Social Work with the Dead

 

Perhaps it’s the dismal weather we’ve had recently, perhaps it’s the shortening days. Whatever the reason, I’ve been thinking quite a bit about the dead. In particular, my first hand encounters with death.

 

Thankfully, I’ve seldom come face to face with a dead body during my career as a social worker. However, on four occasions I have been in the unfortunate position of being directly involved in the discovery of a recently deceased person.

 

I have already written about two of these on this blog. One was many years ago, but still sticks vividly in my mind. I wrote recently about this sorry tale only last month in Origins 5: Death in Charwood. The other was the case of Lenny, who I wrote about back in July 2011 (Lenny: A Life and Death in the Mental Health System; you can read it here and here).

 

Because encountering a corpse in social work is so rare, when it does happen, it’s not something you tend to forget. So here, then, are accounts of the other two.

 

George

George was in his 50’s and was a  longstanding patient of the Community Mental Health Team. He had a very long history of chronic paranoid schizophrenia, and was on a range of antipsychotic medication, including a fortnightly depot injection. Although I was not his care coordinator, I had had to detain him under the Mental Health Act on a couple of occasions.

 

One day, Jim, his community nurse, went round to his house, where he lived alone, to give him his fortnightly injection. He had been unable to get a reply. Jim returned to the CMHT and discussed this with me.

 

It was not like George to be out on the day his injection was due, or not to answer the door. We decided to go out together to investigate further.

 

We rang the bell and knocked on the door, but there was no reply. The curtains were drawn, but we could hear the television. Jim knelt down and peered though his letter box.

 

“Oh, God,” I heard him say, as he backed away.

 

“What is it?”

 

“I can see him. He’s sitting in his chair in the living room at the end of the corridor. He’s not moving. I think he’s dead.”

 

I had a look myself. His profile could be seen clearly through the open door of his living room. His head lolled to one side, supported by the wings of the armchair. I called, but there was no movement. I feared the worst.

We decided to call the police.

 

When they arrived, we explained the situation to them. They too had a look through the letterbox, then tried to find an open window or unlocked door, without success.

 

One of the police then revealed an arcane piece of knowledge. The windows on this estate all slid within a groove in order to open them. There was a way to jiggle the window so that it could be slid back a little way, even though there was a window lock, and then it was possible to reach through and release the lock so that the window could be opened enough for a person to climb through. He didn’t tell me how he knew about this.

 

The police officer climbed into George’s house and opened the front door. We all entered and went into the living room. His eyes gazed sightlessly at the morning TV programme. He appeared to have been dead for at least a day or so.

 

Once we had formally identified the body, we returned to the CMHT.

 

Jim was pale. He was badly shaken. He was looking at something far away.

 

“So lonely,” he said. “So alone. Looking down that long corridor through the letter box, there he was. He died on his own. He was so alone.” He began to cry quietly. There was nothing I could do for him.

 

Gordon

One morning I had a call from one of my service users. Beth was a middle aged woman with whom I had been working for several years.

 

Not long before I first started to see her, she had finally escaped a long, abusive marriage to Gordon. Gordon was an alcoholic. Throughout the marriage he had terrorised her, undermined her, hit her, and sponged off her.

 

I had helped her through the aftermath of this, including aiding her resolve not to return to him, affirming her decision, and assisting her to go ahead with a divorce. Over time, she had adjusted to being a single parent, and her confidence in her own ability to be a parent for her children slowly increased.

 

In recent months, after a long time with no contact, she had started to see him again – not because there was any prospect she would return to him but through pity. Because of his drinking, he was in very poor physical shape. For the sake of the children, who still had contact with him, she wanted him to get help for his drinking and also tried to persuade him to see his doctor, as he had lost weight and was physically quite frail, even though he was only in his early 50’s.

 

“Masked AMHP,” she said, “I’ve been round to Gordon’s flat, but I can’t get any reply. I was going to do his shopping for him. I’m sure he’s dead. I’m convinced of it.” She began to cry.

 

I arranged to pick her up and go round to the flat again. Sure enough, there was no reply. She has last seen him a couple of days previously, when she had done some shopping for him. He never left the flat. So I called the police.

 

The police managed to get a key from the housing association, and I arranged to meet them at the flat. I persuaded Beth not to come. I didn’t want her to be in the position of having to identify the body, if our worst suspicions were realised. She didn’t want to, anyway.

