Thursday, 16 September 2010

When Mental Health Act Assessments Go Bad

While reading my blog, you may have been thinking: “Hey, this guy is so cool and experienced, I bet he never makes any mistakes!”


Francis was a 21 year old man still normally living with his mother in a small village a few miles outside Charwood. He had been working in Ibiza during the summer, and had somewhat unexpectedly turned up again in the UK having been put on a flight by persons unknown. Friends in this country had been tipped off, and had picked him up from the airport. Concerned at his bizarre behaviour, they spent a few days attempting to “treat” him with a combination of street diazepam and cannabis. When this was unsuccessful, they had dropped him off at his mother’s house. His mother, who worked in the mental health field, immediately recognised that he was unwell, arranged for him to be assessed by mental health services, and he was admitted informally to Bluebell Ward.

He somehow managed to leave the ward unobserved, and a few hours later turned up at his mother’s again. She called the GP, who came out and examined him, gave him a dose of antipsychotic medication, and made a request for an assessment under the Mental Health Act.

Having established that he was still officially an informal patient on Bluebell Ward, I developed a cunning plan. I would visit him at home, and if he was still agreeable, I would simply return him to the ward where he was nominally still an inpatient. No need for forms and doctors at all.

When I arrived and explained this to his mother, she was very happy with this plan. Because of her own professional involvement with mental health services, she was reluctant for him to be detained under the Mental Health Act if it could be avoided, and as she was the nearest relative I necessarily had to take her wishes into account.

Francis appeared vague and confused on interview. He could not remember being admitted to Bluebell Ward, and neither could he remember leaving. He appeared thought disordered. Sometimes he replied to questions with meaningless disconnected strings of words. There was evidence of pressure of speech. He admitted to hearing voices on direct questioning, but could not give any concrete examples. He eventually accounted for his present condition as due to “walking into a microwave” while at work in Ibiza. He got up frequently and wandered around during the interview.

In the absence of any previous history of psychosis and knowing that he was an habitual cannabis user and may also have taken other drugs, it appeared that Francis might have taken something while in Ibiza that had precipitated a drug-induced psychosis. However, he was unable to say whether or not he had taken any suspect substances.

He had earlier taken one of the tablets the doctor had prescribed, and readily took another when his mother offered it to him. I suggested that it would be a good idea for him to return to hospital. He appeared amenable to this suggestion, promptly getting into the back seat of my car and putting on his seatbelt. His mother offered to come with me and we set off on the 10 mile journey to the hospital.

This is when things started to unravel. As we drove, the medication appeared to start wearing off and he became increasingly restless. He tried the door handle, which did not open as I had placed the safety lock on, and then wound down the window. I thought he just wanted air, until I saw in my rear view mirror that he was trying to climb out of the window, with his mother who was sitting next to him trying to pull him back in.

What should I do? Attempt to drive on, while his mother hung onto his legs? That did not imply consent, did it? And was patently dangerous. Take him back home so that he could be reassessed? The same problems of risk applied. Drop him off at the side of the road, as that seemed to be his wish? But that would put him in unnecessary danger.

In the end, I pulled over and spoke to him about the dangers of trying to get out of a moving car and reminded him that we would soon be back at the hospital. He grunted and nodded his head, putting his seatbelt back on. Somewhat reassured, I set off again, and for the next few minutes prayed that he would behave. If this had been an informal admission, rather than a return to hospital of an inpatient, then this might be evidence of a refusal to accept an admission. Did he have capacity to make a decision anyway? And why hadn’t I gone out in the first place with the GP and a psychiatrist and done it by the book? Was this a good time to hand in my warrant?

Once we had arrived at the ward, I allowed myself to feel a little relief. However, Francis’s behaviour became even more erratic. Although clearly under the influence of the medication, he seemed to be restless and fighting the sedative effects. While waiting to be seen by an admitting doctor, he climbed out of the window of the side room on two occasions, although both times did accept being guided back into the ward. I realised that he was in no state to remain as an informal patient, and would need to be detained so that he could be properly assessed. And of course I did not have any medical recommendations. I was a bad, bad AMHP. I prayed for a hole to open up beneath my feet so that I could be cast into the fiery pits of Hell. Anything was preferable to carrying the knowledge that because of my mishandling of the case events were now completely out of my control.

Just as Francis set off the fire alarm in the process of trying to get out of the fire door, causing the entire ward to be evacuated, the duty doctor arrived and placed him on a Sec 5(2) (this can be used by a single doctor as a holding power until he can be assessed in the usual way). At last there was a legal basis for his detention in hospital!

While all the available male staff were fully occupied in restraining him, I used the diversion to slink off and arrange for a proper Mental Health Act assessment.


  1. Surely you did in fact make the right decision based on the evidence you originally had though? You had an informal patient who had left the hospital, so was it not right to do what you did and go to assess him generally and then make a decision from there as to whether he needed assessing under the MHA? It wasn't your fault his behaviour changed once in the car, and there was nothing you could do by that point. I would be interested to know how you would handle the same situation if it occurred again, ie an informal patient who has left the hospital. Would you do a MHA assessment immediately now, or would you once again go and talk to the patient to see if they would go back informally?

  2. A very honest account. Thank you for sharing it!

    I've found that the times when one looks back and thinks "hmm..." tend to be the times when one tries to cut a corner for reasons of efficiency. In your story, it was about avoiding the need for an emergency community assessment, but I think all of us in the field, whether S12 doctor or AMHP can think of occasions when we've tried to use a short-cut and come a bit unstuck!

    Off the top of my head, some other common "inefficiency through efficiency" situations are:

    - trying our luck going round without a warrant, in case we got lucky and were let in... and then convene again another time, with the warrant
    - trying to convey someone with just an ambulance... and then realising yes, you really do need the police
    - transferring someone from one place of safety to another for convenience of assessment... and then the patient getting more agitated by the transfer.

    I could go on... :)

  3. "male nurses" restraining him ... presumably then, male nurses get paid more than female nurses and are formally tasked with doing this parts of the job. I presumed, as they all got the same pay, they'd contribute equally?

  4. bipidee: Thank you for your comments. I'll see if I can make a post out of this.

    beyondanomie: I always enjoy and appreciate your comments. And I like your blog, too.

    Anonymous: I'm a social worker. I tell it like it was when it happened. I can only say that in my experience as an AMHP, it is male staff who do physical restraint if required. Personally, as a (male) social worker, I do my best to keep out of harm's way. I particularly make a point of avoiding any physical contact with service users if at all possible. Although I'll give a manly handshake if appropriate.

  5. my experience of acute in patient mental health settings, if restraint is required it is best practice that this is carried out by the same 'gender' to preserve a persons dignity. Female staff, and not just nurses in the environments i have worked are also trained to use restraint techniques as a last resort and it does not involve more pay!!