Thursday, 25 February 2010

The Alarming Case of the Absconding Patient

David was in his 30’s. I had had to detain him under the Mental Health Act on a couple of occasions in the past. He had a diagnosis of schizophrenia, but had long periods of being well, and never happily engaged with psychiatric services. During his most recent hospital stay, about a year previously, he had left the ward one day and gone into Charwood town centre and entered a bank. He had patiently waited his turn, and when he reached the front of the queue had politely requested money to use “to alleviate poverty and suffering in the world”. Unaccountably, even though David had not been armed and had shown no aggression, the cashier handed over a considerable quantity of cash to him, which he then distributed to passers by in the street until the police arrived to take him back to hospital.

He had subsequently disengaged from the CMHT and no-one had seen him in recent months, except for a couple of occasions when he had turned up unannounced asking to see me. On both occasions I gained the impression that he was somehow playing with me, offering tantalising glimpses of a florid mental illness, as if he were challenging me to section him, then laughing at me when I tried to probe him. He was clearly enjoying himself, enjoying his illness. But he was also in control.

A few weeks later his mother turned up at the doctor’s surgery one day, dragging a reluctant David with her. The CMHT consultant happened to be holding a clinic at the surgery at the time, saw David with the GP, concluded that he was extremely unwell, and the two had completed medical recommendations for detention under Sec.2 MHA.

By the time the news reached me, he had gone home with his mother. I went round to conduct my assessment. David’s mother answered the door and let me in. His sister was also there.

David looked drawn and haggard, and not at all happy, in marked contrast to my last contact with him. It looked as if he had now lost control of his illness. The illness was now controlling him. He was clearly irritable, with aggression seething underneath his calm exterior. He was carrying a wet flannel

“I’m going to hit you with this flannel,” he said, smiling rigidly. He flicked my head with it, then threw it at me, as if he wanted me to play catch. I caught it.

“I know what you’re thinking,” he said. “But you’re wrong. I’m not mad, you know, and I can prove it to you. I can project thoughts into your head.”

He closed his eyes and concentrated. But I was not aware of any thought insertion.

“I don’t think that worked,” I said. “But I do think you are unwell.”

“Then I may as well kill myself, hadn’t I?” he said. Although he continued to smile, a tear flowed down his cheek.

I took his mother and sister to one side.

“David’s very unwell,” I said. “I’m very worried about him. He does need to be in hospital.”

“I really don’t want him to go,” his mother said. “Hospital won’t do him any good. He’d be better off here with his family. We can take care of him. I don’t want him to be sectioned.”

I talked it over with them. I explained my concerns. Since we were considering a Sec.2 I didn’t need the approval of the nearest relative. They pleaded with me to give them a chance to get him well at home. They assured me they would make sure he had his medication, that they wouldn’t leave him alone for even a minute, that they would let us know if they had any concerns, however small, that they would call us or the police the minute he tried to leave the house

I decided to give it a try. This did, after all, constitute an “alternative to compulsory admission”, it was worth trying as part of the decision making process. I had the two medical recommendations, I could review the situation daily, and complete an application at any time if I felt that things were breaking down.

I explained this to David. I told him that if he wanted to avoid going into hospital he would have to take the medication and stay with his mother and sister. I told him I would visit him tomorrow to see how he was getting on. He smiled and nodded, smiled and nodded. He was still smiling and nodding as I left.

I had barely returned to the CMHT when I received a call from his mother.

“David’s gone!” she shouted. “Just after you left he grabbed his car keys and he’s gone off in his car! He said he’s going to kill himself!”

My mouth felt very dry as I completed my application, formally detaining him under Sec.2.

Then I rang the police, explaining the situation to them. Then I waited.

I discovered that chewing my fingernails helped to pass the time. About half an hour later, the phone rang. It was the police.

“We’ve had a report of an incident,” the police officer said. “A car went through a red light at road works and hit a lorry head on. There’s an ambulance on its way now.” The officer promised to keep me updated.

I sat in the office, thinking. Worrying. Worrying about David. Worrying about myself. Would I have to give evidence at an inquest? What would I say? Where would the finger of blame point?

A few minutes later I received another call.

“A man answering the description of your patient was driving the vehicle. The ambulance is taking him to hospital now. We don’t have any more details.”

I set off for the hospital, and went to the Accident and Emergency Department, dreading what I would find. How badly injured would he be? Would he survive? Was anyone else injured?

