Tuesday, 19 April 2011

When Detained Patients Appeal Part V: Nearest Relatives and Tribunals

Although Nearest Relatives can attend Tribunals, they rarely do. Sometimes this is because they want to distance themselves from the legal process, or do not wish to confront their detained relative. It can be difficult to side with the psychiatrist and AMHP when their patently unwell relative is protesting that they do not need to be detained. The patient may not be able to recognise that their relative may really have their interests at heart, or may even be frankly terrified of them.

I have attended a few Tribunals where the Nearest Relatives have had a crucial role to play in assisting the Tribunal members to reach a decision. Sometimes this has been by the relatives telling some harsh truths about the patient. Sometimes they have facilitated their discharge in the face of opposition from the professionals.

Doreen was a woman in her early 60’s. She had a history of bipolar affective disorder going back nearly 40 years. During that time she had had a number of acute admissions under the Mental Health Act, most recently about 6 years previously. She normally managed well with a fortnightly depot injection and some oral mood stabilising medication. In fact she literally swore by its efficacy: “That injection,” she once told me, “it’s fucking marvellous!”

Doreen was a large and imposing lady. Even when well, she probably ran a bit fast: she was always loud, and often very crude, but in an amiable and rather likeable way. She tended to fill a room, both in reality, because of her bulk, but also with her gravely voice, which had been roughened and deepened by her 50 cigarettes a day habit, and her frequent peels of laughter after having told a particularly off colour joke.

It as unclear what had precipitated this admission; her husband thought that she had stopped her medication because of fears it was causing her constipation. The result, however, was that her behaviour became more and more unmanageable by her usually very tolerant husband, and even the input of the Crisis Team could not prevent an admission to hospital. When she decided to leave a few days later, she was placed under Sec.3.

Outraged at this, she appealed.

She had a manager’s hearing within a couple of weeks. I wrote her Social Circumstances Report. I interviewed her husband, who told me that he thought she needed a combination of oral and injected medication. He did not feel she was well enough to be at home at present. I put this in my report. When I interviewed Doreen for the report, she was still clearly displaying symptoms of hypomania, talking very quickly, darting around from subject to subject – and also displayed symptoms of paranoia, focusing on ward staff and her husband. The ward staff, she confided in me, were trying to kill her. She had a fixed belief that the nurses were “wicked animals” who had left her for dead suffering from hypothermia. Her husband, she told me, was a wicked old man who was also trying to kill her, in order to inherit her jewels.

The manager’s hearing considered her case, but did not discharge her from detention.

Doreen remained on the ward, protesting that she did not want oral medication. She continued to be happy to have her depot injection, as she always had been, but she became more and more unmanageable on the ward, being openly hostile to female staff, at times slapping nurses as they passed her in the corridor, and was also sexually disinhibited with male staff and patients. The ward decided to transfer her to the local PICU (Psychiatric Intensive Care Unit).

The PICU is classified as a low secure unit. This means that it is locked. I attended her first review. I had to go through an airlock, leaving any sharp objects, keys, and my mobile phone at reception. Doreen was still voluble and showed evidence of hypomania, but was not being verbally or physically aggressive to staff. She did, however, attempt to seduce the male nurse who was present at the meeting. She continued to refuse oral medication, but appeared more settled. After about a month a date for a Tribunal was set.

I interviewed both her and her husband for the report. He told me that he was willing for his wife to return to the marital home, as long as her mood was stable and she was complying with her medication. Certain areas of need have been identified, including some aids and adaptations to the house, and a support worker to take Doreen out. He was also considering taking early retirement in order to spend more time with her. Doreen's mental state did seem to have improved, but there was still evidence of pressure of speech, as well as evidence of disinhibition in the content of her conversation with me. Her relationship had clearly improved with her husband, who had been visiting her on the ward. However, she remained adamant that she should never have been detained, and that she did not need oral medication. I concluded in my report that "although I am aware of some improvement in Doreen's mental state, she is still presenting with a mental illness of a nature and degree that warrants her continued detention under Sec.3, and that were she not detained under the Mental Health Act she would intend to leave the ward and return home. This would not be in the interests of Doreen, or her nearest relative and carer, and could jeopardise her long term rehabilitation prospects." I suggested that she should return to the local ward prior to her eventual discharge home.

