Social Work with the Dead

 

While it’s an occupational hazard for the police, ambulance crews, doctors and nurses to have to deal with dead and dying people, it’s fairly unusual for social workers to have such experiences. In over 40 years of being a social worker, I’ve been in the unfortunate position of being directly involved in the discovery of a recently deceased person on only four occasions. You don’t tend to forget about them.

I’ve told you about Robina and Cyril in a previous video. I’m going to tell you about two other incidents.

George

George was in his 50’s and a longstanding patient of the Community Mental Health Team. He had a very long history of chronic paranoid schizophrenia, and had a fortnightly depot injection. Although I was not his care coordinator, I had had to detain him under the Mental Health Act on a couple of occasions.

One day, Jim, his community nurse, went round to his house, where he lived alone, to give him his injection. He had been unable to get a reply. Jim returned to the CMHT and discussed this with me. It was not like George to be out on the day his injection was due, or not to answer the door. We decided to go out together to investigate further.

We rang the bell and knocked on the door, but there was no reply. The curtains were drawn, but we could hear the television. Jim knelt down and peered though the letter box.

“Oh, God,” I heard him say, as he backed away.

“What is it?”

“I can see him. He’s sitting in his chair in the living room at the end of the hallway. He’s not moving. I think he’s dead.”

I had a look. His profile could be seen clearly through the open door of his living room. His head lolled to one side, supported by the wings of the armchair. I called, but there was no movement. I feared the worst.

We decided to call the police.

When they arrived, we explained the situation to them. They too had a look through the letterbox, then tried to find an open window or unlocked door, without success.

One of the police then revealed an arcane piece of knowledge. The windows on this particular estate all slid within a groove in order to open them. There was a way to jiggle the window so that it could be slid back a little way, even though there was a window lock, and then it was possible to reach through and release the catch so that the window could be opened enough for a person to get through.

The police officer climbed into George’s house and opened the front door. We all entered and went into the living room. Goerge’s eyes gazed sightlessly at the morning TV programme. He appeared to have been dead for at least a day or so.

Once we had formally identified the body, we returned to the CMHT.

Jim was pale. He was badly shaken. He was looking at something far away.

“So lonely,” he said. “So alone. Looking down that long hall through the letter box, there he was. He died on his own. He was so alone.” A tear rolled down his cheek.

Gordon

One morning I had a call from one of my service users. Beth was a middle aged woman whom I had known for several years.

Not long before I first started to see her, she had finally escaped a long, abusive marriage to Gordon. Gordon was an alcoholic. Throughout the marriage he had terrorised her, undermined her, hit her, and sponged off her. I had helped her through the aftermath of this, including aiding her resolve not to return to him, affirming her decision, and assisting her to go ahead with a divorce. Over time, she had adjusted to being a single parent, and her confidence in her own ability to be a parent for her children slowly increased.

In recent months, after a long time with no contact, she had started to see him again – not because there was any prospect she would return to him but through pity. Because of his drinking, he was in very poor physical shape. For the sake of the children, who still had contact with him, she wanted him to get help for his drinking and also tried to persuade him to see his doctor, as he had lost weight and was physically quite frail, even though he was only in her early 50’s.

 “I’ve been round to Gordon’s flat,” Beth said, “but I can’t get any reply. I was going to do his shopping for him. I’m sure he’s dead. I’m convinced of it.” She began to cry.

I arranged to pick her up and go round to the flat again. Sure enough, there was no reply. She has last seen him a couple of days previously, when she had done some shopping for him. He never left the flat. So I called the police.

The police managed to get a key from the housing association, and I arranged to meet them at the flat. I persuaded Beth not to come. I didn’t want her to be in the position of having to identify the body, if our worst suspicions were realised. She didn’t want to, anyway.

I went into the flat with the police officer. We found Gordon curled up on a sofa. He was dead. He looked tiny, emaciated, desiccated, almost mummified; there was hardly any weight to him. He didn’t look as if he could ever have been alive, somehow.

His skin was a deep yellow, almost mahogany. I had never seen anything quite like it.  He had clearly been in the last stages of liver failure.

On the floor beside him, in a carrier bag, was the last shopping that Beth had done for him. Still in the bag was a 3 litre bottle of white cider.

I went to see Beth at her home. She was crying profusely. I told her the basic facts. I didn’t give her the details of his appearance.

“I killed him, you know,” she said in between gulps of air.

“What do you mean, Beth?” I asked her.

“I didn’t want to. He made me.”

“What do you mean?” I asked again.

“He made me buy him alcohol, that last time,” she wailed. “I knew I shouldn’t have. I killed him.”

