Sec.117 Aftercare: A Brief Guide for Patients and Relatives

I quite often get emails from relatives of people with mental illness asking questions relating to Sec.117 of the Mental Health Act 1983. From the information they give, it often appears that the regulations and guidance relating to Sec.117 are not being adhered to, or patients and relatives are not being kept in the loop when arrangements for aftercare are being made. I thought therefore that it might be helpful to lay out the basics relating to Sec.117 for the benefit of the consumer, so to speak.

 

What is Sec.117?

 

Sec.117 lays down a duty for the local authority and the NHS to provide services for people who have been detained and then discharged from certain sections of the Act. The most common section is Sec.3, where a patient has been detained for treatment. There are some other sections of the Act relating to people who have committed criminal offences for whom Sec.117 also applies. These are Sections 37, 45A, 47 and 48. Detention under these sections is much less common.

 

A patient who has only ever been an informal patient, or who has only ever been detained under Sec.2 (for assessment) is not entitled to aftercare under Sec.117. However, this does not mean that someone with mental health needs, but who has never been detained for treatment, is not entitled to services.

 

What is Sec.117 Aftercare?

 

The Code of Practice to the Mental Health Act says:

 

“After-care is a vital component in patients’ overall treatment and care. As well as meeting their immediate needs for health and social care, after-care should aim to support them in regaining or enhancing their skills, or learning new skills, in order to cope with life outside hospital. (27.5)”

 

Before anyone detained under the relevant sections is discharged from hospital, there has to be a meeting involving any relevant professionals or others, including the patient, relatives, and carers. There’s an extensive list in the Code of Practice as to what should be considered (27.13). These include: the psychological needs of the patient, as well as their family and carers; their physical healthcare; daytime activities or employment; appropriate accommodation; identified risks and safety issues; social, cultural or spiritual needs; assistance in welfare rights and managing finances; contingency plans and crisis contact details. There are many other things to be considered as well.

 

Once the patient is discharged, there have to be regular reviews in the community.

 

Will I have to pay for aftercare?

 

The most significant aspect of Sec.117 is that any aftercare provided under this section cannot be charged for. The MHA Reference Guide observes: “Because the Act provides no power to charge anyone for after-care services provided under section 117, they must be provided free of charge.” (24.18) Therefore, the patient cannot be charged for the cost of day care services, or residential care, for example, as long as it is specifically to meet the mental health needs of the patient.

 

Are there any exceptions to this?

 

There are some things that are not covered by Sec.117 aftercare. These are things which are considered to be basic needs, and not needs arising from the person’s mental health problems. These things include food and clothing, and rent for a flat. It may also be considered that if someone had mental health problems and a physical disability, needs arising from the physical disability might not be covered, and might therefore be chargeable, subject to an individual’s personal resources, of course.

 

I am the nearest relative of someone who has been detained in hospital under Sec.3 MHA. What can I expect to happen?

 

There should be regular Sec.117 Aftercare planning meetings. These take place while the person is an inpatient and well before they are discharged, and also periodically, usually at 6 monthly intervals, once they have been discharged.

 

At the meeting there should be the patient, their nearest relative, a representative of the local authority (for instance, a social worker), the patient’s Psychiatrist, a nurse, and then anyone else who might be involved in providing their aftercare, for example, someone from a day centre or a care home.

 

This meeting should set out what the patient’s mental health needs are, and what services are required to support them with these needs once they are discharged. The aftercare plan could be very simple, for example, stating that the patient will see a mental health professional regularly, that they should have regular outpatient appointments and that they should take specified medication. However, an aftercare plan may also entail placement in a residential care home, attending a day centre, the involvement of other professionals or care providers, etc.

 

Is Sec.117 aftercare time limited?

 

Sec.117 aftercare has no time limit. As long as the patient continues to require aftercare, even at a basic level, such as periodic outpatient reviews with a psychiatrist, then Sec.117 aftercare rules will continue to apply. Sec.117 aftercare can only cease if both the mental health service and the local authority are in agreement that it is no longer necessary, and they have to make a formal decision about this.

 

If someone has been detained under Sec.3 once 10 years ago, but since then has had a number of informal admissions, or admissions under Sec.2 alone, the subsequent admissions do not invalidate or strike out Sec.117. There should still be Sec.117 aftercare planning meetings even for someone who is an informal patient, no matter how long ago it was that they were detained under Sec.3.

