(This assessment took place before the Mental Capacity Act 2005 came into force. Had the MCA been in place at the time, the outcome might have been very different.)
Ernie was in his late 80’s. He lived alone and had no known relatives. In recent months the GP had become concerned about possible dementia, and he had been seen by a psychiatrist on one occasion.
It was the middle of winter. The GP had visited Ernie and found him crouched in front of a one bar electric fire, surrounded by squalor, and with a strong smell of excrement in the air. She was very concerned about swelling in his legs, and had arranged for an ambulance to take him to hospital. But when the ambulance had arrived, Ernie had refused to leave his bungalow, and so the ambulance went away. The GP then made a request for him to be detained under the Mental Health Act.
In view of his frailty and the possibility of a life threatening condition, I went out straight away and did a home visit with the GP. His bungalow was pretty much as she had described it. There was evidence of many years of neglect: plastic carrier bags filled with junk and rubbish filled his hallway, his kitchen was filthy, with little evidence of food, the walls were black with grime, and spiders’ webs hung from the corners of the rooms. Ernie himself was sitting in his armchair in front of his fire when we came in (his front door was not locked).
It took him a few moments to register we were there. He seemed quite moribund. He was clearly worse than he had been an hour or so ago when the ambulance had come. He barely recognised the GP. He would not allow the GP to give him a proper medical examination. The only coherent thing he said to us was: “I’m not going to no fucking hospital!”
We went back to the GP’s surgery.
“This isn’t a case for the Mental Health Act,” I began. “He’s physically ill. He needs to be in hospital. This is an emergency. He’s getting worse by the minute. We need to get an ambulance out again and bundle him into it, whether he likes the idea or not.”
“But we can’t,” she replied. “He has a diagnosis of dementia. He’s been seen by a psychiatrist. He has a mental disorder. That means we can only admit him under the Mental Health Act.”
“The Mental Health Act really doesn’t come into this. We’re not admitting him for his dementia, we’re admitting him because he’s dying.”
But the GP wasn’t having it. She was convinced that the existence of a diagnosed mental disorder meant that only the Mental Health Act could be used to remove him from his home. Continuing to argue about it was just wasting time, time that Ernie did not have. We had to get him to hospital somehow, and as soon as possible. And we really didn’t have time for a psychiatrist to come out and assess him. So I decided we had to go for admission under Sec.4.
But this only made things much, much worse.
I rang Ambulance Control.
“I need an ambulance for an elderly man detained under Sec.4 of the Mental Health Act. He needs to be admitted to the general hospital. He’s very ill and frail physically. It’ll be a blue light job.”
“We can’t admit someone under Sec.4 to a general hospital. In any case, we’d have to take him to Accident and Emergency first, and if he’s on Sec.4 he could only be taken directly to a ward that will admit him,” the controller helpfully told me.
I could see his point.
“OK,” I eventually said. “We’ll admit him to the psychogeriatric ward. But we need the ambulance as soon as possible. This is an emergency. He’s really very ill.”
“If he’s detained under the Mental Health Act we can only classify your request as urgent, not as an emergency. We will try to get an ambulance to you within an hour.”
I tried to argue this point. But as I have found on many occasions before, arguing with Ambulance Control is invariably futile. And neither is pleading, begging and crying any more effective.
When I rang the hospital to arrange a bed, the bed manager understandably wondered why Ernie wasn’t being taken to a general hospital. I tried to explain. I recognised that almost as soon as he was formally admitted to a psychiatric ward, he would need to be transferred to A & E – a further hurdle to getting him the appropriate medical treatment, but it seemed I had no option. The bed manager reluctantly agreed, and the GP and I completed the application under Sec.4.
I went back to Ernie’s bungalow to wait for the ambulance. In the event it came within half an hour. By now Ernie was so weak, he put up no struggle at all when the ambulance crew lifted him onto a stretcher and got him into the ambulance.
He did not put up any struggle when they took him by stretcher into the psychiatric ward. The ward sister looked askance at Ernie as he was wheeled past her.
