Perdita: Encounters with a woman with dissociative identity disorder. Part 1: I'm asked to assess Perdita under the Mental Health Act – but is it the best way forward?

 

Perdita had suffered horribly for most of her life. She had been abused physically, sexually and emotionally as a child, and as an adult had gone from one abusive relationship to another. Along the way she had developed a wide range of coping strategies, including cutting, overdosing, denial of food, and dependence on alcohol and drugs.

She had also acquired a range of alternate personalities, some of whom coped well and appeared “normal”, and some of whom you would not like to meet on a dark night. Or even in broad daylight, come to that.

These personalities all had names. There was Perdita of course, with all her problems. But there was also Grendel. Grendel was extremely unpleasant. She would swear, shout, scream, throw things around, gouge at her arms, take massive overdoses, and swing her favourite weapon, a baseball bat, at anyone she happened not to like. Which was everyone.

And then there was Mavis, a very sensible, impeccably behaved woman who appeared when she had to in order to clear up the mess left by Grendel.

Perhaps more surprisingly, she also had a charming, polite and remarkably well adjusted 12 year old daughter called Ophelia. Perdita had always done her best to protect her from her behaviours, not always successfully. Children’s Social Services kept a wary eye on Ophelia.

Perdita had been involved with psychiatric services for most of her adult life, and had acquired a range of psychiatric diagnoses, most notably Dissociative Identity Disorder.

Her community nurse was a very experienced woman who generally managed to help Perdita keep her coping behaviours under control. However, a mix up with her methadone prescription had destabilised her, and Grendel was beginning to emerge. Perdita began to write a series of suicide letters, and confided to her nurse that she had been taking controlled but potentially dangerous amounts of paracetamol. Her nurse was becoming increasingly concerned about the welfare and safety not only of Perdita but also Ophelia.

After a couple of weeks, during which things continued to worsen, she arranged for a home visit with Perdita’s psychiatrist, who considered that Perdita ought to go into hospital. Perdita refused to consider this. The Crisis Team were called out to assess for home treatment, but when they visited, Grendel answered the door, baseball bat in hand, and told them to go away. Although not using those words. They went away.

That was when I was asked to get involved.

Armed with a S.2 recommendation from Perdita’s psychiatrist, I went out to see Perdita with another S.12 doctor and her community nurse.

I wasn’t sure whether it was an angry Perdita or a subdued Grendel who answered the door and reluctantly let us in. Either way, there was no sign of the baseball bat.

She was not amused when I told her why we were there. She became instantly hostile, telling us to leave with an impressive selection of insults and swear words. I continued to explain the importance of allowing us to interview her. In response she turned up the TV so loudly that it was impossible to continue.

We sat patiently for a few minutes, and after a while she turned it down. This gave me an opportunity to speak.

“Perdita,” I began, “This is really important. You’re really struggling at the moment. You’re not in control. This isn’t fair on Ophelia. We have to keep you both safe.”

I had by now concluded that Perdita was so chaotic that there was no alternative but to detain her in hospital. The doctor and I left the house and retreated to my car to complete the paperwork.

I went back in to tell her. But Perdita had switched. The aggression and hostility had evaporated. In its place was a spectacularly melodramatic level of contrition.

“I’m begging you not to send me to hospital! I’m begging you on my knees not to put me away!”

She did indeed kneel on the floor in front of me, gazing beseechingly into my eyes, tears flowing freely down her cheeks. “Please, please, please, let me stay. Look, I’ll cook a nice meal for Ophelia, we’ll sit down together and watch a DVD, and then I’ll take my medication and go to bed.”

This level of apology and contrition was actually worse to handle than her insults and aggression.

But I had made a decision. I had completed my application. She was now officially liable for detention under the Mental Health Act. The risks of not admitting her to hospital were high. She had switched once. She might switch back at any time. Surely it was too late to go back on all this.

But then again...

