Thinking out of the Box: Reminiscences of an Out-of-Hours Social Worker #5

Throughout the 1980’s and 1990’s, as well as being a social worker during the day, I also used to do shifts on the emergency out of hours service.

You were pretty much on your own, based at home, receiving calls via a deputising service.

We received every conceivable type of request, ranging from referrals for child protection, through to Mental Health Act assessments and requests for night sitters for elderly people.

You also got requests that were so out of the ordinary that they didn’t readily fit into any category, and required finding solutions by thinking out of the box.

One night, I was contacted by the local police about a couple of New Age travellers, who lived in a traditional horse drawn caravan and would tour the commons and heaths of the county, camping for a few nights at a time before moving on.

They didn’t bother anyone, always clearing up their site before leaving, and no-one bothered them.

Until one night. They had a fire in their caravan, and although they had managed to rescue most of their belongings, and the caravan had been burnt out.

The police were asking for assistance to sort them out with emergency accommodation. This was complicated by the fact that they had two horses and a dog.

As they didn’t have any children, and could not be regarded as vulnerable, social services did  not really have any responsibility for assisting them.

In any case, finding accommodation for a couple of able bodied people at such short notice, late in the evening, was a non starter. And finding emergency accommodation for two horses, not to mention a dog, was virtually impossible.

But being a social worker, I still felt that I should do something if I could. It called for some lateral thinking.

I had an idea. I consulted my file of useful resources that I had compiled over the years, and started to make phone calls.

Eventually, I got hold of a local voluntary organisation and had a chat with them. They were able, and willing, to help. It was arranged that they would provide a large tarpaulin and deliver it to the site.

The travellers were therefore able to construct a bender using the tarpaulin and remain on the common, at least for the time being. This meant that they could also continue to look after their dog and their horses. Problem solved.

A Christmas Eve Mental Health Act Assessment

 

What every AMHP dreads: being on duty on Christmas Eve and getting a MHAA request just as you’re finishing.

When Love Goes Wrong 2: Psychotic or Delusional Disorders

 

Psychotic or delusional disorders can manifest in two basic ways:

Morbid jealousy (also known as Othello Syndrome) is when a person holds a strong delusional belief that their spouse or sexual partner is being unfaithful in the absence of any actual evidence.

Jealousy is a very common emotion, but when jealousy is entirely baseless then it can become pathological in nature. This can range along a spectrum between essentially normal feelings of jealousy, perhaps arising from an individual’s basic sense of insecurity or personal inadequacy, through to full blown psychotic illness.

Morbid jealousy is likely to take the form of constantly checking what the person’s partner is doing at any time of the day. The person may look on their partner’s mobile phone to see who they’ve been ringing or texting. They may interrogate them during the evening about what they’ve been doing, who they’ve been talking to.

This can be obsessional, but essentially non-psychotic in nature and therefore amenable to treatment, in which case, a talking therapy such as Cognitive Behavioural Therapy, can be effective in tackling and addressing the individual’s personal insecurities and anxieties. However, if it is truly delusional in nature, then it can be much more difficult to treat. It can also extend into stalking behaviour.

De Clerambault’s Syndrome (also known as erotomania) is a delusional belief that the person is in love with another, and that that love is reciprocated. This seems to occur most commonly in women. Usually, the subject of the person’s attention is only a casual acquaintance, and the affection is entirely unreciprocated. This belief can also lead to stalking behaviour.

I knew Sian for over 10 years. She provides an interesting illustration of both these disorders. Sian was in her late 20’s when she came to the attention of psychiatric services. She has first assessed in the court cells 12 years previously, having been arrested for harassment of her ex-husband and his partner. Although this assessment was inconclusive, there were a dozen further incidents of harassment over the next 6 months.

Things finally came to a head when she was arrested after being found hiding in the wardrobe of her ex-husband’s bedroom, having broken into his house. She was arrested on suspicion of burglary, and assessed by a psychiatrist in police cells, who recommended an assessment under Sec.35 MHA. Following this assessment, she was detained in hospital from Court under Sec.37.

I first became involved with Sian when she appealed to the Hospital Managers against her detention. It is a comparatively little known aspect of the Mental Health Act that, although a patient cannot appeal to a Tribunal against Sec.37 in the first 6 months of detention, they do have the right to appeal to the Managers of the hospital, who can, if they wish, discharge the patient.

I had to provide a social circumstances report and appear at the Hearing. This is when I discovered her story.

Sian had led a completely normal life until her late 20’s. She was married and they had one daughter. After a few years of marriage she became more and more suspicious of her husband, coming to believe that he was having an affair. She began to check his whereabouts, ringing him up constantly to find out what he was doing and where he was, and searching through his clothes and belongings. This behaviour began to put increasing strain on their marriage. In an effort to make him jealous and win back his affection, Sian had a brief affair with a friend of her husband. This only succeeded in finally ending the marriage.

On an impulse, Sian left the matrimonial home, leaving her daughter in the care of her husband. Her husband applied for residence, which was granted. After a year or so, her husband obtained a divorce and his new partner moved in. This provoked the increasingly abusive and violent attacks by Sian which eventually resulted in her being arrested, and spending a week or so on remand in prison until she was admitted to hospital.

When I interviewed Sian, she was still wearing her wedding ring, even though they had been divorced for a year and her ex-husband was now engaged to his new partner. She denied that it was possible that their relationship was over, and could not believe that her ex-husband could be having an intimate relationship. They were just friends, and Sian was certain that if she could cause a rift between him and his fiancée, then he would return to her. These beliefs were completely unshakeable.

Sian was not discharged by the Managers, and remained in hospital for about 4 months, during which time she was treated with antipsychotic medication and appeared to make a reasonable recovery, gradually realising that it was futile to believe that she and her ex-husband could ever get back together again. She was discharged from hospital with the rather vague diagnosis of “delusional disorder”.