 

I went into the flat with the police officer. We found Gordon huddled on a sofa. He was dead. He looked tiny, emaciated, desiccated, almost mummified; there was hardly any weight to him. He didn’t look as if he could ever have been alive, somehow. Although I had never met Gordon in life, I had no doubt it was him. His skin was a deep yellow, almost mahogany. I had never seen anything quite like it.  He had clearly been in the last stages of liver failure.

 

Beside him on the floor, still in a carrier bag, was the last shopping that Beth had done for him. Still in the bag was a 3 litre bottle of white cider.

 

I went to see Beth at her home. She was crying profusely. I told her roughly what had happened. I didn’t give her the details of his appearance.

 

“I killed him, you know,” she said in between gulps of air.

 

“What do you mean, Beth?” I asked her.

 

“I didn’t want to. He made me.”

 

“What do you mean?” I asked again.

 

“He made me buy him some alcohol, that last time,” she wailed. “I knew I shouldn’t have. I killed him.”

 

“Beth, he never opened the bottle. He didn’t have a drink before he died. It was drink that killed him. But not that particular drink.”

 

Over the months following this incident, I had to spend many sessions helping her to work through her bereavement and guilt issues. But the fact that I had gone in that day, and had found that bottle, and had seen that it hadn’t been touched, and could tell her this, certainly helped to absolve her of at least some of her guilt.

The Masked AMHP Profiled in Guardian Select

You can read the fascinating things The Masked AMHP has to say to the Guardian about himself and his blog here.

On Assessing People Who Conceal Their Symptoms

Over the years, I have frequently found myself in a position where I have had to assess someone under the Mental Health Act where their presentation on assessment is directly at odds with the reports from relatives and other professionals of their behaviour and symptoms.

What is the AMHP supposed to do in these situations? While it is important for the AMHP to “interview in a suitable manner” and reach their own conclusions about the need or otherwise for admission to hospital, it is not sufficient to take the patient’s reports at face value; the AMHP also has to be satisfied “in all the circumstances of the case” that the patient needs to be admitted, whether formally or informally. It is therefore essential for the AMHP to obtain information from relatives and carers, as well as other professionals who have had involvement with the person.

One has to be very careful in weighing up this evidence. On the one hand, people who may be depressed and suicidal, or seriously and dangerously psychotic, may be fully aware that if they are truthful about their symptoms, they are likely to be admitted to hospital against their will. After all, if your intent is to take your own life, you won’t want an AMHP interfering with your plans by detaining you in hospital.

Equally, if you know beyond doubt that there is a global conspiracy initiated by alien invaders from the Dog Star designed to prevent you from achieving your potential as the saviour of the world, you are likely to believe that the nosy AMHP asking you probing questions is simply part of the nefarious plot.

On the other hand, someone may have unusual but not necessarily psychotic beliefs; while you personally may have difficulty in believing that Jesus visited the American continent and left the evidence on gold plaques which later mysteriously disappeared, many people do believe this, and most are probably not thought disordered.

It is also not unknown for people to make malicious and false allegations about the mental health of their relative. I have had a number of demands from estranged husbands to assess their partner under the MHA because they are clearly unreasonable and deluded in objecting to their applications for custody of the children.

A good illustration of these difficulties is the case of Siobhan. Siobhan was a single woman with a school age daughter who lived in a local authority house in Charwood. Her mother, who was originally from the Republic of Ireland, also lived in Charwood. Over a period of more than 10 years, I received a number of requests from her mother to assess Siobhan under the MHA.

On the first occasion, Siobhan’s mother reported a range of behaviours and incidents that anecdotally seemed to indicate that she may be psychotic. However, when I formally assessed her, Siobhan presented at entirely free of any symptoms of mental illness, presenting as warm and appropriate. We took no further action.

A few months later, however, we received a letter from the GP saying that Siobhan had been taken by her mother to the Republic of Ireland and had been admitted to a psychiatric hospital there. She had been diagnosed with paranoid schizophrenia and started on depot injections of antipsychotic medication. She was now back in Charwood and needed the CMHT to give her injections.

I was bemused. Did she or did she not have a psychotic illness? The nurse who gave her her injections found Siobhan to be much as I had, warm, appropriate and without symptoms. But then that could be due to the medication. After a year, Siobhan decided she did not want her depot any more. She disengaged from mental health services. We were not unduly concerned, as we only had anecdotal evidence that she had a mental illness.