It seemed Grendel had gone for the time being. The threat of admission seemed to have brought Perdita back in control. She was making reasonable plans for the immediate future. And what would be the effect on Ophelia of being separated from her mother?

So in the end I decided to use the discretion given in S.6(1)(a) MHA – this gives an AMHP 14 days to complete the admission. It’s not actually used very much – in nearly all cases, especially S.2, an admission follows as quickly as a hospital bed can be arranged.

I did a deal with Perdita. She would cooperate with us. She would allow us to help her keep herself safe. She would tell us if she wasn’t managing. She would not put herself or Ophelia in danger. I would visit her the next day to see how she was doing. She agreed to all this and was embarrassingly grateful. And when I visited the following morning, despite still feeling low and sad, she was calm, collected, polite and cooperative.

I continued to monitor her closely over the next week. Things continued to improve. The crisis was over.

I shredded the papers.

S.13(4): The Right of the Nearest Relative to request a Mental Health Act Assessment

 

Relatives are often unaware of their right under s.13(4) MHA to request an assessment of their relative under the Mental Health Act.

Those who are aware, are often under the mistaken belief that this will inevitably trigger a visit to their relative by an AMHP and two doctors.

S.13(4) states:

(4) It shall be the duty of a local social services authority, if so required by the nearest relative…, to make arrangements … for an AMHP to consider the patient’s case with a view to making an application for his admission to hospital; and if in any such case that professional decides not to make an application he shall inform the nearest relative of his reasons in writing.

The Reference Guide has very little to say to enlarge upon this, except to state that “the nearest relative can require the local authority (verbally or in writing)…to arrange for an AMHP to ‘consider the patient’s case’ including whether there is a need for compulsory admission to hospital.”

The only thing the Code of Practice adds is to state that the local authority must respond not only to a direct request from the NR, but also to a request “on behalf of” the NR.

So what does all this mean to the nearest relative and to the AMHP receiving such a request?

The NR doesn’t need to put the request in writing, but can make a request by phone. They can also ask someone else to make a request, such as another relative, or their GP, and this must be considered as if it were a direct request from the NR.

The local authority AMHP service has to respond to this request. But this does not necessarily mean that they will conduct a formal assessment. An AMHP only has to “consider the patient’s case”. If, having done this, they do not think that an assessment is merited, there is no requirement to assess.

From the AMHP point of view, there may be many reasons why it is not appropriate to assess the patient under the MHA. A typical reason may be that other arrangements are being, or have been made. This might include a GP referring the patient to the local crisis team for assessment. It would therefore be wrong to pre-empt this assessment, under the principle of the least restrictive option.

Another reason might be that the patient is already involved with a community mental health team, who are managing the patient’s condition and would not welcome an AMHP’s intervention, or do not consider that a formal assessment is necessary.

It may be that, while the relative is concerned about the patient, the patient has not actually seen a doctor recently. In which case, I would always advise the relative that they should arrange for the patient to see a doctor first.

In some cases, the request may be “mischievous”; in other words, the relative may have made frequent or recent requests for their relative to be assessed, and unless there has been any significant changes in the patient’s condition, it would be oppressive to keep making fresh assessments.

I recall one such case, where the mother of the patient, a pregnant single parent with a young child, reported that she was expressing a range of alarming paranoid delusions, especially around her unborn baby. The ex-partner of the patient also corroborated this.

I went out with the GP and a psychiatrist, to find her preparing tea for her daughter and a school friend. Everything appeared completely normal, and she spoke politely and rationally to us for about an hour. We were unable to elicit any symptoms of mental illness, but based on the reports of the relatives, with heavy hearts we decided to detain her, and she was detained under s.2 for 28 days.

During that time she was not given any medication, and did not provide any evidence to ward staff of any mental illness.

On another occasion, I received a request from the husband of a woman. They were recently separated. His concerns seemed to boil down to the view that since his wife did not want to talk to him, and would not agree to what he wanted to happen to the property and children, then she must be mentally ill. I did not respond to this request.