Over the next few years Sian seemed to manage fairly well, getting a flat, and a job as a shop assistant, although she had a tendency to avoid contact with her care coordinator, and at times stopped taking her medication. At such times, she would become delusional again, invariably believing that someone she had served once or twice in the shop was in fact in love with her. She would then start stalking him, finding out where he lived and staking out his house. It was usually possible to persuade her to restart her medication, and these beliefs would then evaporate.

Sian’s most recent admission to hospital came out of the blue. She had been engaging well with the CMHT, was clearly taking her medication, and I had begun to explore with her some of the issues from her past. She had enduring guilt about abandoning her daughter, as she saw it, and I began to analyse her history and the breakdown of her relationship with her husband, in the context of the insidious onset of a psychotic illness over which she had no control. She seemed to have good insight into this, and it appeared to be reassuring her.

Then suddenly, over the course of two weeks, Sian began to behave increasingly bizarrely. She threw out all her clothes, resigned from her job, destroyed all her identity documents, and declared to her daughter, who was now an adult, that a man she had met in a pub a few days previously was her soul mate and one true love. She presented as highly distressed, agitated and tearful, with pressure of speech. Her daughter called out the Crisis Team, as it was at the weekend, and they assessed her and admitted her informally.

After her admission, I spoke to her daughter and discovered that Sian had only met this man twice, and only in the company of others, and that he had no romantic interest in her.

It took several months for her to return to normality, but eventually she was able to recognise that this wonderful, perfect relationship was entirely delusional.

When Love Goes Wrong 1: Adjustment Disorders

Love can sometimes give rise to bizarre and irrational behaviour. Indeed, it has been argued that since the definition of a delusion “is a sustained belief that cannot be justified by reason”, then being “in love” with someone could itself be regarded as a delusional state.

There are a number of well defined psychiatric conditions that could be said to arise from, or are manifested as, love and issues with relationships. Some of them are sudden and intense but fleeting, while others may be persistent, insidious and difficult to resolve. Either way, they can present as acute psychiatric emergencies requiring formal assessment under the Mental Health Act.

I would divide these disorders roughly into two types: adjustment disorders, and delusional or psychotic states. Today I’ll look at adjustment disorders.

A good definition of an adjustment disorder is “an emotional and behavioural reaction that develops within 3 months of a life stress, and which is stronger or greater than what would be expected for the type of event that occurred”. This can frequently be precipitated by the ending of a relationship, and in my experience, seems to occur more commonly among men.

Anybody can feel upset, bereft, or even suicidal when a loved one wants to end their relationship. Most people can fairly quickly accommodate and adjust to it, but some people have extreme and bizarre reactions, or develop a complete refusal to accept the reality of the situation. Here are a few examples from my professional experience.

Carl worked on a pig farm. One day he went to the local police station in a state of agitation and distress, saying that he had killed his wife. The body could be found on the farm, buried in a heap of pig slurry. He said he’d been clearing the slurry when his wife’s body had emerged. Although he had no memory of it, he concluded that he must have killed her.

The police immediately investigated, searching through tons of pig manure, but did not find the body of Carl’s wife, or indeed of anyone else.

They did manage to find out what happened. She was safe and well, having left Carl a few weeks previously and gone to live somewhere else in the country. Nothing untoward had happened between them.

It was as if Carl found the idea of his wife being dead more bearable than the fact that she had left him. When Carl was confronted with this, he began to recall what had actually happened, and his distress gradually abated over the next couple of days.

Colin had been married for 15 years. One day, his wife unexpectedly told him that she did no longer loved him and wanted to leave. He went off to work as usual, but when he returned home in the evening, he was shocked to find teenage children in the house whom he did not recognise. He also did not recognise his wife. He demanded to know what they had done with his young wife and infant children.

His wife called the on call GP who sedated him.

I saw Colin with his wife the following morning. The crisis was over by then. It appeared that his brain’s response to the news of the end of their relationship had been to develop a form of hysterical amnesia, where he had “lost” the previous 10 or so years, taking him back to a golden past in which he and his wife had young children and a happy marriage.

Overnight, the amnesia had worn off, and he was reluctantly beginning to accept the reality of the situation.

Chris presented to the A&E department one day with global amnesia. He did not know his name, or where he lived. He had no memory of his past. He was unable to give any information about himself.

He was examined for head trauma, but he had no injuries of any sort, and was admitted to a psychiatric ward.

After a couple of days a police trawl of missing persons revealed who he actually was, and his mother visited him on the ward. He did not recognise her.

Over a period of about two weeks, his memory gradually returned, and the story of what had actually happened emerged. And guess what? It was all about the ending of a relationship. His girlfriend had told him she wanted to finish with him. His immediate reaction was one of rage, and he had literally picked his girlfriend up off the ground and hurled her across the room. Fortunately, she was shaken, but not otherwise physically harmed. He then stormed off – and promptly wiped everything from his mind, including his entire life history.

These three cases featured forms of amnesia as a way of coping with intolerable news. Other people will simply refuse to accept that anything has changed, and will attempt to carry on despite all evidence to the contrary.

I was asked to assess Charles by his GP. Charles was a man in his 40’s who had been married for about 20 years. The couple had two teenage sons. 3 or 4 months previously his wife had told him that she wanted a divorce. She asked him to leave, but he refused. Since then, he had been living in the dining room. He had put locks on the inside of the door and only left the room in the middle of the night when the rest of the family were in bed. Then he would creep out and use the kitchen to prepare food for himself.

His wife had initiated formal divorce proceedings and had decided to put the house on the market. When she told him about this, he vacated the dining room one night and moved into the garage.

I went out to try and see him. His wife let me in and showed me photographs of the dining room that she had taken after he had vacated it. He had constructed a network of tunnels using cardboard boxes and blankets that had filled the room.

I went out to the garage, which had an up and over door which was closed. A car was in the garage, and he appeared to be living in that. There then followed one of my more unusual attempts to interview “in a suitable manner”. I could not induce him to open the door so that I could talk with him face to face, and had to make do with talking to him through the door.

