Green Lycra and Fairy Wings: Arrested for attempted murder, is Stella mad, bad – or completely innocent?

 

I was at the CMHT when I got a call from the Criminal Justice Liaison Nurse. He had been asked to see Stella, a 62 year old woman in the local Police Station, who was under arrest on suspicion of attempted murder.

 “I’ve just seen her,” he said. “She gives long rambling answers to even the simplest questions. I asked her about her next of kin, and she said: ‘I usually I do everything in 12’s and 24’s because I used to be a Playboy Bunny’. She isn’t making any sense. She’s not fit to be interviewed. She needs an assessment under the Mental Health Act.”

Stella had called for an ambulance late the previous evening. When it arrived they found her husband with a kitchen knife sticking out of his ribs. The police were called and arrested her. Her husband was now in intensive care.

I went with our local psychiatrist and a s.12 doctor. Stella had no psychiatric history, so we had very little information to go on. The only thing I’d been able to find out was that her husband had spent a brief time in a psychiatric unit over ten years ago being treated for “alcoholic hallucinosis” – vivid and often frightening hallucinations resulting from acute alcohol withdrawal.

The custody officer told us that when the police had attended, they found a man with a knife embedded in his chest, and with only one other person in the house they reached the conclusion that the uninjured person had inflicted the wound on the injured person, and had therefore arrested Stella. The police do have suspicious minds.

“The reports we’ve had from the hospital so far suggest that the husband is mentally ill himself. He says there are people hiding under his bed who want to kill him. He says he stuck the knife into himself. They think he’s psychotic. They’re arranging for him to have a mental health assessment as well,” the custody officer told us. “And we’ve had reports from the officers investigating the incident that indicate Stella’s known in the area for being ‘different’ to say the least.”

Stella was a slight woman, conservatively and appropriately dressed, with evidence of good self care. She seemed intelligent and articulate. She maintained good eye contact with us throughout and cooperated with the interview.

I began by explaining to her why we were there, then I asked her to tell us what had happened the previous evening.

She proceeded to tell us at great length everything she had done, giving us a minute by minute account of the entire evening. We were quite keen for her to tell us how her husband had come to have a knife in his abdomen, but she could not be diverted from answering the question in as much detail as possible.

She’d gone out on her bike to the supermarket and had then visited a friend. She gave us more details than we wanted of what they had said to each other and how many cups of tea she had drunk. She’d eventually returned to the house at 10.00 pm. She said she felt there was something wrong, as her husband seemed to be staring at something in the corner of the room and was mumbling as if talking to someone. To snap him out of it, she suggested they have a cup of tea, and he had then gone into the kitchen.

When here husband hadn’t returned, she went into the kitchen. She saw blood on the floor and found her husband collapsed in the corner with a knife in his chest. She then rang for an ambulance.

Throughout our interview, Stella appeared lucid and coherent. There was no evidence of being under the influence of alcohol or drugs. She was fully orientated. There was no evidence of dementia, or emotional lability or abnormal mood. In fact, there was no evidence at all of any mental disorder.

The only thing of note was that she seemed somewhat detached, with little evidence of emotional distress at either the situation she was currently in, or of the events that had led up to her arrest for attempted murder. But this was not sufficient to cause us undue concern.

“The person who spoke to you earlier said something about you ‘thinking in 12’s and 24’s’. Could you tell us a bit more about that?” I asked her. On the face of it, this seemed at the very least an unusual, if not irrational, comment to make.

She explained that when she was in her 20’s she had trained as a Playboy bunny. This mainly entailed learning how to work in a casino, including operating the blackjack and roulette tables. This, she told me, required an ability to calculate quickly in multiples of 12. A rational enough explanation.

The two doctors and I had a discussion. We concluded that, whatever may have occurred that night, Stella was not suffering from a mental disorder of a nature or degree sufficient to warrant detention in hospital under the Mental Health Act.

I told the custody officer it was our view that Stella was fit to be interviewed. The custody officer gave us a look.

“You’re sure about that, are you?” he said. “Perhaps you’d better have a word with the officer dealing with the case.”

He called in the detective sergeant.