Origins 7: My First Caseload: Aggie and Mother

Part 7 in an occasional series about my early years as a social worker in the 1970’s and 1980’s. Written down before I forget.

Aggie was in her early 60’s. She lived with her 97 year old mother on a smallholding in a particularly remote part of the Charwood Social Services catchment area.

The smallholding consisted of about 10 acres of small fields and meadows enclosed by hedges, an oasis in the midst of the vast, open, intensively farmed fields of an industrial style farm.

To reach her home, you had to drive a couple of hundred yards along a track across one of these huge fields, ploughed over in the winter, and swaying with wheat, or barley, or oats in the summer.

Once through the gate of Aggie’s smallholding, you had to park up and walk the rest of the way through meadows full of wild flowers, where her small herd of cows grazed, until you reached what she referred to as the farmhouse.

It took a leap of imagination to see this structure as a “farmhouse”. In reality, it was a single storey timber clad barn with a corrugated iron roof, a few small windows, and a dilapidated door that led into what passed as her kitchen cum living room.

It had been built by hand about 50 years previously by her father, who had a little money after serving in the 1st World War. He bought a few acres in the tiny hamlet and decided to raise his family there. He had died many years previously, but his daughter and wife still lived there.

Aggie and her mother lived in the most primitive conditions imaginable. They had no electricity or running water. All their water was obtained from a well just outside the back door. There was a tiny corrugated iron outbuilding which contained a plank of wood with a large hole in it and a bucket underneath the hole.

The interior of the “farmhouse” consisted of the kitchen cum sitting room, which contained an ancient and inefficient coal fired range that was kept alight all the time. It was the only heating or cooking facility they had. In the winter, the temperature rarely rose above 10C.

Unaccountably, the room was furnished with a range of fine antique furniture, all of it now very dilapidated and wormy. There was also a piano, and on the walls, in the dim light, could be seen huge Victorian oil paintings, some of them reaching from floor to ceiling. It was almost impossible to tell what the subjects of these paintings were, as they were covered in a film of soot from the oil lamps which were Aggie’s only source of light.

There was what Aggie called a parlour, but which she mainly used as a store room, and there were two bedrooms. Aggie slept in one, and her mother slept in another.

Aggie always took pride in introducing me to “Mother” during my visits. This meant a visit to the bedroom, where Mother appeared to spend her entire life.

Mother had had a number of strokes. This had left her almost completely immobile, and apparently incapable of speech. I certainly never heard her say a coherent word. She probably had dementia as well, but it was hard to tell.

It is very difficult to adequately describe Mother’s appearance. She was very obese, and very pale. Folds of flesh covered her face. Her eyes rarely opened. Her body was covered in tattered and ragged, mainly white layers of old fashioned nightdresses, which put one in mind of Miss Havisham in Great Expectations. In fact, the entire experience of visiting Aggie and her mother was exactly like stepping into a Dickens novel.

Mother was incontinent, and Aggie’s solution to this was to cover the mattress with roofing felt. As well as protecting the mattress, this also served the function, she would tell me, of preventing Mother from slipping too far down in the bed.

During these visits, Aggie would introduce me to Mother, and then prop her up in a sitting position. Mother very occasionally would open one eye to examine me, and even more rarely would make some sort of noise in response. I was never sure she had any idea what was going on, but Aggie would delightedly interpret these possibly random utterances as insightful comments about the weather or current events.

Aggie tried to keep alive the dream her father had of living the good life off the land, but to be honest, she was not very good at this.  She kept chickens, and tried to grow vegetables. She had a grape vine and would attempt to make wine out of the juice come the Autumn. She once offered me a bottle of this concoction, but I could not bring myself to try it.

She also used to make jam, with a minimum of sugar, as it was expensive, which meant that a layer of mould would soon appear on the top. I know this, because she once kindly gave me a jar. She also made various medicinal preparations using traditional recipes. One of my predecessors had once been reckless enough to try one of Aggie’s special complexion ointments, and had come out in a rash.

She and her mother lived a life of most extreme poverty. Their main source of income was their pensions, and although periodically Aggie would arrange for one or two of the cows or calves to go off to market, I suspected that the herd cost her more to maintain than the income she obtained from it.