During the interview I was unable to elicit any overt signs of psychosis, and he generally answered questions rationally, although avoided any discussion of the impending divorce. I concluded that despite the unusual circumstances, there was no evidence of risk that would merit obtaining a magistrate’s warrant under Sec.135. He was simply in denial, and unprepared to accept reality.

I advised his wife to get legal advice about evicting him from the property, and subsequently heard that after a few weeks he left of his own volition.

None of the above were actually detained under the MHA. In other cases, precipitated by rejection and the end of a relationship, people can self harm or become suicidal and present with high levels of risk. But do they actually have a mental disorder that makes them liable to be detained?

In the case of most adjustment disorders, the acute response will quickly resolve, or the absence of serious risk factors do not merit use of the MHA.

Rosemary’s MHA Assessment from the Channel 4 series Bedlam

 

This is an extract from a Channel  4 series called Bedlam. This particular episode was first broadcast on 14^th November 2013, and features what I believe is the only actual assessment under the Mental Health Act to have been filmed.

The episode followed Jim Thurkle, an AMHP working in the Speedwell  Community Mental Health Team in South London, as he went about his work in the community. In particular, it focused on Rosemary, a woman with schizophrenia who had stopped taking her medication, and was evading contact.

I have extracted the scenes involving Rosemary, including Jim’s attempts to see Rosemary and his efforts to avoid a formal assessment under the Mental Health Act and the day the inevitable assessment takes place, and edited them together. Because of patient confidentiality, the cameras are unable to follow Jim into Rosemary’s house where the assessment takes place.

You can find a link here to the review of this episode that I wrote for Community Care magazine.

Another inquest for a death in a private mental hospital – why do we even have private hospitals?

 

On 11th June 2019 Brooke Martin, who was 19, was found suspended from a ligature point in her bedroom at Chadwick Lodge Hospital run by Elysium Healthcare. She had diagnoses of Autism and Emotionally Unstable Personality Disorder and had been detained under s.3 of the Mental Health Act. The inquest ended on 1st July 2021.

The solicitor for her family stated that the inquest had revealed “stark failures in risk assessment, information sharing and observation setting in a mental health hospital dealing with an exceptionally vulnerable patient group.”

The inquest heard that only 5 days before her death she had tried to hang herself, but this incident was not properly recorded or communicated with staff and there was no risk assessment or review of her observations. Earlier that evening Brooke was twice found by staff to have something that could be used as a ligature which she had concealed under her duvet. No action was taken as a result of this that could have protected her.

Elysium Healthcare admitted that had they taken appropriate action, Brooke would not have died.

Elysium Healthcare was founded in 2016 and is owned by BC Capital. They bought up several mental health hospitals, mainly from the Priory Group and Partnerships in Care.

For the year ended 2019 Elysium reported a turnover of over £74 million. This came predominantly from either NHS England or Clinical Commissioning Groups – in other words, public money that would otherwise have been spent on services within the NHS.

A couple of weeks ago I reported on the death of Peggy Copeman, who died in a private ambulance on the hard shoulder of a motorway, while being transferred from the Cygnet Hospital in Taunton, another private hospital. She was allowed to leave the hospital despite her being “the most poorly patient on the ward”.

Another major provider of private mental health beds is Priory Healthcare.

In 2017 the Priory Roehampton was rated “inadequate” by the CQC, and there had been little improvement when it was inspected a few months later.

Priory Healthcare also owns St John’s House in Suffolk. This is a specialist unit providing a low and medium secure environment for men and women with learning disabilities. They are all detained under the Mental Health Act.

In December 2020 it was placed in special measures, after a CQC inspection saw CCTV footage showing "a patient being dragged across the floor... a patient being pushed over and the seclusion room door trapping a patient's arm and making contact with a patient's head when closed". On five occasions staff were asleep when they should have been completing patient observations. There was low staffing, with a heavy dependency on agency workers, poor record-keeping and 204 instances of physical restraint in a six-week period.

A subsequent inspection in April 2021 discovered that many issues causing concern “remained unchanged”.  They again found staff were asleep when they should have been observing patients, including all three members of staff assigned to one patient. The CQC said "Our latest inspection found the overall quality of care had not improved and many of the issues we previously raised remained unchanged."

You might think that private psychiatric hospitals would offer levels of care superior to NHS hospitals, since isn’t that what you would expect if you were paying for care and treatment? But frequently the reverse is the case.

A Guardian report from 5th July 2021 revealed that there were 23,447 NHS mental health beds in 2010-11 but only 17,610 in 2020-21, a reduction of 5,837 (25%). This is in spite of the fact that there has been a 21% increase in people involved with mental health services since 2016,  and an increase of 53% of people being detained under the Mental Health Act, 13,437 in March 2016 to 20,494 in March this year. This has inevitably led to a huge increase in people being admitted to out of area beds – this being a euphemism for “private hospitals”. These beds are frequently over 100 miles away.

In March 2021 alone the NHS spent £11.5 million on funding out of area placements.

These private placements can be enormously expensive. As Keir Harding, who has long been a champion of improving servicers for people with personality disorder, has pointed out, a locked rehabilitation unit claiming to be a specialist personality disorder unit will charge around £250,000 a year per patient.

For over 10 years, the Conservative Government has tampered with the NHS and services for people with mental health needs, weakening or destroying effective community based services, cutting funding to local authorities, who are responsible for social care, and forcing the increased use of private hospitals.

You can reduce the numbers of psychiatric hospital beds, or you can cut back on community services, but if you do both, it won’t save money, it will simply put pressure on other public services, such as A&E departments, the courts, and the police and ambulance services. Most importantly it creates misery for people who are denied the care and treatment they need, forcing them into avoidable and traumatising situations.

One example of this is the now discredited Serenity Integrated Mentoring (SIM) scheme, which many areas have been introducing (without any significant evidence of efficacy) as a means of managing people with emotionally unstable personality disorder who appear to be disproportionately coming to the attention of A&E, police and ambulance services. Rather than offering a therapeutic approach to dealing with their distress, the outcome is often to criminalise people and if anything to increase their distress.

