The hostel where Daisy had lived for over 15 years decided that they could no longer manage her and gave her notice to quit while she was in hospital. In the event, this was to Daisy’s advantage, as being a vulnerable and potentially homeless person, she was allocated a nice flat away from a hostel environment. When she was recovered, she moved into her new flat, with some community support. She was content. For about 5 years she remained well, although her physical health did not improve. Through her continued obesity, she developed Type II diabetes, and her liking for sweet and fatty foods made it difficult to control. Her legs had become ulcerated, probably because of her poor control of her diabetes. But her mental state remained so stable that the CMHT reduced its involvement to little more than periodic medical reviews with the team psychiatrist and weekly support with practical things such as shopping.
Then her father died. She was understandably upset, but this also served to destabilise her. Over a period of a few months, her manic symptoms returned. By now, her daughter was an adult and frequently visited her in her flat.
One Friday, her daughter came to the CMHT to tell us that she had visited Daisy and had found her mother washing her cups and plates in the washing machine. When she tried to challenge her about this, she explained to her that a Shaman had told her this was the best way to do it, as it would bode well for the future. Daisy had also phoned the RSPCA to report the presence of a five inch diameter spider in her bath (she was very exact about this), and had also reported to the police an attempt to burgle her flat from below (it was a groundfloor flat). She was again spending lots of money on food, and her fridge was crammed with smoked salmon, pate de fois gras, roast partridge, oysters, and champagne. Her daughter had also found her prescription of lithium, with evidence that few had been taken in the last couple of weeks.
Daisy happened to have an appointment with the psychiatrist that afternoon, so I stood by to find out the outcome of this. The psychiatrist popped her head round my door. “I think you’d better come in,” she said.
Daisy was sitting regally in the psychiatrist’s room.
“Oh, hello,” Daisy said when she saw me. “Have you come to section me? I’m not going to hospital, because I will die of a heart attack if I step foot in a hospital. They’re bad places. People are always dying in hospitals. Best to avoid them completely. A Shaman has foretold this. So it will come to pass.”
She continued in this vein for some minutes, despite attempts to ask her questions and discuss the situation with her. Her GP and her daughter joined us, and got no further with her than we had. It was becoming clear that Daisy needed to go to hospital again.
I took her daughter to one side.
“Your mother needs to go into hospital, I’m afraid. She’s clearly not going to agree to an informal admission this time. Since we know her diagnosis and we know she needs treatment, we’re planning to use Sec.3 of the Mental Health Act. As her Nearest Relative under the Act, I need to know if you have any objection to this.”
“Actually, I do,” she told me. “There’s a friend of hers coming this weekend, and mother would be very disappointed if she missed him.”
Her daughter would not be swayed in this. So we could not proceed with an admission under Sec.3 at that point.
We cobbled together a plan for the weekend. Her daughter would try to get her medication into her, and her care co-ordinator would review her on Monday and we would take it from there. The ward were alerted to the possible imminent need of an admission and a bed was reserved
As it happened, things did not go well over the weekend. Daisy would not take her medication, she became so excited by the prospect of her friend visiting that she did not sleep at all, and her mood continued to spiral out of control. Somehow or other, her daughter managed to persuade her to go into hospital, and on Monday she was making her presence felt on the ward.
She remained as an informal patient for about month. Then I received a request to assess her for detention under Sec.3. Although Daisy was showing no signs of wishing to leave the ward, she was also not taking her medication. In addition, she resisted attempts to stabilise her diabetes by refusing to have blood glucose tests or take her diabetic medication.
“Oh, it’s you again, is it?” she said, when I went into her room, accompanied by a female social work student as a chaperone. She was sitting in a chair beside her bed. Her legs had recently been rebandaged, but she seemed intent on loosening the bandages.
“You like me, don’t you? I know you do. That’s why you keep coming to see me. You are undressing me with your eyes. You want to get in my knickers, don’t you? Would you like to see my knickers?”
I was suddenly very glad I was not on my own.
“Daisy,” I said. “I am here, again, to see whether or not you need to be detained in hospital for treatment.
“Treatment? Treatment? I don’t need any treatment. There’s nothing wrong with me.”
“You are mentally unwell at present. And you’re also physically unwell. You’re not letting the staff help you manage your diabetes. You keep interfering with your bandages on your legs.”
“I don’t need any help with my diabetes. I’ve been taught by a Shaman how to control my diabetes with my will alone. In any case, diabetes does not really exist. It’s only a shortage of sugar in the diet that creates the illusion of diabetes. Everything’s an illusion. These bandages are an illusion. They’re not really there at all.”
“Well, it they’re not really there, perhaps you could leave them alone,” I said, becoming slightly irritated.
“Are you being sarcastic? Because if you are, I shall have to ask you to leave.”
Our conversation continued in this vein for some minutes. It was clear that she was manic, that she was delusional, that she would not accept the treatment she needed, and that her mental illness was also affecting her physical health. She did need to be detained.
But her inpatient stay dragged on and on this time. Her mental state did not seem to improve. In some ways, it seemed to deteriorate.
The hospital gave her a brain scan. The results weren’t good. There was evidence of atrophy in her frontal lobes. She was developing dementia in addition to her mental illness. This would explain her disinhibition.
But there was no treatment for this. And she would continue to deteriorate.
Daisy was eventually placed under Guardianship (Sec.7 MHA) and transferred to a nursing home. Five years on she is still there. She seems to enjoy it there, but still protests that she wants to return to her flat in Charwood, where she would be able to make her diabetes fade away using only the power of her will and a regular supply of doughnuts.
Saturday, 20 March 2010
Sunday, 14 March 2010
Daisy's Story: Part 1
People with bipolar affective disorder are frequently intelligent and fascinating. They can lead completely normal and often exceptional lives, sometimes with medication and sometimes without. But bipolar disorder can also destroy people. There is no moral to this story, but this is, I am very much afraid, not a story with a happy ending.
I first met Daisy when she was admitted to the local hostel for people with mental health needs in the 1980’s. I was on the management committee at the time. She had a diagnosis of bipolar affective disorder. She was in her thirties and had spent a long time in hospital following an acute manic episode. The illness had effectively destroyed her life. Up until then she had been happily married, with a young daughter, living in a nice house in a nice part of Charwood, and working in the town as an assistant bank manager. She was an intelligent woman who had great ambition. But the onset of bipolar affective disorder had changed all that.
As her mental illness took hold, she became more and more grandiose and disinhibited. Her work suffered. She lavishly spent money she didn’t have on ridiculous schemes. She began to neglect her daughter. She embarked on reckless affairs which put increasing strain on her marriage. Eventually everything imploded and she was admitted to hospital. During her incarceration her husband filed for divorce and got custody of their daughter. He kept the house and she became effectively homeless. By the time she was admitted to the hostel, she was thin and ghostly in appearance, hardly ever saying a word, afraid to look anyone in the eye, and on an extensive medication regime of mood stabilisers and antipsychotics.