Because of their isolation, several miles from the nearest shop, Aggie relied on a local grocer who would deliver in his van to obtain her weekly groceries. She had a standing order which would be delivered every week. She was fearful of changing this order for fear of upsetting the grocer and losing their lifeline.

One of the consequences of this was that she would have a carton of salt delivered every week without fail. She once showed me her stockpile of salt that she kept in the parlour. It occupied nearly half of the room. Even though she now had enough salt to last her the rest of her life, she would not entertain cancelling this part of the order “just in case”.

Aggie was very frugal and economical. If she wore out the cuffs of a shirt or blouse, she would simply cut off the sleeves up to the elbow and then attach some other sleeves using large stitches of wool. It didn’t matter whether or not the fabric matched in any way.

Despite apparently living life in the past, Aggie had a portable radio and would listen to Radio 4 all day long, so she was always up to date on national and world events, and actually had a keen and intelligent mind.

Although she had never seen a psychiatrist, Aggie probably had schizophrenia. She would often suddenly start whispering in the middle of a conversation, pointing to the ceiling and muttering under her breath about how the neighbouring farmer had fitted listening devices and was spying on her.

At this point, you may be wondering exactly what good a social worker was doing for Aggie and Mother. What I was endeavouring to do was to preserve the lifestyle they had chosen, and at times to deflect demands for “something to be done”. I would make sure that they had the benefits to which they were entitled, and my regular visits also monitored Aggie’s needs as a carer and provided Aggie with an outlet in which she could engage in an adult conversation.

One day, I had a phone call from Aggie. This took quite an effort for her. It meant she had to cycle the mile to the nearest public phone box.

She was beside herself. Mother had had another stroke. She needed a doctor.

I phoned Mother’s GP. I arranged to do a home visit with him.

I met him at the “farmhouse” and he examined Mother.

He agreed that she had had a stroke and that she needed to be in hospital.

This horrified Aggie.

“Mother won’t like it in hospital!” she wailed. “She won’t be able to hear the lowing of the cows, and the dawn chorus! She’ll pine away! She needs to stay here!”

But the doctor was clear. She was ill and needed to be in hospital. He was off to the nearest phone box to call them.

But I was thinking. What was in Mother’s best interests?

I knew for a fact that, once she was in hospital, she would never be allowed to return to the Victorian hovel that Aggie regarded as home. A district nurse would take one look at their living conditions and would refuse to allow it.

I was convinced that Mother would die in hospital if she were to be admitted.

Aggie offered Mother love and uncomplaining round the clock care in the environment that Mother had always known. So far, she had managed to keep her alive despite her poor health and extreme age. It wasn’t all about the physical environment.

I argued this case to the GP. Although he was clearly looking at the situation from the point of view of a medic who sees a medical condition and has a set of routines for dealing with it, he did nevertheless listen to me. He could see my point.

In the end, it was agreed that he would drop in on Mother over the next few days to observe her progress. She would not be admitted to hospital after all.

I felt pleased. I told Aggie the good news. But she was so distressed by the threat that she felt she needed to focus her distress on someone.

“It’s your fault!” she said. “You’ve come here wearing grey. Grey is an unlucky colour! You’ve put a jinx on Mother! This would never have happened if it wasn’t for you!”

And despite my successful efforts to produce an outcome that would be best for Mother and for Aggie, Aggie refused to see me again.

You don’t often get thanks as a social worker. But that’s all part of the job.

How to survive in social work: The Masked AMHP's latest Guardian piece

When dealing with hostile and aggressive people you should not take it personally, advises the blogger Masked AMHP.

You can read the Masked AMHP's latest piece in the Guardian Social Care Network here.

Delays and More Delays: The College of Social Work AMHP Practice Survey 2013

Two AMHP's waiting for an ambulance

It’s official: Mental Health Act Assessments are beset with unacceptable delays all over the country (or at least England). That’s the message from The College of Social Work’s recent AMHP Practice Survey, the results of which were released at the end of May. And it’s the AMHP’s (and of course the patients) who are suffering the most.

101 of the 152 local social services authorities responded.

There were three main areas leading to delays in admission: lack of suitable hospital beds, problems with ambulances, and lack of police availability.