Private, for profit, hospitals should have no place in the effective provision of mental health services. The only solution is reinstating proper funding for health and social care. The new Health and Social Care Secretary, Sajid Javid, has an opportunity to rectify this. As MarkTrewin recently said in Community Care:

"We have a new Secretary of State who has the opportunity to put right some of the mistakes of the past. Let’s have a social care reform plan before the end of this year that is creative and radical, that includes mental health, younger people and autism and that is designed with people who use services to genuinely improve the lives of all those people with mental health issues currently struggling within the system, and the hard-working professionals who work with them."

Rectifiable & non rectifiable errors on MHA forms

 

This fascinating yet also informative post is all about how to fill in statutory MHA forms correctly.

This is vitally important, as an invalid form could lead to the patient being subject to unlawful imprisonment and they could sue.

It’s all in the Mental Health (Hospital, Guardianship and Treatment Regulations) 2008, which were amended in 2020 to accommodate electronic production and transmission of forms. This states that there are certain statutory forms that have to be used for compulsory admissions and other legal aspects of the MHA, and these regulations give the wording that has to be used on the forms.

Traditionally, these forms are pink, although they don’t have to be. It’s the wording on the forms which is statutory, not the forms themselves – you could write them out by hand if you wanted, as long as you used the wording set out in the Regulations.

These forms present the information that has to be provided to the managers of a hospital in order for them to be able legally to receive and detain the patient. As the Code of Practice says:

People who sign applications and make the supporting medical recommendations must take care to comply with the requirements of the Act. People who act on the authority of these documents should also make sure that they are in the proper form, as an incorrectly completed or indecipherable form may not constitute authority for a patient’s detention.

The Code goes on to say:

If admission documents reveal a defect which fundamentally invalidates the application and which cannot, therefore, be rectified..., the patient can no longer be detained on the basis of the application.

Because of the potential risk of a form being invalid, it tends to be best practice to go with, or at least to follow, the patient to hospital, and then not leave until someone authorised to do so has scrutinised the documents and made sure they are legally sound. That way, if there are any mistakes, at least on the AMHP’s form, they can be rectified while the AMHP is still there.

The current chronic shortage of psychiatric beds has meant that patients often have to be transported long distances to mainly private hospitals, so this can make going with the patient impracticable. In those cases, it’s a good idea to fax or email the forms to the hospital beforehand, so that they can be checked and approved before the patient arrives.

There are rectifiable and non rectifiable errors, and s.15(1) MHA allows 14 days for rectifiable errors to be corrected.

Many years ago, the CQC issued useful guidance on scrutinising and rectifying statutory forms. It gives examples of errors that can be rectified (although it’s a bit more vague when it comes to defining non-rectifiable errors). This document says that:

Documentary irregularities fall into three broad groups:
♦ Those that are both incapable of retrospective correction and sufficiently serious to render the patient’s detention invalid.
♦ Those that may be rectified within 14 days after admission, but which, if not rectified, are sufficiently serious to render the application invalid at the expiry of that period.
♦ Errors and omissions that, even if they are not corrected within the statutory period, are not sufficiently serious to render the admission application invalid.

Rectifiable errors are usually fairly minor things, like minor errors in the address or name of the patient, or not crossing out things that needed to be, or leaving blank spaces where you should have written something. An example might be not crossing out the bit on the application referring to being unable to identify the nearest relative, when in fact you have identified the nearest relative. But they can be bigger errors, such as two doctors from the same clinical team providing recommendations. But as long as you get another medical recommendation within 14 days, you’re all right.

Non rectifiable errors include things like naming the wrong hospital, or failing to sign a form. Another one would be a form completed by someone not authorised to complete the form, for example an application made by someone who was not actually an AMHP.

Another would be using the wrong forms. I can remember an occasion when I was called out to do an assessment by a GP. However, by the time I arrived at the patient’s home, the patient had already gone off to hospital in an ambulance. When the ambulance arrived at the hospital, the patient was brought onto the ward, clutching a single piece of pink paper in their hand. This turned out to be a Nearest Relative Application form. The Nearest Relative had completed the first part of the form, and the GP had then written in a space on the back “I certify that this person should be detained under the Mental Health Act” and had then signed it.

But anyone can make a mistake, especially when things get a little bit out of control. I’ll tell you about an occasion in which I made a fatal error.

One day, I was called to assess a patient who was well known to me, and who had been detained several times before under s.3. I set up the assessment at her house, and arranged for two doctors to meet me there. When I arrived, she was in the street behaving in an erratic manner. The police had been called, and took her to the police station under s.136.

I let the doctors know before they arrived, and they then went to see her at the police station, which was being used as a place of safety.

By the time I got there, they had already assessed her, and gave me a completed joint medical recommendation. I then assessed her myself, completed an application under s.3, and arranged for an ambulance to take her to hospital.

I followed in my car, with the pink forms on the passenger seat, I happened to glance at the paperwork as I was driving, and realised with horror that the doctors had completed a form for a s.2, not a s.3, as I had assumed. So I pulled into the next layby and hurriedly completed an application for a s.2 to make the whole thing legal again.

The Peggy Copeman Inquest and what it says about Mental Health Services

 

This is a special post looking at the implications of the Peggy Copeman Inquest, which concluded on Friday, 25th June 2021.

Peggy Copeman died in a private ambulance on the hard shoulder of the M11 on the 16th December 2019, while being transferred between hospitals while detained under the Mental Health Act. This is what happened.

Peggy was 81 years old, and had been a resident in a care home in Norfolk. She had a long standing diagnosis of schizophrenia. A request for an assessment under the Mental Health Act was made when she appeared to be experiencing a significant deterioration in her health. She was refusing medication, food and drink and acting out against staff - actions described as "out of character". 