A year later, Siobhan’s mother again contacted the CMHT. Siobhan had a partner, and was pregnant. She and the partner were both concerned about Siobhan’s mental health. Both her mother and her partner came to the CMHT to see me. They reported that Siobhan believed that she was not giving birth to a human baby, but to an alien. She had told her partner that she was preparing to be transported to another planet when her alien baby was born. She was neglecting herself and her daughter, and keeping her daughter off school for no good reason.

These were very disturbing reports. I arranged to assess her at home with the CMHT psychiatrist and her GP.

We arrived late afternoon. She answered the door and welcomed us warmly in, even though she was not expecting us. Her daughter and a friend from school were there, playing a game in the living room. Siobhan was preparing a meal for them in the kitchen.

Throughout the assessment, Siobhan again presented as rational, calm, warm and cooperative. The house was in good order, and her daughter appeared well and relaxed. Siobhan denied having said any of the things reported, but said that she and her partner had been having problems and she was unsure if she wanted the relationship to continue.

The psychiatrist, the GP and I retreated to my car to have a discussion. The contrast between Siobhan’s presentation and the reports of the relatives simply did not fit together. I was inclined to go with my impression of Siobhan as she was today, except – this time it was not only her mother reporting psychotic symptoms, but her partner as well. She was pregnant – what if she really did think her unborn child was an alien? What risks to the child might arise from that?

We all felt deeply uncomfortable with the decision, but eventually we decided to believe the mother and partner, and with heavy heart I made an application for Siobhan to be detained under Sec.2 for assessment.

Siobhan took it all with calm resignation. We made arrangements for her mother to look after Siobhan’s daughter and take the friend home, and Siobhan packed a bag and came with me to hospital.

For a fortnight, Siobhan was observed and assessed on Bluebell Ward. During that time she was not given any medication. Also during that time, she did not display any symptoms of mental illness. After 14 days, the section was discharged and she went home.

Despite having displayed no symptoms of mental illness, she did agree to seeing a nurse from the CMHT. She gave birth uneventfully to another daughter, and there appeared to be no problems.

Four years later, Siobhan’s mother again came to the CMHT in a state of agitation. She told us that Siobhan had assaulted a number of people and had also broken her own window. She was insisting that she was mentally ill and needed to be in hospital. While she was telling us this, the police arrived. They had gone out to see Siobhan at mother’s request, and she was not prepared to let the police into the house. The police were expressing concern, as Siobhan’s two children were also in the house.

I decided to go out with her nurse and the police. When we arrived at the house, the police had gained entry. We found Siobhan in the sitting room.

Throughout the interview Siobhan presented as understandably stressed, but nevertheless calm and collected. Her manner and affect were entirely appropriate for the situation, and she did not reveal any symptoms of thought disorder. She said that she had been pressured by her mother and had broken the window as a response to this. She readily admitted that there had been times in the past when she had been unwell, and was aware of her early warning signs. She also said that she wished to continue taking her present medication.

I saw both of Siobhan’s daughters. They both appeared unperturbed by the situation. They were clean, well dressed, and well nourished. They happily reported to me what they had had for breakfast and lunch (cereals, and meatballs with rice respectively). There was no evidence that the children were neglected or in danger. The house was untidy but not dirty, and appeared to be in good decorative order. Again, there was no evidence of significant neglect in the house. I concluded that there were no grounds to consider admission to hospital either formally or informally.

I suggested to Siobhan that we could arrange a meeting with herself, her mother, her nurse, her psychiatrist, and me, to try to reach some agreement about a course of action. Siobhan readily agreed to this idea. I arranged to call in to see her the next morning.

We returned to the CMHT and saw Siobhan’s mother in the presence of two police officers. She was very agitated, and was reluctant to listen to what we had to say about our assessment. She became quite abusive. The police officers were clearly irritated by her. They told her not to harass her daughter, and they wanted Siobhan to be told to inform the police if her mother harassed her further.

The next morning I visited Siobhan as arranged. There was no reply, but the lights were on upstairs and I saw that a venetian blind was momentarily opened.

I phoned her from my car.

“Hello,” I said. “This is The Masked AMHP. Can I come in and see you?” I knocked again, but again there was no reply. However, I heard noises from inside and heard her tell the children to stay in a room.

I phoned her again.

“Do you know who I am?” she screamed down the phone at me.

“You’re Siobhan,” I replied calmly.

“No I’m not,” she shrieked, “I’m her Royal Highness, the Queen of the World!”

