Wednesday, 23 March 2011

When Detained Patients Appeal – Part III: Trevor and the Tribunal

It appears that I have not been discreet enough. Since my last post, my AMHP student has discovered my identity as The Masked AMHP. I guess that wearing my glasses over the mask wasn't enough after all. I don't think the cowboy hat helped either. Or the rawhide chaps.

Anyway, on to my humiliating experience at Trevor's Tribunal.

Trevor was in his early 20’s. He had been involved with psychiatric services for 4 years. He had spent a good deal of that time detained under Sec.2 or Sec.3 of the MHA in a range of hospitals.

Trevor was very complex. He had not so much a dual diagnosis as a triple diagnosis. He had a history of abuse of drugs, had acquired a diagnosis of paranoid schizophrenia during his frequent hospital stays – and had a psychopathic personality disorder.

He had a serious history of assaults and threats to his parents and to professionals, especially nurses. This began during his first admission. While detained under Sec.3 on Bluebell Ward he had hidden in his room behind the door with the lights out, waiting for a nurse to come looking for him. The female nurse entered the room, and he attempted to strangle her with a ligature – in this case, a tie he had managed to hide. Had she not been able to set off her panic alarm, he could have killed her.

Somewhat surprisingly, he was not charged with an offence, but was instead transferred to a medium secure unit, where one evening while playing a game of table tennis with another nurse, he calmly reached over to get his coffee, and without warning threw the hot drink straight into the nurse’s face, causing serious scalding.

The longer I worked with Trevor, the harder I found him to like.

He regularly appealed against detention during his hospital spells, and an appeal was pending against detention in this particular hospital. The day after this incident I visited him in order to write my social circumstances report. He appeared somewhat the worse for wear, with some fresh contusions on his face, and he was complaining of a sprained wrist. He wished to make a complaint against the staff for excessive restraint.

“After I threw the coffee,” he told me calmly, with the hint of a smile on his face, “the staff used excessive control and restraint. They didn’t need to grab me. I just stood back and put my hands up. I expected them to escort me to the seclusion room. I wasn’t going to struggle.”

It is possible that staff were overzealous in restraining him. However, in view of his history (he had also held his GP at knife point on another occasion that led to his detention under the MHA) and what he had done out of the blue the previous evening, it is quite possible that the staff were frankly terrified of him and weren’t about to take any more risks.

The main thing I learned from his account of this incident was that Trevor knew exactly what he was doing. He had not been told to scald the nurse by a voice. He had not had any delusional beliefs about the nurse. He had just decided to do it for the sheer hell of it, having learned that being a detained patient absolved him of responsibility for his actions.

I wrote several social circumstances reports for Trevor over a number of years, and was responsible for detaining him under the MHA on a couple of occasions. The last time was somewhat unusual. Before the 2007 Act came into force, the application form for Sec.3 required the Approved Social Worker (the predecessor to the AMHP) to state the nature of the mental disorder that required treatment. There was a space in which to enter: “mental illness, mental impairment, severe mental impairment, psychopathic disorder (whichever of these is appropriate)”. For the only time, I inserted both “mental illness” and “psychopathic disorder”.

He had been an informal patient for a period of time, and had been stretching the boundaries of acceptable behaviour for some weeks. We were reluctant to use the MHA again, but following an assessment by the local forensic consultant psychiatrist, who had been prepared to make a formal diagnosis of psychopathic disorder and recommended that he should be admitted to a specialist unit, we assessed him again. During the assessment, his room was searched and a bag containing large shards of glass which he had taken out of a skip during unescorted ground leave was found in a drawer. He was just too dangerous.

Trevor was transferred again to a medium secure unit, and again appealed against detention. While there, he had unexpectedly suffered from a seizure and had been admitted to a local general hospital. While there, he took a syringe from a nurse and darted them in the face with it. Again, having played the detained patient card, he was not arrested or charged with an offence. He was instead transferred to another secure unit.

I attended the Appeal Tribunal at this new secure unit, which was a long way from Charwood. Trevor had only been there for a few weeks, and the consultant there, although knowing his history, had found him to be compliant and fairly agreeable. I was the only person at the Tribunal who had known him over an extended period of time.