Once an AMHP has considered the case, and has either decided not to undertake a formal assessment, or has assessed and has decided not to detain, they have a legal requirement to write to the referring relative. These letters have to be very carefully written. The Code of Practice states: “Such a letter should contain, as far as possible, sufficient details to enable the nearest relative to understand the decision while at the same time preserving the patient’s right to confidentiality.”

Displacing the Nearest Relative

 

The Mental Health Act 1959 first introduced the concept, role and statutory rights and duties of the Nearest Relative applying to patients subject to the Act.

The 1983 Act and the 2007 Act hardly made any changes. In certain circumstances, the NR under the Mental Health Act can be displaced, and replaced with an acting NR.

The Code of Practice states: “An acting nearest relative can be appointed by the county court on the grounds that: the nearest relative is incapable of acting as such because of illness or mental disorder; has objected unreasonably to an application for admission for treatment or a guardianship application; has exercised the power to discharge a patient without due regard to the patient’s health or wellbeing or the safety of the public; is otherwise not a suitable person to act as such; or the patient has no nearest relative within the meaning of the Act, or it is not reasonably practicable to ascertain whether the patient has a nearest relative or who that nearest relative is.”

So - is there any guidance to the practicalities of executing the role of acting nearest relative for professionals?

While displacing a patient’s NR and appointing an acting NR is not a very common procedure, it happens often enough that all local authorities have detailed written procedures for how AMHP’s may displace nearest relatives. However, none of them appear to give written guidance on exactly how an individual appointed to take on that role should discharge that duty.

Neither the Code of Practice nor the Reference Guide have anything say about how someone appointed to act as a nearest relative should act. The MHA itself makes the only reference to specific duties, in Sec.116. Sec.116(1) states: “Where a patient to whom this section applies is admitted to a hospital ... the authority shall arrange for visits to be made to him on behalf of the authority, and shall take such other steps in relation to the patient while in the hospital as would be expected to be taken by his parents.”

Sec.116(2) defines to whom this section applies. It predominantly applies to children and young people, but it also includes “(c) a person the functions of whose nearest relative under this Act are for the time being transferred to a local social services authority.”

Richard Jones in the Mental Health Act Manual has little to add to the bare words of the MHA. However, David Hewitt, the author of The Nearest Relative Handbook, says that the acting nearest relative “must be treated as if they were the substantive nearest relative”. He interprets this to mean that they should exercise all the nearest relative rights, interestingly including the right to delegate nearest relative status. He points out that to act as a patient’s representative is not the identified role of the NR.

This means that the local authority appointed acting NR is a distinct role from that of the Independent Mental Health Advocate (IMHA). He acknowledges that the role of the acting NR is ill-defined, but points out that this is also the case for a normal NR.

The NR has some wide ranging powers and duties. These include the right to be consulted regarding decisions being made by professionals concerning the patient, the right to make an application in their own right under Sec.2, 3, 4 or 7, and the right to request that an AMHP assess the patient under Sec.13(4) MHA.

If the acting NR is an AMHP employed by either the local authority or the local MH Trust, it is actually quite difficult to see how they might comfortably exercise some of these powers and functions.

Indeed, David Hewitt points out that there is considerable scope for conflicts to arise with the role of the AMHP, the role of the IMHA, the wider advocacy role, and with the role of the Director of Adult Services. He has suggested that possible solutions to these conflicts could be by neighbouring local authorities having reciprocal arrangements to provide this role, or even to use some sort of external independent provider.

How to survive in social work

 

One day, while I was still working in a Community Mental Health Team, one of our nurses returned to base in tears. She had been visiting one of her patients, a woman with bipolar affective disorder. She knew she was relapsing and had been trying to support her and her relatives and had been striving to avoid a hospital admission for several days.

