Harry is a man in his late 80’s. He is divorced and lives alone in his own home. He has a number of physical health problems associated with old age and is provided with a package of home care by the Older People’s Social Services Team.
He likes cats and encourages strays to enter his home, feeding these visitors and encouraging them to take up residence in his living room, which is also where he sleeps. The whole house is in a state of squalor and decay, with large piles of rubbish and possessions strewn throughout the house. It is virtually impossible to go upstairs. He likes to keep his house warm and has electric heaters on constantly. He has also invented a system of heating his kitchen by piling firebricks onto the hotplate of his gas cooker.
The carers, who shop for him and ensure he takes his medication, are becoming increasingly reluctant to enter the house because they believe that it is infested with rats. Carers have complained that rats “the size of cats” have been seen cavorting on his bed. The local Environmental Health Officer has been contacted. The support plan is at risk of collapse.
Things get even worse. Some clothing that he had hung too close to his heater catches fire and the fire brigade are called. He begins to ring the out of hours social services number with unreasonable demands, and is abusive to the people taking his calls.
The local psychogeriatrician is asked to make an assessment. She visits him at home with Harry’s social worker and concludes that it is difficult to make a thorough assessment in the conditions, but thinks he probably has “mild vascular dementia.” Further assessment cannot be made without an admission to a psychiatric ward. Harry will not agree to an informal admission and gives a graphic description of what will happen to anyone who tries to make him go to hospital.
I am asked to assess Harry. I speak to the psychogeriatrician, who has visited Harry a couple of times. She is herself in two minds about whether or not Harry is detainable, but on balance decides that an admission for assessment would be appropriate and provides me with a medical recommendation.
I spend the morning gathering information from the social worker, social services files, and the nearest relative, a son who lives out of the area. He tells me that his father has always been a difficult man, who was physically abusive to him as a child and made his mother’s life a misery. He rings him at least once a week and visits him occasionally. He says that his father’s house has been deteriorating for at least 15 years, ever since his mother finally left him. He’s a stubborn man, he says. You will have difficulty persuading him to do anything he doesn’t want to do.
I arrange to visit with the social worker and Harry’s GP. The two GP practices in the town take turns to have him on their books, because he is such a difficult patient. Based on the evidence, I am already leaning towards a decision to detain for assessment.
The house is exactly as described. We enter his living room, where he spends nearly all his time. Cats rummage through the heaps of rubbish.
Harry is sitting on his bed, dressed in rags, with a straggly beard. He is watching television. He welcomes us when we enter, and I introduce myself. I ask him some basic questions designed to check out the degree of dementia. He had watched the England World Cup qualifying match the previous evening, and could tell me not only the final score, but also the half-time score and even who scored the goals. When I discussed in more detail the purpose of our visit, he becomes more hostile, and asks us to leave.
The GP the social worker and I huddle in his kitchen. It’s a difficult decision to make, in view of the pressure to admit, and the real concerns about Harry’s safety. The trouble is, I can find no evidence of dementia or any other mental disorder. The GP agrees with me. On this basis, I can’t justify detention in hospital.
Harry is not happy we are talking about him. He insists that we leave, shouting and repeating this in my face. He won’t let me tell him what our conclusions are and bundles us out of his house.
Some sixth sense tells me his social worker isn’t happy with the outcome. On the pavement outside, I discuss the reasons for my decision with him.
Social workers often find themselves dealing with people whose behaviour is eccentric and considered unacceptable by their community, people who, although no danger to others, appear to live in situations of permanent risk, and have lifestyles others find unacceptable or repugnant. It’s often the task of social workers to enable such people to continue to live as safely as possible, to maintain them in the community in the way they would like to live. It is only appropriate to consider compulsion if it can be established that they do not have the mental capacity to make choices about how they live. One of the basic tenets of the Mental Capacity Act is that people have the freedom to make unwise decisions.
Harry may or may not have Diogenes Syndrome: a description applied to people like Harry, who live in situations of domestic squalor, self neglect, social isolation and who tend to hoard rubbish. However, this is not a mental disorder in itself. Harry is clearly not a very nice man; but then he has always been a not very nice man, and this does not constitute a mental disorder either.
Things continue to deteriorate. The carers continue to complain about the rats. The social worker arranges for a visit with an environmental health officer.
Pressure mounts on me to revise my decision, so I attend a case discussion with the psychogeriatrician and the social worker. Mainly on the basis of the reports of rats and the risk to Harry’s health, I agree to another assessment.
The psychiatrist, the social worker and the GP gather on the pavement outside Harry’s house. The social worker visited Harry’s home with the Environmental Health Officer that morning, and tells us that the officer, who is an expert at detecting the presence of vermin, inspected the house from top to bottom, as well as searching the overgrown garden. He could find no evidence of rats – no rat runs, no droppings, no urine, no evidence of chewing – nothing.
This makes a significant difference. The carers have no reason to refuse to enter the premises. It reduces the risk factors. We decide to try to some changes to his medication to see if this reduces his agitation in the evenings. The social worker is resigned to trying to continue to maintain Harry in the community.
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