She was assessed on 11th December, but the Norfolk and Suffolk Mental Health Foundation Trust had no beds available, and arranged for her to be admitted to the Cygnet Hospital in Taunton, a private hospital 280 miles away.

The admission took place by private ambulance on 12th December.

While at the Cygnet hospital, she was diagnosed with a urinary tract infection and received treatment. On 15th December it was reported that she appeared dehydrated and was described as sunken, pallid, and having a dry mouth. There were concerns about her fluid intake. A nurse reported "She was the most poorly patient on the ward."

Nevertheless, the NSFT arranged for her to be transferred back to Norfolk when a bed became available a few days later, and a private ambulance service, Premier Rescue, provided transport on 16th December.

Despite her age, frailty, and physical ill health, a Ford Transit van with a crew of 3 was sent.

The driver said : "I was shocked at how old she was. I have not transported anyone of that age before. The patients we deal with are young and more spritely." He added that they had to "practically lift her in" to her seat.

After 2 hours, the transport stopped at a Motorway Services and Peggy was asked if she'd like a coffee. However, she only responded by groaning.

Undeterred, they continued on their way until the driver heard a noise "so loud I thought there was something caught under the car." He was told it was Peggy snoring. The other staff then noticed mucus coming out of her nose, and at this point they pulled onto the hard shoulder of the motorway, and Peggy then took her last breath.

It was reported that initially they contacted the Cygnet for advice and were told to ring 999. By the time an emergency ambulance arrived, Peggy was dead.

Dr Khalid Khan, a cardiology expert, said that in his view the ambulance staff had failed to recognise the Peggy was in respiratory or cardiac distress and she had "effectively died whilst sitting between them". He thought that they did not act promptly in calling emergency services in a "reasonable or timely matter". He concluded that her life may have been saved had a defibrillator been on board.

It was revealed that none of the ambulance staff had any medical training, with one member trained in CPR, and another shadowing.

The Coroner Jacqueline Lake, in a narrative statement concluded: "Peggy Copeman died from a fatal ventricular arrhythmia as a result of ischaemic heart disease. 

"Her death has been escalated by a short time by not being recognised and acted on whilst being transported on December 16 2019."

She said that evidence suggested Mrs Copeman would not have survived a hospital discharge but said that  the use of a defibrillator may have allowed her family to see her and "say their goodbyes and for her to die in an appropriate and dignified setting."

This tragic case highlights all that is wrong with the current state of mental health care.

All the services involved failed in their duties. The Cygnet Hospital failed to make a proper physical assessment of Peggy's ability to survive a journey of 280 miles. The private Premier Rescue Ambulance Service did not supply a suitable ambulance or properly trained staff.

But ultimately her death in such appalling circumstances could have been avoided if only the Norfolk and Suffolk Foundation Trust had had enough suitable beds to meet needs.

The NSFT has been in special measures since 2017, with little sign of any significant improvement. Several years ago it closed all the beds in King's Lynn for older people, meaning the only beds for older people in Norfolk are in Norwich, even though demand for beds has increased during that time. It has half the average number of beds for older people, despite it serving an area with an ageing population. In the year 2019-20 alone it spent £7 million on out of area beds.

However, the problem is much deeper and more intractable. This dire state of affairs has been made possible by the massive national cutbacks in funding for mental health services and the NHS in general, and the encouragement by stealth of privatisation in the NHS and the creation of an internal market through dividing the NHS into Trusts.

An example of this is the creation of regional ambulance trusts, who then contract with Clinical Commissioning Groups to provide services. These contracts can often be arbitrary and not reflect the actual needs. One example was that of the East of England Ambulance Trust, who would happily transport a patient detained under s.136 to a Place of Safety, but once that person had been assessed and a decision made to admit them to a hospital, that subsequent journey was not covered by their contract.

Having worked in statutory mental health for going on 40 years, I know that in the past local ambulance services would if necessary take a patient to a hospital anywhere in the country. The East of England Ambulance Trust, which covers Norfolk and Suffolk, will not transport patients outside the area covered by the Trust, meaning that AMHP services and the NSFT are reliant on private ambulance services to do this. Although all private ambulance services have to be approved by the CQC, those using them have little control over the quality of the service provided.

Private hospitals are another area where vast amounts of NHS money are spent, for often very poor services.

St Andrews Healthcare is a good example. It has, among other hospitals, a vast psychiatric hospital in Northampton with over 650 beds. Its annual report for 2019-20 states:

St Andrew's receives almost all of its income from NHS commissioners... Our single biggest source of such funding is NHS England... Our other main source of funding is the Clinical Commissioning Groups who commission our services for their patients with complex needs.

NHS England reported that it had directly purchased £294,796,282.22 of services from St Andrews Healthcare over the period January 2014 to July 2017. 

In February 2018 St Andrews Healthcare Northampton was rated by the CQC as “inadequate”.

Then there's Priory Healthcare. They are probably best known for providing drug and alcohol detox programmes for high profile celebrities, but it is one of the biggest private mental health care providers in the country. In 2017 it had an operating profit of £2 million.

In December 2020, the Priory Group was sold to a Dutch private equity company for £1.08 billion.

On 17.04.19. the Priory Group was fined £300,000 over the death of a 14-year-old girl, Amy el-Keria, in their hospital in Ticehurst, East Sussex, in 2012. Amy had a recent history of self-harm and suicide attempts and was found hanged in her room, a room that had been assessed by an untrained staff member to have “medium risks” with a number of ligature points, but this assessment had not been followed up. There was a catalogue of poor and negligent practice. Staff did not promptly call 999 or a doctor and were not trained in CPR. The hospital’s lift was too small to accommodate the ambulance service’s stretcher. Nobody from the hospital went with Amy in the ambulance.

Sounds a bit familiar, doesn't it?

I'd like to think that Peggy's death will lead to national changes to the provision of mental health care. But I doubt it.

When the people you’re trying to help seek to deceive #2: Nigel

 

From the early 80’s to the late 90’s I used to do out of hours standby duty sessions. I covered nights and weekends, in addition to the day job.