We had been looking for a specialist unit that would be able to treat the psychopathic aspect of Trevor’s mental disorder. Just before the tribunal, we had heard that a suitable unit had accepted him. I had also heard that funding had been agreed for this specialist (and eye-wateringly expensive) placement.

I had spent a considerable time preparing the report. I had interviewed Trevor’s parents, who were frankly terrified of him, since they had on a many occasions borne the brunt of his violent and unpredictable behaviour. They had told me that they were no longer able to provide a home for him, and were in full agreement with our plans to admit him to a specialist unit. I included this in my report.

I also included a detailed account of Trevor’s history of dangerousness and of the numerous and frankly disastrous attempts that had been made to manage him in the community. He had been tried in hostels, in supported accommodation, and in his own flat. Regardless of the level of support provided, he had invariably alienated his neighbours, had threatened support staff, had done his best to avoid medication, except for the illegal sort, and had invariably ended up in a police cell being assessed under the Mental Health Act.

I concluded my report: “While dangerous and unpredictable outbursts remain a feature of Trevor’s behaviour, combined with an unwillingness to cooperate with community staff to reduce risk and relapse, Trevor would continue to be an unacceptable risk to members of the public and those professionals attempting to help him, and further incidents of violence could lead to even more restrictive measures needing to be taken. He is fortunate that the incidents against the person outlined in this report were not referred to the police. For these reasons, I do not consider that it is appropriate to discharge him from compulsory detention at this time”.

Trevor’s solicitor presented Trevor’s case to the Tribunal. He wished to challenge the grounds for detention, and cross examined the consultant at some length. He made much of the fact that this particular consultant had not been witness to any of the unpredictable and dangerous behaviour outlined in his history. The consultant, when asked, felt unable to say that Trevor had a mental disorder of a “degree” to justify detention under the MHA, stressing instead the “nature”. Establishing the existence of a mental disorder of a “nature or degree” is a crucial requirement in a Tribunal, otherwise the Tribunal would be legally bound to discharge the patient. However, it is actually only necessary to establish nature or degree, not both.

This particular Tribunal seemed to forget this. Trevor’s solicitor encouraged this oversight. Trevor was on his best behaviour. He certainly did not present as being psychotic. (To be frank, I was never convinced that he had any significant psychosis. But the diagnosis had stuck fast.) He was also being almost embarrassingly polite to the Tribunal members. When dealing with people in positions of power, he usually either ignored them, insulted them, or attempted to assault them. I had at various times experienced all three.

I had the urge to remind the Tribunal of this point of law relating to “nature or degree”, since the consultant was clearly not going to, but I also knew that Tribunals do not expect or welcome interruptions, and like those present to keep quiet unless spoken to.

It came time for me to be examined over my report. The solicitor picked out the point I had made about his parents not wanting him home.

“Mr Masked ASW”, he asked (this was before I was The Masked AMHP), “have you spoken to Trevor’s parents recently?”

As is often the case, the report had been prepared several weeks previously. I said that I had not.

“Then would you be surprised to know that only yesterday Trevor’s parents said that they would be delighted to have their son home to live with them?”

I agreed that I would be very surprised to hear this.

The non-legal member of the Tribunal looked at me closely. “Isn’t it a pity,” he said, “that you did not check before the Tribunal and furnish us with an addendum?”

I had to agree that it was a pity. I was certain that Trevor’s parents had only changed their minds under duress, and because they could not say to his face that they did not want anything further to do with him. But I could not say this to the Tribunal. I was getting the feeling that things were not going well.

Then Trevor had the opportunity to say anything he wanted to say to the Tribunal.

“The Masked ASW,” he said. “I don’t trust him. He’s had it in for me for years. He lies in his reports about me. He doesn’t even try to get the facts right.”

The three Tribunal members looked accusingly at me.

“Trevor certainly doesn’t appear to be suffering from any mental disorder today, does he?” the chairman observed.

I wanted to reply that actually, Trevor was providing ample evidence to the Tribunal of his psychopathic disorder, the existence of which appeared to have been forgotten by them, but again, it was not my place to speak, and I had to remain silent.

After a brief adjournment, Trevor was discharged from Sec.3 with immediate effect.