“Siobhan, can you let me in?” I asked her, approaching the door again. I heard her thump the inside of the door and then she turned up the stereo to full volume.

I returned to the car to phone her one more time.

“I’m the fucking princess!” she bawled at me when she answered.

It was clear that she was not going to let me in, so I retreated back to the CMHT.

I called the police and explained what had happened. They agreed to go out straight away, especially as the children were inside the house with her.

I returned rather quickly with Siobhan’s GP. There wasn’t time to get a Sec.12 doctor.

The police had managed to gain entry. I found Siobhan curled up in a foetal ball under the stairs. She looked up at me as I knelt down beside her.

“Are you my daddy?” she asked me.

 I detained her under Sec.4.

Clustering and Payment by Results: The End of Service User Centred Mental Health Care?

Most mental health service users will be completely unaware that when they are assessed by Community Mental Health Teams or in hospital their mental health problems and symptoms are now subjected to an arcane system known as Clustering.

The Department of Health issued guidelines in October 2011 (a link is here) which proudly announced:

“2012-13 is the introductory year for what is a major change in the way that mental health care is currently funded, a shift from block grants to PbR currencies which are associated with individual service users and their interactions with mental health services.”

(PbR, by the way, stands for Payment by Results. Payment by Results is the new way in which local NHS Trusts will be funded by the GP consortia that are due to replace PCTs in 2013.)

It is the preliminary stage in “introducing the mental health care clusters as the contract currency for 2012-13 with local prices. This means that prices will be agreed between commissioners and providers, and are not set at a national level.”

Mental Health Professionals working within the NHS are now expected to assign everyone they assess to a specific “cluster”, using the Mental Health Clustering Tool. This tool has 18 scales. Examples include “Non-accidental self injury”, “Problems associated with hallucinations and delusions”, and “Depressed mood and ideation”. The assessor has to assign a score between 0 (no problem) and 4 (severe to very severe problem). Depending on these scores, the assessor can then assign each service user to a cluster.

A cluster is not a diagnosis but rather a description of an individual’s mental health problems and its impact on their ability to manage daily living. Someone presenting with moderate depression, for example, might be assigned to Cluster 3, which is defined as “Non Psychotic (Moderate Severity)”. Someone with chronic schizophrenia might be assigned to Cluster 7, “Enduring Non-psychotic Disorders (High Disability)”. Someone with a borderline or emotionally unstable personality disorder might be assigned to Cluster 8: “Non-Psychotic Chaotic and Challenging Behaviours”. 

I wrote about Clustering in the Guardian back in January of this year (link here). At the time of writing that article I was still quite new to clustering. Now, I have over a year’s experience of clustering service users in Charwood Community Mental Health Team where I am based. I have also been on further training.

So far, it has become clear that it is very difficult to use this assessment tool in any sort of meaningful way. The point of clustering is apparently to assign service users to the care or treatment package that best meets their identified needs. However, unless these care packages are known, it is almost impossible to know which cluster to assign to a specific individual. And these care packages themselves have not yet been defined, which the training course admitted.

It’s a bit like being on one of those TV cookery competitions, and being given a pile of ingredients but without being told what dish you’re supposed to be preparing.

I apologise if this post has appeared a little dry and boring so far. Imagine what it’s like for mental health professionals trying to apply clustering to their assessments. Unfortunately, even though inserting sharp objects into one’s own rectum might appear a preferable pastime to using the Mental Health Clustering Tool, it is now not only a compulsory requirement, but it will also have a profound effect on the funding of mental health trusts.

And this, of course, is what clustering is really about. It actually has little to do with actually trying to identify the needs of service users, and then providing care and treatment according to those needs. That is the old, unfashionable, “needs led” approach.

Over 20 years ago, when Charwood CMHT was first created, the team spent a considerable time trying to identify what a CMHT was for. It was, of course, to try to meet the needs of people with severe and enduring mental health problems, as well as those in acute distress where there was a severe risk to that person or their ability to function. Our services were therefore developed to try to meet the needs of those individual service users.

One example of this was the identification that many people presenting to the CMHT with depression, self harming and suicidal behaviours had significant histories of childhood abuse. If all we did was give them some antidepressants and some supportive contact until the crisis was over and then discharge them, we realised that these people would keep coming back. So we started to develop specialist counselling within the team that was designed to address their underlying problems. If the reasons for a person’s low mood or urges to self harm were dealt with and resolved, then not only would they feel much better, but they would also be less likely to relapse.