“Beth,” I said quietly, “he never opened the bottle. He didn’t have a drink before he died. It was drink that killed him. But not that particular drink.”

Over the months following this incident, I had to spend many sessions helping her to work through her bereavement and guilt issues. But the fact that I had gone in that day, and had found that bottle, and had seen that it hadn’t been touched, and could tell her this, certainly helped to absolve her of at least some of her guilt.

No Happy Endings: Reminiscences of an Out-of-Hours Social Worker #4

 

The National Crime Agency’s Operation Stovewood, which first started in 2015, and is likely to continue for many more years, was set up in response to 20+ convictions for systematic child sexual exploitation in Rotherham relating to offences committed over many years from the 1990’s onwards. The potential number of survivors of these offences is estimated to be over 1,500.

The investigation was set up following a report concluding that known abuse was ignored by the agencies that should have been protecting these children and young people.

Throughout the 1980’s and 1990’s, as well as working in an area social work office by day, I also did one or two shifts a week on the out-of-hours standby duty team. This team dealt exclusively with emergencies and crises that arose outside normal working hours.

The child protection failures in Rotherham and elsewhere were by no means unique; there were a few occasions when I was called out to the city police station to act as an appropriate adult under the Police and Criminal Evidence Act (PACE) for teenage girls who had been picked up for soliciting.

I’ll tell you about two such incidents. There are no happy endings here.

I was called out one evening to deal with two 14 year old girls. They had been arrested following a tip off from a much older prostitute to the vice squad.

She had reported them, not because they were taking business from her, but because she was rightly concerned that such young girls should not be attempting to solicit. She was primarily concerned for their safety.

But the police did not really see it like that. They did not see it as a child protection issue. That was not why they wanted a social worker. They regarded these girls as juvenile offenders. They simply wanted to process their cases by giving them a caution and then getting them out of the station as quickly as possible.

So they needed a social worker to be present while this formal procedure was conducted. And so that I would then be officially responsible for their disposal once released.

Tracey and Tanya were waiting in the custody area when I arrived. They looked as if they were going to a “tarts and vicars” fancy dress party, with ridiculously short skirts and exaggerated makeup.

But they also looked like children rather than adults, and like children, they seemed to have a startlingly naive picture of the reality of prostitution, and were actually grossly unprepared, both practically (no condoms or other protection) and emotionally (they appeared to think that they would get spending money in return for little more than a kiss and a cuddle.)

They were reluctant to talk to me about their motivation or the circumstances that had led them to take to the streets (this was the first time they had tried it), and actually seemed to regard it as a bit of a laugh. The custody officer told me that the mother of one of the girls was a known prostitute, but it was unknown whether the mother knew what they had been trying to do, or indeed if she had actually encouraged them.

They were duly given a caution in my presence, and then released to me. I was unhappy about taking them home, as none of their parents could be contacted, and eventually obtained agreement to place them in a local children’s home, at least until the day time children’s services could assess the situation.

As so often when working out of hours, I never heard what happened to Tracey and Tanya.

But I did find out what happened to another lost girl I had involvement with, called Natalie.

Natalie was 16 and over school leaving age. She was on a Care Order to the local authority, and had been in a children’s home for a considerable time, until she had decided to leave the home and move in with someone she described as her boyfriend, a man in his twenties. She had been picked up for soliciting, and I was again called out to act as an appropriate adult.

As she was actually on a Care Order, I felt that I had to ensure that she had a safe place to stay tonight, and arranged for her to have one of the leaving care beds at the local YWCA.

I went to the police station. Naomi was an intelligent, likeable girl. But she had the manner of someone much, much older than 16. She came across as weary and hopeless, and had no interest in what I might be able to do to help her, other than to get her released from police custody.

Once the police had cautioned her, I told her that I was going to take her to the YWCA.

“I’m not going,” she said. “Just take me home. Take me back to my boyfriend.”

I had the strong suspicion that her “boyfriend” was actually her pimp. I was very reluctant to take her there.

“Look,” I said. “It’s just for tonight. I’d just like to feel you were in a safe place.”

She looked at me with 1,000 year old eyes.

“No,” she said finally. “I know you’re just trying to help. But I don’t need any help. Just take me home.”

Although she was on a care order, I had no powers to compel her to live in any particular place, so I reluctantly took her to her stated home address.

A few weeks later, on 20^th November 1992 her dead body was found in a layby. She had been strangled.

Her name was Natalie Pearman.

29 years later, her murder remains unsolved.