Lack of beds
The report found that two thirds of local authorities had encountered delays in assessment due to lack of a hospital bed. This figure went up to 80% when reporting delays to compulsory admission. The longest delay to admission was apparently 21 days. (Is this a record, or do you know better? I recall once being involved in an assessment of a man in a care home with learning difficulties where the medical recommendations, which are valid for 14 days, expired not once but twice, before a suitable bed could be found.)

The shortage of a hospital bed in the patient’s locality was also highlighted. This had at times led to either the patient or the nearest relative objecting to an admission to an out of area hospital. This has then led to otherwise avoidable compulsory detentions, and in two cases the nearest relative was displaced because of objections about the distance to the admitting hospital.

I have certainly been forced on a number of occasions to admit a patient to a hospital over 70 miles from the patient’s home. The worst case I have come across locally was a patient detained under Sec.2 to a hospital 150 miles away.

The shortage of beds has also led to undesirable alternatives, and to the bending, if not outright breaking, of the law. Nearly 80% of respondents had experienced patients being kept in police cells or A&E departments for far longer than should have been necessary for this reason.

Lack of hospital beds has also led to delays in the ability of an AMHP to make an application. 42.9% of respondents identified that there had been delays due to Sec.12 doctors being unable to write the name of a hospital on their recommendation. The same would apply to AMHP’s who cannot formalise a detention until they can write the name and address of the admitting hospital on the form.

Another disturbing finding was the use of formal detention rather than informal admission. 16.5% of respondents reported occasions when a patient had been detained because an informal admission was not available. This flies in the face of the requirements of Sec.131(1) MHA. Sec.131(1) states, in rather convoluted language:

“Nothing in this Act shall be construed as preventing a patient who requires treatment for mental disorder from being admitted to any hospital … without any application, order or direction rendering him liable to be detained under this Act.”

This means, essentially, that a hospital should not refuse to admit a patient unless they are detained. Insistence on only accepting detained patients directly contravenes this section of the Act.

Ambulance delays
Anecdotally, wherever in the country I have been, AMHP’s I have spoken to have complained about delays in admission due to the unavailability of ambulances. Certainly, in my local authority, the issue of ambulance delays has been such a problem that private ambulance services are often used, and there was even put in place an arrangement for transport to be available via the Crisis Team if all else failed.

The College of Social Work survey bears this out. Over half of respondents reported that local arrangements with ambulance services were either not working very well, or were not working at all.

Police delays
The survey reports that two thirds of respondents reported that MHA assessments had had to be postponed because the police were unavailable to provide support at the assessment.

What is causing these reported problems? I am afraid I would have to lay the blame for this at a cumulative and multifaceted collapse of some of the essential functions of the NHS due to service cutbacks.

One such example was a staffing crisis at the A&E Dept at the Norfolk and Norwich Hospital. The Eastern Daily Press reported in April 2013 that at one point there were 12 ambulances queuing up outside the hospital for up to 3 hours because of delays in processing admissions. At one point it was reported that an inflatable tent was erected outside the A&E Dept. to try to cope with the workload. There was then a knock on effect on the availability of ambulances for other tasks, such as transporting mental health patients to hospital. It has been reported to me that one AMHP had to wait 17 hours for an ambulance to arrive because for these delays.

At the same time, the East of England Ambulance Service, which covers this area, was in crisis. Again the Eastern Daily Press reported high levels of low morale among staff. Tony Hughes, GMB organiser, reported that the Ambulance Trust needed to boost ambulance numbers and recruit more paramedics to relieve stress amongst staff. He stated: “The ambulance service is in total disarray. Lots of investment needs being put in to get it right and policies and procedures are not fit for purpose. Staff morale is almost zero. All efforts should be put in to look after patients rather than wasting time on foundation trust status.”

Then there are the closures of psychiatric hospital beds which has been accelerating at the same time as massive cutbacks in community mental health staff who could reduce the pressure on admission are being initiated. In 2012 the CQC reported that 2000 psychiatric beds, or 12% of the total, were lost over the previous year. In November 2012 the Sunday Express reported that “Six per cent of psychiatric wards have more patients than beds and a further 10 per cent are at full capacity”. It also reported that “in south Hampshire, 30 per cent of psychiatric beds, 58 in total, were axed last year. Six patients had to be sent to the private Priory clinic in London for a total of 127 days at a cost of £66,500."

