Paul: Another Death in a Psychiatric Hospital

An article in the Observer of 27th May 2012 noted that there is on average one death a day of patients in psychiatric hospitals. It went on to say: “There were 3,628 deaths in mental health detention (501 self-inflicted) between 2000 and 2010, accounting for 61% of all deaths in state custody.” The main thrust of the article was to press for all deaths of psychiatric inpatients to be independently investigated.

The article examined the circumstances of the death of Janey Antoniou, a mental health campaigner who was also a service user. Janey died in Northwick Park Hospital in Harrow in 2010. The inquest reported that she died "following self-harming by use of ligature".

This case reminds me of another patient I worked with who met a similar, but perhaps inevitable, end.

By the time I came to assess Paul under the Mental Health Act it was already far too late.

Paul and his two older sisters were adopted by a couple when he was about four years old. They had been removed from an abusive home situation, and had spent a year or so in care before the adoption. Abuse of a different kind had continued while they were with foster parents.

Despite the best efforts of their adoptive parents, the damage the children had suffered could not be healed. Both sisters had become patients of Charwood CMHT in adulthood, the oldest one, who had experienced and remembered the worst of their abuse, and who had tried to protect her younger siblings, was a patient of the team for many years.

Paul, though, had managed to keep out of mental health services until he was 33. When his girlfriend, with whom he had lived since he was 19, finally left him because she could no longer tolerate his mood swings, he drank a bottle of vodka and tried to hang himself. It was probably only this relationship that had kept him out of mental health services for so long. Without her, he was completely lost. He was detained under Sec.2 MHA, but discharged to the CMHT after a few weeks.

Paul decided to track down his biological parents. He managed to find his biological father and made contact with him. His father was welcoming, and even invited him to come and live with him. Pau, perhaps rather hastily, took him up on the offer and left the Charwood area.

However, it seems that discovering that his biological father had a large and apparently happy family, and that he had never been a part of that family, was too much for him.

He made a series of three suicide attempts, the last one, an overdose of 100 paracetamol, resulting in another admission under Sec.2 to the local psychiatric hospital. However, he was discharged after only a few days because he was able to convince them that this was just an aberration, and that he was no longer a risk to himself.

His adoptive mother persuaded him to return to Charwood and he moved in with her. Only a few days later he got drunk, took several kitchen knives from the house and went missing. His mother informed the police. When he returned in one piece in the early hours of the morning, she and his elder sister asked for an assessment under the MHA.

I visited him at his mother’s home to assess him with his GP and the CMHT Consultant, and with a trainee AMHP in tow.

Paul was in bed, and would not come downstairs. We assessed him in his room. He remained hidden under the duvet for the whole interview. He told us that as overdoses hadn’t worked he would try a different method. We suspected that he had kept some knives.

It was the unanimous decision that Paul needed to be detained under the MHA for his own safety. We were convinced that he was intent on killing himself. As he had already had two recent detentions under Sec.2, we decided to detain him under Sec.3, for treatment.

In view of his unpredictability, and the knowledge that he did not want to go to hospital, and that he probably had knives in his possession, we asked for the police to attend to assist.

When the police arrived, I went upstairs to tell Paul that he had been detained under Sec.3 and that he was going to be admitted to hospital.

He emerged from under the duvet and looked at me, his face an emotionless mask.

“Give me a minute, I need to get dressed,” he said calmly.

I allowed him some time to get dressed. But I felt deeply uneasy.

He came downstairs, looked at the police and me waiting in the living room, then continued down the hallway.

“I think he’s going to try and get away out of the back door,” I said to the police.

He was.

Fortunately, it was not easy to get over the garden wall, and the two police officers managed to pull him back before he had had time to scale it.

He was very resistant, and did his best to provoke the police. He seemed to want them to hurt him.

“Fucking pansies,” he said to them as they rolled around with him on the lawn, “I bet you like sucking cocks don’t you?” He carried on in this vein, becoming more and more explicit about their sexual preferences.

I was impressed by the two officers. Despite his strenuous efforts to escape and resist them, and despite the extreme verbal provocation, they acted entirely professionally throughout, using only the minimum force and restraint necessary to put the handcuffs on him. He went to hospital. He was safe.

Three days after his admission under Sec.3, the section was rescinded.

I was surprised, to say the least, when I discovered this. I did not feel that three days, two of which had been the weekend, was long enough to conduct a proper assessment, never mind to treat Paul. I thought that he remained a severe suicide risk. But it is only my job to make the decision about detention. What happens after admission I have no control over.

Paul remained as an informal patient for a week or so, and was then allowed some home leave. While at home, he cut his wrists.

He returned to the ward, still as an informal patient.

In the early hours of the following morning, only two weeks following his detention under Sec.3, ward staff found him in his bathroom. He was dead. He had used his belt to hang himself, using the closed bathroom door as a ligature point.

At the Inquest, the Coroner stated: “Paul's father and stepmother visited him in hospital. Paul told them they were selfish for wanting him to stay alive, and he remained underneath the bed cover for the whole of the visit. They went to staff and said they had never seen Paul so bad, and asked them to keep a close eye on him and make sure he had nothing to harm himself with.

"That night Paul rang his girlfriend and told her he was going to kill himself. She called the hospital and told staff what Paul had said to her, and asked them to remove a belt and knife she thought he had, and to keep a close watch on him."

The inquest revealed that Paul had put clothes and blankets under the bedclothes to make it appear that he was asleep in bed when ward staff did their hourly observations. He had probably been dead for several hours before he was discovered.

The Coroner noted in the narrative verdict that there had been shortcomings in Paul’s treatment while in hospital. Changes were made to procedures on the ward, including changing the design of the doors on the en suite bathrooms so that they could not be used as ligature points.

Although I had been unhappy, both from a professional and personal point of view, that the hospital had discharged him from his section so soon after admission, I don’t ultimately think that Paul’s death would have been avoided had the hospital kept him on Sec.3, although the inpatient team may have been more reluctant to allow him leave from hospital.

At the very least, an independent inquiry might have highlighted ways to make such an unfortunate event less likely to recur.

But while I do think that more could have been done to prolong Paul’s life, I also can’t help thinking that his death by suicide was inevitable. In a way, he had died many years previously, at the hands of his biological parents.