Sunday, 20 June 2010

Ricky, No Wonder

Ricky was an electrician. He also had bipolar affective disorder. The two things did not necessarily go well together.

Back in the mists of time (well, in the very early years of the 1983 Mental Health Act at any rate) I was called on to assess Ricky on two separate occasions.

You’ve read my advice to AMHP’s in the previous two posts. Now see how many rules were broken during these assessments.

The First Assessment

I was called by Dr Grundy, an old style country GP, an amiable but slightly idiosyncratic man, as most country GP’s seemed to be back then.

“Ricky’s gone completely bonkers, old chap,” he said. “He was doing some electrical work at my house, but this morning didn’t turn up. He eventually rang me to say that he had run out of electricity and had been delayed because he was generating some more to bring over to replenish my supply. I think he might need sectioning.”

I arranged to meet with Dr Grundy at Ricky’s house, which was in a small village. Ricky answered the front door, and it was immediately apparent that he was as high as the proverbial kite.

“Come in, come in,” he said expansively, without enquiring as to who I was (he recognised Dr Grundy) or the purpose of our visit. “Let me take your hats. No hats? Well let me give you some hats!” He himself was wearing a deerstalker at a jaunty angle, and he rummaged in a chest of drawers in the hallway, muttering, “Everyone must have hats, everyone must have hats”, until he finally produced a straw hat and a motor cycle helmet which he gave to us. Dr Grundy put on the straw hat, but I put the motorcycle helmet down (There are some things I draw the line at.)

“Dr Grundy thinks you may not be well at the moment,” I began. “He thinks maybe you need to be in hospital.”

“Does he, does he? Hospital, eh? Hospital. Lots of different hats in hospital, aren’t there?”

“You can have as many hats as you like, if you go to hospital,” Dr Grundy said. I rather wished he hadn’t. You shouldn’t lie to patients.

Somewhat to my surprise, Ricky agreed. I think he was dazzled by the thought of all the hats he would be able to wear.

“Let’s go then,” he said. “No time to waste. No time at all.” He strode out of the house and climbed into the doctor’s Volvo estate, which Dr Grundy had left unlocked. (Rule 47: Never leave your car unlocked when conducting a Mental Health Act Assessment.) He then locked all the doors from the inside.

Dr Grundy knocked on the car window. Ricky beamed out at him. Dr Grundy mimed winding down the window. Ricky also mimed winding down the window. Dr Grundy found this amusing. So, it must be said, did I. But then, Ricky hadn’t locked himself in my car.

Eventually, after a great deal of furious miming on the part of Dr Grundy, Ricky cottoned on and wound the window down a little way.

“Can I help you, Dr Grundy?” he asked in a serious voice.

Dr Grundy choked a little on his laughter, then said, “Would you be a very good chap and get out of my car? You’ll be going in the other car.”

Ricky leaned out of the window and looked at my car dubiously. “That looks like a German car. I don’t like German cars.”

“It’s not a German car,” I assured him.

“I like this car better,” he said, and wound the window up again. He started to move the steering wheel round as if he were driving.

Dr Grundy was trying so hard to control his mirth that I began to fear he might have an aneurysm. But he had a cunning plan. The tailgate was unlocked, so he opened it and crawled into the boot, then climbed over the back seat until he could unlock one of the doors. It was the first time I had seen a GP get so hands on during a Mental Health Act Assessment.

Ricky eventually agreed to get into my car. I had him sit in the back seat. But as I was alone, and the doctor needed to get back to his surgery, I did not have an escort.

However, Ricky seemed more than happy about going to hospital, and we set off on the 15 mile journey.

He laughed and chuckled and fidgeted in the back seat. I wondered what he was up to, and tried to keep an eye on him in my rear view mirror. At one point he said, “Are you sure this isn’t a German car?”

“No it definitely isn’t a German car. It’s a Fiat. A Fiat 127.”

“Only I don’t like the Germans. They fought us in the War, you know. Who makes Fiats?”

“The Italians,” I replied, without thinking.

“Weren’t the Italians in the War too, on the German side?” he asked, a little threateningly I thought.

“Er, no, I’m sure there weren’t,” I lied.

“Well, that’s all right then,” he said, and went back to his chuckling and fidgeting.

Eventually we arrived at the hospital. I pulled my seat forward to let him out.

That was when I discovered that Ricky had taken a screwdriver with him. And throughout the journey, he had been systematically removing all the screws he could find in the back of the car. The screws were in a tidy heap on the back seat. The component parts of the interior of the rear of my car were in another tidy heap.

The Second Assessment

I received another request from Dr Grundy to assess Ricky a year or so later. Deciding that it was likely that Ricky would agree to an informal admission if required, I went out initially without Dr Grundy this time.