Over a number of years, however, I saw her gradually change. Several different combinations and doses of medication were tried, and her personality and something of her old spark began to return. At the regular dinners the committee members had with residents, she began to converse more, and her intellect began to shine through. She was a personable, articulate, well educated and vivacious woman, with good conversational skills. In time, she moved on to a self contained flat attached to the hostel, requiring less and less support.
But then, over 15 years on from her first breakdown, the bipolar disorder began to kick in again, and she became more and more manic. She began to spend large amounts of money on huge quantities of luxury foods which she could not possibly eat, and which was inevitably wasted. Since she had a very good pension from the bank where she had worked, she had accumulated a large amount of savings which she proceeded to squander. She was disinhibited, swearing in a way she would never normally have done, and flirting indiscriminately with males and females alike.
Eventually I was asked to assess her under the Mental Health Act. We arranged for her to come to the CMHT offices. When she arrived the button on her jeans was undone, as was her zip, and her jeans were halfway down her buttocks. She had put on a lot of weight, and much of this was on display. She was completely oblivious to this, and when she saw me she told me to “fuck off” before I could even speak to her, directed an impressive range of swearwords at several invisible people in the room, then walked out again.
I caught up with her again a day or two later, when she came to see her care coordinator at the CMHT. Although Daisy appeared a little less elevated than the day before, she nevertheless spoke rapidly and intensely, and was very difficult to interrupt. I gradually told her that in my opinion she was exhibiting symptoms consistent with hypomania, and listed them, explaining their meaning and the direct evidence I had to support my opinion. These included pressure of speech, flight of ideas, disinhibition -- arising not only from her state of dress yesterday but also from numerous occasions in which she had spoken loudly and inappropriately about her romantic and sexual desires for a male friend of hers, and the reckless spending of money.
“None of that is true, and you know it! I’ll have you for slander. I have friends in the legal profession who will sue you! I’ve only got to ring them!” she told me with the absolute certainty that only the most manic (and deluded) can possess. “If you persist in carrying on in that tone, I shall have no alternative but to hit you across the head!”
“Daisy,” I began, as calmly as possible. “If you were to hit me, it would only confirm my opinion. You would never dream of doing something like that if you were well. I do think you need to be in hospital at present.”
“Well,” she said, “If you’re thinking of sectioning me, I shall just have to jump in front of a lorry! What do you think of that?”
I did not think this was a good idea. However, I also did not think she was likely to carry out this threat.
“Look, why don’t you take a little more medication. You might be able to avoid going into hospital.”
She thought about this – for about a millisecond.
“And why don’t you go and fuck yourself!” she answered.
Her care coordinator decided to contribute to the conversation. “Daisy, that is an idea. I could take you to see Dr Drinkwater [her GP]. Let’s see what he thinks.”
Daisy liked Dr Drinkwater. “He is a very good friend of mine,” she said. “I do trust him. I’ll ask him what he thinks.”
I heard later from her care coordinator that Dr Drinkwater had agreed with me, and had recommended an increase in her medication. Amazingly, she had agreed to this. She therefore avoided a compulsory admission, and in time her manic episode subsided.
Two years later, however, she became manic again. All the symptoms had returned. Once again I was asked to assess her under the Mental Health Act.
She agreed to come and see me at the CMHT, arriving like a galleon in full sail, and walked into an interview, saying, “You can tell that fucker I’m here, and let’s see if he dares to section me.”
I sat down with her. “Hello, Daisy. You know what this is about. You know I have to assess you under the Mental Health Act, and you know I have the power to detain you if I think it is necessary. However, the last time we were in this situation, that didn’t happen, did it?”
“I can’t imagine why you think I need to go to hospital. I’ve asked all my friends, and they all agree that there’s nothing wrong with me.” She proceeded to give me the full details of all the people she had consulted and what they had said, at breakneck speed, so that it was impossible to interrupt her or get a word in edgeways. So I just sat there for a few minutes, waiting for her to stop.
During this monologue something strange and unexpected started to happen. Liquid started to flood from her seat onto the floor all around her. After a moment of shocked surprise I realised that she was urinating. She clearly eventually realised this too. She stopped talking, in order, it seemed, to give it her full attention.
The cascade of urine seemed to be interminable, but probably lasted no more than 4 or 5 minutes. She obviously needed to go. The puddle on the carpet began to extend inexorably towards me. I moved my feet discreetly.
Daisy sat there looking totally unconcerned as steam rose around her and the room filled with a miasma of hot urine. When she had completely finished, and the Niagara of urine had finally abated, she said with immense dignity, “I do have a urinary tract infection, you know,” as if no further explanation were necessary.
This time, Daisy did go to hospital.
I first met Daisy when she was admitted to the local hostel for people with mental health needs in the 1980’s. I was on the management committee at the time. She had a diagnosis of bipolar affective disorder. She was in her thirties and had spent a long time in hospital following an acute manic episode. The illness had effectively destroyed her life. Up until then she had been happily married, with a young daughter, living in a nice house in a nice part of Charwood, and working in the town as an assistant bank manager. She was an intelligent woman who had great ambition. But the onset of bipolar affective disorder had changed all that.
As her mental illness took hold, she became more and more grandiose and disinhibited. Her work suffered. She lavishly spent money she didn’t have on ridiculous schemes. She began to neglect her daughter. She embarked on reckless affairs which put increasing strain on her marriage. Eventually everything imploded and she was admitted to hospital. During her incarceration her husband filed for divorce and got custody of their daughter. He kept the house and she became effectively homeless. By the time she was admitted to the hostel, she was thin and ghostly in appearance, hardly ever saying a word, afraid to look anyone in the eye, and on an extensive medication regime of mood stabilisers and antipsychotics.
Over a number of years, however, I saw her gradually change. Several different combinations and doses of medication were tried, and her personality and something of her old spark began to return. At the regular dinners the committee members had with residents, she began to converse more, and her intellect began to shine through. She was a personable, articulate, well educated and vivacious woman, with good conversational skills. In time, she moved on to a self contained flat attached to the hostel, requiring less and less support.
But then, over 15 years on from her first breakdown, the bipolar disorder began to kick in again, and she became more and more manic. She began to spend large amounts of money on huge quantities of luxury foods which she could not possibly eat, and which was inevitably wasted. Since she had a very good pension from the bank where she had worked, she had accumulated a large amount of savings which she proceeded to squander. She was disinhibited, swearing in a way she would never normally have done, and flirting indiscriminately with males and females alike.