“What the hell have you brought him here for in this state? He needs to be on a medical ward!”
I miserably tried to explain yet again why I had taken the decision. By now, I wasn’t even able to convince myself.
He was transferred to A & E within minutes of his formal admission under Sec.4 Mental Health Act, and was then admitted to a medical ward. As he should have been hours previously.
And three days later, he died.
Wednesday, 21 April 2010
Sunday, 18 April 2010
When To Use a Section 4 (and When Not To)
Detention under Section 4 of the Mental Health Act only requires one medical recommendation. It should be used “only in a genuine emergency, where the patient’s need for urgent assessment outweighs the desirability of waiting for a second doctor.” (5.4 Code of Practice). There should be evidence of “an immediate and significant risk of mental or physical harm to the patient or to others; danger of serious harm to property; or a need for physical restraint of the patient.” (5.6 CoP).
In 27 years of working within the Mental Health Act, I have used Sec.4 on only 17 occasions (and only once in the last 7 years). Most of those took place in the early years of the Act, when it was often impossible to get a second medical recommendation within a realistic time frame, especially in a rural area; when hospital bound consultants would still say: “Be a good chap and bring them in under a 4, and I’ll convert it to a 2 when you get here.”
I’ve written on this blog about the first time I used Sec.4 (Emma, posted on 11th July 2009) and the most recent time I’ve used it (Mavis, 24th April 2009). Here’s another example.
William was 40. He had learning difficulties and had been placed in a care home in our area for about a year. He had a history of impulsive and aggressive behaviour, and this had been getting worse over the last few weeks. He had assaulted two staff members and had been arrested, then bailed back to the home. Two days later, he assaulted three more staff members and was again arrested. He had again been bailed, but this time the home was no longer prepared to accommodate him. His Consultant Psychiatrist had arranged for a bed in a low secure private hospital and made a request for assessment for admission under Sec.2 Mental Health Act.
One might have imagined that this was a comparatively straightforward assessment of a man with learning difficulties (at least there was a bed – sometimes a bed for a patient with learning difficulties can take weeks to obtain, leaving the AMHP unable to complete an application because there is no hospital to put on the form, and sometimes having to obtain further medical recommendations because the first ones have run out of time).
But as I obtained more information, my heart sank. Firstly, the Consultant had not actually provided a medical recommendation, and was not currently available. Secondly, William was not at the police station, since he had been bailed and the staff had picked him up. And he was not at the care home, because they were refusing to take him back, and he was refusing to go back. At the time I received the request, he was being driven round the county in the home’s minibus, in the company of four of the staff. It was the only way to keep him happy and prevent him from beating them all up.
So somehow I had to arrange for the assessment of an aggressive and impulsive man with learning difficulties (and epilepsy and diabetes) who was only being managed by taking him wherever in the county he had a whim to go, otherwise he was going to assault even more staff. The Consultant, who had seen him and who could have furnished a recommendation, was unavailable. It did seem to be a matter of “urgent necessity” to admit him to hospital. It seemed logistically impossible to get two doctors in one place at the same time as the patient, and would involve unreasonable delay.
So I arranged for the assessment to take place at the GP’s surgery. I contacted the staff in the minibus on their mobile, liaised with the GP, and we all met up in the car park within an hour of receiving the call. The GP and I persuaded him to come into the surgery, where we interviewed him. Although he remained calm with us, this was probably more because of the novelty of the location, and the fact that he was supplied with a plate of biscuits. He did, however, become touchy when asked anything about the care home, and we felt we needed to finish our assessment at that point. With the GP’s lone recommendation I made an application under Sec.4 and rang the hospital to inform them that he was on his way.
But that was too easy, wasn’t it?
“We’re a low to medium secure unit,” the admitting nurse told me. “We only take patients who are detained under Sec.2 or Sec.3, or under Part III of the Act [relating to mentally disordered offenders].”
