The inquest on Bryan Jobson, who lived in
Leeds, was concluded on 1st
May 2013. Mr Jobson hanged himself with a noose suspended from his loft hatch
in February 2011.
What was particularly remarkable in this case, and which resulted in the inquest being reported not only in the Yorkshire Evening Post, but also in the DailyMirror, was that two mental health nurses from the local Crisis Team had visited him the day before he killed himself, and saw the noose hanging from the open loft hatch, with a chair directly underneath it.
It is reported that Mr Jobson, who was 44, had previously attempted suicide, that his relationship with his wife had broken down, and that he had recently experienced the loss of others close to him. The visit by the two nurses was in response to a call he had made to the Crisis Team.
It was reported that one of the nurses, who saw the noose and chair, told the inquest: “We were thinking about legal aspects. We are not allowed to touch things without their permission. I know it seems ridiculous, but we have rules to abide by.”
The nurses left him after gaining an assurance from Mr Jobson that he would not take his own life and would engage with the Crisis Team.
I do not know all the circumstances of this case other than what I have read in the press, and do not wish to comment further on this specific case, except to say that, from the inquest report, it is clear that these professionals were caring and experienced people who were acting in what they genuinely felt were the best interests of Mr Jobson.
However, the situation those two workers found themselves in does merit further examination.
Community Mental Health Workers often find themselves in the position of having to make an assessment of risk. This can be in a routine assessment, when a patient reveals a history of self harm or suicide attempts, or tells the interviewer that they feel suicidal and have plans to end their life.
It can also be in situations of acute risk, where the worker discovers that a patient has been stockpiling medication with suicidal intent, or has purchased a hose to connect to their car exhaust, or has made a noose or other ligature.
In these situations, a professional has to make a decision as to whether or not further action needs to be taken, such as arranging for a hospital admission, or considering conducting an assessment under the Mental Health Act.
In all cases, the risk of harm to the patient has to be balanced with the need to allow the person self determination and to respect their privacy and personal rights.
Certainly our local Mental Health Trust’s Policy on Self Harm encourages positive risk taking, which is described as “a person centred approach focusing on the service user’s strengths and the support required to enable them to take control over their behaviour.”
I often work with people who deliberately self harm, typically by cutting themselves, although there can be a wide range of self harming behaviours. It is important to distinguish cutting as a means of releasing distress, with cutting designed to cause serious harm or even death.
But what do you do when a patient reports that they not only have the means to take their own life, but also have the stated intent?
It is reported in Bryan Jobson’s inquest that the nurses were prevented from touching the property of a patient because of “rules that had to be abided by”.
I am not actually aware of any National or local guidelines or policies that prevent a mental health professional from taking action designed to reduce the risk of death or serious self harm.
Certainly, on the local psychiatric ward, one of the first things staff do when someone is admitted is to inspect their property and remove anything that could be used to harm themselves, or cause harm to others, such as razor blades, laces, belts, or other things which could readily be used as a ligature. This goes equally for informal as well as detained patients.
To reinforce such basic commonsense steps to safeguard vulnerable people, the Mental Capacity Act is designed at least in part to provide guidelines on what constitutes reasonable action to take to safeguard people who lack capacity.
One of the fundamental principles of the Mental Capacity Act is that anything done should be in the best interests of the person. However, “people have the right to make decisions that others might think are unwise. A person who makes a decision that others think is unwise should not automatically be labelled as lacking the capacity to make a decision.” (MCA Code of Practice Ch2.)
It should not therefore automatically be assumed, just because someone is stating the intent to end their life, that they lack capacity.
But any person, not just a mental health professional, is able to make an assessment of risk and take appropriate action in order to protect another.
A very basic example is that of a small child who is about to step into the path of a lorry. Their carer will make an instant assessment of the risk of harm if the child were to step off the kerb, and would then act to prevent the child from doing so.
The same would apply to an adult with learning difficulties who lacked capacity and was oblivious to the danger.
Not long ago, I was working with a woman with severe depression. She confided to me during one of my visits that she had been systematically going round the local pharmacies and had been stockpiling paracetamol. She made it clear that she was intending to take these tablets.
I asked her to let me have the tablets and give an undertaking that she would not attempt to take her own life. She agreed to this. We were able to involve the Crisis Team, who worked with her until the risk subsided, and we were able to avoid a hospital admission.
But what if she had refused to give me the tablets? While I would not have felt able to physically snatch them from her, I would have taken account of this refusal in terms of the additional risk it posed, made a brief assessment of her capacity to make the decision to refuse, and would have initiated an assessment for her detention under the Mental Health Act.
And if she had been in the act of swallowing the tablets, then indeed, I would have forcibly removed them from her.
After all, what would I rather have to do? Justify my decision to a court, because the person was suing me for interfering with their property, or to a disciplinary panel because I had broken some rule or another?
Or justify my decision to an inquest?