Eventually I was asked to assess her under the Mental Health Act. We arranged for her to come to the CMHT offices. When she arrived the button on her jeans was undone, as was her zip, and her jeans were halfway down her buttocks. She had put on a lot of weight, and much of this was on display. She was completely oblivious to this, and when she saw me she told me to “fuck off” before I could even speak to her, directed an impressive range of swearwords at several invisible people in the room, then walked out again.
I caught up with her again a day or two later, when she came to see her care coordinator at the CMHT. Although Daisy appeared a little less elevated than the day before, she nevertheless spoke rapidly and intensely, and was very difficult to interrupt. I gradually told her that in my opinion she was exhibiting symptoms consistent with hypomania, and listed them, explaining their meaning and the direct evidence I had to support my opinion. These included pressure of speech, flight of ideas, disinhibition -- arising not only from her state of dress yesterday but also from numerous occasions in which she had spoken loudly and inappropriately about her romantic and sexual desires for a male friend of hers, and the reckless spending of money.
“None of that is true, and you know it! I’ll have you for slander. I have friends in the legal profession who will sue you! I’ve only got to ring them!” she told me with the absolute certainty that only the most manic (and deluded) can possess. “If you persist in carrying on in that tone, I shall have no alternative but to hit you across the head!”
“Daisy,” I began, as calmly as possible. “If you were to hit me, it would only confirm my opinion. You would never dream of doing something like that if you were well. I do think you need to be in hospital at present.”
“Well,” she said, “If you’re thinking of sectioning me, I shall just have to jump in front of a lorry! What do you think of that?”
I did not think this was a good idea. However, I also did not think she was likely to carry out this threat.
“Look, why don’t you take a little more medication. You might be able to avoid going into hospital.”
She thought about this – for about a millisecond.
“And why don’t you go and fuck yourself!” she answered.
Her care coordinator decided to contribute to the conversation. “Daisy, that is an idea. I could take you to see Dr Drinkwater [her GP]. Let’s see what he thinks.”
Daisy liked Dr Drinkwater. “He is a very good friend of mine,” she said. “I do trust him. I’ll ask him what he thinks.”
I heard later from her care coordinator that Dr Drinkwater had agreed with me, and had recommended an increase in her medication. Amazingly, she had agreed to this. She therefore avoided a compulsory admission, and in time her manic episode subsided.
Two years later, however, she became manic again. All the symptoms had returned. Once again I was asked to assess her under the Mental Health Act.
She agreed to come and see me at the CMHT, arriving like a galleon in full sail, and walked into an interview, saying, “You can tell that fucker I’m here, and let’s see if he dares to section me.”
I sat down with her. “Hello, Daisy. You know what this is about. You know I have to assess you under the Mental Health Act, and you know I have the power to detain you if I think it is necessary. However, the last time we were in this situation, that didn’t happen, did it?”
“I can’t imagine why you think I need to go to hospital. I’ve asked all my friends, and they all agree that there’s nothing wrong with me.” She proceeded to give me the full details of all the people she had consulted and what they had said, at breakneck speed, so that it was impossible to interrupt her or get a word in edgeways. So I just sat there for a few minutes, waiting for her to stop.
During this monologue something strange and unexpected started to happen. Liquid started to flood from her seat onto the floor all around her. After a moment of shocked surprise I realised that she was urinating. She clearly eventually realised this too. She stopped talking, in order, it seemed, to give it her full attention.
The cascade of urine seemed to be interminable, but probably lasted no more than 4 or 5 minutes. She obviously needed to go. The puddle on the carpet began to extend inexorably towards me. I moved my feet discreetly.
Daisy sat there looking totally unconcerned as steam rose around her and the room filled with a miasma of hot urine. When she had completely finished, and the Niagara of urine had finally abated, she said with immense dignity, “I do have a urinary tract infection, you know,” as if no further explanation were necessary.
This time, Daisy did go to hospital.
Thursday, 25 February 2010
The Alarming Case of the Absconding Patient
David was in his 30’s. I had had to detain him under the Mental Health Act on a couple of occasions in the past. He had a diagnosis of schizophrenia, but had long periods of being well, and never happily engaged with psychiatric services. During his most recent hospital stay, about a year previously, he had left the ward one day and gone into Charwood town centre and entered a bank. He had patiently waited his turn, and when he reached the front of the queue had politely requested money to use “to alleviate poverty and suffering in the world”. Unaccountably, even though David had not been armed and had shown no aggression, the cashier handed over a considerable quantity of cash to him, which he then distributed to passers by in the street until the police arrived to take him back to hospital.
He had subsequently disengaged from the CMHT and no-one had seen him in recent months, except for a couple of occasions when he had turned up unannounced asking to see me. On both occasions I gained the impression that he was somehow playing with me, offering tantalising glimpses of a florid mental illness, as if he were challenging me to section him, then laughing at me when I tried to probe him. He was clearly enjoying himself, enjoying his illness. But he was also in control.
A few weeks later his mother turned up at the doctor’s surgery one day, dragging a reluctant David with her. The CMHT consultant happened to be holding a clinic at the surgery at the time, saw David with the GP, concluded that he was extremely unwell, and the two had completed medical recommendations for detention under Sec.2 MHA.
By the time the news reached me, he had gone home with his mother. I went round to conduct my assessment. David’s mother answered the door and let me in. His sister was also there.
David looked drawn and haggard, and not at all happy, in marked contrast to my last contact with him. It looked as if he had now lost control of his illness. The illness was now controlling him. He was clearly irritable, with aggression seething underneath his calm exterior. He was carrying a wet flannel
“I’m going to hit you with this flannel,” he said, smiling rigidly. He flicked my head with it, then threw it at me, as if he wanted me to play catch. I caught it.
“I know what you’re thinking,” he said. “But you’re wrong. I’m not mad, you know, and I can prove it to you. I can project thoughts into your head.”
He closed his eyes and concentrated. But I was not aware of any thought insertion.
“I don’t think that worked,” I said. “But I do think you are unwell.”
“Then I may as well kill myself, hadn’t I?” he said. Although he continued to smile, a tear flowed down his cheek.
I took his mother and sister to one side.
“David’s very unwell,” I said. “I’m very worried about him. He does need to be in hospital.”
“I really don’t want him to go,” his mother said. “Hospital won’t do him any good. He’d be better off here with his family. We can take care of him. I don’t want him to be sectioned.”
I talked it over with them. I explained my concerns. Since we were considering a Sec.2 I didn’t need the approval of the nearest relative. They pleaded with me to give them a chance to get him well at home. They assured me they would make sure he had his medication, that they wouldn’t leave him alone for even a minute, that they would let us know if they had any concerns, however small, that they would call us or the police the minute he tried to leave the house
I decided to give it a try. This did, after all, constitute an “alternative to compulsory admission”, it was worth trying as part of the decision making process. I had the two medical recommendations, I could review the situation daily, and complete an application at any time if I felt that things were breaking down.
