I last wrote about Harry in July 2009. Harry was an elderly man living alone in squalor, probably with Diogenes Syndrome, causing carers and other professionals (including the Fire Service) problems, whom on two occasions despite the risks I did not detain under the Mental Health Act. I concluded then that I had not heard the last of him, and I also speculated, tongue in cheek, that another AMHP might be asked to assess him.
Well, that’s exactly what happened. A couple of months later, while I was away on holiday, there was another request for a Mental Health Act assessment. This time, the AMHP concluded that it was appropriate for him to be detained under Sec.2 for assessment and he was admitted to the local psychogeriatric ward. I have no argument with that – AMHP’s act independently, and two AMHP’s may validly reach different conclusions from the same information. In any case, situations can change, risk factors may vary from day to day, and I am sure that the AMHP who detained him made the correct decision at that time.
A few weeks later I was asked to assess him again, this time for detention under Sec.3 for treatment. When I interviewed him in the hospital he was clearly in a much better physical condition than when I had seen him at home. He was clean, well groomed, had put on weight, and was obviously enjoying the comparatively salubrious environment of the hospital ward. But I had to decide whether, in all the circumstances of the case, it was most appropriate for him to be detained in hospital under the MHA.
There was some evidence of memory problem, he did not remember my visit to him a few months before, was vague about other facts, and he certainly did not regard his home conditions as in any way a problem. When I discussed the reason for my visit he became furious, swearing at me and threatening to harm me. But did this amount to anything significantly different from my previous assessment?
This time he did have a diagnosis of vascular dementia, so certainly had a mental disorder within the meaning of the Mental Health Act, but was it of a nature or degree to warrant his compulsory detention?
I thought long and hard about my decision. And in the end I applied for his detention under Sec.3 as requested.
I was covered legally. There were two medical recommendations. He had a mental disorder. But I still felt uneasy.
What swayed me in the end was the fact that circumstances had now irrevocably changed. My previous decision was about whether or not to remove him from his home. My decision now was about whether or not to allow him to return to his home. With this decision came even greater potential risk to Harry. He had already made it very clear to me that if he were not detained he would insist on going back to the squalor and fire hazard that was his house, and this time would probably be even more distrustful of authority that he had been before. His risks of being at home would be significantly greater now than they had been earlier. If he were ever to have a chance of surviving in a community setting, there would have to be considerable changes in his home circumstances.
And strangely enough, detention under Sec.3 could facilitate that, since any elements of his aftercare package would now have to be paid for by the local authority and/or the NHS. He would no longer be charged for home care, and indeed, any works to improve his home, through a major cleaning programme or even alterations to the house, could also be free of charge. He was wily enough to see that there could be advantages to his continued detention – although he would never admit it.
Thursday, 31 December 2009
Tuesday, 22 December 2009
Sectioned on Christmas Day
Back in the days when I used to do out of hours on call duties, Christmas Day was generally considered a good shift to have – you got double pay for the bank holiday, and no-one ever called Social Services on Christmas Day – Boxing Day, yes, New Year’s Day, yes, but never Christmas Day.
Unless someone had chosen that day to go mad.
It was a snowy evening, very festive. I had had my Christmas dinner, and was settling down in front of the TV, confident I would not get a call, when my home phone rang. Robert was a 30 year old man who lived alone. He had only a minimal history of mental illness. He had been referred to the CMHT a few months before after having had an odd transient psychotic episode following general anaesthetic for minor surgery. I had actually seen him on one occasion, and although I had found him a little odd, he had not displayed any overt symptoms of mental illness and had not been seen again.
His father, who lived in a village some miles from Robert, had decided to invite him for Christmas dinner. Since Robert did not have any transport, his father had picked him up and brought him to his house. His father had found him rather quiet and subdued, but Robert had been like this for some months, so he thought nothing of it.
But as the day progressed, Robert’s father became increasingly worried about him. He appeared very stiff, as if his muscles were seizing up, and had to be helped to the dining table. His father would try to engage him in conversation, and got the impression that Robert was trying to reply, but no words would emerge. Robert had sat motionless throughout the meal, staring at his plate, but had eaten nothing. After the meal, his father had been unable to persuade him to leave the table. He called the duty doctor, who gave him a physical examination and found nothing wrong with him, but was equally unable to persuade him to talk or move. He came to the conclusion that mental illness was the only explanation, and called us.
I managed to locate the duty psychiatrist, who was surprisingly easy to persuade to attend – perhaps he had had a fraught day with his family – and we arranged to meet the GP at the house.
Robert was still seated in the chair at the table. The table had been cleared, and he seemed to be staring intently at the table cloth.
“Hi, Robert,” I began, sitting down at the table with him. “Do you remember me?”
His eyes flickered, as if he were straining to move them in my direction, and eventually they moved enough so that he could see me. However, his neck and body stayed absolutely still. I could see his throat quivering, as if he were trying to speak, but the only sound that came out of his slightly open mouth was a low gurgle.
We asked him a number of questions, but during the 20 minutes or so of the interview the only words he managed to utter, and clearly with much effort, were: “My heart.”
It was impossible to make a further assessment. Our impression was that it was a classic case of catatonic schizophrenia, which can be characterised by a complete inability to move or speak. He clearly needed further assessment, was unable to give any indication of consent, and we concluded that he needed to be detained in hospital under Section 2 for assessment.
When the ambulance arrived, the crew had to physically lift him, still in a seated position, into the ambulance, and he remained in that position all the way to the hospital.
He did indeed have catatonic schizophrenia, and in fact I was called on a number of occasions in subsequent years to assess him, frequently with the same presentation. But never again on Christmas Day.
Festive postscript:
As I was collating the paperwork and writing up my assessment at the hospital, I suddenly noticed his date of birth. It was the 25th December.
Unless someone had chosen that day to go mad.
It was a snowy evening, very festive. I had had my Christmas dinner, and was settling down in front of the TV, confident I would not get a call, when my home phone rang. Robert was a 30 year old man who lived alone. He had only a minimal history of mental illness. He had been referred to the CMHT a few months before after having had an odd transient psychotic episode following general anaesthetic for minor surgery. I had actually seen him on one occasion, and although I had found him a little odd, he had not displayed any overt symptoms of mental illness and had not been seen again.
