Thursday, 3 September 2009

Just Another Day

First thing in the morning I had to go to Woodland House, our local psychiatric hospital, to attend a Managers Hearing for a patient detained under Sec.3 MHA. Denise had been detained a couple of weeks previously, and had appealed. Patients have the right to appeal against their detention under the MHA. Their case will first be heard by a panel of Hospital Managers: these are essentially unpaid volunteers rather than NHS employees, who have an interest in the functioning of the psychiatric hospital. They have the power to discharge a patient from detention. If they refuse to discharge the patient, the patient can then appeal to a somewhat more judicial Tribunal, which is a panel consisting of a lawyer, a consultant psychiatrist, and a lay person.

It looked like being a busy morning: as soon as the Hearing had finished, I had to go over to Bluebell Ward to assess another patient, Terry, for detention under Sec.3. This request had come a day or so before. He had been an inpatient for a couple of weeks after being admitted under Sec.2. I had already arranged for a Sec.12 doctor to assess him to provide a second medical recommendation, so everything was set up.

I had known Denise for about 2 years. She had paranoid schizophrenia. I had been instrumental in getting her properly assessed and treated, since for several months she had been presenting with increasingly bizarre and disturbed behaviour, shouting and screaming and throwing things around in her flat to such an extent that most of her neighbours had given in their notice. I had been trying to engage with her, visiting her at home, and having conversations full of non sequiturs and conversational cul-de-sacs. To Denise, nothing made sense. At some time in the last 15 years, all the books had been changed so that they ceased to make sense to her. According to her, every book in the library had been substituted for ones that made no sense, as had all the magazines in the shops. Worse than that, street signs and place names had been altered, as well as maps and guidebooks. She lived in a perpetual state of perplexity, which must have been terrifying for her. I eventually managed to get her seen by our psychiatrist, and between us we managed to persuade her to agree to an informal admission. She consented to take antipsychotic medication, made an exceptionally good recovery, and had been fine for a year, until she had gone on holiday for a week without her medication. On her return, all her symptoms had returned, only this time she had refused to accept medication, since it, too had been changed and was not real, and she had ended up being detained under the MHA.

This time, however, she was far less cooperative, and did not seem to be responding to treatment. So she had appealed, and we had a Hearing.

A Managers Hearing consists of a panel of 3 Hospital Managers. They have a clerk who records their deliberations and their decision. The patient is invariably present, along with a legal advisor, who represents them. Also present is their consultant psychiatrist, a nurse involved with their care, and their community care coordinator, who is generally a community nurse or a social worker. On this occasion, that person was me. All three will have provided written reports covering their nursing care and progress on the ward, their psychiatric history and diagnosis, and the social and community background of the patient.

The Hearing was fairly informal, with the managers introducing themselves and explaining what was happening. They then discussed aspects of the reports with their authors. The patient’s legal representative is also able to cross examine each participant and question their report, and will present the wishes of the patient to the Hearing.

The patient is able to make direct representations to the Managers as well. Denise took full advantage of this, pointing out that the reports did not make sense, that her medication was not real medication, that she did not really have schizophrenia or indeed any other mental illness, and that it was the world itself that was ill. I detected a note of desperation in her lawyers summing up at the end.

After due consideration of the merits of her case, the Managers declined to discharge her from detention.

One task down, another to go. It was all going quite smoothly. However, on arriving at Bluebell Ward, I was told that there was an urgent assessment under the MHA back in town, and was given the mobile phone number of a health visitor. Intrigued, since health visitors (community nurses who look after the welfare of preschool children) do not usually get involved in Mental Health Act assessments, I rang her.

She had just visited a new mother, a young Latvian single parent who had only been in this country for a couple of months. She had arrived heavily pregnant and had duly delivered a baby a few weeks ago. The health visitor was very concerned about both mother and baby. She feared the mother had post natal depression, and was not coping with the baby. She also had no money, and no entitlement to state benefits because of her nationality. To top it all, she had no other relatives in this country, and did not speak any English. The health visitor had spoken to the patient’s doctor, who had told her to arrange an assessment under the Mental Health Act.

This was when my sometimes almost supernatural ability detected an opportunity to avoid getting involved. The doctor had not actually seen the patient. She was not known to the local psychiatric services. There had been no exploration of alternatives to compulsory admission, such as informal admission, or home treatment. In any case, Woodland House did not have facilities to accommodate a mother and baby, so maintaining her in the community in some way would be likely to be in the best interests of both the patient and her baby. Children’s Social Services needed to be involved. I pointed all this out to the health visitor, and suggested that the doctor should see the patient himself first, and then ask the local Crisis and Home Treatment Team to make an initial assessment.

Having dealt with that, I attempted to clear my mind and get into an appropriate state of relaxed alertness for my planned assessment.

Terry also had a diagnosis of paranoid schizophrenia. He was reported to be creating considerable management problems for the nursing team because of his erratic and at times disturbed behaviour. His symptoms included paranoid delusions that he was being poisoned, severe thought disorder, and flight of ideas.

I saw him alone in an interview room. Terry smiled amiably at me as I explained who I was and why I was there.

“I see,” he said, “Only a genius or professor can section me.”

“I’m afraid I’m neither of those. Terry, can you tell me something about how you came to be admitted?”

“I open the box of Pandora – that means that I am nothing, but aware.”

I left him time to elucidate, but he subsided into an amiable silence.

“Er, Terry, do you think you are unwell at present?”

“It is because my National Insurance number belongs to the parliament of Scotland. You see, the angels of the world are flying over my house, and although I am wise, they can see me for what I am.”

“Right… Do you think the medication you are taking is helping you?”

“I have a high level of testosterone because of my proximity to women. The tablets help me to discharge my energy. It is all the same in the cosmos.”

He continued in this vein for several minutes, warming to his incomprehensible topic. I had not the faintest idea what he was talking about, and at the soonest available opportunity I thanked him for his cooperation and told him I had to now go and consider my decision.

“You are not part of the blue circle. Nobody speaks for a moment. There are millions of people. They implanted two chips in my shoulder. Two veins go from these chips into my heart,” he said to me, smiling, as he left.

I confess that it did not take me long to reach a decision.

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