Unfortunately, Hampshire is not the only place where this is happening. This pattern of bed closures, and the resulting need to use distant and expensive private beds, is being repeated all over the country.

I fear that the major reforms to provision of NHS services, involving the creation of community care groups who will commission mental health services, which came into being this April, are likely to make this an even bigger problem.

The College of Social Work survey reported that “in many cases AMHP’s and AMHP leads are… remaining with patients until the situation is resolved.” As a humble AMHP, I can only see myself and my colleagues having to spend even more time trying to get mentally unwell patients into hospital, with no choice but to wait with the patient in their home and try to manage their distress, and the distress of their relatives and carers. And wait. And wait. Until the job is done.

When is it “not reasonably practicable” to consult the Nearest Relative? Some recent Case Law

Police discreetly executing a Sec.135 Warrant

A very recent (8th May 2013) High Court Case, TW v London Borough of Enfield and Another [2013] EWHC 1180 (QB) was asked to consider whether or not there was a case that Sec.139 was incompatible with the Human Rights Act.

 

As all AMHP’s will know, Sec.139 Mental Health Act 1983 exempts AMHP’s and others who are doing “any act purporting to be done in pursuance of this Act” from civil or criminal proceedings “unless the act was done in bad faith or without reasonable care”.

 

While at first glance this appears to be of interest primarily to lawyers, in fact the case hinges on the legality of a patient’s detention under Sec.3, and whether or not the ASW (the actual incident took place prior to the introduction of AMHP’s in 2008) acted unlawfully by not consulting with the patient’s Nearest Relative.

 

The bare bones of the case are as follows.

 

On 29^th June 2007 an ASW, 2 doctors and police executed a Sec.135 warrant and entered the property of TW. TW was then detained under Sec.3 MHA for treatment from her home and admitted to hospital. She remained subject to Sec.3 until she was discharged by a Tribunal on 14^th September 2007.

 

TW’s case was that, as her Nearest Relative was not consulted in accordance with the requirements of Sec.11(4), then the application was illegal and that the LA and the ASW had “acted in bad faith or at least with a lack of reasonable care.” She therefore wished to sue the MH Trust, the Local Authority and the ASW.

 

In fact, there is a considerable amount of information in the Judgment relating to the psychiatric history and the behaviour of TW. She had a formal diagnosis of OCD, and had had inpatient treatment in a psychiatric hospital in the past.

 

There were letters written by TW and other statements that she had made in regarding her relationship with her parents. Her father was the Nearest Relative. One of the letters to her psychiatrist stated: “"my Mum and Dad called the police and my Dad threatened to hit me and my Mum ran next door to a neighbour's house. I was outside when the police came. My Mum and Dad tried to section me through the police who tried to smash the car window and get me out but I was able to stay in the car and drive away fast. … There are to be no meetings with my family." She subsequently left a message stating that no information should be given to her parents.

 

In another letter she stated: “My Dad threatened to smash my face in once again on the phone on my birthday and my Mum was making it worse”. This letter went on to say that “I would like my Mum to be taken off as my next of kin and my Dad off as the nearest relative." She suggested that she would like another person to act as her NR.

 

The Sec.135 and subsequent Sec.3 were triggered by a number of incidents prior to 29th June 2007. It was reported that TW “had hit a neighbour on 17th June 2007. She had been taking the rubbish out of the neighbour's dustbins into her flat. She had been unwilling to engage with support services or to allow them access to her flat. The flat was filled with rubbish and posed a risk to her and others because of the fire hazard.”

 

The Judgment records both the patient’s account of her assessment and detention, and the ASW’s account. They differ markedly from each other.

 

TW stated: "29th June 2007 was the day I was sectioned. More than nine people, including three police officers, doctors [and] officers from Environmental Health to section me. I was upstairs about to wash my hair and therefore when they knocked on the door I did not come to the door straightaway. They smashed my door in and humiliated me in front of all my neighbours. I was extremely frightened and felt totally helpless. As I did not recognise anyone in particular I shouted out aloud to them to call my parents. They must have heard me but simply ignored my requests."