His father, who lived in a village some miles from Robert, had decided to invite him for Christmas dinner. Since Robert did not have any transport, his father had picked him up and brought him to his house. His father had found him rather quiet and subdued, but Robert had been like this for some months, so he thought nothing of it.
But as the day progressed, Robert’s father became increasingly worried about him. He appeared very stiff, as if his muscles were seizing up, and had to be helped to the dining table. His father would try to engage him in conversation, and got the impression that Robert was trying to reply, but no words would emerge. Robert had sat motionless throughout the meal, staring at his plate, but had eaten nothing. After the meal, his father had been unable to persuade him to leave the table. He called the duty doctor, who gave him a physical examination and found nothing wrong with him, but was equally unable to persuade him to talk or move. He came to the conclusion that mental illness was the only explanation, and called us.
I managed to locate the duty psychiatrist, who was surprisingly easy to persuade to attend – perhaps he had had a fraught day with his family – and we arranged to meet the GP at the house.
Robert was still seated in the chair at the table. The table had been cleared, and he seemed to be staring intently at the table cloth.
“Hi, Robert,” I began, sitting down at the table with him. “Do you remember me?”
His eyes flickered, as if he were straining to move them in my direction, and eventually they moved enough so that he could see me. However, his neck and body stayed absolutely still. I could see his throat quivering, as if he were trying to speak, but the only sound that came out of his slightly open mouth was a low gurgle.
We asked him a number of questions, but during the 20 minutes or so of the interview the only words he managed to utter, and clearly with much effort, were: “My heart.”
It was impossible to make a further assessment. Our impression was that it was a classic case of catatonic schizophrenia, which can be characterised by a complete inability to move or speak. He clearly needed further assessment, was unable to give any indication of consent, and we concluded that he needed to be detained in hospital under Section 2 for assessment.
When the ambulance arrived, the crew had to physically lift him, still in a seated position, into the ambulance, and he remained in that position all the way to the hospital.
He did indeed have catatonic schizophrenia, and in fact I was called on a number of occasions in subsequent years to assess him, frequently with the same presentation. But never again on Christmas Day.
Festive postscript:
As I was collating the paperwork and writing up my assessment at the hospital, I suddenly noticed his date of birth. It was the 25th December.
Sunday, 6 December 2009
Miranda
It was 4.30 on a Friday afternoon in November. It was raining outside. I was looking forward to the weekend. Then the phone rang.
Miranda was 71. She lived alone in her own bungalow. She had never been married. She had a long history of involvement with mental health services, and had been transferred to the older people’s mental health service when she became 65. She had a history of detention under the Mental Health Act, had had many admissions over the years, and had variously been diagnosed with psychosis and bipolar affective disorder. She was currently on an interesting combination of an antipsychotic, two mood stabilisers and an antidepressant. She had been seen a month ago by her consultant, who had suggested an admission to hospital, which she had politely declined. Earlier in the week she had been seen by a GP who had diagnosed a suspected urinary tract infection and had prescribed her an antibiotic.
Her community nurse had been to see her earlier in the afternoon. She had found Miranda working her way through a bottle of wine, writing a list of music she wanted playing at her funeral. She passed her a suicide note, and asked for her favourite GP to sign her death certificate after the weekend. She was not prepared to go into hospital.
I spoke to the duty GP, who had not seen her today, but was prepared to come out if required. I talked things over with her nurse, and we decided to visit her together so that I could make at least an initial assessment. The nurse had arranged for a bed to be available if needed.
We stood outside Miranda’s bungalow in the November rain, waiting for her to answer the door. She looked at us both, then let us in, seeming resigned to a visit from mental health professionals. She had finished the bottle of wine, and now had a glass of ginger wine in her hand. Although her bungalow was cluttered and somewhat neglected, she had a high quality sound system in her living room, with piles of classical CD’s covering most available surfaces. Bach’s Mass in B Minor, sung by the Sixteen, filled the room. Tears were flowing silently down her face.
She was still working on the list of music for her funeral. It was tasteful but melancholy music: Bach, Handel, Fouré, and some solemn, mournful medieval plainsong for the most part.
“Miranda,” I said gently, “What’s happened? Why are you feeling like this?”
She told me she had been feeling bad for a few days and that she did not know why. She could not think of any incident or trigger. She subscribed to a postal CD company, and had received the CD she was playing that morning. “When I have listened to it to the end, I will end my life,” she said slowly and with the exaggerated dignity that only the intoxicated can manage. Since it spread over two CD’s and lasted nearly two hours, I estimated that we had some breathing space at least.
Things were stacking up against her. As I had gone through the bungalow, I had noticed that her bed was piled high with junk, and had clearly not been slept in for some time. I went into the kitchen to talk to the nurse, and she showed me Miranda’s empty fridge. There was evidence that she was neglecting herself. The nurse told me that Miranda did not usually drink, so her drinking today was perhaps a symptom of her underlying mental condition rather than the cause. I was unhappy about the odd assortment of medication she was taking, and thought that a review of her medication would be a good idea. I was also mindful of the effect a urinary tract infection might be having on her mood and general mental state.
What was clear was that she did need to be in hospital for assessment and treatment, and for her own safety. It was too dangerous to leave her over the weekend. She seemed to have every intention of killing herself before the weekend was out. I was prepared to use compulsion if need be, but wanted her to have the opportunity to preserve her dignity.
“Miranda,” I said to her. “I think you need to go into hospital for a while. You know what my function is. You know I can detain you under the Mental Health Act if I need to. But I really don’t want to do that. You will have more control over your admission and stay if you go in voluntarily.”
“Can I take my music with me?” she asked.
The nurse nodded. “Yes you can. There won’t be any problem, if you have a portable CD player and headphones.”
Miranda looked into my eyes. Then she looked down.
“Very well,” she said.
Her community nurse and I helped her pack an overnight bag and we found a portable CD player. She got into the back of the car, with her nurse sitting next to her. Miranda seemed relieved, if anything. She talked about the music she loved and gradually her tears dried. We took her uneventfully to hospital.
