Thursday, 25 February 2010

The Alarming Case of the Absconding Patient

David was in his 30’s. I had had to detain him under the Mental Health Act on a couple of occasions in the past. He had a diagnosis of schizophrenia, but had long periods of being well, and never happily engaged with psychiatric services. During his most recent hospital stay, about a year previously, he had left the ward one day and gone into Charwood town centre and entered a bank. He had patiently waited his turn, and when he reached the front of the queue had politely requested money to use “to alleviate poverty and suffering in the world”. Unaccountably, even though David had not been armed and had shown no aggression, the cashier handed over a considerable quantity of cash to him, which he then distributed to passers by in the street until the police arrived to take him back to hospital.

He had subsequently disengaged from the CMHT and no-one had seen him in recent months, except for a couple of occasions when he had turned up unannounced asking to see me. On both occasions I gained the impression that he was somehow playing with me, offering tantalising glimpses of a florid mental illness, as if he were challenging me to section him, then laughing at me when I tried to probe him. He was clearly enjoying himself, enjoying his illness. But he was also in control.

A few weeks later his mother turned up at the doctor’s surgery one day, dragging a reluctant David with her. The CMHT consultant happened to be holding a clinic at the surgery at the time, saw David with the GP, concluded that he was extremely unwell, and the two had completed medical recommendations for detention under Sec.2 MHA.

By the time the news reached me, he had gone home with his mother. I went round to conduct my assessment. David’s mother answered the door and let me in. His sister was also there.

David looked drawn and haggard, and not at all happy, in marked contrast to my last contact with him. It looked as if he had now lost control of his illness. The illness was now controlling him. He was clearly irritable, with aggression seething underneath his calm exterior. He was carrying a wet flannel

“I’m going to hit you with this flannel,” he said, smiling rigidly. He flicked my head with it, then threw it at me, as if he wanted me to play catch. I caught it.

“I know what you’re thinking,” he said. “But you’re wrong. I’m not mad, you know, and I can prove it to you. I can project thoughts into your head.”

He closed his eyes and concentrated. But I was not aware of any thought insertion.

“I don’t think that worked,” I said. “But I do think you are unwell.”

“Then I may as well kill myself, hadn’t I?” he said. Although he continued to smile, a tear flowed down his cheek.

I took his mother and sister to one side.

“David’s very unwell,” I said. “I’m very worried about him. He does need to be in hospital.”

“I really don’t want him to go,” his mother said. “Hospital won’t do him any good. He’d be better off here with his family. We can take care of him. I don’t want him to be sectioned.”

I talked it over with them. I explained my concerns. Since we were considering a Sec.2 I didn’t need the approval of the nearest relative. They pleaded with me to give them a chance to get him well at home. They assured me they would make sure he had his medication, that they wouldn’t leave him alone for even a minute, that they would let us know if they had any concerns, however small, that they would call us or the police the minute he tried to leave the house

I decided to give it a try. This did, after all, constitute an “alternative to compulsory admission”, it was worth trying as part of the decision making process. I had the two medical recommendations, I could review the situation daily, and complete an application at any time if I felt that things were breaking down.

I explained this to David. I told him that if he wanted to avoid going into hospital he would have to take the medication and stay with his mother and sister. I told him I would visit him tomorrow to see how he was getting on. He smiled and nodded, smiled and nodded. He was still smiling and nodding as I left.

I had barely returned to the CMHT when I received a call from his mother.

“David’s gone!” she shouted. “Just after you left he grabbed his car keys and he’s gone off in his car! He said he’s going to kill himself!”

My mouth felt very dry as I completed my application, formally detaining him under Sec.2.

Then I rang the police, explaining the situation to them. Then I waited.

I discovered that chewing my fingernails helped to pass the time. About half an hour later, the phone rang. It was the police.

“We’ve had a report of an incident,” the police officer said. “A car went through a red light at road works and hit a lorry head on. There’s an ambulance on its way now.” The officer promised to keep me updated.

I sat in the office, thinking. Worrying. Worrying about David. Worrying about myself. Would I have to give evidence at an inquest? What would I say? Where would the finger of blame point?

A few minutes later I received another call.

“A man answering the description of your patient was driving the vehicle. The ambulance is taking him to hospital now. We don’t have any more details.”

I set off for the hospital, and went to the Accident and Emergency Department, dreading what I would find. How badly injured would he be? Would he survive? Was anyone else injured?

But he was the only casualty. And miraculously (and also because he was wearing a seatbelt) he had escaped with nothing worse than a few cuts and bruises. In fact, he was medically fit for discharge.

And since Woodland House psychiatric unit was on the same site as the general hospital, I arranged for him to be taken directly to Bluebell Ward.


  1. Love the way you put across what you want us to know. That must have been a long wait to see what had happened. Well written.

  2. phew that was a close one, great writing by the way.

  3. don't know how quickly people respond on here. but i'm typing up my portfolio for amhp approval and have a case where a gent, in the community was assessed under the act and the two dr's wrote a joint recommendation for a S2. However, it had gone past 5pm and the agency amhp was saying he would hand conveyancing over to EDT. However the gent then decided he would leave his home and the amhp would phone police to pick him up and take him to S136 suite at the psychiatric hospital. The amhp has left now and i'm wondering about the legalities of it. Do the Police need to use S136 power in this instance (gent is 'liable to be detained'), and would the S2 begin as soon as the application and med recs made there way to the S136 suite? Unfortunately we didnt have a chance to discuss 'what happened next'. Thanks

    1. If the AMHP had a hospital to admit to, and completed an application, then the patient was liable to be detained. If he then went well, the police would have the power to convey the patient to the named hospital. No need to take to s.136 suite. On the basis of your information the AMHP might need some refresher training to ensure their practice is within the law and compliant with the HRA