Over the intervening years, there have been many changes to the shape and organisation of community mental health care. 20 years ago, the CMHT was part of Charwood District Health Authority. Then it became Charwood Health Partnerships Trust. Then it became a Mental Health Foundation Trust.

Other teams were created: the Early Intervention in Psychosis Team, the Assertive Outreach Team, the Crisis Resolution and Home Treatment Team. Some of those changes made our job a little easier; some made it more difficult. But despite those difficulties, we always tried to keep the needs of the service user at the centre of what we did. We didn’t always succeed in this, but we always tried.

Clustering and Payment by Results, while giving lip service to the concept of service user led service provision, in fact does nothing of the sort. The “customer” is not the service user. Under this new model, the service user, or rather their cluster, explicitly becomes a unit of currency. So mental health services become a market place in which this currency can be spent.

The real “customers” in all this are the new GP consortia. With their cluster currency, they can shop around, looking for the best deals. The potential implications of all this are that interested businesses can cherry pick certain treatment packages.

Many Tesco stores have pharmacies and even dentists. What’s to stop them offering cut price treatment packages for Cluster 3 (Non-Psychotic, Moderate Severity) or even Cluster 11 (Ongoing Recurrent Psychosis, Low Symptoms)?

CMHT’s could simply become places where people are assessed and sorted, a bit like an egg grading production line, before being farmed off to any of a range of private or voluntary organisations offering the cheapest prices.

But how many of these organisations would see the commercial potential in Cluster 14 (Psychotic Crisis)? And what about Cluster 8, Non-Psychotic Chaotic and Challenging Disorders – after all, people with personality disorders aren’t very rewarding to work with are they? They’re difficult and challenging, take a long time to treat, and above all can be very expensive in terms of services. They’ll probably be left for what’s left of NHS mental health services to pick up.

Is this really what the changes in the NHS are all about: a means of privatising the NHS by stealth, using the GP’s as unwitting stooges, and at the same time cutting back on funds? Ultimately, these “currencies” are nothing more than Monopoly money; the Government can and will control their actual value.

And despite the Government maintaining that NHS spending is increasing, in spite of the evidence of cutbacks that people working in the NHS are faced with every day, the actual evidence is that, certainly in mental health, funding has decreased. The Observer on Sunday 27.09.12. stated: “After inflation, expenditure fell by 1% in 2011-12, dropping by £65m to £6.63bn, according to reports published by the department of health. Older people's mental health was hit hardest, seeing a real-terms spending decrease of 3.1% to £2.83bn in 2011-12.”

Phew! Perhaps a bit radical for the Masked AMHP! The trouble is, I’ve endured and survived so many changes to service provision over the 35+ years I’ve worked in social care. I fear that this is one change too many.

Origins 5: Death in Charwood

 

Part 5 of an occasional series about my early years as a social worker in the 1970’s.

Within a few months of starting as an unqualified social worker in Charwood Area Social Services Department it was decided that I could take part in the Area on call rota.

Charwood provided a local out of hours emergency service. Every social worker in the team had to be on the rota. This meant that about once a fortnight I was on call during a week night. About every three months I had to cover a whole weekend, from the end of the day on Friday until the following Monday morning. Being the late 1970’s, there was no such thing as a mobile phone or even a pager, so your home number was placed on the office answer phone and you could not leave home as long as you were on duty – unless, of course, you had to respond to an emergency.

I was on call one cold February Saturday when Robina phoned.

Robina was an elderly woman who was well known to Charwood Social Services Dept. When her husband died, she fell to pieces and her behaviour became disinhibited and erratic. She developed a somewhat cavalier attitude to continence, and was frequently incontinent of urine and faeces. I had on one occasion had to visit her at home, and discovered that, if she was taken short while in bed, she would simply scoop up the excrement and place it on the windowsill. The windowsill consequently contained a neat line of turds in varying stages of decomposition.

Robina lived in a village a few miles out of Charwood, and liked to go to Charwood market on a Saturday. However, she was banned from using the local bus because of her incontinence. Her solution to this was to hitchhike into Charwood. She had a unique method of doing this, which consisted of lying in the middle of the road with her voluminous dress over her head. When a concerned driver stopped to investigate, she would leap up and ask for a lift into town.

When I look back at what I have just written, it seems apparent to me that if a social services department was confronted with this situation in the present day, Robina would probably end up either being detained under the Mental Health Act, or being placed in residential care using the Mental Capacity Act.