When I eventually saw a copy of the written adjudication, the Tribunal stressed the lack of evidence of mental illness, and stated as a finding of fact that as the relationship between Trevor and myself had broken down irretrievably, my evidence carried little if any weight.

I felt sick. I felt this was an implicit attack on my professional integrity. It was clear that they had believed Trevor, and therefore they believed that I would act in an unprofessional manner. That really hurt. What hurt even more, was the knowledge that an opportunity had been lost for Trevor to receive treatment that could reduce his risk to others.

The Tribunal had also disregarded crucial aspects of Trevor’s diagnosis and risk factors, and I felt that they had possibly even reached a perverse decision which amounted to a breach of the law. But I had no power to challenge this decision. I brought it up with my superiors, but neither the Mental Health Trust nor the Local Authority had any interest in making a legal challenge, so nothing happened. It was too late anyway.

Trevor went home. 6 weeks later, his parents threw him out. He took a load of drugs, attacked some strangers in the street, and was detained again. And so it went on. Several years down the line, after much more mayhem, Trevor was eventually placed in the specialist unit that had been identified in the first place.


  1. I would offer the view, as a policeman, that after the ligature incident and certainly after the syringe incident, he should have been prosecuted for hte offences, with a view to seeking a s37/41 hospital order. I would like to say I'm amazed that this wasn't done, but the truth is, I'm not ... police and / or CPS response to violence and aggression against staff and other patients within in-patient psychiatric units is not as good as it should be.

    For me, a prosecution should have occured, so that the Tribunal to which he appealed was constitued in terms of Part III of the Act, instead of the Part II / s3 MHA Tribunal. "Serious risk of harm"? ... or I think so.

  2. I agree with you entirely that there are times when Part III of the Act ((orders imposed by the Courts) should be used in preference to Part II. Trevor was just such a case. I may write about more in the blog. Thankfully, subsequently it was written into Trevor's care plan that it may be more appropriate for him to be taken to court for disposal than for him to be diverted from the criminal justice system. This eventually resulted in him spending time on remand and finally detained under Sec.37/41.

  3. Excellent post.

    I found myself inwardly cringing at several points during your description of the Tribunal's behaviour/knowledge. I can only imagine how appalled you must have been.

  4. I found as an ASW that Tribunals were often very sensible. There was one occasion however when I suggested that my client's delusional belief that there were surveillance cameras in her car watching her every move might have an effect on her ability to drive. This caused amusement among the Tribunal and they discharged her. I wish they had been there to see her the following day; brought back in under S.3 following a head-on collision going the wrong way on the motorway trying to escape her imaginary pursuers. it was amazing no-one died but she was covered in bruises - a very sorry sight.

  5. Hello

    I feel that generally MHRT decision making is of a high quality and it's right that professionals to have to demonstrate clearly why a radical invasion of someone's personal liberties is justifiable. A tribunal session is the one place I've seen a psychiatrist break into a sweat. All very healthy.

    However, I have been in some tribunal sessions where the normal high standard has not been maintained. Sometimes tribunal members have been hostile in questioning and more usually, I've seen members fail to restrain, or be intimidated by, the service user's lawyer. Again, most lawyers are better behaved and I respect their professionalism.

    Being forced to admit that you haven't seen something with your own eyes is a classic bad lawyer trick. Obviously, most professionals will see service users for only a tiny proportion of their time and obviously some 'high consequence' events are worthy of comment regardless of the provenance of information about them. Most evidence presented at a Tribunal would be dismissed as unsupported hearsay in any other court setting. At present this can't be any other way as there's no effective mechanism for compelling witnesses to attend MHRT. (And risk assessment procedures often take for granted alleged behaviour that service users would dispute, and these documents would not pass any evidential test in Court).

    The classic hostile approach is a lawyer using the hearing to replay and dispute the (often far from ideal) circumstances of a community MHA assessment. Obvious the MHRT is supposed to be considering current circumstances but I was always surprised how often this was allowed to happen. A complaint or even judicial review would be a more appropriate way of dealing with an assessment that had seriously gone wrong but I don't think I've ever heard of a lawyer pursuing either option, perhaps demonstrating that this was just a Tribunal tactic.

    Another common 'bad' approach is alleging hostility or partiality by people presenting reports: there's a lot to be said for reports being produced by people other than key workers.