But he was the only casualty. And miraculously (and also because he was wearing a seatbelt) he had escaped with nothing worse than a few cuts and bruises. In fact, he was medically fit for discharge.

And since Woodland House psychiatric unit was on the same site as the general hospital, I arranged for him to be taken directly to Bluebell Ward.

Tuesday, 23 February 2010

Obscure (and Awful) AMHP Joke

Q: How many AMHP's does it take to change the fuse on a plug?
A: 13.
[Even more obscure (and terrible) answer: 13(4).]

Tuesday, 16 February 2010

Rule One: Keep at a Safe Distance

The course of an assessment under the Mental Health Act is quite often unpredictable: this one, although it took place some years ago now, particularly sticks in my mind.

I was on night duty one evening when I got a call from the local police station. They had a man detained under Sec.136 – this is when a police officer who finds someone in a public place who “appears to him to be suffering from mental disorder and to be in immediate need of care or control” can “remove that person to a place of safety”. Nowadays there are usually specially designated places of safety on hospital sites where people can be taken to be assessed, but back then a police station was the usual “place of safety”.

There was nothing at all known about Andrew except for his name, age (30) and address. The police had been called to an incident in the street outside his house. He had resisted all attempts to calm him down, and then started to atack the police who had attended. The police had found his house in a squalid condition, floors covered with dog faeces and rotting food in the kitchen. His electricity had been disconnected long ago. He had a rather neglected looking dog which was taken to a boarding kennel. There was no record of any previous psychiatric involvement, and he did not even seem to be registered with a GP.

I assessed him with two doctors. As we approached his cell he could be heard talking to himself and making odd noises. He abruptly stopped as we entered and looked at us with some hostility. I was glad we also had a police officer with us, and kept at a safe distance.

Andrew was unable to concentrate on what we were saying, and was unable to give us any information about his home circumstances, relatives or friends. He stared straight ahead most of the time, and after a while he began pacing the cell and breathing increasingly heavily, forcing the breath in and out through his clenched teeth until he began to foam at the mouth. This was disturbing.

We reached a tentative conclusion that he was experiencing a hypomanic episode. The state of his house seemed to indicate that his mental health had been deteriorating for some time. It was possible that this was a drug induced psychosis, but he had vehemently denied illegal drug use when asked. Either way, he needed further assessment and was in no state to give informed consent to this, so we completed an application under Sec.2.

I informed Andrew of the decision and explained to him that he would be taken to hospital by ambulance. Surprisingly, he seemed quite happy about this, followed us meekly out of the cell and strolled down the corridor flanked by two police officers.

I left the police station to get to my car, which was parked outside the police compound. I watched as an ambulance backed up to the rear entrance, from where Andrew and the two officers were emerging. One of the ambulance crew got out and opened the ambulance doors, and then stood there in the orange light of the sodium compound lights, waiting for the group to approach.

I watched as Andrew suddenly broke free from the police officers and lunged forward. I watched as the ambulance man folded up when Andrew’s head connected with his stomach, and the two disappeared into the ambulance. I watched as the police officers dived into the ambulance after them. I watched as the ambulance began to shake violently and two other police officers dived in. Then the ambulance doors were suddenly closed from inside, the blue lights started to flash, and the ambulance sped off to the hospital.

This broke me out of my stunned state. I quickly got into my car and followed the ambulance to the hospital, where it parked right outside the admission ward. One of the police officers opened the ambulance doors and went to the ward. He returned with two male nurses and the duty doctor. Even though Andrew was being restrained by three police officers, he was still struggling, causing the ambulance to shake constantly. The nurses restrained him some more, while the doctor administered an injection of intramuscular Haloperidol, of a dose considered more than sufficient to incapacitate him.

Andrew continued to attempt to struggle, hissing and panting through his teeth all the while, flecks of foam landing on the arm of the officer closest to his head. I saw that somewhere along the way he had incurred a head injury, and blood was oozing down his face. The officer nearest him also had a cut over his eye, which was also oozing blood. There seemed to be quite a bit of blood in the ambulance.

After 15 minutes, the doctor decided that the injection should have taken effect and they attempted to try and transfer him into the ward. But as they momentarily adjusted their grip on him, he took the opportunity to make a break for it, and very nearly got away.

It took another injection and another 20 minutes of relentless restraint before he was sufficiently sedated to be transferred safely into the ward.