However, back then, it seemed quite natural to tolerate this sort of behaviour, and although Charwood SSD was involved with her, intervention was focused on keeping her in the cottage in which she had lived for the previous 50 years, and she had a home help who would keep an eye on her and ensure that she had regular meals.

Charwood SSD had a number of clients, especially in the outlying villages, who could probably best be described as eccentric, but who were generally tolerated within their community. The main object of intervention was to preserve them in their own homes for as long as was feasible.

“Hello, it’s Robina here. I’ve just been to see Cyril. He’s awful ill. I don’t know what to do.” Robina went on to tell me that Cyril lived in Charwood. He was an elderly man who lived alone. I decided that I would have to go out and investigate. Robina couldn’t be left to handle this on her own.

I found Cyril’s address. It was at the end of a terrace of ancient cottages in the older part of Charwood. The door wasn’t locked so I went straight in. It was like walking into a Dickens novel. The cottage was quite literally a “2 up, 2 down”. The front door opened directly into what might have been a living room, except that it had no furniture. The only things in the room was a wooden stump with an axe, and a pile of split logs. A rickety staircase led up from the corner of the room.

I went through into the next room, which was a kitchen/parlour. This contained a stone sink with a cold tap above it. Beside it was the back door into the small garden. There was an ancient Victorian kitchen range which appeared to provide the only source of heating and cooking for the cottage. It had gone out, and the room was bitterly cold. In a corner was a small table with a wooden chair on which Robina was sitting.

It was very dim in the room, but when I looked around for a light switch, I realised that Cyril had no electricity in the house, and never had had. I could not even find a candle or an oil lamp.

The only other furniture in the room was a battered armchair in which Cyril was slumped. He was only partially clothed. It was apparent to me from a single glance that he was in a bad way. He appeared to be conscious, with his eyes staring, and was breathing shallowly. However, he was quite unable to respond to any questions.

I looked around for something to cover him up with. There was nothing in the kitchen, so I went upstairs. There was no furniture at all in the landing bedroom. In what must be Cyril’s bedroom there was only an old brass bedstead with a bare mattress, which was piled high with old coats. I took one of the coats and attempted to cover him up with it.

“Is he all right?” Robina asked me.

“No, he isn’t, Robina. I’ll call the doctor and get him to have a look at him. You wait here while I go to a phone box.”

I went down to the nearest phone box and rang the on call doctor, who was one of the surgery’s GP’s. This was back in the days when GP practices covered their own patients with a rota of GP’s attached to the practice. He said he’d come right out.

I returned to Cyril’s house and told Robina what I had done. Then I waited for the GP, confident that he would examine him and then probably arrange for an ambulance to admit him to hospital.

The doctor arrived, looking rather grumpy. He gave Cyril a very cursory examination, which did not even appear to include checking his pulse, heart or temperature.

Then he stood up and said to me, “There’s nothing much wrong with this chap. He just needs feeding up in the local old people’s home.”

I was aghast. Cyril was clearly immobile, and to my eyes appeared to have had a stroke or some similar serious health crisis. No care home would have him in this condition. I told the GP this.

“That’s not my problem,” the GP replied when I pointed this out. “There are no hospital beds, and he can’t stay here, can he? With that, he left.

“What’s going to happen now?” Robina asked me.

“I don’t know, Robina. I don’t know. I’m going to have to leave now and try and sort something out. Can you keep an eye on him?”

This was way out of my experience zone. I went to the local authority old people’s home in Charwood and spoke to the manager. She confirmed that Cyril was in no condition to be admitted to them. I used their phone to ring my own manager. She did her best to reassure me, and said she make a few calls and get it sorted.

I waited at the home for half an hour or so until my manager rang me back.

“I’ve spoken to a doctor on the geriatric ward at Charwood Hospital and he’s happy to admit him. I’ve called an ambulance and they’ll be there any minute.”

Much relieved, I returned to Cyril’s house.

Robina was still sitting beside Cyril with his hand in hers.

“Hello, Robina, it’s all sorted out. Cyril’s going to hospital. The ambulance will be here any minute. How is he?”

She looked up at me.

“I think he’s dead,” she said.

I had a close look at Cyril. His eyes were staring sightlessly. He was not breathing. She was right.

The ambulance arrived.

The crew took one look at Cyril.

“He’s dead,” one of them said.

“I know that,” I replied.

