Thursday, 31 December 2009

Update - Harry

I last wrote about Harry in July 2009. Harry was an elderly man living alone in squalor, probably with Diogenes Syndrome, causing carers and other professionals (including the Fire Service) problems, whom on two occasions despite the risks I did not detain under the Mental Health Act. I concluded then that I had not heard the last of him, and I also speculated, tongue in cheek, that another AMHP might be asked to assess him.

Well, that’s exactly what happened. A couple of months later, while I was away on holiday, there was another request for a Mental Health Act assessment. This time, the AMHP concluded that it was appropriate for him to be detained under Sec.2 for assessment and he was admitted to the local psychogeriatric ward. I have no argument with that – AMHP’s act independently, and two AMHP’s may validly reach different conclusions from the same information. In any case, situations can change, risk factors may vary from day to day, and I am sure that the AMHP who detained him made the correct decision at that time.

A few weeks later I was asked to assess him again, this time for detention under Sec.3 for treatment. When I interviewed him in the hospital he was clearly in a much better physical condition than when I had seen him at home. He was clean, well groomed, had put on weight, and was obviously enjoying the comparatively salubrious environment of the hospital ward. But I had to decide whether, in all the circumstances of the case, it was most appropriate for him to be detained in hospital under the MHA.

There was some evidence of memory problem, he did not remember my visit to him a few months before, was vague about other facts, and he certainly did not regard his home conditions as in any way a problem. When I discussed the reason for my visit he became furious, swearing at me and threatening to harm me. But did this amount to anything significantly different from my previous assessment?

This time he did have a diagnosis of vascular dementia, so certainly had a mental disorder within the meaning of the Mental Health Act, but was it of a nature or degree to warrant his compulsory detention?

I thought long and hard about my decision. And in the end I applied for his detention under Sec.3 as requested.

I was covered legally. There were two medical recommendations. He had a mental disorder. But I still felt uneasy.

What swayed me in the end was the fact that circumstances had now irrevocably changed. My previous decision was about whether or not to remove him from his home. My decision now was about whether or not to allow him to return to his home. With this decision came even greater potential risk to Harry. He had already made it very clear to me that if he were not detained he would insist on going back to the squalor and fire hazard that was his house, and this time would probably be even more distrustful of authority that he had been before. His risks of being at home would be significantly greater now than they had been earlier. If he were ever to have a chance of surviving in a community setting, there would have to be considerable changes in his home circumstances.

And strangely enough, detention under Sec.3 could facilitate that, since any elements of his aftercare package would now have to be paid for by the local authority and/or the NHS. He would no longer be charged for home care, and indeed, any works to improve his home, through a major cleaning programme or even alterations to the house, could also be free of charge. He was wily enough to see that there could be advantages to his continued detention – although he would never admit it.

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