Miranda was 71. She lived alone in her own bungalow. She had never been married. She had a long history of involvement with mental health services, and had been transferred to the older people’s mental health service when she became 65. She had a history of detention under the Mental Health Act, had had many admissions over the years, and had variously been diagnosed with psychosis and bipolar affective disorder. She was currently on an interesting combination of an antipsychotic, two mood stabilisers and an antidepressant. She had been seen a month ago by her consultant, who had suggested an admission to hospital, which she had politely declined. Earlier in the week she had been seen by a GP who had diagnosed a suspected urinary tract infection and had prescribed her an antibiotic.
Her community nurse had been to see her earlier in the afternoon. She had found Miranda working her way through a bottle of wine, writing a list of music she wanted playing at her funeral. She passed her a suicide note, and asked for her favourite GP to sign her death certificate after the weekend. She was not prepared to go into hospital.
I spoke to the duty GP, who had not seen her today, but was prepared to come out if required. I talked things over with her nurse, and we decided to visit her together so that I could make at least an initial assessment. The nurse had arranged for a bed to be available if needed.
We stood outside Miranda’s bungalow in the November rain, waiting for her to answer the door. She looked at us both, then let us in, seeming resigned to a visit from mental health professionals. She had finished the bottle of wine, and now had a glass of ginger wine in her hand. Although her bungalow was cluttered and somewhat neglected, she had a high quality sound system in her living room, with piles of classical CD’s covering most available surfaces. Bach’s Mass in B Minor, sung by the Sixteen, filled the room. Tears were flowing silently down her face.
She was still working on the list of music for her funeral. It was tasteful but melancholy music: Bach, Handel, Fouré, and some solemn, mournful medieval plainsong for the most part.
“Miranda,” I said gently, “What’s happened? Why are you feeling like this?”
She told me she had been feeling bad for a few days and that she did not know why. She could not think of any incident or trigger. She subscribed to a postal CD company, and had received the CD she was playing that morning. “When I have listened to it to the end, I will end my life,” she said slowly and with the exaggerated dignity that only the intoxicated can manage. Since it spread over two CD’s and lasted nearly two hours, I estimated that we had some breathing space at least.
Things were stacking up against her. As I had gone through the bungalow, I had noticed that her bed was piled high with junk, and had clearly not been slept in for some time. I went into the kitchen to talk to the nurse, and she showed me Miranda’s empty fridge. There was evidence that she was neglecting herself. The nurse told me that Miranda did not usually drink, so her drinking today was perhaps a symptom of her underlying mental condition rather than the cause. I was unhappy about the odd assortment of medication she was taking, and thought that a review of her medication would be a good idea. I was also mindful of the effect a urinary tract infection might be having on her mood and general mental state.
What was clear was that she did need to be in hospital for assessment and treatment, and for her own safety. It was too dangerous to leave her over the weekend. She seemed to have every intention of killing herself before the weekend was out. I was prepared to use compulsion if need be, but wanted her to have the opportunity to preserve her dignity.
“Miranda,” I said to her. “I think you need to go into hospital for a while. You know what my function is. You know I can detain you under the Mental Health Act if I need to. But I really don’t want to do that. You will have more control over your admission and stay if you go in voluntarily.”
“Can I take my music with me?” she asked.
The nurse nodded. “Yes you can. There won’t be any problem, if you have a portable CD player and headphones.”
Miranda looked into my eyes. Then she looked down.
“Very well,” she said.
Her community nurse and I helped her pack an overnight bag and we found a portable CD player. She got into the back of the car, with her nurse sitting next to her. Miranda seemed relieved, if anything. She talked about the music she loved and gradually her tears dried. We took her uneventfully to hospital.
Friday, 9 October 2009
Ones That Got Away Part II
Gerry was a 19 year old young man whose father was a banker. He had attended a private school and had done very well academically. He was in the middle of his gap year prior to commencing a degree in Art History at university when his behaviour became more and more erratic and grandiose. He used his new credit card to pay for the publication of a book of (truly awful) poetry from a vanity publisher, made plans to hire a recording studio and session musicians to record a rap album, and had announced to his parents that he no longer needed to sleep because his brain was receiving energy directly from the cosmos.
I first became involved with him when I was asked to write a report for an appeal tribunal after he was detained under Sec.2 MHA for assessment. When I interviewed him he was still plainly hypomanic, with grandiose delusions, although the medication was beginning to take effect.
By the time of the hearing (two weeks after detention) he stood a fighting chance of being discharged from hospital – as long as he kept his delusions to himself. Indeed, he did manage to keep himself under control for most of the hearing, right up until the point where the chairman of the tribunal asked him if he had anything he wished to say to them.
“As a matter of fact,” he said, “I would like you to know that Aphrodite is smiling on you all, you are all blessed by the light of the goddess of love, beauty and sexual rapture. Tonight you will feel the power of her love and beneficence.”
Since the Tribunal decided not to discharge him, he remained as a detained patient, and I was asked to assess him for detention under Sec.3 for treatment. This seemed like a reasonable request.
However…
Gerry may have been acutely mentally unwell, but he had not lost his intellectual capacity. He realised that he was likely to be detained for a longer period if assessed, so he arranged not to be assessed. He absconded from the ward the very morning I was due to assess him. However, unlike most absconded patients, who tend to turn up at home, there was no sign of him, until a day or so later, when his parents received a call from him – in Paris.
He stayed in a 4 star hotel in Paris until the Sec.2 had expired, then returned to this country. He clearly knew something about the Mental Health Act – going to a foreign country is a good way of avoiding it. He managed to remain free for several months, before he completely lost control of his illness and was inevitably detained for treatment.
I first became involved with him when I was asked to write a report for an appeal tribunal after he was detained under Sec.2 MHA for assessment. When I interviewed him he was still plainly hypomanic, with grandiose delusions, although the medication was beginning to take effect.
By the time of the hearing (two weeks after detention) he stood a fighting chance of being discharged from hospital – as long as he kept his delusions to himself. Indeed, he did manage to keep himself under control for most of the hearing, right up until the point where the chairman of the tribunal asked him if he had anything he wished to say to them.