 

It was reported that, according to the ASW, TW “spoke to the assessing team through her window but continued to refuse to open the door. The police then had no alternative but to execute the warrant to enter the property. The Applicant came downstairs shouting that she did not want anyone to come into her property, but then allowed Dr Duignan and Ms Muschett [the ASW] in.”

 

In considering whether or not to consult the Nearest Relative, the ASW clearly considered the case law of R(E) v Bristol City Council (2005). In this particular case, “the patient did not wish her nearest relative, namely her sister, to be involved with her case and there was evidence that she would be so distressed by the sister being consulted that it could harm her health. The sister likewise did not wish to become involved.” In that case, the Judge concluded that “"practicable" and "reasonably practicable" can be interpreted to include taking account of the Applicant's wishes and/or her health and well-being."

 

This Judgment is frequently considered by AMHP’s when deciding whether or not to consult with the NR, and evidence that an AMHP has thought about this is often sought in AMHP’s MHA Assessment Reports.

 

It appears that TW wanted things both ways. She wanted mental health services to respect her wishes that they not give any information to her parents, and gave testimony that the relationship with her parents had irretrievably broken down. At the same time, however, she wanted to sue the same authorities for not consulting with them.

 

The Judge stated that TW “had repeatedly, in dictated letters, instructed Enfield's staff not to involve her family. She had gone so far as to refer to having obtained solicitors' advice about breaches of patient confidentiality. These were not deluded ravings, and Ms Muschett and her colleagues were right to treat them seriously.”

 

He concluded that: “The evidence of Enfield's witnesses is that they considered that involving TW's father on 29 June 2007 would be likely to cause her distress and emotional upset... The test on this issue is a subjective one, and a matter of professional judgment.”

 

The Judge went on to say “it is clear that it was "not reasonably practicable", within the meaning of Sec.11(4) of the Mental Health Act 1983, for Enfield to have consulted TW's father before applying for her admission for treatment on 29 June 2007; and that the claim against Enfield is therefore bound to fail.”

 

This is further reinforcement of the AMHP’s duty to consider very carefully the implications of consultation with the Nearest Relative when making an application under Sec.3, and not to be afraid to take into account the wishes of the patient in relation to consultation with the NR, and therefore to make a decision not to consult where the evidence indicates that harm or distress may be incurred by the patient.

Origins 6: More of My First Caseload

Part 6 in an occasional series about my early years as a social worker (also known as Reminiscence Therapy.)

May contain triggers for abuse

Bobby’s story has been buzzing around in my mind for months, but I’ve been hesitating to write it down. It is so outlandish as to be almost unbelievable. And yet, when I inherited his case as a very junior, inexperienced and unqualified social worker in the 1970’s, I remember that I just took it all in my stride. Working with such people is just what a social worker does, I assumed. And Bobby’s story somehow needs to be told, somewhere.

Bobby was in his 30’s. He had severe learning difficulties. He lived with his mother and two brothers in a primitive cottage in a small village a few miles outside Charwood.

I began by reading Bobby’s file. Bobby’s file went back to his birth in the 1940’s. At birth, he was formally classified as having severe “mental subnormality”. In fact, his official designation was “cretin”. “Idiot” and “imbecile” were other classifications of “mental subnormality” in common clinical use at the time he was born.

Bobby had a full-scale IQ of around 40. I’m not sure how they were even able to calculate that with any degree of certainty. He also had severe congenital abnormalities. He had gargoylism, which I now know to be a genetic condition characterised by dwarfism, learning difficulties and facial abnormalities. Bobby was a little over 4 feet tall, with a barrel chest and a large head, with eyes that somehow appeared to display awareness and intelligence.

His mother also had learning difficulties, as did two of his three brothers. In fact, they had all been inmates of Fairville, the local learning difficulties hospital at various times, and for various reasons. Fairville, despite its name, was a rather miserable looking Victorian asylum in the middle of the countryside which specialised in “mental handicap”, as the politically correct term for it was in the late 70’s (“mental subnormality” having fallen out of favour by the time I began in social work).

The deeper I delved into the file, the more incredible this family’s story appeared.