“We’ve spoken to the neighbours,” she told us. “Stella’s known locally as ‘Psychedelic Stella’. One of the neighbours told me she’d known her for 10 years and had ‘never had a sensible conversation with her’. They told us she was ‘not on the planet’. They’ve said she often rides round on her bike wearing ‘green lycra and fairy wings’. You should see the house and front garden. There’s rubbish and junk everywhere. You can hardly get to the front door.”

Even if Stella did indeed ride her bike dressed in green lycra and fairy wings, it still didn’t justify detaining her under the Mental Health Act. I saw no reason why this should influence our decision.

“But what if we have to bail her?” the detective sergeant asked.

“Then she’ll go home,” I answered. “At the present time both her account and that of her husband seem to corroborate each other. Of course, if there is evidence that she was the perpetrator and he was just covering up for her, then a further psychiatric assessment might be appropriate.”

The custody officer and the detective sergeant didn’t seem that impressed with our conclusion. But that was no reason to change our minds.

The next day I contacted the medical ward where Stella’s husband was being treated. He had been fortunate. He had missed damaging any internal organs. He had had a psychiatric assessment and had been given medication to help with acute alcohol withdrawal; he had had alcoholic hallucinosis again.

I spoke to the detective sergeant who was satisfied the injury had been self inflicted.

I rang Stella to talk to her about the assessment and to see how she was. But she wasn’t terribly happy with me, and told me politely but firmly that she wanted nothing more to do with me

I couldn’t blame her, really.

MHA assessments can sometimes get seriously out of control!

 

During the 1980’s and ‘90’s, as well as my day job as a social worker, I also did shifts on the out of hours service.

I was on duty one evening when I got a call from the police. They had detained a man under s.136 – this is when a police officer who finds someone in a public place who “appears to him to be suffering from mental disorder and to be in immediate need of care or control” can “remove that person to a place of safety”. Nowadays there are specially designated places of safety on hospital sites where people can be taken, but back then a police station was the usual “place of safety”.

There was nothing at all known about Andrew except for his name, age (30) and address. The police had been called to an incident in the street outside his house. He had resisted all attempts to calm him down, and then became violent to the police who had attended. The police had found his house in a squalid condition, floors covered with dog faeces and rotting food in the kitchen. His electricity had been disconnected long ago. He had a rather neglected looking dog which was taken to a boarding kennel. There was no record of any previous psychiatric involvement, and he did not even seem to be registered with a GP.

I assessed him with two doctors. As we approached his cell, he could be heard talking to himself and making odd noises. He abruptly stopped as we entered and looked at us with some hostility.

Andrew was unable to concentrate on what we were saying and would not give us any information about his home circumstances, relatives or friends. He stared straight ahead most of the time, and after a while he began pacing the cell and breathing increasingly heavily, forcing the breath in and out through his clenched teeth until he began to foam at the mouth. This was disturbing.

We reached a tentative conclusion that he was experiencing a hypomanic episode. The state of his house seemed to indicate that his mental health had been deteriorating for some time. It was possible that this was a drug induced psychosis, but he had vehemently denied illegal drug use when asked. Either way, he needed further assessment and was in no state to give informed consent to this, so we completed an application under s.2.

I informed Andrew of the decision and explained to him that he would be taken to hospital by ambulance. His demeanour changed, he seemed quite happy about this, and followed us out of the cell and strolled down the corridor flanked by two police officers.

That’s when it all started to unravel.

I left the police station to get to my car, which was parked outside the police compound. I watched as an ambulance backed up to the rear entrance, from where Andrew and the two officers were emerging. I watched as one of the ambulance crew got out and opened the ambulance doors, and then stood there under the harsh sodium lights, waiting for the group to approach.

Then things suddenly seemed to go into slow motion. Andrew suddenly broke free from the police officers and lunged forward. The ambulance man folded up as Andrew’s head connected with his stomach and the two disappeared into the ambulance. The police officers dived into the ambulance after them. The ambulance began to shake violently and two other police officers dived in. Then the ambulance doors were suddenly closed from inside, the blue lights started to flash, and the ambulance sped off to the hospital.

