Wednesday, 21 April 2010

A Little More on Section 4

(This assessment took place before the Mental Capacity Act 2005 came into force. Had the MCA been in place at the time, the outcome might have been very different.)

Ernie was in his late 80’s. He lived alone and had no known relatives. In recent months the GP had become concerned about possible dementia, and he had been seen by a psychiatrist on one occasion.

It was the middle of winter. The GP had visited Ernie and found him crouched in front of a one bar electric fire, surrounded by squalor, and with a strong smell of excrement in the air. She was very concerned about swelling in his legs, and had arranged for an ambulance to take him to hospital. But when the ambulance had arrived, Ernie had refused to leave his bungalow, and so the ambulance went away. The GP then made a request for him to be detained under the Mental Health Act.

In view of his frailty and the possibility of a life threatening condition, I went out straight away and did a home visit with the GP. His bungalow was pretty much as she had described it. There was evidence of many years of neglect: plastic carrier bags filled with junk and rubbish filled his hallway, his kitchen was filthy, with little evidence of food, the walls were black with grime, and spiders’ webs hung from the corners of the rooms. Ernie himself was sitting in his armchair in front of his fire when we came in (his front door was not locked).

It took him a few moments to register we were there. He seemed quite moribund. He was clearly worse than he had been an hour or so ago when the ambulance had come. He barely recognised the GP. He would not allow the GP to give him a proper medical examination. The only coherent thing he said to us was: “I’m not going to no fucking hospital!”

We went back to the GP’s surgery.

“This isn’t a case for the Mental Health Act,” I began. “He’s physically ill. He needs to be in hospital. This is an emergency. He’s getting worse by the minute. We need to get an ambulance out again and bundle him into it, whether he likes the idea or not.”

“But we can’t,” she replied. “He has a diagnosis of dementia. He’s been seen by a psychiatrist. He has a mental disorder. That means we can only admit him under the Mental Health Act.”

“The Mental Health Act really doesn’t come into this. We’re not admitting him for his dementia, we’re admitting him because he’s dying.”

But the GP wasn’t having it. She was convinced that the existence of a diagnosed mental disorder meant that only the Mental Health Act could be used to remove him from his home. Continuing to argue about it was just wasting time, time that Ernie did not have. We had to get him to hospital somehow, and as soon as possible. And we really didn’t have time for a psychiatrist to come out and assess him. So I decided we had to go for admission under Sec.4.

But this only made things much, much worse.

I rang Ambulance Control.

“I need an ambulance for an elderly man detained under Sec.4 of the Mental Health Act. He needs to be admitted to the general hospital. He’s very ill and frail physically. It’ll be a blue light job.”

“We can’t admit someone under Sec.4 to a general hospital. In any case, we’d have to take him to Accident and Emergency first, and if he’s on Sec.4 he could only be taken directly to a ward that will admit him,” the controller helpfully told me.

I could see his point.

“OK,” I eventually said. “We’ll admit him to the psychogeriatric ward. But we need the ambulance as soon as possible. This is an emergency. He’s really very ill.”

“If he’s detained under the Mental Health Act we can only classify your request as urgent, not as an emergency. We will try to get an ambulance to you within an hour.”

I tried to argue this point. But as I have found on many occasions before, arguing with Ambulance Control is invariably futile. And neither is pleading, begging and crying any more effective.

When I rang the hospital to arrange a bed, the bed manager understandably wondered why Ernie wasn’t being taken to a general hospital. I tried to explain. I recognised that almost as soon as he was formally admitted to a psychiatric ward, he would need to be transferred to A & E – a further hurdle to getting him the appropriate medical treatment, but it seemed I had no option. The bed manager reluctantly agreed, and the GP and I completed the application under Sec.4.

I went back to Ernie’s bungalow to wait for the ambulance. In the event it came within half an hour. By now Ernie was so weak, he put up no struggle at all when the ambulance crew lifted him onto a stretcher and got him into the ambulance.

He did not put up any struggle when they took him by stretcher into the psychiatric ward. The ward sister looked askance at Ernie as he was wheeled past her.

“What the hell have you brought him here for in this state? He needs to be on a medical ward!”

I miserably tried to explain yet again why I had taken the decision. By now, I wasn’t even able to convince myself.

He was transferred to A & E within minutes of his formal admission under Sec.4 Mental Health Act, and was then admitted to a medical ward. As he should have been hours previously.

And three days later, he died.


  1. What a sad story, but I'm glad he didn't die alone in his house. At least he had people caring for him. You do an amazing job for people, it must be nice to have a job that really matters.

  2. How sad. Poor Ernie. Sorry just want to clarify, today could you alone have sectioned Ernie and would this have meant he could have still gone to A&E straight away. Has the ambulance situation and admittance procedure changed as well.

  3. My view with Ernie was that under common law he could be taken to hospital despite his protestations as it was in his best interests and it was in order to save his life. That would have been legal then, and it is legal now. The Mental Capacity Act "legalises" the common law; it provides a framework where such acts can be justified on the basis that the person lacks capacity and it is in their best interests. If you were helping somoeone with dementia or learning difficulties to cross the road and they suddenly decided to run in front of a car, it would undoubtedly be in their best interests to stop them. The Mental Capacity Act provides some protection for people acting to protect people lacking capacity.
    This is necessarily a simplification of the Mental Capacity Act (which is quite separate from the Mental Health Act); AMHP's and others must now factor in the MCA when making decisions under the MHA.

  4. Hmm... this is VERY interesting. I worked for the Canadian Mental Health Association for a little while prior to working in a Women's Shelter, as well as having placement experience with mental health. It's interesting to read of your experience in the mental health sector in the UK. I am moving over in September (I have already registered with the GSCC)), and assumed I'd be working in CP because of the demand for QSWs in this field, but maybe Adult care is a better fit for me.... or at least more of an interest.

    I'll be following along!

  5. So basically, you did not save his life but deprived him of the opportunity of being in his own home when he died. Not everybody sees dying alone as sad. Some prefer it that way. I certainly would. The whole point of hospitalization is preventing death or saving one's health, if that is still possible. Once there is no hope, the patient's wish to die at home should be respected.

  6. The Masked AMHP4 August 2011 at 07:25

    I hope it's apparent from the post that I was unhappy about the way I was forced to take actions and use the MHA when the decision whether or not to admit him to hospital was medical and not mental health. I would, however, add that he was not in any state to make an informed decision about dying or not dying.