Friday, 24 April 2009

Why is there never a bed when you really, really need one?

I’d barely had time to get into work and make myself a coffee when I received a request for a MHA assessment. The GP was at the patient’s house, the patient was agitated, verbally aggressive, deluded and psychotic, an ambulance crew and the police were in attendance, and the GP needed an AMHP as soon as possible. I rang him straight away. He sounded nearly as agitated as the patient, a woman in her 50’s who had recently had her bowel and colon removed following cancer. He had gone round expecting a medical problem, only to find she was apparently acutely mentally ill. In addition to a stoma bag, she had a range of physical health problems, the most concerning of which was insulin dependent diabetes, since she was refusing to check her blood glucose levels and had not taken any insulin for a day.

Her name rang a bell. I looked in my records and realised that I had detained her under Sec.2 nineteen years previously. I realised that I actually remembered that assessment. She had then presented in an extremely bizarre fashion. On interview she was drinking glass after glass of water, could not keep still, was unable to engage in any sort of conversation, and would periodically walk out of the room into her back garden and scream “FUCK OFF!!” at the top of her voice, before coming back in and sitting down again as if nothing had happened.

Her records showed that she had subsequently had involvement with community mental health services for health anxiety, rather than psychosis, and had received more than one course of cognitive behavioural therapy.

Whatever her history, she was presenting as an acute emergency. I tried the local psychiatrist to see if she could attend, but she was unable to. In the circumstances, I decided I should go out and assess the situation without obtaining a psychiatrist, since the nearest available Sec.12 approved psychiatrist was about 30 miles away, and there really didn’t seem time to ring round to find one.

Within a few minutes of receiving the call I was at Mavis’s house – it was easy to find, as there were an ambulance and two police cars parked outside. As I approached the open front door, I could hear her shouting and swearing, and it became clear that she was presenting in a similar way to how she had all those years ago. Her vocabulary consisted mainly of the word “fuck”, and no-one seemed to have any control. I introduced myself and asked her if she remembered me. She actually appeared to recall my involvement with her in the past, but still told me to fuck off, as there was nothing wrong with her except that she had Aids.

Taking the partner to one side, I found out that she had had major surgery because of cancer a few months ago. His mother had died two weeks ago, and Mavis had attended an outpatient appointment just a few days ago in connection with something that had shown up on X-Ray on her lung. Although there was in fact nothing to worry about, it appeared this was the tipping point which had apparently precipitated a reactivation of her health anxiety and a stress-induced psychosis. She believed she had Aids, despite having several times had negative blood tests, and was displaying delusions relating to sex. She refused to consider medication, including her insulin and usual prescribed medication, would not agree to seeing a psychiatrist, and the carer was quite clearly at the end of his tether. I therefore decided the best course of action was to detain her under an emergency Sec.4 with a single medical recommendation from the GP, on the basis that obtaining a second medical recommendation would involve undesirable delay. He was very pleased to oblige, and gratefully scuttled off to his more normal patients.

With an ambulance crew and the police present, what could possibly go wrong? She would be in the local psychiatric unit within half an hour.

I rang Bluebell ward, our local admission ward.

“Hello, I’m an AMHP and I have just detained Mavis under Sec.4 and need a bed.”

“Will that be a female bed?”

“Mavis is a female, yes.”

“We don’t have a female bed.”

“Well how about Snowdrop ward?”

“I’ll ask them... (pause)… They haven’t got a bed either.”

“How about a leave bed?”

“There’s no-one on leave.”

“I happen to know Janice is on leave at the moment.”

“Janice is back for the ward round.”

“Can you find out from the ward round if they’ll be discharging anyone?”

OK… (Another pause)… No they’re not.”

“Look, I need a bed urgently.” I explained why. “Can I speak to the bed manager?”

“She’s in the 136 suite and can’t be contacted at present.”

“What about the charge nurse?”

“I’m just a bank nurse. Do you want to speak to someone else?”

“Yes, how about the charge nurse?”

“I don’t know where he is.”

“I have someone on a Sec.4 who needs a bed urgently. You will have to find one.”

“Do we have to find a bed?”

“Yes, you do.”

“I’ll try and find somebody and ring you back.”

A paramedic came up to me. “Can we get this patient off to hospital now?”

I screamed inside.

“There doesn’t seem to be a bed. I’m trying to get one. God knows where it’ll be. The last time there wasn’t a bed the nearest bed was 70 miles away.”

After half an hour of waiting outside the patient’s house, with the carer, and the patient, becoming more and more agitated and distressed, I decided to ring someone at the Crisis Team, whose offices happened to be next door to the ward.

I explained the situation.