I explained this to David. I told him that if he wanted to avoid going into hospital he would have to take the medication and stay with his mother and sister. I told him I would visit him tomorrow to see how he was getting on. He smiled and nodded, smiled and nodded. He was still smiling and nodding as I left.
I had barely returned to the CMHT when I received a call from his mother.
“David’s gone!” she shouted. “Just after you left he grabbed his car keys and he’s gone off in his car! He said he’s going to kill himself!”
My mouth felt very dry as I completed my application, formally detaining him under Sec.2.
Then I rang the police, explaining the situation to them. Then I waited.
I discovered that chewing my fingernails helped to pass the time. About half an hour later, the phone rang. It was the police.
“We’ve had a report of an incident,” the police officer said. “A car went through a red light at road works and hit a lorry head on. There’s an ambulance on its way now.” The officer promised to keep me updated.
I sat in the office, thinking. Worrying. Worrying about David. Worrying about myself. Would I have to give evidence at an inquest? What would I say? Where would the finger of blame point?
A few minutes later I received another call.
“A man answering the description of your patient was driving the vehicle. The ambulance is taking him to hospital now. We don’t have any more details.”
I set off for the hospital, and went to the Accident and Emergency Department, dreading what I would find. How badly injured would he be? Would he survive? Was anyone else injured?
But he was the only casualty. And miraculously (and also because he was wearing a seatbelt) he had escaped with nothing worse than a few cuts and bruises. In fact, he was medically fit for discharge.
And since Woodland House psychiatric unit was on the same site as the general hospital, I arranged for him to be taken directly to Bluebell Ward.
He had subsequently disengaged from the CMHT and no-one had seen him in recent months, except for a couple of occasions when he had turned up unannounced asking to see me. On both occasions I gained the impression that he was somehow playing with me, offering tantalising glimpses of a florid mental illness, as if he were challenging me to section him, then laughing at me when I tried to probe him. He was clearly enjoying himself, enjoying his illness. But he was also in control.
A few weeks later his mother turned up at the doctor’s surgery one day, dragging a reluctant David with her. The CMHT consultant happened to be holding a clinic at the surgery at the time, saw David with the GP, concluded that he was extremely unwell, and the two had completed medical recommendations for detention under Sec.2 MHA.
By the time the news reached me, he had gone home with his mother. I went round to conduct my assessment. David’s mother answered the door and let me in. His sister was also there.
David looked drawn and haggard, and not at all happy, in marked contrast to my last contact with him. It looked as if he had now lost control of his illness. The illness was now controlling him. He was clearly irritable, with aggression seething underneath his calm exterior. He was carrying a wet flannel
“I’m going to hit you with this flannel,” he said, smiling rigidly. He flicked my head with it, then threw it at me, as if he wanted me to play catch. I caught it.
“I know what you’re thinking,” he said. “But you’re wrong. I’m not mad, you know, and I can prove it to you. I can project thoughts into your head.”
He closed his eyes and concentrated. But I was not aware of any thought insertion.
“I don’t think that worked,” I said. “But I do think you are unwell.”
“Then I may as well kill myself, hadn’t I?” he said. Although he continued to smile, a tear flowed down his cheek.
I took his mother and sister to one side.
“David’s very unwell,” I said. “I’m very worried about him. He does need to be in hospital.”
“I really don’t want him to go,” his mother said. “Hospital won’t do him any good. He’d be better off here with his family. We can take care of him. I don’t want him to be sectioned.”
I talked it over with them. I explained my concerns. Since we were considering a Sec.2 I didn’t need the approval of the nearest relative. They pleaded with me to give them a chance to get him well at home. They assured me they would make sure he had his medication, that they wouldn’t leave him alone for even a minute, that they would let us know if they had any concerns, however small, that they would call us or the police the minute he tried to leave the house
I decided to give it a try. This did, after all, constitute an “alternative to compulsory admission”, it was worth trying as part of the decision making process. I had the two medical recommendations, I could review the situation daily, and complete an application at any time if I felt that things were breaking down.
I explained this to David. I told him that if he wanted to avoid going into hospital he would have to take the medication and stay with his mother and sister. I told him I would visit him tomorrow to see how he was getting on. He smiled and nodded, smiled and nodded. He was still smiling and nodding as I left.
I had barely returned to the CMHT when I received a call from his mother.
“David’s gone!” she shouted. “Just after you left he grabbed his car keys and he’s gone off in his car! He said he’s going to kill himself!”
My mouth felt very dry as I completed my application, formally detaining him under Sec.2.
Then I rang the police, explaining the situation to them. Then I waited.
I discovered that chewing my fingernails helped to pass the time. About half an hour later, the phone rang. It was the police.
“We’ve had a report of an incident,” the police officer said. “A car went through a red light at road works and hit a lorry head on. There’s an ambulance on its way now.” The officer promised to keep me updated.
I sat in the office, thinking. Worrying. Worrying about David. Worrying about myself. Would I have to give evidence at an inquest? What would I say? Where would the finger of blame point?
A few minutes later I received another call.
“A man answering the description of your patient was driving the vehicle. The ambulance is taking him to hospital now. We don’t have any more details.”
I set off for the hospital, and went to the Accident and Emergency Department, dreading what I would find. How badly injured would he be? Would he survive? Was anyone else injured?
But he was the only casualty. And miraculously (and also because he was wearing a seatbelt) he had escaped with nothing worse than a few cuts and bruises. In fact, he was medically fit for discharge.
And since Woodland House psychiatric unit was on the same site as the general hospital, I arranged for him to be taken directly to Bluebell Ward.
Tuesday, 23 February 2010
Obscure (and Awful) AMHP Joke
Q: How many AMHP's does it take to change the fuse on a plug?
A: 13.
[Even more obscure (and terrible) answer: 13(4).]
A: 13.
[Even more obscure (and terrible) answer: 13(4).]
Tuesday, 16 February 2010
Rule One: Keep at a Safe Distance
The course of an assessment under the Mental Health Act is quite often unpredictable: this one, although it took place some years ago now, particularly sticks in my mind.
I was on night duty one evening when I got a call from the local police station. They had a man detained under Sec.136 – this is when a police officer who finds someone in a public place who “appears to him to be suffering from mental disorder and to be in immediate need of care or control” can “remove that person to a place of safety”. Nowadays there are usually specially designated places of safety on hospital sites where people can be taken to be assessed, but back then a police station was the usual “place of safety”.