“What do you mean?” I asked. I explained the situation to the nurse as clearly as possible, aware that, now William was back in the minibus and expecting to go to hospital (which he said he preferred to the care home), he was again getting twitchy, because he liked to be in a moving vehicle, not in a car park. “If a patient has a lawful detention, I think it is immaterial what particular section they’re detained under.”
“We’ve never had anyone here on a Sec.4.”
“There’s always a first time for everything isn’t there? A Sec.4 was the only way I could see of getting him to a safe place. Once he’s admitted, we can get it converted to a Sec.2 within hours.”
This conversation continued for several more minutes. At one point the nurse transferred me to a social worker. I had a similar conversation with her, stressing that the longer the delay, the more agitated the patient was likely to become. In fact, I was myself beginning to get an inkling of the agitation William might be feeling. However, the social worker did seem to have a better grasp of the Mental Health Act, and of my predicament, and eventually she conceded that a section was, essentially, a section, and he could be admitted.
And within minutes of William’s arrival at the hospital, the Consultant miraculously made an appearance and supplied a second medical recommendation.
In 27 years of working within the Mental Health Act, I have used Sec.4 on only 17 occasions (and only once in the last 7 years). Most of those took place in the early years of the Act, when it was often impossible to get a second medical recommendation within a realistic time frame, especially in a rural area; when hospital bound consultants would still say: “Be a good chap and bring them in under a 4, and I’ll convert it to a 2 when you get here.”
I’ve written on this blog about the first time I used Sec.4 (Emma, posted on 11th July 2009) and the most recent time I’ve used it (Mavis, 24th April 2009). Here’s another example.
William was 40. He had learning difficulties and had been placed in a care home in our area for about a year. He had a history of impulsive and aggressive behaviour, and this had been getting worse over the last few weeks. He had assaulted two staff members and had been arrested, then bailed back to the home. Two days later, he assaulted three more staff members and was again arrested. He had again been bailed, but this time the home was no longer prepared to accommodate him. His Consultant Psychiatrist had arranged for a bed in a low secure private hospital and made a request for assessment for admission under Sec.2 Mental Health Act.
One might have imagined that this was a comparatively straightforward assessment of a man with learning difficulties (at least there was a bed – sometimes a bed for a patient with learning difficulties can take weeks to obtain, leaving the AMHP unable to complete an application because there is no hospital to put on the form, and sometimes having to obtain further medical recommendations because the first ones have run out of time).
But as I obtained more information, my heart sank. Firstly, the Consultant had not actually provided a medical recommendation, and was not currently available. Secondly, William was not at the police station, since he had been bailed and the staff had picked him up. And he was not at the care home, because they were refusing to take him back, and he was refusing to go back. At the time I received the request, he was being driven round the county in the home’s minibus, in the company of four of the staff. It was the only way to keep him happy and prevent him from beating them all up.
So somehow I had to arrange for the assessment of an aggressive and impulsive man with learning difficulties (and epilepsy and diabetes) who was only being managed by taking him wherever in the county he had a whim to go, otherwise he was going to assault even more staff. The Consultant, who had seen him and who could have furnished a recommendation, was unavailable. It did seem to be a matter of “urgent necessity” to admit him to hospital. It seemed logistically impossible to get two doctors in one place at the same time as the patient, and would involve unreasonable delay.
So I arranged for the assessment to take place at the GP’s surgery. I contacted the staff in the minibus on their mobile, liaised with the GP, and we all met up in the car park within an hour of receiving the call. The GP and I persuaded him to come into the surgery, where we interviewed him. Although he remained calm with us, this was probably more because of the novelty of the location, and the fact that he was supplied with a plate of biscuits. He did, however, become touchy when asked anything about the care home, and we felt we needed to finish our assessment at that point. With the GP’s lone recommendation I made an application under Sec.4 and rang the hospital to inform them that he was on his way.
But that was too easy, wasn’t it?
“We’re a low to medium secure unit,” the admitting nurse told me. “We only take patients who are detained under Sec.2 or Sec.3, or under Part III of the Act [relating to mentally disordered offenders].”