This broke me out of my stunned state. I quickly got into my car and followed the ambulance to the hospital, where it parked right outside the admission ward. One of the police officers opened the ambulance doors and went to the ward. He returned with two male nurses and the duty doctor. Even though Andrew was being restrained by three police officers, he was still struggling, causing the ambulance to shake constantly. The nurses restrained him some more, while the doctor administered an injection of IM Haloperidol, of a dose designed to rapidly sedate him.

Andrew continued to struggle, hissing and panting through his teeth all the while, flecks of foam landing on the arm of the officer closest to his head. I saw that somewhere along the way he had incurred a head injury, and blood was oozing down his face. The officer nearest him also had a cut over his eye, which was also bleeding. There seemed to be quite a bit of blood in the ambulance.

After 15 minutes, the doctor decided that the injection should have taken effect and they attempted to try and transfer him into the ward. But as they momentarily adjusted their grip on him, he took the opportunity to make a break for it, and very nearly got away.

It took another injection and another 20 minutes of relentless restraint before he was sufficiently sedated to be transferred safely into the ward.

The little girl with the rat on her shoulder: a case study of Lewy Body Dementia

 

Certain forms of dementia, such as Lewy Body Dementia, can produce the most vivid and outlandish of hallucinations in older people. One man I had to assess was troubled because “there are 3,474,263 people in my room, and they won’t go away.” 

Another elderly man I assessed had pulled up his fitted carpet and piled all his furniture in the corner of the room. When I asked him why he had done this he told me: “there’s lots of calves coming out of the floor and I’m trying to find out where they’re coming from.” He also told me there were a pair of dogs with a litter of pups in the corner, and he would not go into his bedroom because “the ceiling’s covered with thousands of spiders.”

Ethel was a lady in her 80’s with Lewy body dementia. She lived alone, with help from a caring neighbour and some input from home carers. She started to ring the police on a daily basis because “This bloke is there with his 6 dogs in my back garden, and his whole family… He lives in the garden now – I can’t sleep because I don’t know what he’ll be up to next.”

When I first assessed her under the Mental Health Act, she was unshakeable in her belief that this man existed. She could see him with her own eyes. He took out his duvet every evening and slept on her garden bench. On that occasion she spent a month in hospital detained under s.2, and on discharge agreed to take medication and accept a package of home care -- although she was still convinced that there was a man living in her garden.

A few months after discharge I was again asked to assess her. The man in the garden was causing her more problems, to the extent that she had started to ring the police again and was going out at night to try and sort him out. He had now been joined by a little girl, who had a rat on her shoulder and had stolen her door key and would get into her house at night and steal her crisps.

I went round with Ethel’s psychiatrist, her GP and her psychiatric nurse. She readily let us in, and equally readily told us all about the man, his dogs and the little girl with a rat on her shoulder.  The man was “getting on her nerves.”

Although it was clear that Ethel was hallucinating (I did check her back garden just to be sure, and although I could see no-one, she could see him “as clear as day”), the existence of symptoms of mental disorder is of course not enough on its own to justify detention under the Mental Health Act. There has to be evidence of risk to the patient and/or others, as well as evidence that alternatives to hospital admission had been tried and failed.

In Ethel’s case, she was taking medication, since carers were coming in daily and making sure she took it. However, the medication was clearly not making the slightest difference to her mental state.

The appropriateness or otherwise of detention rested on risk to herself or others. While there was no risk to others by her behaviour (apart from irritation of the police), she was at risk by wandering about at night in search of phantoms, and even more importantly, was at risk of self neglect.

It became clear on assessment that Ethel was not drinking enough fluids, and was not eating adequately. She was very thin and looked physically unwell. There was a stone cold cup of coffee on her coffee table which she claimed she had only just made. She told us she had had “a steak and kidney pie and chips – and a sandwich” that day. However, there was no evidence of cooking in her kitchen, which was spotlessly clean, and there was no food waste or wrappers in her bin. There was hardly anything in her fridge except for half a dozen eggs whose use by date had passed over 6 months previously. There were few tins in her cupboard, and most of these had use by dates several years in the past. Nevertheless, she continued to maintain that she was eating heartily.

In the circumstances, we concluded that she did indeed need to be admitted to hospital for treatment. In view of her recent history, knowing her diagnosis and need for treatment, this time we decided to go for a s.3 for admission for treatment.

