Miranda

It was 4.30 on a Friday afternoon in November. It was raining outside. I was looking forward to the weekend. Then the phone rang.

Miranda was 71. She lived alone in her own bungalow. She had never been married. She had a long history of involvement with mental health services, and had been transferred to the older people’s mental health service when she became 65. She had a history of detention under the Mental Health Act, had had many admissions over the years, and had variously been diagnosed with psychosis and bipolar affective disorder. She was currently on an interesting combination of an antipsychotic, two mood stabilisers and an antidepressant. She had been seen a month ago by her consultant, who had suggested an admission to hospital, which she had politely declined. Earlier in the week she had been seen by a GP who had diagnosed a suspected urinary tract infection and had prescribed her an antibiotic.

Her community nurse had been to see her earlier in the afternoon. She had found Miranda working her way through a bottle of wine, writing a list of music she wanted playing at her funeral. She passed her a suicide note, and asked for her favourite GP to sign her death certificate after the weekend. She was not prepared to go into hospital.

I spoke to the duty GP, who had not seen her today, but was prepared to come out if required. I talked things over with her nurse, and we decided to visit her together so that I could make at least an initial assessment. The nurse had arranged for a bed to be available if needed.

We stood outside Miranda’s bungalow in the November rain, waiting for her to answer the door. She looked at us both, then let us in, seeming resigned to a visit from mental health professionals. She had finished the bottle of wine, and now had a glass of ginger wine in her hand. Although her bungalow was cluttered and somewhat neglected, she had a high quality sound system in her living room, with piles of classical CD’s covering most available surfaces. Bach’s Mass in B Minor, sung by the Sixteen, filled the room. Tears were flowing silently down her face.

She was still working on the list of music for her funeral. It was tasteful but melancholy music: Bach, Handel, Fouré, and some solemn, mournful medieval plainsong for the most part.

“Miranda,” I said gently, “What’s happened? Why are you feeling like this?”

She told me she had been feeling bad for a few days and that she did not know why. She could not think of any incident or trigger. She subscribed to a postal CD company, and had received the CD she was playing that morning. “When I have listened to it to the end, I will end my life,” she said slowly and with the exaggerated dignity that only the intoxicated can manage. Since it spread over two CD’s and lasted nearly two hours, I estimated that we had some breathing space at least.

Things were stacking up against her. As I had gone through the bungalow, I had noticed that her bed was piled high with junk, and had clearly not been slept in for some time. I went into the kitchen to talk to the nurse, and she showed me Miranda’s empty fridge. There was evidence that she was neglecting herself. The nurse told me that Miranda did not usually drink, so her drinking today was perhaps a symptom of her underlying mental condition rather than the cause. I was unhappy about the odd assortment of medication she was taking, and thought that a review of her medication would be a good idea. I was also mindful of the effect a urinary tract infection might be having on her mood and general mental state.

What was clear was that she did need to be in hospital for assessment and treatment, and for her own safety. It was too dangerous to leave her over the weekend. She seemed to have every intention of killing herself before the weekend was out. I was prepared to use compulsion if need be, but wanted her to have the opportunity to preserve her dignity.

“Miranda,” I said to her. “I think you need to go into hospital for a while. You know what my function is. You know I can detain you under the Mental Health Act if I need to. But I really don’t want to do that. You will have more control over your admission and stay if you go in voluntarily.”

“Can I take my music with me?” she asked.

The nurse nodded. “Yes you can. There won’t be any problem, if you have a portable CD player and headphones.”

Miranda looked into my eyes. Then she looked down.

“Very well,” she said.

Her community nurse and I helped her pack an overnight bag and we found a portable CD player. She got into the back of the car, with her nurse sitting next to her. Miranda seemed relieved, if anything. She talked about the music she loved and gradually her tears dried. We took her uneventfully to hospital.