“As a matter of fact,” he said, “I would like you to know that Aphrodite is smiling on you all, you are all blessed by the light of the goddess of love, beauty and sexual rapture. Tonight you will feel the power of her love and beneficence.”
Since the Tribunal decided not to discharge him, he remained as a detained patient, and I was asked to assess him for detention under Sec.3 for treatment. This seemed like a reasonable request.
However…
Gerry may have been acutely mentally unwell, but he had not lost his intellectual capacity. He realised that he was likely to be detained for a longer period if assessed, so he arranged not to be assessed. He absconded from the ward the very morning I was due to assess him. However, unlike most absconded patients, who tend to turn up at home, there was no sign of him, until a day or so later, when his parents received a call from him – in Paris.
He stayed in a 4 star hotel in Paris until the Sec.2 had expired, then returned to this country. He clearly knew something about the Mental Health Act – going to a foreign country is a good way of avoiding it. He managed to remain free for several months, before he completely lost control of his illness and was inevitably detained for treatment.
Wednesday, 16 September 2009
Ones That Got Away (Or Tried To) Part I
I already knew Ian. At the beginning of the year I had been called out to assess him at his flat. His family had contacted the GP because he had been saying "funny" things, and his behaviour had become increasingly odd. He was very paranoid, and had been carrying a hammer around for protection. He had told his family that he believed he was being gassed, that gas was coming out of the electricity fittings, that people on TV were talking to him, that he was "not going to be here much longer" and was "going to die". He was becoming increasingly reluctant to allow even family members into his flat.
By the time I got there with the psychiatrist, his doctor and his mother it was after dark. There was a surreal atmosphere. Ian lived in a first floor flat, and some of his furniture was stacked up outside on the balcony. His mother had a key and unlocked the door when there was no reply. We entered the darkened hall, where an armchair was lying on its side. The flat was in darkness, all the bulbs having been removed from their sockets. I managed to find some bulbs and turned on some lights so that we could continue the exploration of his flat.
We eventually found Mark in his bedroom. He got out of bed, apparently unconcerned about his lack of clothing, but was very keen for us to leave. He refused to talk to us and insisted that we leave. He appeared very agitated and suspicious. The flat was generally in a very untidy state, which his mother said was not normal for him. On the balance of probabilities we decided that he needed to be admitted to hospital for assessment, and he was detained under Sec.2.
A few weeks later I assessed Ian on Bluebell Ward. There was more evidence of his paranoia and unstable mental state. He talked to me in more detail about his conviction that the whole town were watching him on their TV’s, and discussed his obsession with unarmed combat and the SAS.
He was detained for treatment under Sec.3, was started on an antipsychotic, and after a couple of months was discharged. However, before long he started to default on his appointments with his community nurse, and we were fairly sure that he was not taking his medication.
Things came to a head in the early winter of that year. His family were again reporting concerns about his behaviour, and it appeared he was paranoid again. Another social worker had conducted an assessment, which had been inconclusive because he had been very guarded about his replies.
But concerns continued to mount, and so I found myself outside the door of his flat after dark once more, in the company of the psychiatrist, his GP, his mother and the community nurse. There was again a surreal atmosphere – this time, I noticed that there were blown hen’s eggs with little faces drawn on them situated in strategic places on his balcony. It was almost as if they were keeping watch for him.
This time Ian was a little more welcoming, with a façade of friendliness. He allowed us into his living room, where he told us that everything was fine, that he had not needed any medication, and that he had not had any recurrence of his earlier symptoms. He had an air of confidence about him, perhaps created by having survived the previous assessment. But I had already assessed him twice, I knew a fair bit about his delusional beliefs and odd behaviours.
I asked him about the eggs on the balcony. He suddenly looked very unhappy.
“They’re just eggs,” he said. “I like eggs.”
“But you’ve drawn faces on the eggs. What does that signify?”
He looked lost for a reply, seemed to cast about mentally for a response, and then somewhat to our surprise he took out a long hunting knife, waved it about in a very threatening manner and told us all to leave his flat.
We left.
I called the police and explained the situation to them. We had decided that he needed to be detained, and clearly we needed their help.
This was when the police decided to take control.
“We’re going to have to treat this as a siege situation,” the duty Chief Inspector told me. “We’ll need a task force and a trained negotiator. It’ll take us a little while to get them together.”
So for two hours we waited on the ground outside his flat, looking up at his balcony, wondering what was going on in the flat, and feeling rather cold in the late November drizzle.
Then suddenly things started to happen. From around a wall an armed response officer emerged, dressed in full riot gear, cradling a rifle in his arms, and crouched down, pointing it at the flat. A similarly armed colleague chose another vantage point. This was the first time I had ever encountered armed police during an assessment under the Mental Health Act. The sense of unreality about the whole thing went up several notches.
Residents of the other flats started to notice what was going on, and leaned over their balconies, watching intently, talking among themselves.
A van arrived and 6 officers dressed in full riot gear, with riot shields, piled out. A female officer in plain clothes arrived in another car, and introduced herself as the negotiator.
Ian’s mother, understandably shaking, gave them the key to Ian’s flat, and we watched as the riot squad went up the stairs, put the key in the door, and then piled in, riot shields and torches in front of them. I could see their torches flashing as they went from room to room. He must have taken out the light bulbs again. Then they emerged onto the balcony, shaking their heads. He wasn’t there.
At some time in the previous two hours, while we had been watching his front door, he had made his escape by jumping out of a window on the other side of the flat and had gone to earth.
I lodged the section papers with Bluebell Ward, and made sure the police were aware that he was a detained patient and that they should take him directly to hospital if they happened to find him.
And sure enough, a few days later, he was found in the woods, having been living rough just as he had learned from his study of the SAS, living in a bivouac made of branches, and catching, skinning and cooking rabbits with the aid of his rather large hunting knife.
By the time I got there with the psychiatrist, his doctor and his mother it was after dark. There was a surreal atmosphere. Ian lived in a first floor flat, and some of his furniture was stacked up outside on the balcony. His mother had a key and unlocked the door when there was no reply. We entered the darkened hall, where an armchair was lying on its side. The flat was in darkness, all the bulbs having been removed from their sockets. I managed to find some bulbs and turned on some lights so that we could continue the exploration of his flat.
