Saturday, 18 August 2012

A Kiss is Just a Kiss: On the Risks Associated With Conveying Patients to Hospital

There is a whole chapter in the Mental Health Act Code of Practice on the conveyance of patients to hospital. Two of the particularly cogent paragraphs are as follows:

"11.2 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.”

“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. In these circumstances there should be an escort for the patient other than the driver.”

The Masked AMHP has of course read these paragraphs, and has taken due notice of them. He does, however, consider that there are situations in which it is appropriate, or necessary, for the AMHP to take the patient to hospital themselves. Sometimes, there just does not seem to be any alternative at the time.

In both of the following cases, in which the Masked AMHP found himself in difficult osculatory situations, the patient was not formally detained under the MHA, but was being transported as an informal patient. I would submit that the Code does not specifically refer to informal admissions.


I have mentioned Leroy before on this blog. He has a very long history of bipolar affective disorder, which is frequently exacerbated by his fondness for amphetamine.

Leroy had been an informal patient, but when allowed leave off the ward, he had not returned. I was asked to visit him at home to check him out, and see if he could either be persuaded to return to hospital, or whether he might need assessing under the MHA.

I went out with Pam, one of our nurses, and knocked on his door.

He came to the door and beamed at us.

“Thank God you’ve come!” he said. “It’s terrible – the TV’s talking to me, and I can’t stop it! I’m begging you, please take me back to hospital!”

We couldn’t really argue with that, and made the decision to take him back straight away.

However, during the journey back, in which I was driving, and Pam was sitting next to him in the back, we began to regret this decision.

Leroy was clearly very high, with marked pressure of speech. He was also patently psychotic.

“Masked AMHP,” he said, “You’re scaring me. You’re speaking with the voice of an alien from Alpha Centauri! Stop it please.”

“I’ll do my best, Leroy,” I said, and decided not to speak at all.

At last we reached the hospital. I took him down the corridor towards Bluebell Ward, keen to get him into a safe place.

Halfway there, he suddenly stopped.

“I’m not gay, or anything, Masked AMHP,” he said, “but I really want to kiss you. On the lips.”

With that, he put a hand round my throat and pushed me against the wall, his lips wide open and his tongue moving rapidly from side to side like a conga eel searching for prey.

I could suddenly see my whole life passing by. Could I survive a kiss from Leroy?

I managed to extricate myself just as he was about to launch himself on me, and hurried on down the corridor, with Leroy in close pursuit.

Once we were on the ward, I suggested that Leroy might need to be detained under Sec.5(2), so that we could arrange a formal assessment.


Florence was a lady in her early 60’s. She, too, had a long history of bipolar affective disorder. I had assessed, and detained her, on several occasions in the past. Her typical presentation was to become hypomanic, with grandiose ideas, and spending money on irrational things.

Her long suffering husband called us, to let us know that she had “gone off” again. I went out to conduct an initial assessment with Dave, her community nurse.

Her husband met us at the door. He was a lot older that Florence, and the strain was telling on him.

“She’s bought a one way ticket on Concorde to the USA,” he said in despair. (This was a few years ago, when Concorde was still in service.) “She wants to see the President to give him some advice.”

We found her in the sitting room, drinking a tumbler of sherry and watching a pornographic video on the TV.

We politely asked her to turn the TV off.

“It’s just getting to the good bit,” she said, taking a swig from her glass.

We eventually persuaded her to turn off the TV. She abruptly got up and wandered off into the kitchen. We followed her there.

She was quite plainly unwell, and her husband was unable to keep up with her.

We tried to talk to her to assess quite how unwell she was, but she kept jumping from one random topic to another.

I suddenly caught a glimpse of something  peering out from the side of their fridge. I pulled the fridge out to be confronted with a fairly large furry animal, which looked up at me with appealing eyes.

“What is this, Florence?” I asked her.

“That’s my new chinchilla,” she said. “I got it yesterday. I was wondering where it was. I’m planning to start a chinchilla farm.”

On this occasion, we managed to persuade her that it would be a good idea to go to hospital. This time, Dave drove, while I sat in the back with Florence.

Florence seemed to take a liking to me. She took off her shoes and put her stockinged legs on my lap. Then she began to sing.

“Somewhere, over the rainbow, skies are blue...”

She continued to sing a medley of songs from 30’s and 40’s movies.

I decided to humour her with a rendition of my own. This was a mistake.

“You must remember this, a kiss is just a kiss –“ I began.

Florence looked at me with sudden affection.

Very well, my dear,” she interrupted, licking her lips, and suddenly lunged forward and planted her moist lips firmly on mine, attempting to thrust her tongue down my throat at the same time.

“Need any help in the back there?” Dave enquired, seeing a commotion in his rear view mirror.

But I was not at that moment able to reply.


  1. Why didn't you just try to convince Florence that she was not even likely to have access to the President, let alone advise him? You could have explained how she would likely have been detained, not listened to, even if, by any chance, she somehow found herself in his presence, such as at some public event. The chinchilla farm may actually have been realistic, even if on a small scale that would have allowed her to get a coat or two for herself. If you didn't think so, you should have talked about costs, how she was going to run her farm, and so on. She would have needed to think about that anyway.

  2. I was hoping the chinchillas were being bred to be pets rather than for their fur!

  3. Really? That's more of a reason to leave her alone. She just had one pet. Maybe she wasn't even going to raise more after all. She was considering the possibility, but that's OK. If that was not a good idea, she should have been persuaded by using rational arguments, such as about finances, not hospitalized. And who knows if that wasn't a good idea after all? As for meeting the President, maybe she was just naive, as fiction (and, apparently, some historical events from a more innocent past, such as Joan of Ark's story) may have given her the impression that it was possible to just go and meet important people without being stopped by security. That was, in fact, possible at times. Any properly dressed individual was allowed to visit Versailles and, with some luck, it may have been possible to meet the king or queen, although more often than not, outsiders simply handed to an assistant some letter that may or may not have been read and responded to.

  4. I am a trainee AMHP and shadowed an assesment where they placed the patient on a S2. The patient was taken by members of the crisis team in their car to hospital. The AMHP stayed behind with the doctors to complete the paperwork and arrived at the hospital about 10 minutes after the patient. Can this be justified in terms of reducing the stress to family members by not waiting between 1-4 hours for an ambulance and fear of the patient absconding?

    1. Transporting the patient in one's own transport can be justified on the grounds of minimising stress to patient and relatives -- however, I'm concerned that the patient was removed from their home BEFORE the paperwork had been completed. The AMHP has to give written authorisation to others who convey the patient, and can only do this once the paperwork has been completed. The patient is not officially liable to detention until the AMHP has completed their application on the basis of two written medical recommendations. Sounds like it's one to debrief with your practice educator, Anonymous.

  5. Thank you for replying. I have gone through the events again; the paperwork was complete but not given to those who had the patient in the car. Can this justified in certain circumstances.

    1. Not really obviously in fast moving and often stressful situations people forget but it doesn't take long to hand over the pinks. It used to be more common for detained patients to be transported in cars but after a tragic incident in a nearby LA we have been advised against it for safety and insurance reasons. I did do it recently after waiting 5 hours for a ambulance with no issues, but don't want to think about any backing i would of got if it had gone wrong