“I’ll go into the ward round and see if I can sort something out.”

Ten minutes later my phone rang. “There’s a bed on Snowdrop Ward.”

And finally off we went.

Thursday, 16 April 2009

Why are people so afraid of the Mental Capacity Act?

The MCA was designed to provide a legal framework to support actions taken on behalf of people who lacked capacity as long as it was considered to be in their best interests – it exists at least in part to provide additional protection for the decisions and actions relating to people lacking capacity taken by carers and other professionals for things that were already being done under common law. The MCA does not even replace common law. However, many of the professionals involved with people who lack capacity, eg. social workers, staff in care homes, ambulance crews, and even relatives, seem to be interpreting the MCA as preventing them from doing things that are in the best interests of service users. AMHP’s are often finding themselves being asked to use the MHA when the MCA might be more appropriate.

One Friday afternoon I was contacted by an older people’s social worker requesting an assessment of an 85 year old lady, Mary. It was reported that neighbours the previous evening had seen smoke billowing out of her kitchen. She is a widow who lives alone and has been diagnosed with vascular dementia. The social worker had visited her this morning and reported that she appeared agitated and had soiled herself. I initially suggested that if there had been a fire, there may have been a risk of smoke inhalation, etc and that perhaps an ambulance should be called so she could be checked out medically. I also suggested that since she was suffering from dementia, the MCA could be used to provide her with physical medical intervention. The social worker insisted that this was not appropriate, saying that Mary had had a mental capacity assessment (although seemed unclear of the outcome), and that only an assessment under the MHA would be suitable.

I went to see the lady’s GP to ask him if he could attend an assessment with me. He was on duty, looked extremely harassed and seemed about to cry when I asked him to. I went through the list of Sec.12 doctors. They were nearly all either on holiday, already committed to an assessment, or were otherwise unavailable. After over an hour on the phone, I was only able to find one Sec.12 doctor.

I established that Mary has home carers visiting her twice daily. In view of the above I rang the social worker back, saying I was having problems getting the full complement of doctors, and enquiring as to whether additional home care could be provided over the weekend as an alternative to admission. The social worker insisted that this was not feasible.

I eventually managed to persuade the GP to meet with me at the patient’s house with the one Sec.12 doctor, who at least happened to be a phsychogeriatrician. (“Couldn’t you do the assessment with the psychiatrist and then just call me when the papers need signing?” “No.”)

By late afternoon I was finally at the patient’s house. The social worker was there, as well as one of the carers. The psychogeriatrician arrived and began an examination of the patient. It very soon became clear that, even if she did have dementia, she had bad cellulitis and also possibly had an acute infection. The psychiatrist was not therefore prepared to consider a detention under the MHA. I went to look for the social worker, and was given a note by the carer to say that she had gone, and had informed the Nearest Relative, a son who lived 100 miles away, that we would be admitting her to the local psychiatric unit. The GP arrived and concurred with the psychiatrist, and prescribed an antibiotic. The kitchen fire was not nearly bad as had been described, and having talked to the home carer, there did not seem to be any significant deterioration in the patient’s mental state to warrant action being taken then and there, especially since the current problem seemed to be physical illness rather than mental disorder, and I spoke to the son who was already on his way to visit his mother over the weekend. I alerted the Out of Hours service of the action taken, and the possible need for extra home care over the weekend.

End of story? No. Having spent the weekend ruminating over the assessment, I concluded that I had been set up. The social worker really wanted Mary to go into residential care, but did not think they could do it under the MCA. So the social worker thought that if an admission under the MHA could be engineered, it would then be much easier to transfer the patient from hospital to residential care.

And still it rumbled on. Over the next few weeks the local Community Mental Health Team became involved with Mary. The local psychogeriatrician agreed to undertake a formal assessment of capacity. He visited Mary and concluded that, now the infection had cleared up, Mary did indeed lack capacity. He was also prepared to consider that an admission for assessment might be justified. So I again went out with the patient’s consultant and her GP, and this time, based on the two medical recommendations, and taking into account a significant deterioration in the patient’s condition, including a recent fall and a mild head injury which she had refused to have treated, I completed an application for detention under Sec.2, and Mary was admitted to hospital. A month or so later she was transferred to residential care.

So why didn’t I detain her a month earlier? Well, apart from the Sec.12 doctor not being willing to make a recommendation, it seemed to me that, even though Mary did not want to leave her home, and had on several occasions turned ambulance crews away when she had had falls, nevertheless, if she lacked capacity and it was in her best interests, then she could still have been taken to hospital, or even a residential care home, and could have avoided a stay on a psychogeriatric ward.

Such are the trials of the AMHP.