We eventually found Mark in his bedroom. He got out of bed, apparently unconcerned about his lack of clothing, but was very keen for us to leave. He refused to talk to us and insisted that we leave. He appeared very agitated and suspicious. The flat was generally in a very untidy state, which his mother said was not normal for him. On the balance of probabilities we decided that he needed to be admitted to hospital for assessment, and he was detained under Sec.2.
A few weeks later I assessed Ian on Bluebell Ward. There was more evidence of his paranoia and unstable mental state. He talked to me in more detail about his conviction that the whole town were watching him on their TV’s, and discussed his obsession with unarmed combat and the SAS.
He was detained for treatment under Sec.3, was started on an antipsychotic, and after a couple of months was discharged. However, before long he started to default on his appointments with his community nurse, and we were fairly sure that he was not taking his medication.
Things came to a head in the early winter of that year. His family were again reporting concerns about his behaviour, and it appeared he was paranoid again. Another social worker had conducted an assessment, which had been inconclusive because he had been very guarded about his replies.
But concerns continued to mount, and so I found myself outside the door of his flat after dark once more, in the company of the psychiatrist, his GP, his mother and the community nurse. There was again a surreal atmosphere – this time, I noticed that there were blown hen’s eggs with little faces drawn on them situated in strategic places on his balcony. It was almost as if they were keeping watch for him.
This time Ian was a little more welcoming, with a façade of friendliness. He allowed us into his living room, where he told us that everything was fine, that he had not needed any medication, and that he had not had any recurrence of his earlier symptoms. He had an air of confidence about him, perhaps created by having survived the previous assessment. But I had already assessed him twice, I knew a fair bit about his delusional beliefs and odd behaviours.
I asked him about the eggs on the balcony. He suddenly looked very unhappy.
“They’re just eggs,” he said. “I like eggs.”
“But you’ve drawn faces on the eggs. What does that signify?”
He looked lost for a reply, seemed to cast about mentally for a response, and then somewhat to our surprise he took out a long hunting knife, waved it about in a very threatening manner and told us all to leave his flat.
We left.
I called the police and explained the situation to them. We had decided that he needed to be detained, and clearly we needed their help.
This was when the police decided to take control.
“We’re going to have to treat this as a siege situation,” the duty Chief Inspector told me. “We’ll need a task force and a trained negotiator. It’ll take us a little while to get them together.”
So for two hours we waited on the ground outside his flat, looking up at his balcony, wondering what was going on in the flat, and feeling rather cold in the late November drizzle.
Then suddenly things started to happen. From around a wall an armed response officer emerged, dressed in full riot gear, cradling a rifle in his arms, and crouched down, pointing it at the flat. A similarly armed colleague chose another vantage point. This was the first time I had ever encountered armed police during an assessment under the Mental Health Act. The sense of unreality about the whole thing went up several notches.
Residents of the other flats started to notice what was going on, and leaned over their balconies, watching intently, talking among themselves.
A van arrived and 6 officers dressed in full riot gear, with riot shields, piled out. A female officer in plain clothes arrived in another car, and introduced herself as the negotiator.
Ian’s mother, understandably shaking, gave them the key to Ian’s flat, and we watched as the riot squad went up the stairs, put the key in the door, and then piled in, riot shields and torches in front of them. I could see their torches flashing as they went from room to room. He must have taken out the light bulbs again. Then they emerged onto the balcony, shaking their heads. He wasn’t there.
At some time in the previous two hours, while we had been watching his front door, he had made his escape by jumping out of a window on the other side of the flat and had gone to earth.
I lodged the section papers with Bluebell Ward, and made sure the police were aware that he was a detained patient and that they should take him directly to hospital if they happened to find him.
And sure enough, a few days later, he was found in the woods, having been living rough just as he had learned from his study of the SAS, living in a bivouac made of branches, and catching, skinning and cooking rabbits with the aid of his rather large hunting knife.
Thursday, 3 September 2009
Just Another Day
First thing in the morning I had to go to Woodland House, our local psychiatric hospital, to attend a Managers Hearing for a patient detained under Sec.3 MHA. Denise had been detained a couple of weeks previously, and had appealed. Patients have the right to appeal against their detention under the MHA. Their case will first be heard by a panel of Hospital Managers: these are essentially unpaid volunteers rather than NHS employees, who have an interest in the functioning of the psychiatric hospital. They have the power to discharge a patient from detention. If they refuse to discharge the patient, the patient can then appeal to a somewhat more judicial Tribunal, which is a panel consisting of a lawyer, a consultant psychiatrist, and a lay person.
It looked like being a busy morning: as soon as the Hearing had finished, I had to go over to Bluebell Ward to assess another patient, Terry, for detention under Sec.3. This request had come a day or so before. He had been an inpatient for a couple of weeks after being admitted under Sec.2. I had already arranged for a Sec.12 doctor to assess him to provide a second medical recommendation, so everything was set up.
I had known Denise for about 2 years. She had paranoid schizophrenia. I had been instrumental in getting her properly assessed and treated, since for several months she had been presenting with increasingly bizarre and disturbed behaviour, shouting and screaming and throwing things around in her flat to such an extent that most of her neighbours had given in their notice. I had been trying to engage with her, visiting her at home, and having conversations full of non sequiturs and conversational cul-de-sacs. To Denise, nothing made sense. At some time in the last 15 years, all the books had been changed so that they ceased to make sense to her. According to her, every book in the library had been substituted for ones that made no sense, as had all the magazines in the shops. Worse than that, street signs and place names had been altered, as well as maps and guidebooks. She lived in a perpetual state of perplexity, which must have been terrifying for her. I eventually managed to get her seen by our psychiatrist, and between us we managed to persuade her to agree to an informal admission. She consented to take antipsychotic medication, made an exceptionally good recovery, and had been fine for a year, until she had gone on holiday for a week without her medication. On her return, all her symptoms had returned, only this time she had refused to accept medication, since it, too had been changed and was not real, and she had ended up being detained under the MHA.