“What do you mean?” I asked. I explained the situation to the nurse as clearly as possible, aware that, now William was back in the minibus and expecting to go to hospital (which he said he preferred to the care home), he was again getting twitchy, because he liked to be in a moving vehicle, not in a car park. “If a patient has a lawful detention, I think it is immaterial what particular section they’re detained under.”
“We’ve never had anyone here on a Sec.4.”
“There’s always a first time for everything isn’t there? A Sec.4 was the only way I could see of getting him to a safe place. Once he’s admitted, we can get it converted to a Sec.2 within hours.”
This conversation continued for several more minutes. At one point the nurse transferred me to a social worker. I had a similar conversation with her, stressing that the longer the delay, the more agitated the patient was likely to become. In fact, I was myself beginning to get an inkling of the agitation William might be feeling. However, the social worker did seem to have a better grasp of the Mental Health Act, and of my predicament, and eventually she conceded that a section was, essentially, a section, and he could be admitted.
And within minutes of William’s arrival at the hospital, the Consultant miraculously made an appearance and supplied a second medical recommendation.
Wednesday, 7 April 2010
Some Notes for Readers of this Blog
When I started writing this blog, it was intended to consist purely of reminiscences of my present and past practice as an Approved Mental Health Professional (and previously Approved Social Worker). Cases were frequently chosen to illustrate the dilemmas and problems with which AMHP’s have to deal. I imagined that the readership (if any) would consist mainly of other AMHP’s or aspiring AMHP’s, and hoped it might be of interest to them.
From the feedback I have received from readers’ comments (which I really appreciate), I am building up a picture of the readership of this blog. As well as other mental health professionals, I am aware that there are also people who have been on the receiving end of the Mental Health Act, as well as others with a wide range of mental illnesses and disorders. This is making me aware that my accounts of assessments under the Mental Health Act might give to those readers an unduly alarming and possibly distorted picture of the consequences of having a mental disorder.
Readers need to be aware that my work as an AMHP is only a comparatively small part of my overall work as a social worker in a community mental health team, and by definition it only deals with crisis situations where people are acutely mentally disordered and may need compulsory detention for their safety and/or the safety of others. I have not written about anyone who has not been subject to an assessment under the MHA.
The people I see in my day to day work have a wide range of mental health problems, including depression, bipolar affective disorder, schizophrenia, personality disorders, anxiety, obsessive compulsive disorder, post traumatic stress disorder, and the long term psychological effects of childhood abuse. The vast majority of them will never find themselves needing to be assessed under the MHA or admitted to a psychiatric ward. Believe it or not, as a team we try to keep people out of hospital. What’s more, the vast majority of the people I see will improve, reach mental equilibrium and stability and be able to manage their disorder, or even recover completely, and will in time move on and cease to require support from mental health services.
I hope that service users and people who might have been detained themselves who read this blog will find it interesting and informative to see the process of assessment from the other side. I hope that they may recognise that AMHP’s are only ever trying to do what is in the interests of the patient and their carers, and that they must comply with the law and adhere to the highest standards. The fact that the AMHP, who makes the actual application for detention, is not a medical professional, is designed as a safeguard against undue medicalisation of the process of assessment in those acute circumstances.
I am aware that some of my accounts appear to have sad or unfortunate endings. I am, of course, only writing about the most severe and difficult situations I have come across in my career.
However, since this is my blog, I can write what I want, so I may also include some accounts of people I have worked with who did not need to be assessed or detained under the MHA, and whose stories have unequivocally happy endings. There are plenty of them.
Thank you all for reading.
From the feedback I have received from readers’ comments (which I really appreciate), I am building up a picture of the readership of this blog. As well as other mental health professionals, I am aware that there are also people who have been on the receiving end of the Mental Health Act, as well as others with a wide range of mental illnesses and disorders. This is making me aware that my accounts of assessments under the Mental Health Act might give to those readers an unduly alarming and possibly distorted picture of the consequences of having a mental disorder.