The front door was ajar. I knocked, but there was no reply. The garage door was open, so I had a look. Ricky’s nearly new Rover was parked inside. However, there was something badly wrong with it. The words: “Brooom! Broooom!” were written down the side of it in large letters in matt black emulsion. The driver’s door was open. Ricky had obviously been busy with his screwdriver again, because most of the dashboard had been dismantled, and dials and wires and various other components were scattered all over the front seats.

I went into the house, calling Ricky’s name. There was no reply. I went into his living room. There was again something very wrong about the room. It was dark, for one thing, although it was the middle of the day, so I turned on the light. That was when I realised that Ricky had painted the glass of the windows with matt black paint. The TV was on in the corner, but he had obscured the screen with matt black paint.

I continued on my journey through the house, into the kitchen, where I saw that the central heating thermostat had been dismantled and was hanging from the wall. The lid of the chest freezer was up, and inside was a dismantled toaster.

But there was still no sign of Ricky.

I went out of the open back door and into the back garden. I finally found him in the greenhouse, sitting on a deck chair and wearing his deerstalker hat and sunglasses. He beamed up at me, lifted up his sunglasses, winked at me broadly, and then gave me a piece of paper. On it he had written: “Jul Aug Sep Oct No Wonder!” I puzzled over this for a few moments, then suddenly realised that this was a list of abbreviations for months of the year, but he had then gone off on a tangent: classic flight of ideas.

“I think it’s time you went to hospital again,” I said to him. Ricky nodded and stood up.

But this time I made sure he didn’t have a screwdriver with him.

Monday, 14 June 2010

This Much I Know Part 2

Be aware of your body language and general demeanour
• It is usually best to maintain good, although not too intense, eye contact. However, people who are plainly paranoid may find this threatening, in which case, avoid too much eye contact when talking to them.
• Appear to be relaxed – even if you aren’t. Sit down if possible, although it is generally better to perch than to be enveloped in a saggy armchair, in case you need to make a quick exit.
• Do not get into the personal space of the patient.
• Maintain an even tone when talking, even if the patient is shouting.
• Do not show that you are frightened or intimidated by a patient.

A foot in the door can be a lot quicker than a Sec.135 warrant
• Remember that under Sec.115(1) of the MHA: “An approved mental health professional may at all reasonable times enter and inspect any premises (other than a hospital) in which a mentally disordered patient is living, if he has reasonable cause to believe that the patient is not under proper care.”
• This is one of the powers of the AMHP, and does give a degree of authority to enter a patient’s house. It may be worth pointing this out to an uncooperative patient before going off to the magistrate.
• It is also worth remembering Sec.129 MHA relating to obstruction:
“(1) Any person who without reasonable cause
(a) refuses to allow the inspection of any premises; or
(b) refuses to allow the visiting, interviewing or examination of any person by a person authorised in that behalf by or under this Act or to give access to any person to a person so authorised; or…
(d) otherwise obstructs any such person in the exercise of his functions,
shall be guilty of an offence.”
• I have to say, however, that I have never had to make use of that particular section, and I am not aware of anyone actually being arrested in connection with this offence. But there’s always a first time.

Try to give the patient choices
• Always show respect for the patient.
• Depending on the degree of capacity of the patient, it is reasonable to explain the choices available to them. You will of course explain the purpose of the assessment. This can include explanation of the options available, such as home treatment, informal admission to hospital, or admission under the MHA.
• Once a decision has been made to admit, offering a choice of admission by ambulance or car, for example, can often result in the patient feeling they have some control over the process and they are then more likely to make a positive choice to go to hospital and can be less likely to object when the time comes to be admitted.

Know when to use the police
• Don’t expose yourself to an unacceptable degree of risk.
• If you have evidence of violence or aggression, arrange for the police to accompany you.
• The police may not actually be required, but it is good to at least alert the police to the possibility that they may be required and to get an incident number, or ideally to have them nearby.
• In my experience, a police uniform, rather than provoking a patient, can be very calming to an agitated or hostile patient.
• Patients will often be more amenable to cooperating with the assessment in the presence of the police.
• Police can be good intermediaries when the AMHP is being seen as the villain of the piece.
• The Police are often very good at explaining to the patient the necessity of cooperating with the admission process.
• In my experience it is rare for the police to actually have to use physical restraint to facilitate an admission.

Never be alone
• Once the assessment has been concluded, and the papers have been signed, doctors are usually very keen to be off. Make sure they don’t leave you on your own with a patient. At the very least, make sure there are relatives or other professionals with you (students can be useful in these circumstances!). Involve the police if you need to.

A Mental Health Act assessment, especially when it takes place at the patient’s home, can be very distressing for the relatives as well as the patient
• Don’t forget the likely distress the relative already has, or the additional distress the relative may have witnessing the actual process.
• Try to spend time explaining to the relative what is happening, the reasoning behind any decisions, and what will happen next.
• It may be appropriate to give the relative the option of accompanying the patient to hospital: this can also assist in reassuring the patient.
• Make sure the relative knows where the patient is going, and other information, such as the phone number of the ward, visiting times, etc.