The patient had shouted at her. She hurled very personal insults at her. She berated her for failing in her job, for letting her down, for not being a good enough nurse. It hit a nerve with my colleague. It triggered her deepest fears. Was she a bad nurse? Was she incompetent? Could she have done more to prevent this crisis? Was she so useless? Should she hand her notice in right away?

The team did their best to support and comfort her. She was a good enough nurse. She had done her best. She had seen a relapse coming, and she had done everything she professionally could to avert it.

This incident made me think about how mental health and other care professionals survive the job. It made me think about how I had managed to continue to function as a (hopefully) effective social worker for four decades.

In my first few months as a social worker, I was allocated Gwen. She and her children were very well known to services and had had many social workers over the years. I was the latest.

I knocked a little nervously on her front door, and when she opened it I introduced myself.

She looked me up and down and did not seem very impressed.

“Well, you’d better come in I suppose, she said, scowling.

I followed her into her front room. She closed the door behind me, took a deep breath and then proceeded to treat me to a tirade of complaints and insults which continued for at least 30 minutes. Throughout this deluge of vituperation, I stood silently and listened diligently.

I stood there mortified. Judging by her comments, I was the very worst and most totally useless social worker in the entire world.

While this destruction of my character continued, it suddenly occurred to me that this had nothing to do with me at all. She was ventilating. She was expressing her anger and despair at the system, and at the world in general. I just happened to be conveniently there. It wasn't personal. It wasn't about me at all.

I learned right then that if I were to survive as a social worker, I had to separate the professional persona and my professional functions from the personal, from the individual me. As I realised this, I suddenly felt a lot better. I waited patiently for her to finish, then got on with the job in hand. She never shouted at me again.

It's a simple lesson, but not necessarily easy to learn. But it helped me to deal with the often hostile and verbally aggressive people who I have had to assess under the Mental Health Act.

It has even helped me to remain mentally intact and sufficiently detached to manage the few occasions when I have been physically assaulted during the course of my work.

It's not actually about you.

An Unusual Social Work Dilemma

 

This video is about an unusual dilemma I found myself in while working in a Community Mental Health Team.

One day, I was asked to follow up a patient who had recently been discharged from the local psychiatric unit.

Elaine was 20 years old. She had been admitted after taking an overdose. Looking at her discharge notes, I saw that she had been born with foetal alcohol spectrum disorder.

She was a pleasant and polite young woman, but I could see that she had some of the facial characteristics often associated with the disorder.

She told me that she had had some physical problems associated with her congenital issues and had needed some heart surgery as a young child. She told me that she had been brought up by her father, and had never met her mother.

She also told me that she had always been impulsive and had taken the overdose after a disagreement with her boyfriend. She regretted it and did not think she would do it again.

Now here’s the thing. Although I had never met Elaine before, I knew a lot about her, from even before she was born.

Because 20 years previously I had worked with her mother, Janine.

Janine had had a serious alcohol problem. She had been in a very unstable relationship with a university lecturer. They were living together, but had frequent arguments, some of which had resulted in the police being called out. All of this culminated in her being thrown out of his house one evening.

At the time, I had helped her get a room in the local hostel and had also attempted to work with her to manage her alcohol problems. It was then that she had discovered she was pregnant.

She continued to drink very heavily and was very erratic about engaging with antenatal care. Consequently, a child protection case conference was convened.

Because of the high risk of the baby being born with foetal alcohol spectrum disorder, the unborn child was placed on the child protection register. It was resolved that the child would be made subject to an emergency protection order at birth.

Despite my efforts to encourage Janine to engage with antenatal and alcohol problem services, she continued to drink, and inevitably, when Elaine was born, she was removed from her.

Her father managed to obtain custody, and Janine then disappeared.

Now here was the dilemma, which had only arisen because I had worked in the same area for so many years.

Elaine had lived with her father more or less since birth, but she had never met her mother, and knew nothing about her.