“He’s not one for us,” he said. “I’ll call the police and let them know.” They left.

Everyone was leaving.

I went back to the phone box and called the GP again.

“Oh, it’s you again, is it?” he said. “What is it now?”

“You know that old man who you said just needed feeding up in an old people’s home?”

“Yes, what about him?”

“Well, he’s dead.”

There was a brief silence. Then: “Oh shit,” the doctor said. “I’ll come straight out.”

 When I got back to Cyril’s house, the police and a police hearse had arrived. The GP came soon after and formally certified Cyril as dead. He studiously avoided eye contact with me and left rather quickly.

As the hearse crew zipped Cyril into a body bag and carried him out to the hearse, I comforted Robina, who was crying.

“He was a good friend, Cyril was,” she said. Then she looked around the room, Spying a box of eggs on the table, she took a few out of the box and put them into her shopping bag.

“Cyril won’t miss these, will he?” she asked me.

“No, he won’t, Robina. You may as well have them.”

She saw a pile of split logs ready to go on the fire, and slipped a few of them into her shopping bag too, with predictable results.

“Let me take you home,” I said.

“A lift, oh good, with such a nice young man,” Robina replied, and smiled at me.

A Kiss is Just a Kiss: On the Risks Associated With Conveying Patients to Hospital

There is a whole chapter in the Mental Health Act Code of Practice on the conveyance of patients to hospital. Two of the particularly cogent paragraphs are as follows:

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

“11.21 AMHPs should not normally agree to a patient being conveyed by car unless satisfied that it would not put the patient or other people at risk of harm and that it is the most appropriate way of transporting the patient. In these circumstances there should be an escort for the patient other than the driver.”

The Masked AMHP has of course read these paragraphs, and has taken due notice of them. He does, however, consider that there are situations in which it is appropriate, or necessary, for the AMHP to take the patient to hospital themselves. Sometimes, there just does not seem to be any alternative at the time.

In both of the following cases, in which the Masked AMHP found himself in difficult osculatory situations, the patient was not formally detained under the MHA, but was being transported as an informal patient. I would submit that the Code does not specifically refer to informal admissions.

Leroy

I have mentioned Leroy before on this blog. He has a very long history of bipolar affective disorder, which is frequently exacerbated by his fondness for amphetamine.

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

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

He came to the door and beamed at us.

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

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

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

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

“Masked AMHP,” he said, “You’re scaring me. You’re speaking with the voice of an alien from Alpha Centauri! Stop it please.”

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

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

Halfway there, he suddenly stopped.

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

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

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

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

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

Florence

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

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

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

“She’s bought a one way ticket on Concorde to the USA,” he said in despair. (This was a few years ago, when Concorde was still in service.) “She wants to see the President to give him some advice.”

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

We politely asked her to turn the TV off.

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

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

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

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

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

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

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

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

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

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

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

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

“You must remember this, a kiss is just a kiss –“ I began.

Florence looked at me with sudden affection.

Very well, my dear,” she interrupted, licking her lips, and suddenly lunged forward and planted her moist lips firmly on mine, attempting to thrust her tongue down my throat at the same time.

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

But I was not at that moment able to reply.

AMHP’s in Court: Some Recent Case Law

Case Law relating specifically to the discharge of AMHP’s powers under the MHA is fairly rare. I don’t know whether this is because AMHP’s rarely make mistakes, or whether it is because most people who are detained under the MHA don’t know enough about the legal process to know whether or not an error in law has been made.

Whatever the reason, court cases of relevance to AMHP practice seem to be like buses – you don’t get any for ages, then two come along at once. In fact, the two particular cases I’m writing about were heard within a month of each other – in March and April 2012.

The first is DD v.Durham County Council & Middlesbrough City Council ([2012] EWHC 1053 (QB)). Although the events with which the Claimant took issue occurred at the end of 2009 and the beginning of 2010, the Claimant did not actually issue proceedings until nearly the end of 2011.

DD had been serving a prison sentence. When the sentence ended, but during a period in which DD continued to reside in the prison, he was assessed under the MHA by two AMHP’s, and the decision was made to detain him under Sec.2 for assessment. He was admitted to a medium secure psychiatric unit. Before this expired, he was assessed by two more AMHP’s, who decided that he should be detained for treatment under Sec.3. Because the location of the assessment was not in the Durham area, and because of the adverse weather conditions pertaining at the time, a Middlesbrough AMHP subsequently assessed and applied for his detention under Sec.3.