There was nothing at all known about Andrew except for his name, age (30) and address. The police had been called to an incident in the street outside his house. He had resisted all attempts to calm him down, and then started to atack the police who had attended. The police had found his house in a squalid condition, floors covered with dog faeces and rotting food in the kitchen. His electricity had been disconnected long ago. He had a rather neglected looking dog which was taken to a boarding kennel. There was no record of any previous psychiatric involvement, and he did not even seem to be registered with a GP.
I assessed him with two doctors. As we approached his cell he could be heard talking to himself and making odd noises. He abruptly stopped as we entered and looked at us with some hostility. I was glad we also had a police officer with us, and kept at a safe distance.
Andrew was unable to concentrate on what we were saying, and was unable to give us any information about his home circumstances, relatives or friends. He stared straight ahead most of the time, and after a while he began pacing the cell and breathing increasingly heavily, forcing the breath in and out through his clenched teeth until he began to foam at the mouth. This was disturbing.
We reached a tentative conclusion that he was experiencing a hypomanic episode. The state of his house seemed to indicate that his mental health had been deteriorating for some time. It was possible that this was a drug induced psychosis, but he had vehemently denied illegal drug use when asked. Either way, he needed further assessment and was in no state to give informed consent to this, so we completed an application under Sec.2.
I informed Andrew of the decision and explained to him that he would be taken to hospital by ambulance. Surprisingly, he seemed quite happy about this, followed us meekly out of the cell and strolled down the corridor flanked by two police officers.
I left the police station to get to my car, which was parked outside the police compound. I watched as an ambulance backed up to the rear entrance, from where Andrew and the two officers were emerging. One of the ambulance crew got out and opened the ambulance doors, and then stood there in the orange light of the sodium compound lights, waiting for the group to approach.
I watched as Andrew suddenly broke free from the police officers and lunged forward. I watched as the ambulance man folded up when Andrew’s head connected with his stomach, and the two disappeared into the ambulance. I watched as the police officers dived into the ambulance after them. I watched as the ambulance began to shake violently and two other police officers dived in. Then the ambulance doors were suddenly closed from inside, the blue lights started to flash, and the ambulance sped off to the hospital.
This broke me out of my stunned state. I quickly got into my car and followed the ambulance to the hospital, where it parked right outside the admission ward. One of the police officers opened the ambulance doors and went to the ward. He returned with two male nurses and the duty doctor. Even though Andrew was being restrained by three police officers, he was still struggling, causing the ambulance to shake constantly. The nurses restrained him some more, while the doctor administered an injection of intramuscular Haloperidol, of a dose considered more than sufficient to incapacitate him.
Andrew continued to attempt to struggle, hissing and panting through his teeth all the while, flecks of foam landing on the arm of the officer closest to his head. I saw that somewhere along the way he had incurred a head injury, and blood was oozing down his face. The officer nearest him also had a cut over his eye, which was also oozing blood. There seemed to be quite a bit of blood in the ambulance.
After 15 minutes, the doctor decided that the injection should have taken effect and they attempted to try and transfer him into the ward. But as they momentarily adjusted their grip on him, he took the opportunity to make a break for it, and very nearly got away.
It took another injection and another 20 minutes of relentless restraint before he was sufficiently sedated to be transferred safely into the ward.
I was on night duty one evening when I got a call from the local police station. They had a man detained under Sec.136 – this is when a police officer who finds someone in a public place who “appears to him to be suffering from mental disorder and to be in immediate need of care or control” can “remove that person to a place of safety”. Nowadays there are usually specially designated places of safety on hospital sites where people can be taken to be assessed, but back then a police station was the usual “place of safety”.
There was nothing at all known about Andrew except for his name, age (30) and address. The police had been called to an incident in the street outside his house. He had resisted all attempts to calm him down, and then started to atack the police who had attended. The police had found his house in a squalid condition, floors covered with dog faeces and rotting food in the kitchen. His electricity had been disconnected long ago. He had a rather neglected looking dog which was taken to a boarding kennel. There was no record of any previous psychiatric involvement, and he did not even seem to be registered with a GP.
I assessed him with two doctors. As we approached his cell he could be heard talking to himself and making odd noises. He abruptly stopped as we entered and looked at us with some hostility. I was glad we also had a police officer with us, and kept at a safe distance.
Andrew was unable to concentrate on what we were saying, and was unable to give us any information about his home circumstances, relatives or friends. He stared straight ahead most of the time, and after a while he began pacing the cell and breathing increasingly heavily, forcing the breath in and out through his clenched teeth until he began to foam at the mouth. This was disturbing.
We reached a tentative conclusion that he was experiencing a hypomanic episode. The state of his house seemed to indicate that his mental health had been deteriorating for some time. It was possible that this was a drug induced psychosis, but he had vehemently denied illegal drug use when asked. Either way, he needed further assessment and was in no state to give informed consent to this, so we completed an application under Sec.2.
I informed Andrew of the decision and explained to him that he would be taken to hospital by ambulance. Surprisingly, he seemed quite happy about this, followed us meekly out of the cell and strolled down the corridor flanked by two police officers.
I left the police station to get to my car, which was parked outside the police compound. I watched as an ambulance backed up to the rear entrance, from where Andrew and the two officers were emerging. One of the ambulance crew got out and opened the ambulance doors, and then stood there in the orange light of the sodium compound lights, waiting for the group to approach.
I watched as Andrew suddenly broke free from the police officers and lunged forward. I watched as the ambulance man folded up when Andrew’s head connected with his stomach, and the two disappeared into the ambulance. I watched as the police officers dived into the ambulance after them. I watched as the ambulance began to shake violently and two other police officers dived in. Then the ambulance doors were suddenly closed from inside, the blue lights started to flash, and the ambulance sped off to the hospital.
This broke me out of my stunned state. I quickly got into my car and followed the ambulance to the hospital, where it parked right outside the admission ward. One of the police officers opened the ambulance doors and went to the ward. He returned with two male nurses and the duty doctor. Even though Andrew was being restrained by three police officers, he was still struggling, causing the ambulance to shake constantly. The nurses restrained him some more, while the doctor administered an injection of intramuscular Haloperidol, of a dose considered more than sufficient to incapacitate him.
Andrew continued to attempt to struggle, hissing and panting through his teeth all the while, flecks of foam landing on the arm of the officer closest to his head. I saw that somewhere along the way he had incurred a head injury, and blood was oozing down his face. The officer nearest him also had a cut over his eye, which was also oozing blood. There seemed to be quite a bit of blood in the ambulance.
After 15 minutes, the doctor decided that the injection should have taken effect and they attempted to try and transfer him into the ward. But as they momentarily adjusted their grip on him, he took the opportunity to make a break for it, and very nearly got away.