In the 1920’s, Bobby’s mother had become pregnant at the age of 15. The father was her cousin. The child was born with learning difficulties. Bobby’s mother was placed in Fairville for being a “moral defective” and spent several years there, although subsequently appeared to have been allowed to have her baby back.

Bobby’s mother then had two more sons. It was unclear who the father was, as she never married. One of them I never met, although he also appeared to have had learning difficulties, and the file recorded that he had been incarcerated in Fairville at some stage for being a “moral defective” after being convicted of sexual offences against animals.

Then Bobby’s mother became pregnant again, and gave birth to Bobby.

The file recorded that the social worker at the time that Bobby was about 8 years old conducted a home visit, and Bobby complained to him that he was prevented from sleeping in his mother’s bed because his elder brother kept throwing him out of the room.

There was an investigation. It turned out that Bobby’s eldest brother was, in fact, also his father.

His brother went to court (it appears they spared Bobby’s mother). He was found guilty of incest and was placed in Fairville as being deemed to be a “moral defective”.

But all that was in the past, long before I became Bobby’s social worker.

So despite the extremely murky history, Bobby lived with his mother, a brother who also happened to be his father, and one other brother. The other brother did not have any learning difficulties, and actually held down a full time job.

So what was my task as a social worker with Bobby?

This mainly consisted of supporting his mother as Bobby’s main carer, as well as troubleshooting the scrapes that Bobby got himself into from time to time.

Bobby was far too disabled to attend the local sheltered workshop for people with learning difficulties (such places used to be called adult training centres), so his main pastime was roaming the lanes of the village while chewing a catalogue. He loved catalogues. The bigger the better. He would put it to his mouth as if playing a harmonica, then chew it.

The villagers in general had a high threshold of acceptance for Bobby and his family. But occasionally I would get letters from the clerk to the parish council complaining about his behaviour. The principle problem was Bobby’s need to urinate from time to time during his village forays. He was oblivious to where he might be, or who might be watching, during these necessary interludes. I would then have to have words with Bobby’s mother and write some sort of ameliorating reply to the clerk to the parish council.

During the two years that I worked with Bobby, I never understood a single word he spoke, although his mother appeared to be able to converse with him, and would then interpret.

From time to time, I would arrange respite care for Bobby. This was generally in a respite ward at Fairville.

At other times, I would take him and his mother to see the doctor if he became ill. When Bobby developed a cold or other infection, he appeared to become psychotic. It was apparent from the way he moved his eyes and head that he was responding to voices, and during these times would converse unintelligibly with them.

At Christmas, I would take the family a box of groceries. Charwood Social Services would always receive hampers of basic food items at Christmas, and we would then distribute them to needy clients. Bobby’s mother always made sure she was on my list, by writing me a gentle reminder a little before the time.

“I’m just taking the pleasure in writing to you,” she always began, before launching into a request for assistance. She always signed these letters, “Your Sturly”.

With the benefit of hindsight, and in the light of the many years of changes in Society’s attitude to people with learning difficulties, I do wonder whether there was more that I could have done for Bobby and his mother.

It was as if they were fixed by their life experiences, going back to the 1920’s in his mother’s case, and living as they were in a cottage, and a rural community, which had changed little since Victorian times. Bobby’s mother still remembered the old “Poor Law” system, where it was necessary to defer to those with power over you in order to get even basic support. And there was always the risk of being branded a “moral defective” and being locked up in an asylum if you didn’t toe the line.

But, paternalistic or not, at least the social services department was assisting the family to stay together in the community in which they had always lived.

When Do You Intervene When Someone’s Suicidal?

The inquest on Bryan Jobson, who lived in Leeds, was concluded on 1^st May 2013. Mr Jobson hanged himself with a noose suspended from his loft hatch in February 2011.

 

What was particularly remarkable in this case, and which resulted in the inquest being reported not only in the Yorkshire Evening Post, but also in the DailyMirror, was that two mental health nurses from the local Crisis Team had visited him the day before he killed himself, and saw the noose hanging from the open loft hatch, with a chair directly underneath it.

 

It is reported that Mr Jobson, who was 44, had previously attempted suicide, that his relationship with his wife had broken down, and that he had recently experienced the loss of others close to him. The visit by the two nurses was in response to a call he had made to the Crisis Team.