It always seemed to be that the most extraordinary and perplexing cases turned up outside normal working hours. Nigel was certainly one of those.

One Saturday, I received a call from the Samaritans in a town in the county I covered. They needed the help of a social worker. But it wasn’t the sort of problem they usually dealt with.

Nigel had just turned up at their offices in some distress. It took a while to coax the story out of him. They eventually gathered that Nigel had been living in some sort of residential facility in a county 150 miles away. They thought he had learning difficulties. He told them one of the staff had shouted at him, so he had decided to leave. He had packed a few belongings in a bag and left.

He went to the local coach station and got on a random coach, which had eventually dropped him off in the town. Lost and upset, he had found the first place that seemed to offer help.

My first step was to try and find out more about him. If he had left a residential care home, then he would have been reported as missing. I rang the standby service for the area he had apparently come from to see if they had an alert out on him. Unfortunately, they were unable to tell me one way or the other.

I decided I would have to see Nigel, and make an assessment. If he appeared to be a vulnerable person, I would then need either to arrange bed and breakfast for him through the local housing authority, or if necessary, try and find an emergency residential placement for him until we could return him to his home area.

When I arrived, one of the volunteers took me through to a side room where Nigel was ensconced with a cup of tea, milk three sugars, and a sandwich.

Nigel appeared to be in his forties. He was wearing an anorak zipped up to his neck and had a round face and rosy cheeks.

“Hello,” I said to him gently, and told him my name. He peered up at me through the thick lenses of his glasses. “I Nigel,” he replied.

I attempted to find out his full name, his address, and a contact phone number. He told me the place he had come from, but was unable to give me any other information.

“The bad man did shout at me,” he said. “I didn’t like it. So I wanted to leave. I got a coach. I got off here. Here I am.”

I asked him if he had any sort of identification. He shook his head. I asked him if he had any medication with him. He took a bottle of pills out of his duffel bag and showed them to me. They were anticonvulsants. They came from a pharmacy in the town where he said he had run away from.

I decided that we would have to look after him until he could be returned to his home county. He seemed far too vulnerable just to arrange bed and breakfast.

In those days I didn’t have a mobile phone, so I was reliant on the Samaritans to let me use their phone. They were only too pleased to help. They showed me into a small cubicle which contained a small desk, a phone, and a chair.

I made some calls to the local social services residential homes that specialised in learning difficulties. Eventually,  one of the homes called back, confirming that they would accommodate Nigel over the weekend, until further enquiries could be made.

I went to see Nigel and explained to him what was happening. This seemed to distress him.

“They won’t hurt me? They won’t hurt me? I don’t like it when they hurt me!”

He stood up and picked up his duffel bag.

“I go to the bus station. I get a bus.”

“It’s OK, Nigel, nothing’s going to happen. You’ll be safe.”

He eventually calmed down and allowed me to take him to the care home.

The next day being Sunday, I rang the next social worker on duty and explained the situation to them. They would chase up the local authority where he came from and get some more information, and hopefully arrange for his safe return.

I saw my standby colleague a week or two later.

“Remember Nigel?” he said. “I got through to his local authority. I managed to speak to someone who knew him. They knew him all right. He wasn’t missing – but they did accommodate him in one of their care homes a few weeks ago when he turned up one weekend saying that he’d run off from somewhere in another county a long way away. That is, until they made their own enquiries – and got the same story. Then they sent him on his way! Once we found this out, we confronted him with it and he left, rather quickly. I wonder where he is now?”

There is a postscript to this story.

A couple of years later I was speaking to a social worker in a neighbouring county. I told him the story of Nigel. He immediately recognised him.

“We put Nigel up in one of our mental health care homes for about 6 months,” he said. “Then we had a full psychological assessment done, and it turned out he had a completely normal IQ and everything. Then he mysteriously disappeared.”

From time to time I think of Nigel, traveling the country, turning up in distress, like a lost person with learning difficulties, in need of care and shelter, being taken in and looked after, at least until the truth about him was found out, then moving on again. What drives someone to live their life like that?

He’s not the only one who does it. I knew of another case, of a young girl, apparently in her early teens, who turned up one day, wearing a nightie and clutching a teddy bear, claiming to have been abandoned. She was placed with foster carers for several months, until it was discovered that she was actually 25 and had the tenancy of a flat in another part of the country.

Does it constitute a mental disorder, or is it simply a means to an end, a way of being looked after without any responsibilities? How many are there like Nigel and the “little lost girl”? And how many are so successful that they’re never found out?

A kiss is just a kiss: On the perils associated with transporting patients to hospital

 

There’s a whole chapter in the Code of Practice on the transport of patients to hospital. Two of the particularly cogent paragraphs are as follows:

17.3 Patients should always be transported in the manner which is most likely to preserve their dignity and privacy consistent with managing any risk to their health and safety or to other people.

17.17 AMHPs should agree to a patient being transported by private vehicle only if they are satisfied that the patient and others will be safe from risk of harm and that it is the most appropriate way of transporting the person.

I am of course familiar with these paragraphs. I have at times found myself in situations in which it seems necessary for the AMHP to take the patient to hospital themselves. There just didn’t seem to be any alternative at the time.

In both of the following cases, in which I found myself, shall we say, in difficult osculatory situations, the patient was not being formally detained. In my defence would submit that the Code does not specifically advise on informal admissions.

Let this be a warning.

Leroy

Leroy had a very long history of bipolar affective disorder, which was frequently made worse by his fondness for amphetamines. I had had to detain him under the MHA on several occasions.

On this occasion he had been an informal patient, but when allowed leave off the ward, he had not returned. I was asked to visit him at home to check him out, and see if he could either be persuaded to return to hospital, or whether he might need formally assessing.

I went out with Pam, one of the CMHT nurses, and knocked on his door.

He immediately opened the door and was unusually welcoming.

“Thank God you’ve come!” he said. “It’s terrible – the TV’s talking to me, and I can’t stop it! I’m begging you, please take me back to hospital!”