But I had known Janine and was in the unique position of being able to give Elaine some information about her birth mother and the circumstances of her birth.

However, I was also aware of issues of confidentiality. I shouldn’t divulge any information about a service user to another person without their permission.

So should I just sit there and keep quiet about it?

Or should I tell Elaine that I had known her mother and offer to tell her something about her?

The Sorry Tale of a Failing Mental Health Trust, a Murder – and 2 Inquiries

In 2022 the Norfolk and Suffolk Mental Health Foundation Trust failed a Care Quality Commission Inspection for the fourth time since its ill considered and disastrous reconfiguration in 2013, the only Mental Health Trust in the country to have so abjectly failed in its responsibilities to provide an efficient and effective mental health service for so long.

Its failure was inevitable once it had gone ahead with a massive reconfiguration of service provision 10 years ago. It disbanded locality based community mental health teams, relocating them in a few centralised locations, inevitably meaning that those teams were less responsive to community needs, and had to travel further to have face to face contact with services users, making the service innately less efficient.

They also had the brilliant idea of encouraging the most experienced staff to take early retirement or redundancy, then expecting them to re-enlist on lower pay grades. Not only was this very expensive, but it left a huge shortfall in expertise, with an expectation that lower paid and less experienced staff would take on larger caseloads with more responsibility.

Then to top it all, the Trust systematically closed many inpatient beds, making it necessary to use expensive private hospitals to provide an often inferior service many miles away.

Throughout the 25 plus years that I worked in multidisciplinary community mental health teams, I always maintained that you could close beds, or reduce community based staff, but to do both would result in disaster. The Norfolk and Suffolk Trust proves the evidence of the truth of that.

The Trust has continued to perform with dazzling incompetence. In June 2023 it was revealed that a report into patient deaths in the Trust had been toned down in an attempt to deflect attention away from the failings of senior management. In the first draft, it was said that there had been "poor governance" in the way deaths data was managed, with governance also being called "weak" and "inadequate".

But the final report released to the public did not have these descriptions.

It was then discovered that the Trust had presented grossly inadequate statistics relating to the number of children known to the Trust These showed that more than 4,000 children were on waiting lists for mental health assessments, with more than 1,000 apparently waiting longer than a year, but they had included 3,000 other cases, mainly adults with ADHD.

While the current management in the Trust appears incapable of doing anything to improve its performance, early evidence for chronic mismanagement goes back at least two decades, to a time when the Trust was then known as the Norfolk and Waveney Mental Health Partnership NHS Trust.

A prime example is the case of Richard King.

On 7th August 2004, Richard King stabbed his stepfather, John West, 11 times, killing him.

Richard King had a diagnosis of paranoid schizophrenia and had been a patient of the Trust since 1991.

He was first assessed under the Mental Health Act in December 2002, when he was detained under s.2 for assessment. He was discharged after only three days.

Between then and 2004 there were a total of 8 admissions to hospital, mainly informal, but some under s.2 or s.3 of the Mental Health Act. He frequently reported paranoid delusions, and there was increasing concern about the safety of his wife and others.

On 15th July 2004, Richard’s social worker, who was also an Approved Social Worker, the predecessor to an AMHP, received a call to say that his wife was very upset and Richard had locked her out of the house. She visited, and as she knew him well, she was able to calm the situation somewhat. Richard agreed to an informal admission, and the social worker, accompanied by a police officer, and with a police car following, took him to hospital.

After a few days, Richard was allowed home leave at his request. He was in contact with the home treatment team during that time. After 11 days he was discharged without being seen by doctors at the hospital.

Less than two weeks later he killed his stepfather.

On 21st January 2005, he was found guilty of the murder of John West and was detained under s.37/41 Mental Health Act.

The Norfolk and Waveney Trust arranged for what was described as an independent inquiry into this serious incident. The Inquiry reported in June 2005.

