire, le rapport propose notamment une conférence de consensus sur le sujet, la création d’un repérage des troubles mentaux (pour éviter un recours systématique à l’expertise psychiatrique par les magistrats), la mise en place d’équipes pluridisciplinaires au niveau régional et un relèvement de la rémunération des experts. L’évaluation et l’orientation des détenus doivent être revues pour être « plus performantes », sur le modèle de ce qui est fait au Centre national d’observation (CNO) de Fresnes mais en le renforçant. Le rapport préconise également de renforcer les coopérations entre les institutions (psychiatrie, police, justice) pour clarifier les obligations déontologiques et les devoirs de coopération de chacun, en prenant appui sur des principes qui seraient établis au niveau national et interministériel sur les cas d’intervention au domicile d’un patient, de transport, de rupture d’une obligation de soins ambulatoire, de fugues d’un patient hospitalisé sous contrainte et d’intervention des forces de l’ordre en milieu hospitalier.

Ces travaux pourraient aboutir à la rédaction d’un schéma départemental des coopérations entre les collectivités locales, la santé, la police nationale, la gendarmerie nationale, les sapeurs-pompiers, les services de probation et d’insertion professionnelle des établissements pénitentiaires en relation avec la justice.

This Post Has 699 Comments

  1. here are some links to internet sites that we link to mainly because we feel they are really worth visiting

  2. please visit the sites we stick to, which includes this one particular, as it represents our picks in the web

  3. Super-Duper website! I am loving it!! Will come back again. I am bookmarking your feeds also.

  4. Christine dit :

    Hi there! This is my first comment here so I just wanted to give a quick
    shout out and say I really enjoy reading through your articles.
    Can you suggest any other blogs/websites/forums that deal with the same subjects?

    Thanks for your time!

  5. I love your blog.. very nice colors & theme. Did you make this website yourself or did
    you hire someone to do it for you? Plz reply as
    I’m looking to design my own blog and would like to find out where u got this from.

    cheers

  6. Hi Dear, are you genuinely visiting this web page on a regular
    basis, if so afterward you will absolutely take fastidious know-how.

  7. I totally understand everything you’ve said.
    In fact, I looked through your various other posts
    and I think you happen to be certainly right. Great job
    with this website.

  8. Daarom hebben we besloten om deze cheat hulpmiddel te creëren.

  9. Thanks for another informative web site. The
    place else may just I get that type of information written in such an ideal approach?

    I’ve a project that I’m simply now operating on, and I have been at the glance out for such info.

  10. Every as soon as inside a when we pick blogs that we read. Listed below are the most recent sites that we pick

  11. Wonderful story, reckoned we could combine a handful of unrelated information, nevertheless truly worth taking a look, whoa did one study about Mid East has got extra problerms at the same time

  12. Aimee dit :

    I every time spent my half an hour to read this blog’s articles
    or reviews all the time along with a mug of coffee.

  13. male sex doll dit :

    below you will come across the link to some sites that we consider you need to visit

  14. zero repair dit :

    It’s nearly impossible to find educated people about this subject, but you
    seem like you know what you’re talking about! Thanks

  15. hay day forum dit :

    In the buildings that you will obtain, you can produce goods that you
    can sell to stroll-in customers and use them for distinct orders as well.

    You can find such orders either on the ironing board of a truck in the vicinity of the road or often on the berth of a ship.

  16. Greetings! Very helpful advice within this post! It is the little changes that make the greatest changes.
    Thanks a lot for sharing!

  17. Maude dit :

    Magnificent beat ! I would like to apprentice while you amend your site, how
    could i subscribe for a blog site? The account aided me a
    acceptable deal. I had been a little bit acquainted of
    this your broadcast provided bright clear concept

  18. that may be the end of this post. Right here youll uncover some internet sites that we consider youll enjoy, just click the links over

  19. Dpf dit :

    Dpf

    […]one of our guests not long ago encouraged the following website[…]

  20. here are some links to websites that we link to since we assume they’re really worth visiting

  21. If some one needs expert view about blogging and site-building afterward
    i propose him/her to pay a visit this website, Keep up the
    good job.

  22. bridge quote dit :

    To make it even more attention-grabbing, you can add some stepping stones, terra cotta fowl homes, wind chimes and other easy equipment that you could be already find
    round your backyard similar to outdated picket chairs and
    ladders.

  23. Hi it’s me, I am also visiting this web page
    on a regular basis, this web site is truly nice and
    the people are truly sharing good thoughts.

  24. How to Buy Step by Step

    […]Here are some of the web sites we advise for our visitors[…]

  25. make money from home

    […]here are some links to web pages that we link to because we feel they are really worth visiting[…]

  26. Many householders wish to have pond bridges so they can enjoy watching the fish life or possibly listen to the sound of water trickling down a
    artifical waterfall.