DD wanted to instigate proceedings under Sec.139 MHA. This relates to liability for acts “done in bad faith or without reasonable care”. In effect, he wanted to sue one or more of the AMHP’s who had been involved for detaining him illegally.

DD argued that both the AMHP’s who had completed the Sec.2 application and the subsequent Sec.3 had breached their duties under Sec.13(2) MHA.

Sec.13(2) states:

“Before making an application for the admission of a patient to hospital an approved mental health professional shall interview the patient in a suitable manner and satisfy himself that detention in a hospital is in all the circumstances of the case the most appropriate way of providing the care and medical treatment of which the patient stands in need.”

He argued that the AMHP in question had “a duty to investigate the proposed place of detention, the location where the patient will be kept while there and the regime to which he will be subject. This is said to arise because of the need to make a recommendation in the light of ‘all the circumstances’”. This was because he was objecting to the secure unit he was sent to, instead preferring to go to Rampton.

The Judge in the case dismissed this argument in one paragraph:

“It is obvious than an AMHP is not directly responsible for the medical or other regimes to which a detained person is subjected… An AMHP has certain responsibilities under the Mental Health Act which include recommending a person for detention under s.2 or under s.3. Their responsibilities have to be discharged in the light of all the relevant circumstances of the case, which would include taking into account the assessments of qualified doctors. Their functions do not extend, however, to choosing an institution in which the person concerned is to be detained – still less to researching the available facilities or carrying out a reconnaissance to assess their quality.”

This is reassuring confirmation of what I am sure is a universal view held by AMHP’s, which is that they only need to decide whether or not a patient needs to be detained, and not the suitability or otherwise of the hospital they will be admitted to.

DD described himself as having “a paranoid, narcissistic and antisocial personality disorder”. This observation would be entirely consistent with the nature of his complaint.

While in this case, the AMHP’s involved were all exonerated, this was not the outcome in GP v. Derby City Council ([2012] EWHC 1451 (Admin)).

At the time of the court hearing, GP had been detained under Sec.3 in a low secure unit since July 2011. He was challenging the legality of this detention on the grounds that the AMHP had failed to consult with the patient’s Nearest Relative as required under Sec.11(4)(a).

The AMHP who made the application maintained that he had attempted to contact the NR on her mobile phone, but had not been able to speak to them. He therefore stated that it was not reasonably practicable, or would involve unreasonable delay to do so, and completed the application. In the space provided on Form A6, he had written: "I have tried to contact several times but the mobile went to answer machine. As GP Section 2 is due to lapse later today and given his current state I felt it would involve unreasonable delay to consult with Ms P."

This assessment was concluded at around 1600 hrs on the day that the existing Sec.2 detention was due to expire at midnight. The AMHP had been under pressure of time, and was also being pressured by the ward staff to complete the application on the basis that the patient needed to be transferred to a Psychiatric Intensive Care Unit (PICU).

The Judge noted that the AMHP had been ringing the wrong number, but that the correct number was available on medical records. He also noted that the AMHP himself had stated in evidence that it was his usual practice to visit the NR at their home in order to consult with them under Sec.3. The Judge concluded that there had been enough time to visit the NR, and that the AMHP should have done this. He therefore concluded that the AMHP had indeed failed in his duty to consult with the NR, and as a consequence, this rendered the Sec.3 unlawful.

The Judge said:

“On the evidence that is available, the question has to be asked as to whether it was plainly wrong to proceed with an immediate certification in the circumstances as they were. I conclude that it was because, as I have attempted to explain, section 11 provides constitutional protection for those that are faced with detention under the Mental Health Act. Compliance with the requirements of section 11(4) is therefore the price which is paid for the ability of those charged with the treatment of those with mental illnesses and disabilities to detain people without immediate recourse to a court and in a way which is compliant with Article 5. Thus there is a heavy duty on those who carry out these tasks to ensure that those statutory provisions are complied with.”

This case has considerable implications for AMHP practice. The Judge makes it clear that, in order not to breach Article 5 of the Human Rights Act (The right to liberty and security), an AMHP must go to considerable and quite possibly arduous lengths to fulfill their legal obligations. It is not enough to ring the NR a couple of times and then fill in the form saying that it is impracticable to consult with them. The AMHP must show far more evidence of their efforts.

The consequence of this particular lapse was that the patient was deemed to have been unlawfully detained for up to 9 months.