One of its key conclusions was this:

“It is very probable that Richard King would not have been in a position to kill Mr West had he been correctly admitted under Section 3 of the Mental Health Act 1983 in July 2004. This would have allowed for a proper risk assessment and a mental state examination to be completed to the required standard during the course of admission. It would also have prevented the discharge being enacted without the patient being seen. He would not have been discharged or given leave until it was considered safe to do so.”

A daylong meeting was subsequently held in which all of Norfolk’s Approved Social Workers were present, to feed back the findings of the report and make practice recommendations in response to its conclusions.

This is where I make a confession. I know exactly what happened at this meeting, and the reaction of those present because I was there. I was one of those ASW’s.

The ASW’s were not happy about the recommendations. It was felt that undue blame was placed on the ASW and on the community nurse who had been involved in Richard King’s care in the community, while little was said about the role of psychiatrists in allowing him to be discharged without having been seen.

It was considered that the ASW who had arranged for Richard’s informal admission had acted competently and in accordance with the letter and spirit of the Mental Health Act, seeking the least restrictive option. The ASW’s home visit was not initiated as part of a Mental Health Act assessment, and since Richard had agreed to an informal admission, there had been no need to conduct a formal assessment. Even if such an assessment had taken place, it would have been unlikely that detention under s.3 would have been considered at that point. It might have been more usual to admit under s.2 for assessment.

Unison, the local government union, described the report as“flawed”, contained factual errors and misunderstandings, and had unfairly scapegoated social workers.

The local MP was also highly critical of the report, and Indeed, there was so much dissatisfaction that eventually, a properly independent inquiry was convened.

This report, entitled “Looking Through the Reeds”, was published in June 2008.

The report is too long to comment at length on its findings. However, the report noted that the social worker “did not regard herself as working within an effective team given the reception she received when arriving at the hospital and the subsequent abrupt discharge, without consultation with the community staff.” It also noted that an internal investigation had found that the social worker “had not breached departmental policies and procedures or acted unlawfully in failing to use the Mental Health Act on this occasion.”

The Inquiry further concluded that “We are not in agreement with findings of the previous panel in this regard. A s.3 could have been arranged at any time if Richard King had tried to leave the hospital. It was not.”

This inquiry also considered at length the nature and substance of the first inquiry.

It noted that the first inquiry was not independent of the Trust, and it did not comply with the appropriate guidance.

In relation to the first inquiry’s laying blame at the door of the social worker, the second inquiry was clear:

“We cannot agree with the inquiry’s conclusion, that had Richard King been detained under s.3 he would probably have spent longer in hospital and would not have been given early home leave. Scrutiny of previous admissions would have demonstrated that his admissions were, with one exception, extremely short whether voluntary or involuntary. He had left the hospital without leave on other admissions. In our view, the panel reached its opinion on this point against the weight of the evidence.”

The second inquiry was also critical of the way that the Trust handled the aftermath of the murder of John West.

It observes:

“Several members of staff that we interviewed told us how they were affected by criticism from the first inquiry and were not given any formal support to help them cope with the devastating effect of public criticism. While some moved to different posts and some were told of competencies that should be achieved, no one received any specific training to address deficits in their practice. Several felt victimised… There was no indication that the Trust had helped staff to prepare for the external inquiry and support them through the process.”

After all these years has the Norfolk and Suffolk Mental Health Foundation Trust learned the lessons of the past sufficiently to make the profound changes to its performance needed? In view of ongoing criticism and scrutiny by the press and the BBC, right up to when I posted this video in September 2023, I fear not. 

JG, section 117 and ordinary residence: recent case law from the Supreme Court

 

S.117 of the Mental Health Act 1983 stipulates the important duty for local authorities and the NHS to provide aftercare for patients who are ordinarily resident in their area and have been detained for treatment under s.3 (as well as some Part 3 sections relating to patients convicted of criminal offences).