“I wouldn’t have told you about that man, and the little girl with the rat, if I’d known you would do that,” she said when I told her.

She complained of chest pains on the way to hospital. I began to feel uneasy – it doesn’t look good if your patient dies before you get them to hospital – but her nurse examined her and reassured her that it was indigestion.

“But I haven’t had anything to eat today,” she said.

ECT and the Mental Health Act

Electroconvulsive Therapy was first introduced as a treatment for mental illness in 1938. Today, its main use is in severe treatment resistant depression, as well as in catatonia and the depressive phases of bipolar affective disorder.

The most recent statistics for the UK indicate that over 1,800 patients received courses of ECT during the year 2021. The average number of treatments per course was around 10.

The perception of ECT as a treatment was not helped by its depiction in the Jack Nicholson film One Flew Over The Cuckoo’s Nest, but in reality it is a lot safer than most antidepressant medication.

The mortality rate for ECT treatment is 0.002% that is, the chances of dying as a direct result of receiving ECT are only 1 in 100,000. When compared to the suicide risk for people with severe depression, that seems like good odds, if it works. ECT even compares well to mortality rates for antidepressant medication.

In the past, patients were given vast amounts of ECT. I once worked with a woman with a very long history of bipolar affective disorder, who was incarcerated in an old-style asylum for 10 years during the 1960’s. She reports that she received several hundred ECT treatments, and I have no reason to doubt her. However, according to the most recent figures, the average number of treatments per course is only 10.

Because of its controversial nature, the whole issue of ECT has a special place in the Mental Health Act. One of the amendments to the Act in 2007 was the addition of s.58A. This section applies to detained patients and to all patients aged under 18, whether or not they are detained. ECT cannot be given to a detained patient unless they consent and are deemed to have the capacity to consent. Equally importantly, ECT cannot be given to a patient lacking in capacity who has made a valid advance decision to refuse ECT.

There are, however, still circumstances in which patients can receive ECT even though they lack the capacity to consent, or when they do have capacity and have refused. This is where a SOAD (a Second Opinion Approved Doctor)  certifies that the patient lacks capacity to consent and  considers that the treatment is appropriate, there is no advance decision refusing treatment, no one with power of attorney objects, and there is no conflict with any Court of Protection decisions.

This means that ECT can only be given if an independent, specially approved psychiatrist has looked at the individual’s case and has authorised it.

In the case of a person who does have capacity, but has refused to have this treatment, the only circumstances in which ECT can still be given are when treatment with ECT is immediately necessary to save the patient’s life, or will prevent a serious deterioration of their condition or will alleviate serious suffering by the patient”, or will prevent the patient from behaving violently or being a danger to himself or to others.

Important Note: If you are a service user (or potential service user) who objects to the idea of ECT, but thinks it’s possible you might be given ECT at some future time, it is important to make an advance decision now (under the Mental Capacity Act) stating clearly what your wishes for treatment are. Ideally, you should get a solicitor to draw up this document to ensure that it is legally sound.

There are two main situations in which the issue of ECT is likely to arise in a professional context for AMHP’s.

The first is when an AMHP is asked to make an application under Sec.3 for treatment for the specific purpose of giving them emergency ECT. This can present an AMHP with a dilemma: should the MHA be used to compel a treatment which the Act itself regards as being of a different order from other treatments for mental illness, to the extent that it was amended specifically to reflect the unease with which many people regard ECT?

Whatever the personal view of an AMHP regarding the use of ECT, an AMHP must remember that their role is only to make a decision regarding whether, in all the circumstances of the case, a person needs to be detained under the Act in order to receive treatment; it is not their role to decide what form that treatment should take.

The other occasion in which an AMHP may become involved is for consultation under Sec.58A(6). The SOAD, before certifying that a patient should have ECT but is lacking in capacity, must consult with two other professionals who have been involved with the patient’s treatment; while one of these has to be a nurse, the other must be “neither a nurse nor a registered medical practitioner”. An AMHP who has assessed the person could therefore be the second consultee.

For more information on ECT statistics, take a look at this excellent blog, the title of which says it all.

For a positive account of ECT, take a look at this Guardian article.