Readers need to be aware that my work as an AMHP is only a comparatively small part of my overall work as a social worker in a community mental health team, and by definition it only deals with crisis situations where people are acutely mentally disordered and may need compulsory detention for their safety and/or the safety of others. I have not written about anyone who has not been subject to an assessment under the MHA.
The people I see in my day to day work have a wide range of mental health problems, including depression, bipolar affective disorder, schizophrenia, personality disorders, anxiety, obsessive compulsive disorder, post traumatic stress disorder, and the long term psychological effects of childhood abuse. The vast majority of them will never find themselves needing to be assessed under the MHA or admitted to a psychiatric ward. Believe it or not, as a team we try to keep people out of hospital. What’s more, the vast majority of the people I see will improve, reach mental equilibrium and stability and be able to manage their disorder, or even recover completely, and will in time move on and cease to require support from mental health services.
I hope that service users and people who might have been detained themselves who read this blog will find it interesting and informative to see the process of assessment from the other side. I hope that they may recognise that AMHP’s are only ever trying to do what is in the interests of the patient and their carers, and that they must comply with the law and adhere to the highest standards. The fact that the AMHP, who makes the actual application for detention, is not a medical professional, is designed as a safeguard against undue medicalisation of the process of assessment in those acute circumstances.
I am aware that some of my accounts appear to have sad or unfortunate endings. I am, of course, only writing about the most severe and difficult situations I have come across in my career.
However, since this is my blog, I can write what I want, so I may also include some accounts of people I have worked with who did not need to be assessed or detained under the MHA, and whose stories have unequivocally happy endings. There are plenty of them.
Thank you all for reading.
Thursday, 1 April 2010
Shane
I was contacted first thing one Monday morning by our Criminal Justice Liaison Worker. Part of her job is to liaise with the police and the courts and to identify and assist with mentally disordered offenders.
She was ringing from Charwood Magistrates’ Court. There was a 15 year old boy in the cells, waiting to be charged with robbery and aggravated vehicle taking. The more she told me about the circumstances, the more appalled I became.
Shane had been a perfectly unremarkable boy until a terrible thing happened to him when he was 14. He was seduced and sexually abused by the mother of one of his friends. Since then he had become increasingly depressed and suicidal. He began to self harm. Three months before, he had cut his wrists quite badly and was assessed under the Mental Health Act and detained in a children’s psychiatric ward for about two months. He was a patient of the Child & Adolescent Mental Health Service (CAMHS).
A week previously Shane had taken a serious overdose and received medical treatment at the local Accident & Emergency Department. He had then run off, taken his parents’ car and was arrested and charged with aggravated vehicle taking. He was on bail when he was arrested again late on the Friday evening. He had stolen a car from a woman at knifepoint and had then crashed it, with the explicit intention of crashing it into a tree and killing himself. It was only the car’s insistence, through an annoying and persistent warning noise, to put on his seat belt that had saved him from serious injury. He was found by police wandering down the road in a very distressed condition, and had asked to be arrested. The police duly obliged.
What should then have happened:
The police, knowing his previous record of attempted suicide and self harm, should have arranged for a formal assessment under the Mental Health Act without delay. He could then have been detained under the Mental Health Act and admitted to a children’s ward for appropriate treatment.
What actually happened:
He was seen by a Forensic Medical Examiner, who unaccountably decided that he was fit to be interviewed. He was then interviewed, cautioned and remanded in custody until the next available court. Which was on the Monday. A suicidal, severely mentally ill child had been held in the cells for over 60 hours.
We attempted to retrieve the situation as much as possible. A social worker from the Youth Justice Team came to the court. We contacted the CAMHS consultant psychiatrist who also came to the court. His parents were already there with him, understandably extremely anxious and distressed about the entire situation.