It took another injection and another 20 minutes of relentless restraint before he was sufficiently sedated to be transferred safely into the ward.
Sunday, 31 January 2010
The Section 2 That Wasn’t
Perdita had suffered horribly for most of her life. She had been abused physically, sexually and emotionally as a child, and as an adult had gone from one abusive relationship to another. Along the way she had developed a wide range of coping strategies, including cutting, overdosing, denial of food, dependence on alcohol and drugs, and a range of alternate personalities, some of whom coped well and appeared “normal”, and some of whom you would not like to meet on a dark night. Or even in broad daylight.
Her alternate personalities all had names. There was Perdita of course, whom her community nurse encouraged to be in control. But there was also Grendl. Grendl was extremely unpleasant. She would swear, shout, scream, throw things around, gouge at her arms, take massive overdoses, and swing her favourite weapon, a baseball bat, at anyone she happened not to like. Which was everyone. And there was also Mavis, a very ordinary, impeccably behaved woman who appeared when she had to in order to rather resignedly clear up the mess left by Grendl.
Not surprisingly, Perdita had been involved with psychiatric services for most of her adult life, and had acquired a range of psychiatric diagnoses, including Dissociative Identity Disorder, Anorexia Nervosa, and of course Borderline Personality Disorder.
Perhaps more surprisingly, she also had a charming, polite and remarkably well adjusted 12 year old daughter called Ophelia (Perdita liked flowery names). Perdita had always done her best to protect her daughter from her behaviours, not always successfully. Children’s Social Services kept a wary eye on Ophelia.
Her community nurse was a patient and very experienced woman who generally managed to help Perdita keep her coping behaviours under control. However, a mix up with her methadone prescription had destabilised her, and Grendl was beginning to emerge. Perdita began to write a series of suicide letters, and confided to her nurse that she had been taking controlled but potentially dangerous amounts of paracetamol. Her nurse was becoming increasingly concerned about the welfare and safety not only of Perdita but also Ophelia. After a couple of weeks of escalating out of control behaviour, she arranged for a home visit with Perdita’s psychiatrist, who considered that Perdita ought to go into hospital. Perdita refused to consider this. The Crisis Team were called out to assess for home treatment, but when they visited, Grendl answered the door, baseball bat in hand, and told them to go away. Although not using those words. They went away.
That was when the Masked AMHP was asked to get involved.
The consultant gave me a recommendation for an admission under Section 2 MHA for assessment, and I went out to see Perdita in the company of another Sec.12 approved doctor and Perdita’s community nurse. I figured we’d probably be a lot safer if we went with someone who had a good rapport with her.
I wasn’t sure whether it was an angry Perdita or a subdued Grendl who answered the door and reluctantly let us in. Either way, there was no sign of the baseball bat.
She was not amused when I told her the purpose of our visit. She became almost instantly hostile, asked us to leave and shared with us an impressive selection of insults and swear words. I tried to continue to explain the importance of allowing us to interview her. In response she turned up the TV so loudly that it was impossible to speak to her.
We sat patiently for a few minutes, and after a while she turned down the TV to a reasonable level. This gave me an opportunity to speak.
“Perdita,” I began, “This is really important. You’re really struggling at the moment. You’re not in control. This isn’t fair on Ophelia. We have to keep you both safe.”
I had by now concluded that Perdita was so out of control that there was no alternative but to detain her in hospital for assessment. The doctor and I left the house and retreated to my car to complete the paperwork.
I went back into the house to break the news to her. Perdita had switched. The aggression and hostility had evaporated. In its place was a melodramatic level of contrition.
“I’m begging you not to send me to hospital! I’m begging you on my knees not to put me away!” She did indeed kneel on the floor in front of me, gazing beseechingly into my eyes, tears flowing freely down her cheeks. “Please, please, please, let me stay. Look, I’ll cook a nice meal for Ophelia, we’ll sit down together and watch a DVD, and then I’ll take my medication and go to bed.” This level of apology and contrition was actually much worse to bear than her anger, insults and aggression.
I had made a decision. I had completed my application. She was now officially detained under the Mental Health Act. The risks of not admitting her to hospital were high. She had switched once. She might switch back at any time. Surely it was too late to go back on all this.
But...
Grendl did seem to have gone for the time being. The threat of admission did seem to have brought Perdita back in control again. She was making reasonable plans for the future (at least the immediate future). And what would be the effect on Ophelia of being separated from her mother?
So in the end I decided to use the discretion given in Sec.6(1)(a) MHA – this gives an AMHP 14 days to complete the admission. It’s not actually used very much – in nearly all cases, especially Sec.2, an admission follows as quickly as suitable transport to hospital can be arranged.
I did a deal with Perdita. She would cooperate with us. She would allow us to help her to keep herself safe. She would tell us if she wasn’t managing. She would not put herself or Ophelia in danger. I would visit her tomorrow to review the situation. She readily agreed to all of this and was embarrassingly grateful. And when I visited the following morning, she was calm, collected, polite and cooperative, although still clearly feeling low and sad.
I continued to monitor her on a more or less daily basis for the next week. Things continued to improve. The crisis was over. I shredded the papers.
Her alternate personalities all had names. There was Perdita of course, whom her community nurse encouraged to be in control. But there was also Grendl. Grendl was extremely unpleasant. She would swear, shout, scream, throw things around, gouge at her arms, take massive overdoses, and swing her favourite weapon, a baseball bat, at anyone she happened not to like. Which was everyone. And there was also Mavis, a very ordinary, impeccably behaved woman who appeared when she had to in order to rather resignedly clear up the mess left by Grendl.
Not surprisingly, Perdita had been involved with psychiatric services for most of her adult life, and had acquired a range of psychiatric diagnoses, including Dissociative Identity Disorder, Anorexia Nervosa, and of course Borderline Personality Disorder.
Perhaps more surprisingly, she also had a charming, polite and remarkably well adjusted 12 year old daughter called Ophelia (Perdita liked flowery names). Perdita had always done her best to protect her daughter from her behaviours, not always successfully. Children’s Social Services kept a wary eye on Ophelia.
Her community nurse was a patient and very experienced woman who generally managed to help Perdita keep her coping behaviours under control. However, a mix up with her methadone prescription had destabilised her, and Grendl was beginning to emerge. Perdita began to write a series of suicide letters, and confided to her nurse that she had been taking controlled but potentially dangerous amounts of paracetamol. Her nurse was becoming increasingly concerned about the welfare and safety not only of Perdita but also Ophelia. After a couple of weeks of escalating out of control behaviour, she arranged for a home visit with Perdita’s psychiatrist, who considered that Perdita ought to go into hospital. Perdita refused to consider this. The Crisis Team were called out to assess for home treatment, but when they visited, Grendl answered the door, baseball bat in hand, and told them to go away. Although not using those words. They went away.
