I was on AMHP duty recently when I received a request for
an urgent assessment under the Mental Health Act. It had come from the local
criminal justice liaison nurse, who was ringing from the patient’s flat.
This in itself was very unusual. Criminal justice liaison
nurses usually only assess people who are in police custody or in court.
The circumstances were as follows. Every year, the local
housing association has to make a gas safety check of all their properties. One
particular tenant, a man in his late 60’s who lived in a ground floor flat, had
ignored all their letters and calls, and was refusing entry.
Eventually the housing association had obtained a warrant
from a magistrate to enter the premises in order to check the gas supply. Two
officials from the housing association had then attended the man’s flat with
police officers, a locksmith and a gas engineer.
Despite the police attempting to gain entry without
force, the tenant refused to open the door. At this point, the locksmith was employed
to drill the lock and entry was then obtained. The tenant objected strenuously
to what was happening, and the police, noticing a knife on a table near to the
tenant, and fearing an incident, had then restrained and handcuffed him.
The behaviour of the person, and the condition of the
property, gave the police cause to believe that he might be mentally
disordered, and they then asked the liaison nurse to assess, which he did. As
he thought that the person was acutely psychotic, and needed to be assessed
with a view to admission to hospital for assessment, he contacted me.
There was indeed a degree of urgency. There were four
police at the flat, the man was being held in handcuffs, and something needed
to be done as soon as possible to resolve the situation one way or another.
I managed to obtain some background information on the
patient from case records before I took any further action.
He was called Alfred and was 69 years old. He was a
highly educated man, who had graduated with a first in English from Cambridge
University in the 1960’s, and had gone on to teach English literature in a
private school for a number of years.
Sometime in the 1980’s he had been admitted to
psychiatric hospital under Sec.2 and had remained in hospital under Sec.3 MHA
for several months. He had received a diagnosis of paranoid schizophrenia.
He never returned to work, and indeed disappeared from
view for over a decade, when he was found by police sleeping rough, and was
detained under Sec.136. He had again ended up in hospital under Sec.3, and was
discharged to the housing association flat in around 2000, at which point he
was receiving a regular antipsychotic depot injection. The records showed that
after about 5 years it was decided to reduce and then withdraw the depot, and
he was eventually discharged from Sec.117 aftercare and from secondary mental
health services.
So although he had a long history of psychiatric
disorder, he had not had any involvement with mental health services for nearly
10 years.
I quickly managed to obtain two Sec.12 doctors and within
two hours of receiving the call we were all at the flat.
We were told by the housing association staff and the
police that Alfred had been expressing extreme racist views about both the
police and the housing association staff. He had used a range of racially
abusive epithets, which was in itself slightly odd, as all the police and the
staff were white British, as was Alfred.
We were told that Alfred appeared to be paranoid about
infiltration and contamination. He had screwed closed the gas meter box, had
sealed all the ventilation ducts in the flat, and had placed wooden shutters
over the inside of the windows.
We went into the hallway of the flat. The flat itself was
crammed with cardboard boxes. The living room was lined to the ceiling with
bulging cardboard boxes, leaving little room for the dilapidated armchair and a
coffee table. The bedroom was so full of boxes that there was only room for his
single bed.
One of the police ushered me into his kitchen.
“Look at this,” he said, kneeling down and shining his
torch through the glass door of Alfred’s washing machine. The washing machine
was half full of water. Floating in the water were several large, dead fish.
They looked like mackerel, or possibly herring. This added to the overall sense
of unreality.
Alfred himself was sitting on the bed. He was in
handcuffs, and a police officer was crouching in front of him clutching the
handcuffs to prevent him from struggling. There was not enough room for the
doctors and I to enter the bedroom, and we therefore had to attempt to
interview him from the hallway.
It all felt very unsatisfactory. I was not sure this
constituted assessing “in a suitable manner”. I did not feel in control of the
situation.
Alfred unsurprisingly did not cooperate with the
assessment. He harangued and swore at us, accusing us of being part of a
conspiracy by the Muslims to convert him to Islam so that he could be used as a
suicide bomber. He did not believe we were police, or doctors, or an AMHP.
Instead, he appeared to be convinced that we were spies, intent on stealing his
home and shipping him off to Syria through extraordinary rendition.
He was not making much sense.
The doctors and I, despite our disquiet at the
circumstances of the assessment, concluded that Alfred had had a relapse of his
paranoid schizophrenia, and was acutely unwell, and that he needed to be
admitted to hospital for assessment of his mental state. The doctors gave me a joint
medical recommendation for Sec.2 MHA.
At that point, things started to get worse.
In an ideal world, I would have completed an application
for detention under Sec.2, the police would have accompanied Alfred to
hospital, and Alfred’s flat could have been made secure.
But we are not in an ideal world, dear reader.
I rang the bed manager, who told me that there were no
beds anywhere in the Trust. They would look elsewhere in the country, but it
was going to take time, and it would probably be in a private hospital. And
they would require me to fax through to them a full risk assessment, because
private hospitals would not consider anyone without a full risk assessment. The
bed managers appeared to be oblivious to the difficult and untenable situation,
and the pressing need in the circumstances for the patient to be taken to a
hospital.
I explained this to the police. They said they would stay
there for now, but they were obviously unhappy that the patient was in
handcuffs. But then they had taken that action in the first place, and had then
called me.
So I went back to the AMHP office to write a risk
assessment.
And had some space to think about the full implications
of the whole thing.
And started to worry.
In the heat of the moment, and at the behest of the
police and the forensic liaison nurse, I had gone out to assess someone in
their own home without fully considering the legal status of the request.
The warrant the housing association had obtained was
under Sec.2 of the Environmental Protection Act 1990. This is specifically for
the purpose of servicing or maintaining a gas appliance. Did that give me the
power to enter his flat in order to assess him under the Mental Health Act,
even at the request of the police? I wasn’t at all sure that it did.
And now I had assessed him, I was powerless to make it
even a little bit legal by completing an application and therefore making him
“liable to be detained”. This would have then given the police, or an ambulance
crew, the power to convey him to a hospital.
In the meantime, Alfred couldn’t be detained under
Sec.136 and taken to the Sec.136 suite until a bed was available for two
reasons: firstly, he was not in “a place to which the public have access”, as
he was most definitely in his own home; and secondly, as the purpose of
detention under Sec.136 is for a patient to be assessed for possible detention
under the MHA, since he had already been assessed, it would be an abuse of the
Act.
He couldn’t be arrested, and then taken to a place of
safety, as according to the police, he had not actually committed an offence.
So currently there were no legal powers for the police to
keep Alfred in handcuffs, or indeed to remain in his property without his
consent.
I rang the duty sergeant and discussed this with her.
Since there was no immediate prospect of a bed being available, enabling me to
complete an application for his detention, I advised that the police would have
no option but to leave Alfred’s flat immediately.
The following day, I was notified that a bed was
available. The good news was that it was in a local hospital. It meant that I
could complete my Sec.2 application form and render Alfred at last “liable to
be detained”.
However, since it was extremely unlikely that Alfred
would permit anyone to enter his flat in order to take him to hospital, I would
have to obtain a warrant under Sec.135(2), giving the police the power to enter
his flat in order to “take or retake” a patient liable to be detained under the
MHA.
But at least that would be legal.