Over the years, local authorities have often sought to shift this responsibility. This is usually because the cost of providing residential aftercare can be extremely expensive. I have covered some of the case law arising from these disputes on the Masked AMHP blog.

Often these disputes have arisen due to the interpretation to the term “ordinarily resident”.

In order to reduce the need for local authorities to go to the High Court to challenge decisions relating to aftercare, the Care Act 2014 amended s.117 MHA with the intention of clarifying the definition of “ordinarily resident”.

S.117(3)(a) laid this responsibility on the services where:

 “if, immediately before being detained, the person concerned was ordinarily resident in England, for the area in England in which he was ordinarily resident”.

This duty then continued until it was agreed that there was no further need for aftercare services to be provided.

This was generally interpreted as meaning that the local authority where the patient was living at the point of their first detention under s.3 retained the responsibility for s.117 aftercare regardless of where the patient might be living at the time of any subsequent detention under s.3.

This brings me to the case of JG, who was the patient for whom a dispute arose between Worcestershire and Swindon over who was responsible for providing aftercare in her case.

JG had a diagnosis of schizoaffective disorder and was ordinarily resident in Worcestershire. In March 2014 she was detained under s.3 in that area.

As it was deemed that she lacked the capacity to make decisions about where she should live following discharge, it was arranged for her to be placed in a care home in Swindon, near to where her daughter lived.

In May 2015 she was admitted to a hospital in Swindon under s.2 MHA, and this was subsequently detained under s.3.

A dispute arose between Worcestershire and Swindon over where she was “ordinarily resident” at the time of her second detention under s.3, and therefore who was then responsible for aftercare.

The dispute was first considered by the Secretary of State, who concluded that JG was ordinarily resident in Swindon and therefore they were the responsible local authority. This was in accordance with guidance on interpretation of ordinary residence.

Swindon then requested a review of this decision, at which point the Secretary of State reversed the decision, concluding that Worcestershire was in fact still responsible.

Guess what? Worcestershire went to the High Court to challenge this decision, and in 2021 the judge overturned this decision, reasoning that:

“JG was ordinarily resident in Swindon immediately before the second detention so that the second discharge triggered a duty on Swindon to provide after-care services for her; that it could not have been intended that Worcestershire’s duty to provide after-care services consequent on the first discharge should continue in parallel once Swindon’s duty had been triggered; and that section 117 should therefore be construed as imposing the duty to provide after-care services on Swindon alone from that point.”

But that wasn’t the end of it. This time the Secretary of State appealed against this decision to the Court of Appeal. They found that Worcestershire’s duty to provide aftercare was still continuing, despite the subsequent s.3 detention, since no decision had been taken that aftercare was no longer required.

So of course Worcestershire then appealed to the Supreme Court, who heard the appeal in April 2023 and published its decision on 10^th August 2023.

Worcestershire’s reasoning was that its duty to provide after-care services for JG under section 117 ended upon the second discharge, or alternatively that the duty ended at the start of the second detention.

The Secretary of State’s reasoning was that Worcestershire’s placement of JG in a care home in Swindon did not change where she was ordinarily resident, which as a matter of law continued to be in Worcestershire.

The Supreme Court concluded that:

"the duty under section 117(2) to provide after-care services automatically ceases if and when the person concerned is detained under section 3 … In this case, therefore, Worcestershire’s duty to provide after-care services for JG ended upon her second detention. Upon the second discharge a new duty to provide such services arose. Which local authority owed that duty is determined by section 117(3) and depends on where JG was ordinarily resident immediately before the second detention."

So in the end, it was concluded that Swindon was, after all, responsible for providing aftercare for JG.

Perhaps what this case highlights is the importance of legislators to ensure that the wording of legislation and statutory guidance should be as clear and as free of ambiguity as possible.

Will this decision finally put an end to such disputes, which in themselves can cost local authorities a lot in legal expenses and possibly places the subjects of the appeals in a limbo lasting several years?

I wouldn’t hold my breath.