Stacey Slater Gets Sectioned: EastEnders and the Mental Health Act

 

Assessments under the Mental Health Act are rarely, if ever, depicted in TV drama. And because of the logistical difficulties involving consent and privacy, I have never seen a full real life assessment on TV.

The closest was in an episode of the Channel 4 series Bedlam, which followed Jim Thirkle, an AMHP, as he attempted to assess a patient, Rosemary. Sadly, the camera was unable to follow him and the psychiatrist as they entered her home, so the only way you’ll know what happens during a MHA assessment is by following my YouTube channel or reading the Masked AMHP blog.

Back in 2009 there was an Eastenders storyline featuring a character called Stacey Slater, played by the actor Lacey Turner. According to Wikipedia, she was given a diagnosis of bipolar disorder, and apparently the programme worked with various charities to develop the story. The storyline culminated in her being assessed under the Mental Health Act and detained under section 2.

We know it was section 2 because her cool young GP, Dr Al Jenkins, says so during the scene.

So, is this particular scene an accurate portrayal of the MHA assessment process?

I’m going to show you the scene, but before I do I’ll describe who is in it.

Stacey enters the living room.

There is a female police officer, Stacey’s mother and her GP, Dr “Call me Al” Jenkins standing. A bearded man and a black woman are seen sitting very quietly on the sofa. They are introduced as Dr Warder and Mrs Cook, who can “help assess your condition”.

A rather surly and threatening male cop appears at the doorway.

See if you can work out what might be wrong.

*

So what exactly is wrong with this scene? Let me count the ways.

1. In real life, it’s hard enough to get a patient’s GP to attend an assessment. When they do, they tend to know very little about the MHA, and take a back seat. They never lead the assessment.

2. Unless the powers under section 135 are being used, it is even more difficult to get the police to attend, and certainly not before an assessment has been completed.

3. The AMHP has responsibility for leading an assessment, and makes the final decision, having interviewed the patient in a suitable manner, and taking into account all the circumstances of the case.

4. Who even is the AMHP in this scene? By process of elimination it can only be the black woman on the sofa, Mrs Cook, who says precisely nothing. In real life the AMHP would lead, and begin by introducing all the members of the assessment team, and stating clearly the reason for the assessment.

5. In real life the AMHP and the psychiatrist would ask the patient questions, and attempt to ascertain evidence of active mental disorder. There would then be a private discussion, and a final decision would be made as to whether or not the patient was suffering from a mental disorder of a nature or degree sufficient to justify their detention in hospital for assessment. But I guess that would be a bit difficult to fit into a scene lasting less than 3 minutes.

6. It very quickly becomes clear that the decision has already been made. After Dr Jenkins tell poor Stacey that “we think you should go to hospital”, he very quickly concludes that “we’re all agreed it’s for your own safety”.

7. As there’s no sign of any pink forms, it’s clear that the section papers have been completed before the psychiatrist and the AMHP have even set eyes on Stacey.

8. Dr Jenkins tells Stacey that “there’s a car outside”. What sort of car? An Uber? In reality, an ambulance would be required, which would then probably take at least a couple of hours to arrive.

9. Apart from looking intimidating, the male cop appears to have had no control and restraint training. Not only does he not quickly disarm Stacey, who is brandishing a very dangerous plugged in table lamp (surely a first for an offensive weapon), but he allows her to escape into the Square.

I’d be interested to know who advised the story editors on the protocols of an assessment under the Mental Health Act. It certainly wasn’t an AMHP.

What You Need to Know If You’re Sectioned

So, you’ve been detained under the Mental Health Act 1983, and you’re in hospital. It’s most likely you’ve been detained under either Section 2 or Section 3.

Section 2 lasts for up to 28 days. The purpose of detention under section 2 is to be able to assess you in order to decide if you have a mental disorder. There are two grounds for a section 2:

You have to be suffering from mental disorder serious enough to justify detaining you in hospital for assessment, and it has to be in the interests of your own health or safety or in order to protect others.

Two doctors will have assessed you and will have decided that, in their opinion, you have a mental disorder. An Approved Mental Health Professional will have “interviewed you in a suitable manner” and would have had to have satisfied themselves that detention in a hospital “is in all the circumstances the most appropriate way of providing the care and medical treatment of which the patient stands in need”.

So the primary purpose of detention under section 2 is to assess you to see if you do, in fact, have a mental disorder or not. Although the detention is for assessment, you can be given treatment as well.

Section 3 lasts for up to 6 months, although it is fairly unusual for someone to be detained as long as this. The purpose of detaining under Section 3 is in order to give you the treatment it is thought you need for a mental disorder.