  27. When you’ve got a garden bridge customized-made, then you can anticipate it to serve its goal.

  28. Discover many backyard bridges design in many online sites and choose the one you think perfect for your
    yard.

  29. Amazing! Its genuinely remarkable article, I have got much clear idea concerning from this post.

  30. Orlando dit :

    Hello just wanted to give you a quick heads up.
    The words in your article seem to be running off the screen in Safari.
    I’m not sure if this is a format issue or something to do with
    internet browser compatibility but I figured I’d
    post to let you know. The style and design look great though!
    Hope you get the problem resolved soon. Thanks

  31. short bridges dit :

    For that reason, the bridge in your personal Japanese backyard must signify your individual private journey and the
    motion involved.

  32. white dog dit :

    very few sites that take place to be comprehensive below, from our point of view are undoubtedly properly worth checking out

  33. check beneath, are some absolutely unrelated internet websites to ours, nonetheless, they may be most trustworthy sources that we use

  34. Howdy! This post could not be written any better! Reading this post reminds me of my good old room mate!
    He always kept talking about this. I will forward this page to him.
    Fairly certain he will have a good read. Thank you
    for sharing!

  35. Hurrah! Finally I got a website from where I be able to genuinely get helpful facts concerning my study and knowledge.

  36. very couple of sites that take place to be in depth beneath, from our point of view are undoubtedly very well worth checking out

  37. Marilou dit :

    Terrific article! That is the kind of information that are meant
    to be shared across the net. Shame on the search engines for not positioning this submit higher!
    Come on over and consult with my site . Thanks
    =)

  38. Even when we overlook the truth that most of the people who
    own these websites usually are not polygraph examiners, the idea
    of fooling a skilled and skilled examiner is ridiculous.

  39. we came across a cool web-site that you simply could enjoy. Take a look in the event you want

  40. My relatives always say that I am wasting my time here at web, however I know
    I am getting experience all the time by reading thes
    nice articles.

  41. just beneath, are a lot of entirely not associated websites to ours, even so, they are certainly worth going over

  42. The polygraph check, if carried out properly, can precisely make that dedication virtually all of the time.

  43. magnificent post, very informative. I wonder why the other specialists of this sector don’t notice this.
    You must proceed your writing. I am sure, you’ve a huge readers’ base already!

  44. yard bridges dit :

    Garden bridges come in a wide range of styles with an abundance of sizes and shapes to choose from.

  45. An outstanding share! I’ve just forwarded this onto a friend who was conducting a little research
    on this. And he in fact bought me dinner because I found it for him…
    lol. So allow me to reword this…. Thank YOU for the meal!!
    But yeah, thanx for spending the time to talk about this issue here on your web
    site.

  46. Your own home will look exceptionally lovely in case your lawn and backyard are
    beautified accordingly.

  47. Myra dit :

    We stumbled over here different web address and thought I should check things
    out. I like what I see so now i am following you.
    Look forward to checking out your web page repeatedly.

  48. It’s very straightforward to find out any matter on web as compared to books, as I found this article at this web site.

  49. Touche. Solid arguments. Keep up the amazing spirit.

  50. Arron dit :

    Today, I went to the beach front with my children. I found a sea
    shell and gave it to my 4 year old daughter and said « You can hear the ocean if you put this to your ear. » She placed
    the shell to her ear and screamed. There was a hermit crab inside and it pinched
    her ear. She never wants to go back! LoL I know this
    is totally off topic but I had to tell someone!

  51. Thank you for another informative site. The place else may just I am
    getting that type of info written in such an ideal
    way? I have a undertaking that I am simply now working on, and I have been at the glance out for such info.

  52. we prefer to honor a lot of other net web sites on the internet, even if they arent linked to us, by linking to them. Underneath are some webpages worth checking out

  53. American singles dating site

    […]Here are some of the web pages we recommend for our visitors[…]

  54. pure kona dit :

    check beneath, are some entirely unrelated web-sites to ours, nevertheless, they’re most trustworthy sources that we use

  55. usually posts some pretty intriguing stuff like this. If you are new to this site

  56. Excellent blog you have here but I was curious about if you knew of any discussion boards that cover the same
    topics discussed here? I’d really like to be a part of online community where I can get feed-back from other knowledgeable individuals that share the
    same interest. If you have any suggestions, please
    let me know. Thanks!

  57. Here is a superb Weblog You might Locate Exciting that we Encourage You

  58. facial trauma dit :

    that would be the finish of this post. Right here you will uncover some sites that we think you will enjoy, just click the links over

  59. Sherry dit :

    I have been browsing online more than 3 hours today, yet I never found any interesting article like yours.
    It’s pretty worth enough for me. Personally, if all site owners and bloggers made good content as you did, the web will be much
    more useful than ever before.

  60. we came across a cool web page that you simply could love. Take a appear should you want

  61. This is really interesting, You’re a very skilled blogger. I have joined your feed and look forward to seeking more of your fantastic post. Also, I have shared your website in my social networks!

  62. sales arena dit :

    WOW just what I was searching for. Came here by searching for
    sales skills

  63. The information mentioned in the post are a few of the top out there

  64. usually posts some really interesting stuff like this. If youre new to this site

  65. I do trust all of the ideas you’ve introduced to your post.

    They are very convincing and will certainly work. Nonetheless, the
    posts are very short for newbies. May just you please extend them a little from subsequent time?
    Thanks for the post.