When I arrived at the PICU, not only was her husband there, but her daughter and son-in-law had also come. Although her husband had told me only 2 weeks before that he still had worries about her returning home, he was now saying that he wanted her home as soon as possible. They all went off into a side room with Doreen’s solicitor.

With Doreen's consent, her husband and daughter both attended the Tribunal. The solicitor invited them to give evidence to the Tribunal regarding the arrangements they could make to care for Doreen and maintain her mental stability. They were prepared to take her home with them today, were the Tribunal minded to discharge her.

The Tribunal were so minded, she was discharged for the Sec.3 with immediate effect and she went home with her relatives that day.

And reader, to this day Doreen is still at home with her husband, still in good mental health, still accepting her depot injection, and still not taking any oral medication.


  1. It is true that, for various reasons, it is rare for nearest relatives to attend Tribunals. When they do, and support discharge, much depends on whether they come across as realistic or whether they also are considered to be "insightless", or guilty of "minimising". I have only managed to be successful in having my clients discharged on two occasions in the face of fervent opposition from the attending nearest relatives, and on both occasions the nearest relatives managed to present themselves much more badly that the patient! Indeed in one of the cases the nearest relative (female) threatened me after the hearing and proceeded to leave a number of threatening telephone messages on my mobile. However, in both cases the discharges were successful with the client's remaining well in the community (despite their nearest relatives!).

  2. Because except in very rare circumstances the carer/relative ALWAYS knows better than a random MH professional. All patients know they are expected to put on a front and say what they need to and MH professionals will NEVER get a true picture as they have already abused the patients trust by locking them up and in this case continuing to recommned detention. So you will neber be trusted again no matter how 'good' a realtionship you think you have. The husband in this case probably had so little support that he was completely worn down by the situation- this is to do with lack of services meeting hos and his wifes needs. When he felt stronger and could manage he was by far - with her- the best placed person to make a judgment. My family have decide they will always be ultrapolite to all staff and look like they are doing what is expected but in reality they detest mental health workers for failing me repeatedly ( in their eyes). They also feel completely let down as carers. They have had to live with my problems since they were children and they know a million times better than anyone what is what needed and how strong they feel in manageing as there is never any more support in place when i am discharged then when i was admitted. The describe MH professionals - both community and ward based- as arrogant and never to be trusted. And they have absolutely no intention ever of trusting my care to these people simply because they are paid workers. Services are prepared to use carers/family as the main support because they cant be bothered to create person centre care packages and rely on carers to keep people safe. They regularly ignore when carers flag up high risk situations as they are not 'trained' . Not surprising what you see the husband as doing a 360 degree turn in 2 weeks as you probably cannot fathom that he will not ever want to share with you his thought process as you are likely to use it against his wife. You cannot expect anytghing different.

  3. I'm interested to know how a NR stands if the patient doesn't want them to attend a tribunal. Can the tribunal over-rule the wishes of the patient and allow the NR to attend (e.g. if they feel that their evidence would be particularly helpful - e.g. if they happen to be an AMHP themselves). Are there any mechanisms for a NR to appeal a decision if they feel the MHRT made a poor decision - there are for patients, but not sure if there are for NR. MHRT can make decisions which can have profound implications for NR but it doesn't appear there is any kind of legal come-back if the decision is a poor one (in the eyes of the NR).

    1. Still would be interested to know what rights NR have when tribunals make truly appalling decisions. Sadly in my case on the day the person was discharged to my utter horror I predicted they would be detained again and it would have awful consequences for myself and more importantly my children. Stopped taking medication extremely quickly, children ended up children in need and in a lot of distress and we nearly ended up in a refuge and patient disappeared abroad. After living 3 months of utter hell patient was re-detained but is now a shadow of their former self due to the delay in getting treatment. The costs of the appalling decision in terms of hospital care, loss of earnings, services etc are probably now over £100K. Yet the MHRT probably have absolutely no idea of the havoc and damage caused by their decision making and it appears those affected who had absolutely no come-back and just have to swallow the consequences and life changing circumstances.