This time, however, she was far less cooperative, and did not seem to be responding to treatment. So she had appealed, and we had a Hearing.
A Managers Hearing consists of a panel of 3 Hospital Managers. They have a clerk who records their deliberations and their decision. The patient is invariably present, along with a legal advisor, who represents them. Also present is their consultant psychiatrist, a nurse involved with their care, and their community care coordinator, who is generally a community nurse or a social worker. On this occasion, that person was me. All three will have provided written reports covering their nursing care and progress on the ward, their psychiatric history and diagnosis, and the social and community background of the patient.
The Hearing was fairly informal, with the managers introducing themselves and explaining what was happening. They then discussed aspects of the reports with their authors. The patient’s legal representative is also able to cross examine each participant and question their report, and will present the wishes of the patient to the Hearing.
The patient is able to make direct representations to the Managers as well. Denise took full advantage of this, pointing out that the reports did not make sense, that her medication was not real medication, that she did not really have schizophrenia or indeed any other mental illness, and that it was the world itself that was ill. I detected a note of desperation in her lawyers summing up at the end.
After due consideration of the merits of her case, the Managers declined to discharge her from detention.
One task down, another to go. It was all going quite smoothly. However, on arriving at Bluebell Ward, I was told that there was an urgent assessment under the MHA back in town, and was given the mobile phone number of a health visitor. Intrigued, since health visitors (community nurses who look after the welfare of preschool children) do not usually get involved in Mental Health Act assessments, I rang her.
She had just visited a new mother, a young Latvian single parent who had only been in this country for a couple of months. She had arrived heavily pregnant and had duly delivered a baby a few weeks ago. The health visitor was very concerned about both mother and baby. She feared the mother had post natal depression, and was not coping with the baby. She also had no money, and no entitlement to state benefits because of her nationality. To top it all, she had no other relatives in this country, and did not speak any English. The health visitor had spoken to the patient’s doctor, who had told her to arrange an assessment under the Mental Health Act.
This was when my sometimes almost supernatural ability detected an opportunity to avoid getting involved. The doctor had not actually seen the patient. She was not known to the local psychiatric services. There had been no exploration of alternatives to compulsory admission, such as informal admission, or home treatment. In any case, Woodland House did not have facilities to accommodate a mother and baby, so maintaining her in the community in some way would be likely to be in the best interests of both the patient and her baby. Children’s Social Services needed to be involved. I pointed all this out to the health visitor, and suggested that the doctor should see the patient himself first, and then ask the local Crisis and Home Treatment Team to make an initial assessment.
Having dealt with that, I attempted to clear my mind and get into an appropriate state of relaxed alertness for my planned assessment.
Terry also had a diagnosis of paranoid schizophrenia. He was reported to be creating considerable management problems for the nursing team because of his erratic and at times disturbed behaviour. His symptoms included paranoid delusions that he was being poisoned, severe thought disorder, and flight of ideas.
I saw him alone in an interview room. Terry smiled amiably at me as I explained who I was and why I was there.
“I see,” he said, “Only a genius or professor can section me.”
“I’m afraid I’m neither of those. Terry, can you tell me something about how you came to be admitted?”
“I open the box of Pandora – that means that I am nothing, but aware.”
I left him time to elucidate, but he subsided into an amiable silence.
“Er, Terry, do you think you are unwell at present?”
“It is because my National Insurance number belongs to the parliament of Scotland. You see, the angels of the world are flying over my house, and although I am wise, they can see me for what I am.”
“Right… Do you think the medication you are taking is helping you?”
“I have a high level of testosterone because of my proximity to women. The tablets help me to discharge my energy. It is all the same in the cosmos.”
He continued in this vein for several minutes, warming to his incomprehensible topic. I had not the faintest idea what he was talking about, and at the soonest available opportunity I thanked him for his cooperation and told him I had to now go and consider my decision.
“You are not part of the blue circle. Nobody speaks for a moment. There are millions of people. They implanted two chips in my shoulder. Two veins go from these chips into my heart,” he said to me, smiling, as he left.
I confess that it did not take me long to reach a decision.
It looked like being a busy morning: as soon as the Hearing had finished, I had to go over to Bluebell Ward to assess another patient, Terry, for detention under Sec.3. This request had come a day or so before. He had been an inpatient for a couple of weeks after being admitted under Sec.2. I had already arranged for a Sec.12 doctor to assess him to provide a second medical recommendation, so everything was set up.
I had known Denise for about 2 years. She had paranoid schizophrenia. I had been instrumental in getting her properly assessed and treated, since for several months she had been presenting with increasingly bizarre and disturbed behaviour, shouting and screaming and throwing things around in her flat to such an extent that most of her neighbours had given in their notice. I had been trying to engage with her, visiting her at home, and having conversations full of non sequiturs and conversational cul-de-sacs. To Denise, nothing made sense. At some time in the last 15 years, all the books had been changed so that they ceased to make sense to her. According to her, every book in the library had been substituted for ones that made no sense, as had all the magazines in the shops. Worse than that, street signs and place names had been altered, as well as maps and guidebooks. She lived in a perpetual state of perplexity, which must have been terrifying for her. I eventually managed to get her seen by our psychiatrist, and between us we managed to persuade her to agree to an informal admission. She consented to take antipsychotic medication, made an exceptionally good recovery, and had been fine for a year, until she had gone on holiday for a week without her medication. On her return, all her symptoms had returned, only this time she had refused to accept medication, since it, too had been changed and was not real, and she had ended up being detained under the MHA.
This time, however, she was far less cooperative, and did not seem to be responding to treatment. So she had appealed, and we had a Hearing.
A Managers Hearing consists of a panel of 3 Hospital Managers. They have a clerk who records their deliberations and their decision. The patient is invariably present, along with a legal advisor, who represents them. Also present is their consultant psychiatrist, a nurse involved with their care, and their community care coordinator, who is generally a community nurse or a social worker. On this occasion, that person was me. All three will have provided written reports covering their nursing care and progress on the ward, their psychiatric history and diagnosis, and the social and community background of the patient.