We couldn’t really argue with that, and made the decision to take him back straight away.

However, during the journey back, in which I was driving, and Pam was sitting next to him in the back, we began to regret this decision.

Leroy was clearly very high, with marked pressure of speech. He was also patently psychotic.

“Steve,” he suddenly said, for that is my name, “You’re scaring me. You’re speaking with the voice of an alien from Alpha Centauri! Stop it please.”

“I’ll do my best, Leroy,” I said, and decided not to speak at all.

At last we reached the hospital. I took him down the corridor towards the ward, keen to get him into a safe place.

Halfway there, he suddenly stopped.

“I’m not gay, or anything, Steve,” he said, “but I really want to kiss you. On the lips.”

With that, he put a hand round my throat and pushed me against the wall, his lips wide open and his tongue moving rapidly from side to side like a conga eel searching for prey.

I could suddenly see my whole life passing by. Could I survive a kiss from Leroy?

I managed to extricate myself just as he was about to launch himself on me, and hurried on down the corridor, with Leroy in close pursuit.

Once we were on the ward, I suggested that Leroy might need to be detained under Sec.5(2), so that we could arrange a formal assessment.

Florence

Florence was a lady in her early 60’s. She, too, had a long history of bipolar affective disorder. I had assessed, and detained her, on several occasions in the past. Her typical presentation was to become hypomanic, with grandiose ideas, and would spend money on irrational things.

Her long suffering husband called us, to let us know that she had “gone off” again. I went out to conduct an initial assessment with Dave, her community nurse.

Her husband met us at the door. He was a lot older that Florence, and the strain was telling on him.

“She’s bought a first class one way ticket to the US,” he said in despair. “She going to see the President to give him some advice.”

We found her in the sitting room, drinking a tumbler of sherry and watching a pornographic video on the TV.

We politely asked her to turn the TV off.

“It’s just getting to the good bit,” she said, taking a large swig from her glass.

We eventually persuaded her to turn off the TV. She abruptly got up and wandered off into the kitchen. We followed her there.

She was quite plainly unwell, and her husband was unable to keep up with her.

We tried to talk to her to assess quite how unwell she was, but she kept jumping from one random topic to another.

I suddenly caught a glimpse of something peering out from the side of their fridge. Curious, I pulled the fridge out to be confronted with a fairly large furry animal, which looked up at me with appealing eyes.

“What is this, Florence?” I asked her.

“That’s my new chinchilla,” she said. “I got it yesterday. I was wondering where it was. I’m planning to start a chinchilla farm.”

On this occasion, we managed to persuade her that it would be a good idea to go to hospital. This time, Dave drove, while I sat in the back with Florence.

Florence seemed to take a liking to me. She took off her shoes and put her legs on my lap. Then she began to sing.

“Somewhere, over the rainbow, skies are blue...”

She continued to sing a medley of songs from 30’s and 40’s movies.

I decided to humour her with a rendition of my own. This was a mistake.

“You must remember this, a kiss is just a kiss –“

Florence looked at me with sudden affection.

Very well, my dear,” she interrupted, licking her lips, and without warning lunged forward and planted her moist lips firmly on mine, attempting to thrust her tongue down my throat at the same time.

“Need any help in the back there?” Dave enquired, seeing a commotion in his rear view mirror.

But I was not at that moment able to reply.

Anorexia and the Interface Between the Mental Health Act & the Mental Capacity Act

 

There is a growing body of case law relating to the treatment of patients with severe anorexia nervosa. I have looked at several of these on my blog. They include the case of E, the case of X, the case of W, and the case of Z.

While all have been heard in the Court of Protection, and all involve issues relating to capacity to make decisions about treatment, they also illustrate the extent to which the Mental Health Act and the Mental Capacity Act intersect. They highlight the limitations the Mental Health Act may have when dealing with very complex and often intractable mental disorders like anorexia nervosa.

Z is a 46 year old woman. She had had anorexia nervosa since the age of 15 years. The Judge notes: “despite the fact that she has been admitted to hospital on innumerable occasions and received many different treatments, outpatient support and therapeutic input, it is impossible to identify any time in her history where Z has made anything which could be characterised as a sustainable recovery in terms of her weight gain.”

Her physical health has suffered, to the extent that she has osteoporosis “to such a severe degree that her entire skeleton is compromised in a way that would otherwise only be seen in the very elderly”. In October 2016, her Body Mass Index was 9.6 (normal is between 19-25), and in November 2016 she was detained under Sec.3 MHA.

The Trust bringing the case sought a declaration that Z lacked the capacity to make decisions about her care and treatment. This was given in the middle of December 2016, and the Judge concluded that there were three options open to the treating team. These were:

“to continue treatment under section 3 of the Mental Health Act 1983 which would involve detention in hospital and naso-gastric feeding under physical restraint until Z’s weight and physical health improved to the point where it would be possible to discharge her.”

“continuation of feeding, again under section 3 of the Mental Health Act 1983, involving detention in hospital, but the feeding to take place under chemical sedation”

“to be discharged from the framework of the Mental Health Act 1983 and treated, if she is prepared to engage at all, only on a voluntary basis.”

The Judge concluded that the third option should be followed, and that Z would therefore be discharged from detention under Sec.3 MHA and would return to live with her parents.

He noted: “Accordingly, the declarations and orders I make are pursuant to the Mental Capacity Act 2005.  That said, I consider that given this application is heard in the Court of Protection, sitting in the High Court, I would have had the scope to make the declarations under the Inherent Jurisdiction.”

In the other three cases, E, X & W, the Judges reached the same conclusion in the cases of X and W, which was essentially for there to be no forced treatment. Only in the case of E did the Judge advocate continued treatment, and I have heard that treatment did indeed continue for E under s.3 of the Mental Health Act.

So, out of four cases of women with severe anorexia nervosa (and often with complicating conditions such as alcohol dependency and emotionally unstable personality disorder) three were essentially allowed to die. All the cases were deemed to lack the capacity to make decisions about their treatment, and it was concluded that these decisions were in their best interests.