That was when the Masked AMHP was asked to get involved.
The consultant gave me a recommendation for an admission under Section 2 MHA for assessment, and I went out to see Perdita in the company of another Sec.12 approved doctor and Perdita’s community nurse. I figured we’d probably be a lot safer if we went with someone who had a good rapport with her.
I wasn’t sure whether it was an angry Perdita or a subdued Grendl who answered the door and reluctantly let us in. Either way, there was no sign of the baseball bat.
She was not amused when I told her the purpose of our visit. She became almost instantly hostile, asked us to leave and shared with us an impressive selection of insults and swear words. I tried to continue to explain the importance of allowing us to interview her. In response she turned up the TV so loudly that it was impossible to speak to her.
We sat patiently for a few minutes, and after a while she turned down the TV to a reasonable level. This gave me an opportunity to speak.
“Perdita,” I began, “This is really important. You’re really struggling at the moment. You’re not in control. This isn’t fair on Ophelia. We have to keep you both safe.”
I had by now concluded that Perdita was so out of control that there was no alternative but to detain her in hospital for assessment. The doctor and I left the house and retreated to my car to complete the paperwork.
I went back into the house to break the news to her. Perdita had switched. The aggression and hostility had evaporated. In its place was a melodramatic level of contrition.
“I’m begging you not to send me to hospital! I’m begging you on my knees not to put me away!” She did indeed kneel on the floor in front of me, gazing beseechingly into my eyes, tears flowing freely down her cheeks. “Please, please, please, let me stay. Look, I’ll cook a nice meal for Ophelia, we’ll sit down together and watch a DVD, and then I’ll take my medication and go to bed.” This level of apology and contrition was actually much worse to bear than her anger, insults and aggression.
I had made a decision. I had completed my application. She was now officially detained under the Mental Health Act. The risks of not admitting her to hospital were high. She had switched once. She might switch back at any time. Surely it was too late to go back on all this.
But...
Grendl did seem to have gone for the time being. The threat of admission did seem to have brought Perdita back in control again. She was making reasonable plans for the future (at least the immediate future). And what would be the effect on Ophelia of being separated from her mother?
So in the end I decided to use the discretion given in Sec.6(1)(a) MHA – this gives an AMHP 14 days to complete the admission. It’s not actually used very much – in nearly all cases, especially Sec.2, an admission follows as quickly as suitable transport to hospital can be arranged.
I did a deal with Perdita. She would cooperate with us. She would allow us to help her to keep herself safe. She would tell us if she wasn’t managing. She would not put herself or Ophelia in danger. I would visit her tomorrow to review the situation. She readily agreed to all of this and was embarrassingly grateful. And when I visited the following morning, she was calm, collected, polite and cooperative, although still clearly feeling low and sad.
I continued to monitor her on a more or less daily basis for the next week. Things continued to improve. The crisis was over. I shredded the papers.
Tuesday, 26 January 2010
“You’ll Have a Cup of Tea...”
I was on night duty and received the call from the GP early in the evening. Keith was a patient of his in his 50’s. He was a divorced man who lived alone in his own bungalow. He worked as an engineer. He had no previous history of mental illness, but had this evening turned up at the surgery complaining of sleep problems. The sleep problems seemed to relate to Keith spending every night working on a special project in his garage. He was adapting a Reliant Robin.
(For the benefit of those who have never encountered this form of vehicle, the Reliant Robin was a rather flimsy and unstable three wheeled car made of fibreglass, which is now thankfully no longer in production. Their cornering ability was notoriously bad. I once witnessed a Reliant Robin attempting to turn rather faster than it should. The car rolled over onto its side. The driver climbed out, shook his head, pushed it back onto its three wheels, and drove on.)
After a few minutes Keith confided to the GP that the special adaptation he was fitting to this Reliant Robin was an antigravity drive. At this point the doctor gently suggested that it might be a good idea if he were to see a psychiatrist. Keith did not take kindly to this, was uncharacteristically rude to the doctor, and abruptly left the surgery.
The doctor thought that Keith might be showing symptoms of bipolar affective disorder: in particular, grandiose delusions, as well as boundless energy, poor sleep, irritability, and pressure of speech.
I arranged to meet him with a psychiatrist at Keith’s house. It was mid evening by the time we got there, and dark. Keith answered the door, I explained who we were, and he rather reluctantly let us in.
When we were in his living room, I asked him, “Tell me more about your project.”
Despite his reticence, this was clearly a topic close to his heart, and he could not resist telling us about it, the sentences flooding out almost faster than he could move his lips.
“I received a vision about a week ago,” he said. “It was a plan for an antigravity device. It came from the Dog Star. Incidentally, the inhabitants of the Dog Star aren’t at all like dogs, you know, they’re more like furry slugs, and they all fly around on antigravity platforms. They chose me because of my engineering know how. I’ve managed to get most of the parts, and I’m making the ones I can’t buy myself.”
“Why a Reliant Robin?” I asked. “It’s somehow seems an unlikely car to fit an antigravity drive into.”
“Ah,” he said. “You might think that, but you’d be wrong. It’s exactly the right vehicle. You see, it’s made of fibreglass. That means it won’t interfere with the antigravity rays.”
I thought about this. I could see that this made a kind of sense. But not enough.
“I think it might be a good idea if you went into hospital for a while,” I said to him.
“What on earth for?”
“I think you may be mentally unwell at the moment.”
“They said people would think that. Well, you can all just get out of my house. Go on, get out!”
We retreated rapidly, especially as he had picked up a golf club and was waving it about in a threatening way, and heard him locking his front door as soon as we were outside.
It was strange that Keith had suddenly appeared to develop full blown symptoms of bipolar disorder in his 50’s with no previous history of any mental illness. We wondered if there was some organic cause. Whatever the reason, in view of his unpredictability and irritability, we decided that he needed to be in hospital, and was clearly not going to agree to this. We completed an application under Sec.2 MHA, for assessment. Then I called the police.
Four police officers in two police cars turned up a few minutes later. They knocked on his door, but he would not open it. We could see him peering out of his window at us. It looked as if I might have to get a magistrate’s warrant under Sec.135, but I decided to have one last try. I made my way to the front of the melee of police standing at his front door, and knocked again. I could see him through the glass on the other side of the door, and knelt down at his letter box.
“Please let us in, Keith, you have been detained under Sec.2 of the Mental Health Act. You’re going to have to go to hospital. If you won’t let us in now, I’ll have to come back later with a warrant.”
There was a pause. Then I heard him unlocking the door. As he opened it I smartly stepped forward and entered, expecting the police to be right behind me. However, as soon as I was in, Keith quickly shut the door and locked it behind us.