The Hearing was fairly informal, with the managers introducing themselves and explaining what was happening. They then discussed aspects of the reports with their authors. The patient’s legal representative is also able to cross examine each participant and question their report, and will present the wishes of the patient to the Hearing.
The patient is able to make direct representations to the Managers as well. Denise took full advantage of this, pointing out that the reports did not make sense, that her medication was not real medication, that she did not really have schizophrenia or indeed any other mental illness, and that it was the world itself that was ill. I detected a note of desperation in her lawyers summing up at the end.
After due consideration of the merits of her case, the Managers declined to discharge her from detention.
One task down, another to go. It was all going quite smoothly. However, on arriving at Bluebell Ward, I was told that there was an urgent assessment under the MHA back in town, and was given the mobile phone number of a health visitor. Intrigued, since health visitors (community nurses who look after the welfare of preschool children) do not usually get involved in Mental Health Act assessments, I rang her.
She had just visited a new mother, a young Latvian single parent who had only been in this country for a couple of months. She had arrived heavily pregnant and had duly delivered a baby a few weeks ago. The health visitor was very concerned about both mother and baby. She feared the mother had post natal depression, and was not coping with the baby. She also had no money, and no entitlement to state benefits because of her nationality. To top it all, she had no other relatives in this country, and did not speak any English. The health visitor had spoken to the patient’s doctor, who had told her to arrange an assessment under the Mental Health Act.
This was when my sometimes almost supernatural ability detected an opportunity to avoid getting involved. The doctor had not actually seen the patient. She was not known to the local psychiatric services. There had been no exploration of alternatives to compulsory admission, such as informal admission, or home treatment. In any case, Woodland House did not have facilities to accommodate a mother and baby, so maintaining her in the community in some way would be likely to be in the best interests of both the patient and her baby. Children’s Social Services needed to be involved. I pointed all this out to the health visitor, and suggested that the doctor should see the patient himself first, and then ask the local Crisis and Home Treatment Team to make an initial assessment.
Having dealt with that, I attempted to clear my mind and get into an appropriate state of relaxed alertness for my planned assessment.
Terry also had a diagnosis of paranoid schizophrenia. He was reported to be creating considerable management problems for the nursing team because of his erratic and at times disturbed behaviour. His symptoms included paranoid delusions that he was being poisoned, severe thought disorder, and flight of ideas.
I saw him alone in an interview room. Terry smiled amiably at me as I explained who I was and why I was there.
“I see,” he said, “Only a genius or professor can section me.”
“I’m afraid I’m neither of those. Terry, can you tell me something about how you came to be admitted?”
“I open the box of Pandora – that means that I am nothing, but aware.”
I left him time to elucidate, but he subsided into an amiable silence.
“Er, Terry, do you think you are unwell at present?”
“It is because my National Insurance number belongs to the parliament of Scotland. You see, the angels of the world are flying over my house, and although I am wise, they can see me for what I am.”
“Right… Do you think the medication you are taking is helping you?”
“I have a high level of testosterone because of my proximity to women. The tablets help me to discharge my energy. It is all the same in the cosmos.”
He continued in this vein for several minutes, warming to his incomprehensible topic. I had not the faintest idea what he was talking about, and at the soonest available opportunity I thanked him for his cooperation and told him I had to now go and consider my decision.
“You are not part of the blue circle. Nobody speaks for a moment. There are millions of people. They implanted two chips in my shoulder. Two veins go from these chips into my heart,” he said to me, smiling, as he left.
I confess that it did not take me long to reach a decision.
Thursday, 13 August 2009
The Mental Health Act Assessment of Fear
One thing I have learned as an AMHP is never to show patients that you are frightened of them. (Come to think of it, hints and tips for AMHP’s would be a good subject for a future blog). I have been in numerous situations over the years where I have anticipated danger or been threatened with harm, but have in reality been physically assaulted only rarely, and generally where I have misjudged a situation. (Mmmm. There’s another subject for a future blog.)
Derek, however, was really scary.
Back in the days when I used to do shifts in the generic out of hours team as well as doing the day job (I’m far too old for that now), referrals from police stations made up a significant amount of the workload. The police station in the county’s only city was a frequent source of these calls. It was a regular occurrence to visit its custody suite, which was in the subterranean bowels of the building with no natural light.
It was fairly late in the evening. Derek, a man in his mid 40’s, had been detained under Sec.135 after behaving bizarrely and aggressively in a public place and I was called to assess him under the MHA. He was apparently an intelligent man, with a degree in engineering, but had convictions for a range of violent offences.
From the comparatively bright and inviting reception area, I was led down several flights of stairs to the custody suite. Derek had already been seen by the duty doctor, and while I waited for the duty psychiatrist to arrive I decided to see him.
I followed the custody sergeant to Derek’s cell, at the end of a long corridor lined with heating pipes and ducts with the cells opening off. The custody sergeant looked uncomfortable.
“You’d better watch this bloke,” he said uneasily. “Don’t trust him.”
Long before we reached Derek’s cell, I could hear a loud and regular pounding sound echoing down the corridor. The custody sergeant’s unease was rubbing off on me. As we came nearer, I could see water flooding out from under the cell door. I couldn’t help wondering what on earth was going on in there.
Derek was monotonously pounding his cell door. The officer called through the grill to him to back off and then unlocked the door and opened it. Looking into the cell, I could see that Derek had tried to flush his shirt down the toilet in the corner of the cell, blocking it and causing it to overflow, covering the floor of the cell with water.
Derek had his back to us when we entered. Since his shirt was halfway round the U-bend, Derek was naked to the waist. He turned round and glared at us.
I felt a surge of shock. He only had one eye. He stared balefully at me with his one eye, but where the other should have been was just an empty pink socket.
My first thought was that he must have flushed his eye down the toilet. This did not help me to maintain my composure. My voice probably sounded a little shaky when I introduced myself.
He put his hand in his pocket and brought out his second eye, which was made of glass. He popped it into his mouth, sucked on it for a moment, and inserted into the empty socket. He then examined me more closely, as if this action had improved his vision. Although this went some way to improving his appearance, it was hardly reassuring. (I learned later that he had lost his eye at the age of 12 while trying to make homemade fireworks in his bedroom).