  66. I’ve thought about posting something about this before. Good job! Can I use part of your post in my blog?

  67. I’m not sure why but this site is loading incredibly slow for me. Is anyone else having this problem or is it a problem on my end? I’ll check back later and see if the problem still exists.

  68. Google dit :

    Please pay a visit to the web pages we stick to, including this a single, because it represents our picks in the web.

  69. Hi my family member! I want to say that this article is amazing, great written and include approximately all important infos. I’d like to see more posts like this .

  70. Mohamed dit :

    Magnificent site. Plenty of useful info here. I am sending it to some pals ans additionally sharing
    in delicious. And certainly, thanks to your effort!

  71. As regras entraram еm vigor dia 28 de fevereiro, ԛuem foi demitido ɑntes desta data aѕ menarquia antigas continuam
    valendo.

  72. You will be assured that your fish will not be harmed since these bridges are made for such and will not be pressure handled.

  73. usually posts some incredibly interesting stuff like this. If youre new to this site

  74. What i discover troublesome is to find a weblog that may capture me for a minute however your blog is different. Bravo.

  75. These are in fact wonderful ideas in concerning blogging.

    You have touched some nice factors here. Any way keep up wrinting.

  76. Tutor devе aproveitar a possibilidade pɑra aprofundamento do
    tema е também promover processos de reconstruçãօ,
    começando poг assinalar uma incoerência”.

  77. Lona dit :

    …. Se totalmente deres οs filhos ⅾе Amom
    na minha mão, aquilo que, saindo da porta ⅾе minha morada,
    me transpor ao encontro, voltando еu dos filhos de
    Amom em tranquilidade, isso ѕerá ⅾo e também Salvador de sua vida deveria ѕer uma moça
    dedicada ao Ѕô na hoгa certa no momento certo еle enviará não estou ϲom pressa nem estou pensando quero
    ᥙm namorado mas na hora do Parecia qᥙе os homens ѕe afastavam ԁe mim toda veᴢ
    que eu queria aⅼgo severo, mе sentia que estava sendo usada.

  78. Wonderful story, reckoned we could combine some unrelated information, nevertheless truly worth taking a appear, whoa did a single understand about Mid East has got extra problerms too

  79. Bamboo is also used as supplies for many
    foot bridges but wooden is still preferred by most householders
    specifically Rosewood.

  80. NEED A DISCO dit :

    the time to read or stop by the material or web-sites we have linked to below the

  81. very few internet websites that come about to become in depth beneath, from our point of view are undoubtedly nicely worth checking out

  82. What i don’t realize is in reality how you are no longer actually much more well-preferred than you may be right now. You are very intelligent. You understand thus significantly on the subject of this matter, produced me in my view consider it from numerous various angles. Its like women and men don’t seem to be involved unless it’s one thing to do with Lady gaga! Your own stuffs great. Always deal with it up!

  83. hotel cheap sites

    […]we like to honor a lot of other world-wide-web web pages around the web, even when they aren’t linked to us, by linking to them. Under are some webpages worth checking out[…]

  84. After looking at a handful of the blog articles on your
    web page, I truly appreciate your technique of writing a blog.
    I bookmarked it to my bookmark site list and will be checking back soon. Please check out my web site as well and tell me what
    you think.

  85. anal plug dit :

    we came across a cool web page which you might appreciate. Take a search if you want

  86. Great blog! Is your theme custom made or did you download it
    from somewhere? A design like yours with a few simple
    adjustements would really make my blog stand out.
    Please let me know where you got your design. Appreciate it

  87. short bridges dit :

    There are great wood bridges obtainable to swimsuit the
    smallest potential waters or ponds to the most elaborate waterfalls, reflecting pools,
    and they can be utilized in any dry garden décor.

  88. morkie dit :

    we came across a cool site which you could possibly get pleasure from. Take a appear should you want

  89. Kathie dit :

    Great post. I was checking continuously this blog and I’m impressed!

    Very helpful information particularly the last part 🙂 I care for such info a lot.

    I was seeking this particular info for a very long time.

    Thank you and good luck.

  90. The setting of handrails you select will rely upon the dimensions
    and style of garden bridge you’ve got opted for.

  91. Marcia dit :

    Nice blog right here! Additionally your website a lot
    up very fast! What host are you using? Can I
    am getting your associate link to your host? I want my website loaded up as quickly as yours
    lol

  92. sexdoll dit :

    please check out the web-sites we follow, like this a single, because it represents our picks through the web

  93. Aⅼém dos dedos da mão dіreita, na Guitarra elétrica usamos ɑ
    palheta (Com mas freqüência).

  94. Ford F 150 dit :

    very handful of sites that happen to become comprehensive beneath, from our point of view are undoubtedly nicely really worth checking out

  95. Google dit :

    Always a large fan of linking to bloggers that I appreciate but do not get quite a bit of link appreciate from.

  96. buy sell classifieds

    […]Sites of interest we have a link to[…]

  97. below you will locate the link to some web pages that we consider it is best to visit

  98. Clear, concise and easy to access.

  99. image hosting dit :

    image hosting

    […]Sites of interest we have a link to[…]

Leave A Reply