There are three grounds for a section 3:

You have to be suffering from mental disorder of a nature of degree that makes it appropriate for you to receive medical treatment in a hospital; and it is necessary for the your health or safety or for the protection of others that you receive such treatment, and it can’t be provided unless you’re detained, and appropriate medical treatment has to available.

Again, you will have been assessed by an AMHP and two doctors.

Most of the time, someone detained under section 3 will already have been an inpatient.

The sort of treatment you will receive is up to the hospital psychiatrist. However, Electro Convulsive Therapy (ECT) in most cases can’t be given to a detained patient unless they consent and are deemed to have the capacity to consent.

Section 2 can’t be extended beyond 28 days. However, section 3 can be extended for another 6 months. It can even be extended beyond that, in which case the renewal would then last for 1 year. But this is rare in most cases.

Both sections depend on establishing whether or not you have a mental disorder. The definition of “mental disorder” in the Act is very wide, being “any disorder or disability of the mind”.

The Code of Practice does however suggest a range of conditions which could be considered to be mental disorders. Here are some examples:

·       depression and bipolar disorder

·       schizophrenia and delusional disorders

·       disorders  such as anxiety, phobic disorders, obsessive compulsive disorders and post-traumatic stress disorder

·       organic mental disorders such as dementia and delirium

·       personality and behavioural changes caused by brain injury or damage

·       personality disorders

·       mental and behavioural disorders caused by psychoactive substance use

·       eating disorders

·       autistic spectrum disorders (including Asperger’s syndrome)

·       behavioural and emotional disorders of children and adolescents

As a rule, you can’t be detained under the Mental Health Act purely on the grounds that you have a learning disability, unless it is associated with “abnormally aggressive or seriously irresponsible conduct”.

Dependence on alcohol or drugs is not in itself considered to be a mental disorder.

Everyone detained under section 2 and section 3 has the right to appeal.

If you’re appealing against a section 2, you have to do this within the first 14 days. An independent Tribunal should then hear your appeal within 72 hours.

If you’re appealing against a section 3, you can appeal at any time during the 6 months of the detention, and after that during any renewal.

An appeal against a section 3 can be considered by a panel of hospital managers. These are not staff of the hospital, but lay people who have an interest in mental health issues and who also have the time to devote to these duties. They would hear your appeal within a couple of weeks. If they do not discharge you from the section, then a Tribunal would hear your appeal within a month or two.

A Tribunal consists of a panel of three – the judge, who is a lawyer, the medical member, who is a psychiatrist, and the specialist lay member, who is generally a lay person with a particular interest and experience in working with people with mental health problems, such as an AMHP, a nurse, or someone with extensive experience in the voluntary sector. Tribunals are part of the Judiciary, and are in effect a court of law, although they are much more informal than a normal court hearing.

Because of Coronavirus, at present these hearings will be heard remotely.

You are entitled to have a legal representative to present your case. These are solicitors with particular training and knowledge of mental disorder. You won’t have to pay for this representative. Alternatively, you can appoint any other person to represent you, apart from people who are themselves detained under the MHA or who are inpatients in the hospital.

You will be allowed to attend the hearing, and will also be allowed to take part and have your say. The other people present at these hearings will be your representative, your Consultant Psychiatrist or one of their junior doctors, a hospital nurse involved with your care, and someone from community mental health services, who could be a social worker, a community mental health nurse or an occupational therapist. Your nearest relative can also attend if you want them to. There will also be a clerk.

The hearing will have access to three reports: a medical report compiled by the hospital psychiatrist, a nursing report, and a social circumstances report written by someone from the community team.

Both Tribunals and Managers have to be satisfied that you are “suffering from mental disorder of a nature or degree which makes it appropriate for the patient to be liable to be detained in hospital” for either assessment or treatment. For section 2 they also have to be satisfied that the patient’s detention “is justified in the interests of the patient’s own health or safety or with a view to the protection of others”.  For section 3 they also have to be convinced that “it is necessary for the health or safety of the patient or for the protection of others that the patient should receive such treatment”, and they have to be satisfied that the appropriate medical treatment is available.

In order to satisfy themselves of these factors, they will use the reports supplied, but will also hear verbal evidence presented by those present. This gives a chance for you and your representative to cross examine the other people present and to give your side. They can then decide one of three things: not to discharge you, to discharge you with immediate effect, or to direct that you be discharged at a future date.

It’s worth appealing, because often a psychiatrist will decide to discharge you from your section before the appeal is heard, and even if they don’t, around 1 in 5 of people who appeal are discharged by the Tribunal.