When dealing with situations of high risk, at times I ask myself the following question:
• “Would I rather justify my decisions to an Appeal Tribunal or to an Inquest?”
• This does not necessarily mean you should always take the “safe” course, but this question can concentrate your mind.
• There are occasions when it’s definitely in the interests of the patient to return control to them (even if you do have a sleepless night!). It may even restore their faith in Mental Health Services.

You’re always an AMHP
• Once you become an AMHP, it begins to pervade your day to day practise.
• You may be sitting chatting to a service user. Something they say sets alarm bells ringing, and suddenly the interview takes a different course. Suddenly you have your AMHP hat on. But equally suddenly, (and undetectably) you can take it off again.
• If you work in a Mental Health Team, it soon becomes second nature to see case discussions in the light of duties and powers under the Mental Health Act (and the Mental Capacity Act). You may not even say anything differently; but you are thinking differently.
• You find yourself contributing to discussions in ward rounds or team case reviews in the context of possibilities under the MHA.
• Do these discussions and interviews constitute Mental Health Act assessments? In a way, yes. But they can also remove the need to go down the MHA route. It can save a lot of time when a quick chat with a Consultant removes the need for a full blown assessment.

Occasionally, I entertain a little fantasy
• I am in a theatre, watching a play.
• One of the actors begins to behave erratically. They fluff or change their lines, they interrupt other actors when they’re not supposed to, they laugh inappropriately, they don’t respond to cues, they move round the set knocking things over. They start fighting with other members of the cast. Eventually, the curtain falls prematurely.
• A murmur rises from the audience, wondering what has gone wrong, wondering what is happening.
• After a few minutes, the director parts the curtains and stands at the front of the stage.
• “Excuse me,” he announces, his voice rising over the audience. “But is there an Approved Mental Health Professional in the house?”

Sunday, 6 June 2010

This Much I Know Part 1: (Not Necessarily Reliable) Advice from an Old AMHP to a New AMHP

I have now corrected the section on transporting to hospital so that it now actually makes sense.
It is not always necessary to arrange two doctors before attending a MHA assessment.
• I know that quite a lot of AMHP’s will automatically arrange for two doctors to attend when receiving any request for an assessment under the MHA. While this can sometimes save time, it can also cause delays – I know that I’ve often spent an hour or two trying to locate a Sec.12 doctor, and sometimes have not managed it at all.
• There are often occasions when an initial assessment by the AMHP can obviate the need for doctors to attend – remember, you are an AMHP, therefore you are the one making a final decision. If you make the initial assessment and conclude that the patient is not detainable, or there is a clear alternative, or the patient is willing to have an informal admission, then those two medical recommendations would be irrelevant.
• It’s obviously more difficult if you have a long way to go, but if the patient is just round the corner, perhaps in the local police station, then you are in an ideal position to make a rapid decision as to whether or not it is appropriate to use the MHA.
• (And yes, I know that a doctor and an AMHP have to assess a patient detained under Sec.136 – but if the Forensic Medical Examiner has seen the patient you don’t necessarily need a second doctor in order to make your own assessment. There’s been many a time when someone detained under Sec.136 in a police station overnight has no detectable mental disorder when assessed in the morning, by which time they’ve sobered up and have nothing more serious than a bad headache.)

The top of a wheelie bin can provide a good surface for completing the section forms.

Know when to make a strategic retreat.
• Someone I was assessing under the Mental Health Act in their home at one point said to the psychiatrist and me:
“I will count to 10. If you are still in my house by then, I will kill you.”
We left.

Be creative when arranging for transport to hospital.
• While it is usually best for a patient to be transported in an ambulance, especially if they have been formally detained, there are many factors to consider. At least in the area I work, it can sometimes take 2 hours or more for an ambulance to actually turn up. This delay may not necessarily be in the best interests of either the patient or their relatives. There are many occasions when I have had to work very hard to keep the patient or their relatives calm while waiting for transport.
• Consequently, taking into account Para 11.2 of the MHA Code of Practice (“Patients should always be conveyed in the manner which is most likely to preserve their dignity and privacy consistent with managing any risk to their health and safety or to other people") as well as Para 11.21 (“AMHPs should not normally agree to a patient being conveyed by car unless satisfied that it would not put the patient or other people at risk of harm and that it is the most appropriate way of transporting the patient.“), at times I have taken the professional decision to transport the patient by car (but always with at least one escort, and preferably two).
• If you do decide that it is appropriate to transport the patient by car, I would recommend that the patient sits in the back seat behind the front passenger seat, with the escort beside them.

When interviewing a patient, make sure you are sitting between the patient and the door
• In case you need to make a quick exit.

Section 4 does have its place
• I’ve given a number of examples of my use of Section 4 in the blog. In every case it has been out of dire necessity rather than choice.
• A Section 4 can save time, but only if you have identified that it is a genuine emergency and obtaining a second doctor would involve undesirable delay.
• It should never be seen as expedient or a “quick fix”.