 

It was reported that one of the nurses, who saw the noose and chair, told the inquest: “We were thinking about legal aspects. We are not allowed to touch things without their permission. I know it seems ridiculous, but we have rules to abide by.”

 

The nurses left him after gaining an assurance from Mr Jobson that he would not take his own life and would engage with the Crisis Team.

 

I do not know all the circumstances of this case other than what I have read in the press, and do not wish to comment further on this specific case, except to say that, from the inquest report, it is clear that these professionals were caring and experienced people who were acting in what they genuinely felt were the best interests of Mr Jobson.

 

However, the situation those two workers found themselves in does merit further examination.

 

Community Mental Health Workers often find themselves in the position of having to make an assessment of risk. This can be in a routine assessment, when a patient reveals a history of self harm or suicide attempts, or tells the interviewer that they feel suicidal and have plans to end their life.

 

It can also be in situations of acute risk, where the worker discovers that a patient has been stockpiling medication with suicidal intent, or has purchased a hose to connect to their car exhaust, or has made a noose or other ligature.

 

In these situations, a professional has to make a decision as to whether or not further action needs to be taken, such as arranging for a hospital admission, or considering conducting an assessment under the Mental Health Act.

 

In all cases, the risk of harm to the patient has to be balanced with the need to allow the person self determination and to respect their privacy and personal rights.

 

Certainly our local Mental Health Trust’s Policy on Self Harm encourages positive risk taking, which is described as “a person centred approach focusing on the service user’s strengths and the support required to enable them to take control over their behaviour.”

 

I often work with people who deliberately self harm, typically by cutting themselves, although there can be a wide range of self harming behaviours. It is important to distinguish cutting as a means of releasing distress, with cutting designed to cause serious harm or even death.

 

But what do you do when a patient reports that they not only have the means to take their own life, but also have the stated intent?

 

It is reported in Bryan Jobson’s inquest that the nurses were prevented from touching the property of a patient because of “rules that had to be abided by”.

 

I am not actually aware of any National or local guidelines or policies that prevent a mental health professional from taking action designed to reduce the risk of death or serious self harm.

 

Certainly, on the local psychiatric ward, one of the first things staff do when someone is admitted is to inspect their property and remove anything that could be used to harm themselves, or cause harm to others, such as razor blades, laces, belts, or other things which could readily be used as a ligature. This goes equally for informal as well as detained patients.

 

To reinforce such basic commonsense steps to safeguard vulnerable people, the Mental Capacity Act is designed at least in part to provide guidelines on what constitutes reasonable action to take to safeguard people who lack capacity.

 

One of the fundamental principles of the Mental Capacity Act is that anything done should be in the best interests of the person. However, “people have the right to make decisions that others might think are unwise. A person who makes a decision that others think is unwise should not automatically be labelled as lacking the capacity to make a decision.” (MCA Code of Practice Ch2.)

 

It should not therefore automatically be assumed, just because someone is stating the intent to end their life, that they lack capacity.

 

But any person, not just a mental health professional, is able to make an assessment of risk and take appropriate action in order to protect another.

 

A very basic example is that of a small child who is about to step into the path of a lorry. Their carer will make an instant assessment of the risk of harm if the child were to step off the kerb, and would then act to prevent the child from doing so.

 

The same would apply to an adult with learning difficulties who lacked capacity and was oblivious to the danger.

 

Not long ago, I was working with a woman with severe depression. She confided to me during one of my visits that she had been systematically going round the local pharmacies and had been stockpiling paracetamol. She made it clear that she was intending to take these tablets.

 

I asked her to let me have the tablets and give an undertaking that she would not attempt to take her own life. She agreed to this. We were able to involve the Crisis Team, who worked with her until the risk subsided, and we were able to avoid a hospital admission.

 

But what if she had refused to give me the tablets? While I would not have felt able to physically snatch them from her, I would have taken account of this refusal in terms of the additional risk it posed, made a brief assessment of her capacity to make the decision to refuse, and would have initiated an assessment for her detention under the Mental Health Act.

 

And if she had been in the act of swallowing the tablets, then indeed, I would have forcibly removed them from her.

 

After all, what would I rather have to do? Justify my decision to a court, because the person was suing me for interfering with their property, or to a disciplinary panel because I had broken some rule or another?

 

Or justify my decision to an inquest?