The officer led him to an interview room. I stood on one side of the desk, with Derek and the officer on the other side and tried to interview him. He was hostile and asked me who I was. He did not appear impressed when I explained. He was clearly agitated and his mood was elevated. At a guess (I did not have access to his medical records) I thought he had bipolar affective disorder and was probably hypomanic. He kept leaning across the desk and getting his face as close to mine as possible. I didn’t like this. I also didn’t like it when he raised his fist and made as if to punch me in the face, stopping his fist just centimetres from my nose. I don’t know how I didn’t involuntarily recoil.
It didn’t take long for me to conclude my assessment, and I indicated to the officer that he could return him to the cell. I was relieved that I had survived the process without needing a visit to the casualty department. When the officer came back to me, I could see that he was trembling. It did not actually help to know that a police officer was even more scared than I was.
“I don’t mind a bit of aggression in this job,” he confided. “But these mental ones – they really put the wind up me.”
Once the duty psychiatrist had seen him (I decided not to take part in that interview) we were in no doubt that he needed to be detained under Sec.2 for assessment. In view of his volatility and potential for aggression, it was decided to transport him in a police van. He was not happy about this, and swore at me as he was led to the vehicle, each wrist cuffed to a police officer, with two others as escorts.
I went on to the hospital to alert them to the admission, and got there before him. I stood back as he was led down the corridor, but at least felt safe, since he was handcuffed and flanked by two big policemen. I made sure that I was far enough away to be out of danger should he decide to lunge at me.
But as he passed me, he turned to look at me once more, swore, and then spat full in my face.
It’s things like that you remember for a long time.
Scary Post Script. It turned out I got off lightly. A couple of years later I was talking to a social worker who worked in the regional secure unit. I discovered that Derek was a patient there. He was detained under Sec.37/41 (a form of detention imposed by the criminal court for serious offences, which means that a patient can only be released with the consent of the Home Secretary). He had blinded someone by throwing acid into their face.
Derek, however, was really scary.
Back in the days when I used to do shifts in the generic out of hours team as well as doing the day job (I’m far too old for that now), referrals from police stations made up a significant amount of the workload. The police station in the county’s only city was a frequent source of these calls. It was a regular occurrence to visit its custody suite, which was in the subterranean bowels of the building with no natural light.
It was fairly late in the evening. Derek, a man in his mid 40’s, had been detained under Sec.135 after behaving bizarrely and aggressively in a public place and I was called to assess him under the MHA. He was apparently an intelligent man, with a degree in engineering, but had convictions for a range of violent offences.
From the comparatively bright and inviting reception area, I was led down several flights of stairs to the custody suite. Derek had already been seen by the duty doctor, and while I waited for the duty psychiatrist to arrive I decided to see him.
I followed the custody sergeant to Derek’s cell, at the end of a long corridor lined with heating pipes and ducts with the cells opening off. The custody sergeant looked uncomfortable.
“You’d better watch this bloke,” he said uneasily. “Don’t trust him.”
Long before we reached Derek’s cell, I could hear a loud and regular pounding sound echoing down the corridor. The custody sergeant’s unease was rubbing off on me. As we came nearer, I could see water flooding out from under the cell door. I couldn’t help wondering what on earth was going on in there.
Derek was monotonously pounding his cell door. The officer called through the grill to him to back off and then unlocked the door and opened it. Looking into the cell, I could see that Derek had tried to flush his shirt down the toilet in the corner of the cell, blocking it and causing it to overflow, covering the floor of the cell with water.
Derek had his back to us when we entered. Since his shirt was halfway round the U-bend, Derek was naked to the waist. He turned round and glared at us.
I felt a surge of shock. He only had one eye. He stared balefully at me with his one eye, but where the other should have been was just an empty pink socket.
My first thought was that he must have flushed his eye down the toilet. This did not help me to maintain my composure. My voice probably sounded a little shaky when I introduced myself.
He put his hand in his pocket and brought out his second eye, which was made of glass. He popped it into his mouth, sucked on it for a moment, and inserted into the empty socket. He then examined me more closely, as if this action had improved his vision. Although this went some way to improving his appearance, it was hardly reassuring. (I learned later that he had lost his eye at the age of 12 while trying to make homemade fireworks in his bedroom).
The officer led him to an interview room. I stood on one side of the desk, with Derek and the officer on the other side and tried to interview him. He was hostile and asked me who I was. He did not appear impressed when I explained. He was clearly agitated and his mood was elevated. At a guess (I did not have access to his medical records) I thought he had bipolar affective disorder and was probably hypomanic. He kept leaning across the desk and getting his face as close to mine as possible. I didn’t like this. I also didn’t like it when he raised his fist and made as if to punch me in the face, stopping his fist just centimetres from my nose. I don’t know how I didn’t involuntarily recoil.
It didn’t take long for me to conclude my assessment, and I indicated to the officer that he could return him to the cell. I was relieved that I had survived the process without needing a visit to the casualty department. When the officer came back to me, I could see that he was trembling. It did not actually help to know that a police officer was even more scared than I was.
“I don’t mind a bit of aggression in this job,” he confided. “But these mental ones – they really put the wind up me.”
Once the duty psychiatrist had seen him (I decided not to take part in that interview) we were in no doubt that he needed to be detained under Sec.2 for assessment. In view of his volatility and potential for aggression, it was decided to transport him in a police van. He was not happy about this, and swore at me as he was led to the vehicle, each wrist cuffed to a police officer, with two others as escorts.
I went on to the hospital to alert them to the admission, and got there before him. I stood back as he was led down the corridor, but at least felt safe, since he was handcuffed and flanked by two big policemen. I made sure that I was far enough away to be out of danger should he decide to lunge at me.
But as he passed me, he turned to look at me once more, swore, and then spat full in my face.
It’s things like that you remember for a long time.
Scary Post Script. It turned out I got off lightly. A couple of years later I was talking to a social worker who worked in the regional secure unit. I discovered that Derek was a patient there. He was detained under Sec.37/41 (a form of detention imposed by the criminal court for serious offences, which means that a patient can only be released with the consent of the Home Secretary). He had blinded someone by throwing acid into their face.
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