We interviewed Shane. He presented with a range of symptoms of depression and Post Traumatic Stress Disorder, including nightmares and flashbacks relating to the abuse, loss of appetite and weight loss, and severe sleep disturbance. He was experiencing auditory hallucinations. He told us that he kept hearing an external male voice telling him to do things he didn’t want to do, such as cutting his wrists, taking tablets, and crashing the car. He said he had tried to use distraction techniques, but these did not always work. He cried. He wanted to die. He wanted it all to end. It was very clear from this interview that Shane was genuinely mental ill, and desperately needed to be in a safe environment.
In conjunction with the clerk of the court and Shane’s solicitor, we devised a plan. It was too late to use Part II of the Mental Health Act (Sec.2, Sec.3 etc), but we could use Part III of the Act, relating to the powers of the courts to detain mentally disordered patients. A bed was found in a secure children’s psychiatric unit. The Consultant gave evidence of Shane’s mental state to the magistrates. The Court agreed to detain Shane under Sec.35 for assessment. The police duly took him to the unit. Justice, at last, was done.
She was ringing from Charwood Magistrates’ Court. There was a 15 year old boy in the cells, waiting to be charged with robbery and aggravated vehicle taking. The more she told me about the circumstances, the more appalled I became.
Shane had been a perfectly unremarkable boy until a terrible thing happened to him when he was 14. He was seduced and sexually abused by the mother of one of his friends. Since then he had become increasingly depressed and suicidal. He began to self harm. Three months before, he had cut his wrists quite badly and was assessed under the Mental Health Act and detained in a children’s psychiatric ward for about two months. He was a patient of the Child & Adolescent Mental Health Service (CAMHS).
A week previously Shane had taken a serious overdose and received medical treatment at the local Accident & Emergency Department. He had then run off, taken his parents’ car and was arrested and charged with aggravated vehicle taking. He was on bail when he was arrested again late on the Friday evening. He had stolen a car from a woman at knifepoint and had then crashed it, with the explicit intention of crashing it into a tree and killing himself. It was only the car’s insistence, through an annoying and persistent warning noise, to put on his seat belt that had saved him from serious injury. He was found by police wandering down the road in a very distressed condition, and had asked to be arrested. The police duly obliged.
What should then have happened:
The police, knowing his previous record of attempted suicide and self harm, should have arranged for a formal assessment under the Mental Health Act without delay. He could then have been detained under the Mental Health Act and admitted to a children’s ward for appropriate treatment.
What actually happened:
He was seen by a Forensic Medical Examiner, who unaccountably decided that he was fit to be interviewed. He was then interviewed, cautioned and remanded in custody until the next available court. Which was on the Monday. A suicidal, severely mentally ill child had been held in the cells for over 60 hours.
We attempted to retrieve the situation as much as possible. A social worker from the Youth Justice Team came to the court. We contacted the CAMHS consultant psychiatrist who also came to the court. His parents were already there with him, understandably extremely anxious and distressed about the entire situation.
We interviewed Shane. He presented with a range of symptoms of depression and Post Traumatic Stress Disorder, including nightmares and flashbacks relating to the abuse, loss of appetite and weight loss, and severe sleep disturbance. He was experiencing auditory hallucinations. He told us that he kept hearing an external male voice telling him to do things he didn’t want to do, such as cutting his wrists, taking tablets, and crashing the car. He said he had tried to use distraction techniques, but these did not always work. He cried. He wanted to die. He wanted it all to end. It was very clear from this interview that Shane was genuinely mental ill, and desperately needed to be in a safe environment.
In conjunction with the clerk of the court and Shane’s solicitor, we devised a plan. It was too late to use Part II of the Mental Health Act (Sec.2, Sec.3 etc), but we could use Part III of the Act, relating to the powers of the courts to detain mentally disordered patients. A bed was found in a secure children’s psychiatric unit. The Consultant gave evidence of Shane’s mental state to the magistrates. The Court agreed to detain Shane under Sec.35 for assessment. The police duly took him to the unit. Justice, at last, was done.
Saturday, 20 March 2010
Daisy's Story: Part 2
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.
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.
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.
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