What do these cases have to say about anorexia nervosa, and about the Mental Health Act?

Anorexia nervosa is an insidious and pernicious disorder. It is notoriously hard to treat. Mortality is high, whatever treatment is offered. For patients with anorexia serious enough to require inpatient treatment, less than half experience remission of symptoms after 12 years.

When patients lose weight to the extent that their life is endangered, treatment has to consist initially of ensuring that they gain weight and receive adequate nutrition. This often has to take the form of nasogastric feeding, in other words, inserting nutrition directly into the stomach using a tube. This is an exceptionally intrusive process, and often restraint of various forms has to be used. This is difficult and distressing not just for the patient, but for the doctors and nurses having to administer the treatment.

If the patient refuses to accept lifesaving treatment, the Mental Health Act (Sec.3, for treatment) may have to be used.

In the longer term, talking treatments, such as cognitive behavioural therapy and cognitive analytic therapy, have the best outcomes. But these therapies can only be given with the consent and cooperation of the patient, and when they are in a reasonable state of physical health.

The Judge in the case of Z stated that “decisions of this nature impose  a very considerable intellectual and emotional burden on all those involved.” The majority of the decisions in these cases recognised that the clinicians involved with these women had reached a point at which the risks of continuing treatment were not only outweighing the risks of ceasing treatment, but were also causing unjustifiable distress to the patients and their relatives.

I am aware of little equivalent case law relating to other psychiatric disorders. I can only think of the case of C in 2015, a woman diagnosed with narcissistic personality disorder who did not wish to continue treatment for the effects of a serious overdose because she had “lost her sparkle”. There was considerable publicity about this case at the time.

It appears that anorexia nervosa is almost unique in producing case law relating to the ending of treatment for the effects of mental disorder. These judgments seem to suggest that there are times when the Mental Health Act should not be used indiscriminately to preserve and prolong life, that when all possible treatments for a mental disorder are exhausted, at least when it comes to anorexia nervosa, such patients should be allowed to die. The treatment becomes worse than the condition, the treatment becomes oppressive and disproportionate, and in breach of the patient’s human rights.

AMHP’s will undoubtedly continue to be asked to make applications for treatment under the MHA for people with anorexia nervosa, but it is important to weigh up the likelihood that proposed treatment is likely to have the desired effect, and will not merely serve to prolong the patient’s suffering and possibly be in breach of the Human Rights Act.

AMHPs will have to continue to be mindful of the psychiatric opinions informing their decisions. But it may be that referral to the Court of Protection for opinions relating to ongoing invasive treatment should sometimes be considered in preference to the Mental Health Act.

Either way, these are not easy decisions to make.

Personality Disorder, Capacity and the Mental Health Act

 

On 28th May 2019 an inquest in Cornwall reported on the sad case of 23 year old Amy Morby, who died as a result of an overdose.

She had received treatment at the Emergency Department in Truro three times in 4 days in September 2018. A week later she died of a fourth overdose.

The inquest reported that she was a patient of the local CMHT, and had also been assessed by the hospital psychiatric liaison team. The hospital assessor stated that Amy was treated at Treliske’s emergency department following deliberate overdoses on five occasions during 2018, including three times between September 2 and 6, just a week before she died.

He said that: “She was not acutely mentally ill. Amy’s problems were psycho-social stresses. Life was hard and she was going through a difficult time.”

The manager of the Community Mental Health Team said the team were shocked by her death as they did not consider the overdoses on September 2, 4 and 6 were actual suicide attempts. It was concluded that Amy was probably suffering from a borderline personality disorder.

There is, unfortunately, nothing out of the ordinary in this narrative. Many people suffering from a wide range of mental health problems make attempts to end their lives, and some are successful. Mental Health Services do try to help people at risk of suicide, but it is not always possible to achieve this.

Also unfortunately, identifying that a patient has a “personality disorder”, in particular, an emotionally unstable or borderline personality disorder, is often used as an excuse not only not to compel treatment, but also to decline to offer treatment.

However, there was one sentence in this report that particularly struck me:

“The inquest heard that Amy couldn’t be sectioned under the Mental Health Act as she had full capacity and wanted to continue working with the mental health team.”

It is not reported who said this in the inquest, but I know that many AMHPs would disagree.

For a start, I am reminded of the case of Kerry Wooltorton, who I have written about several occasions on my blog. She was allowed to die in hospital after drinking antifreeze, on the basis that she had made an advance decision to refuse treatment. The coroner in her case stated: “Kerrie had capacity and she could not therefore be treated”.

As I have said before, it is not uncommon to assess someone under the MHA who is either seriously planning suicide, or has taken an overdose of a noxious substance and is refusing treatment.

Capacity is not an essential factor in these assessments. Nowhere in the MHA is capacity mentioned in this context. The requirement is for someone to have a mental disorder within the meaning of the Act (which is very broad), and to be in need of assessment and/or treatment.

Detention under either s.2 or s.3 MHA would then provide a legal framework to provide assessment and, if necessary, treatment against the will of the patient.

This is not to suggest that mental capacity has no part in decision making about use of the MHA. Indeed, there is an interface between the Mental Health Act, which is about mental disorder, and the Mental Capacity Act, which is all about mental capacity.

This is reinforced by a considerable quantity of case law, including AM v SLAM, and Cheshire West.

The case law makes a distinction between objecting and non-objecting patients, and capacitous and non-capacitous patients. A non-objecting, capacitous person can be treated in hospital for mental disorder without recourse to the MHA. But both an objecting capacitous person and an objecting non-capacitous person may be detained for assessment and treatment under the MHA, and in many situations should be, if it is the only means by which they can receive the assessment and treatment they require.

Whether deemed to be capacitous or not, Amy Morby could have been made subject to a section of the MHA. The decision should perhaps have been allowed to have been made by an AMHP and 2 psychiatrists.