The police were on the other side of the door. On the wrong side. I was locked in a house with an unpredictable and irritable detained patient. Who had threatened us with a golf club. And the police were outside.
“You’ll have a cup of tea,” Keith said.
It was important not to panic. It was important to show Keith that I was in control of the situation.
“Actually, Keith, I don’t want a cup of tea. I’m actually feeling quite anxious about this. I’d feel a lot better if you unlocked the door.”
“Feeling anxious are you? Well, you’ll have a cup of tea then.”
I tried to find another way out of the house. I went through room after room. But all the windows and external doors were sealed unit double glazed units, all fitted with locks that could only be opened with a key. And Keith had the key.
“What are you doing?” he asked me ingenuously, as he followed me round the house.
“I’m trying to get out. I don’t like the fact that you’ve locked me in.” I could see the police milling about outside, trying windows and doors, but basically looking powerless and ineffectual.
“You’ll have a cup of tea,” he repeated, putting the kettle on.
“I really don’t want a cup of tea right now, Keith. We need to take you to hospital.”
“You’ll have a cup of tea,” he said again, very firmly, putting some teabags into a pot and pouring in the hot water. “You’ll have a cup of tea. Then we’ll go to the hospital.” He got out some cups.
I began to see what was happening. He too was attempting to retain a measure of control over the situation. It was a stalemate.
“All right,” I said eventually. “We’ll have a cup of tea. Then we’ll go to the hospital.”
“Milk?” he said, smiling. “Sugar?”
So we had a cup of tea. He chatted about this and that, while I drank the tea and tried to hide my panic. Then he unlocked the door, stepped out into the night and calmly got into one of the police cars.
(For the benefit of those who have never encountered this form of vehicle, the Reliant Robin was a rather flimsy and unstable three wheeled car made of fibreglass, which is now thankfully no longer in production. Their cornering ability was notoriously bad. I once witnessed a Reliant Robin attempting to turn rather faster than it should. The car rolled over onto its side. The driver climbed out, shook his head, pushed it back onto its three wheels, and drove on.)
After a few minutes Keith confided to the GP that the special adaptation he was fitting to this Reliant Robin was an antigravity drive. At this point the doctor gently suggested that it might be a good idea if he were to see a psychiatrist. Keith did not take kindly to this, was uncharacteristically rude to the doctor, and abruptly left the surgery.
The doctor thought that Keith might be showing symptoms of bipolar affective disorder: in particular, grandiose delusions, as well as boundless energy, poor sleep, irritability, and pressure of speech.
I arranged to meet him with a psychiatrist at Keith’s house. It was mid evening by the time we got there, and dark. Keith answered the door, I explained who we were, and he rather reluctantly let us in.
When we were in his living room, I asked him, “Tell me more about your project.”
Despite his reticence, this was clearly a topic close to his heart, and he could not resist telling us about it, the sentences flooding out almost faster than he could move his lips.
“I received a vision about a week ago,” he said. “It was a plan for an antigravity device. It came from the Dog Star. Incidentally, the inhabitants of the Dog Star aren’t at all like dogs, you know, they’re more like furry slugs, and they all fly around on antigravity platforms. They chose me because of my engineering know how. I’ve managed to get most of the parts, and I’m making the ones I can’t buy myself.”
“Why a Reliant Robin?” I asked. “It’s somehow seems an unlikely car to fit an antigravity drive into.”
“Ah,” he said. “You might think that, but you’d be wrong. It’s exactly the right vehicle. You see, it’s made of fibreglass. That means it won’t interfere with the antigravity rays.”
I thought about this. I could see that this made a kind of sense. But not enough.
“I think it might be a good idea if you went into hospital for a while,” I said to him.
“What on earth for?”
“I think you may be mentally unwell at the moment.”
“They said people would think that. Well, you can all just get out of my house. Go on, get out!”
We retreated rapidly, especially as he had picked up a golf club and was waving it about in a threatening way, and heard him locking his front door as soon as we were outside.
It was strange that Keith had suddenly appeared to develop full blown symptoms of bipolar disorder in his 50’s with no previous history of any mental illness. We wondered if there was some organic cause. Whatever the reason, in view of his unpredictability and irritability, we decided that he needed to be in hospital, and was clearly not going to agree to this. We completed an application under Sec.2 MHA, for assessment. Then I called the police.
Four police officers in two police cars turned up a few minutes later. They knocked on his door, but he would not open it. We could see him peering out of his window at us. It looked as if I might have to get a magistrate’s warrant under Sec.135, but I decided to have one last try. I made my way to the front of the melee of police standing at his front door, and knocked again. I could see him through the glass on the other side of the door, and knelt down at his letter box.
“Please let us in, Keith, you have been detained under Sec.2 of the Mental Health Act. You’re going to have to go to hospital. If you won’t let us in now, I’ll have to come back later with a warrant.”
There was a pause. Then I heard him unlocking the door. As he opened it I smartly stepped forward and entered, expecting the police to be right behind me. However, as soon as I was in, Keith quickly shut the door and locked it behind us.
The police were on the other side of the door. On the wrong side. I was locked in a house with an unpredictable and irritable detained patient. Who had threatened us with a golf club. And the police were outside.
“You’ll have a cup of tea,” Keith said.
It was important not to panic. It was important to show Keith that I was in control of the situation.
“Actually, Keith, I don’t want a cup of tea. I’m actually feeling quite anxious about this. I’d feel a lot better if you unlocked the door.”
“Feeling anxious are you? Well, you’ll have a cup of tea then.”
I tried to find another way out of the house. I went through room after room. But all the windows and external doors were sealed unit double glazed units, all fitted with locks that could only be opened with a key. And Keith had the key.
“What are you doing?” he asked me ingenuously, as he followed me round the house.
“I’m trying to get out. I don’t like the fact that you’ve locked me in.” I could see the police milling about outside, trying windows and doors, but basically looking powerless and ineffectual.
“You’ll have a cup of tea,” he repeated, putting the kettle on.
“I really don’t want a cup of tea right now, Keith. We need to take you to hospital.”
“You’ll have a cup of tea,” he said again, very firmly, putting some teabags into a pot and pouring in the hot water. “You’ll have a cup of tea. Then we’ll go to the hospital.” He got out some cups.
I began to see what was happening. He too was attempting to retain a measure of control over the situation. It was a stalemate.
“All right,” I said eventually. “We’ll have a cup of tea. Then we’ll go to the hospital.”
“Milk?” he said, smiling. “Sugar?”
So we had a cup of tea. He chatted about this and that, while I drank the tea and tried to hide my panic. Then he unlocked the door, stepped out into the night and calmly got into one of the police cars.
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