Wednesday, 16 September 2009

Ones That Got Away (Or Tried To) Part I

I already knew Ian. At the beginning of the year I had been called out to assess him at his flat. His family had contacted the GP because he had been saying "funny" things, and his behaviour had become increasingly odd. He was very paranoid, and had been carrying a hammer around for protection. He had told his family that he believed he was being gassed, that gas was coming out of the electricity fittings, that people on TV were talking to him, that he was "not going to be here much longer" and was "going to die". He was becoming increasingly reluctant to allow even family members into his flat.

By the time I got there with the psychiatrist, his doctor and his mother it was after dark. There was a surreal atmosphere. Ian lived in a first floor flat, and some of his furniture was stacked up outside on the balcony. His mother had a key and unlocked the door when there was no reply. We entered the darkened hall, where an armchair was lying on its side. The flat was in darkness, all the bulbs having been removed from their sockets. I managed to find some bulbs and turned on some lights so that we could continue the exploration of his flat.

We eventually found Mark in his bedroom. He got out of bed, apparently unconcerned about his lack of clothing, but was very keen for us to leave. He refused to talk to us and insisted that we leave. He appeared very agitated and suspicious. The flat was generally in a very untidy state, which his mother said was not normal for him. On the balance of probabilities we decided that he needed to be admitted to hospital for assessment, and he was detained under Sec.2.

A few weeks later I assessed Ian on Bluebell Ward. There was more evidence of his paranoia and unstable mental state. He talked to me in more detail about his conviction that the whole town were watching him on their TV’s, and discussed his obsession with unarmed combat and the SAS.

He was detained for treatment under Sec.3, was started on an antipsychotic, and after a couple of months was discharged. However, before long he started to default on his appointments with his community nurse, and we were fairly sure that he was not taking his medication.

Things came to a head in the early winter of that year. His family were again reporting concerns about his behaviour, and it appeared he was paranoid again. Another social worker had conducted an assessment, which had been inconclusive because he had been very guarded about his replies.

But concerns continued to mount, and so I found myself outside the door of his flat after dark once more, in the company of the psychiatrist, his GP, his mother and the community nurse. There was again a surreal atmosphere – this time, I noticed that there were blown hen’s eggs with little faces drawn on them situated in strategic places on his balcony. It was almost as if they were keeping watch for him.

This time Ian was a little more welcoming, with a fa├žade of friendliness. He allowed us into his living room, where he told us that everything was fine, that he had not needed any medication, and that he had not had any recurrence of his earlier symptoms. He had an air of confidence about him, perhaps created by having survived the previous assessment. But I had already assessed him twice, I knew a fair bit about his delusional beliefs and odd behaviours.

I asked him about the eggs on the balcony. He suddenly looked very unhappy.

“They’re just eggs,” he said. “I like eggs.”

“But you’ve drawn faces on the eggs. What does that signify?”

He looked lost for a reply, seemed to cast about mentally for a response, and then somewhat to our surprise he took out a long hunting knife, waved it about in a very threatening manner and told us all to leave his flat.

We left.

I called the police and explained the situation to them. We had decided that he needed to be detained, and clearly we needed their help.

This was when the police decided to take control.

“We’re going to have to treat this as a siege situation,” the duty Chief Inspector told me. “We’ll need a task force and a trained negotiator. It’ll take us a little while to get them together.”

So for two hours we waited on the ground outside his flat, looking up at his balcony, wondering what was going on in the flat, and feeling rather cold in the late November drizzle.

Then suddenly things started to happen. From around a wall an armed response officer emerged, dressed in full riot gear, cradling a rifle in his arms, and crouched down, pointing it at the flat. A similarly armed colleague chose another vantage point. This was the first time I had ever encountered armed police during an assessment under the Mental Health Act. The sense of unreality about the whole thing went up several notches.

Residents of the other flats started to notice what was going on, and leaned over their balconies, watching intently, talking among themselves.

A van arrived and 6 officers dressed in full riot gear, with riot shields, piled out. A female officer in plain clothes arrived in another car, and introduced herself as the negotiator.

Ian’s mother, understandably shaking, gave them the key to Ian’s flat, and we watched as the riot squad went up the stairs, put the key in the door, and then piled in, riot shields and torches in front of them. I could see their torches flashing as they went from room to room. He must have taken out the light bulbs again. Then they emerged onto the balcony, shaking their heads. He wasn’t there.

At some time in the previous two hours, while we had been watching his front door, he had made his escape by jumping out of a window on the other side of the flat and had gone to earth.

I lodged the section papers with Bluebell Ward, and made sure the police were aware that he was a detained patient and that they should take him directly to hospital if they happened to find him.

And sure enough, a few days later, he was found in the woods, having been living rough just as he had learned from his study of the SAS, living in a bivouac made of branches, and catching, skinning and cooking rabbits with the aid of his rather large hunting knife.

Thursday, 3 September 2009

Just Another Day

First thing in the morning I had to go to Woodland House, our local psychiatric hospital, to attend a Managers Hearing for a patient detained under Sec.3 MHA. Denise had been detained a couple of weeks previously, and had appealed. Patients have the right to appeal against their detention under the MHA. Their case will first be heard by a panel of Hospital Managers: these are essentially unpaid volunteers rather than NHS employees, who have an interest in the functioning of the psychiatric hospital. They have the power to discharge a patient from detention. If they refuse to discharge the patient, the patient can then appeal to a somewhat more judicial Tribunal, which is a panel consisting of a lawyer, a consultant psychiatrist, and a lay person.

It looked like being a busy morning: as soon as the Hearing had finished, I had to go over to Bluebell Ward to assess another patient, Terry, for detention under Sec.3. This request had come a day or so before. He had been an inpatient for a couple of weeks after being admitted under Sec.2. I had already arranged for a Sec.12 doctor to assess him to provide a second medical recommendation, so everything was set up.

I had known Denise for about 2 years. She had paranoid schizophrenia. I had been instrumental in getting her properly assessed and treated, since for several months she had been presenting with increasingly bizarre and disturbed behaviour, shouting and screaming and throwing things around in her flat to such an extent that most of her neighbours had given in their notice. I had been trying to engage with her, visiting her at home, and having conversations full of non sequiturs and conversational cul-de-sacs. To Denise, nothing made sense. At some time in the last 15 years, all the books had been changed so that they ceased to make sense to her. According to her, every book in the library had been substituted for ones that made no sense, as had all the magazines in the shops. Worse than that, street signs and place names had been altered, as well as maps and guidebooks. She lived in a perpetual state of perplexity, which must have been terrifying for her. I eventually managed to get her seen by our psychiatrist, and between us we managed to persuade her to agree to an informal admission. She consented to take antipsychotic medication, made an exceptionally good recovery, and had been fine for a year, until she had gone on holiday for a week without her medication. On her return, all her symptoms had returned, only this time she had refused to accept medication, since it, too had been changed and was not real, and she had ended up being detained under the MHA.

This time, however, she was far less cooperative, and did not seem to be responding to treatment. So she had appealed, and we had a Hearing.

A Managers Hearing consists of a panel of 3 Hospital Managers. They have a clerk who records their deliberations and their decision. The patient is invariably present, along with a legal advisor, who represents them. Also present is their consultant psychiatrist, a nurse involved with their care, and their community care coordinator, who is generally a community nurse or a social worker. On this occasion, that person was me. All three will have provided written reports covering their nursing care and progress on the ward, their psychiatric history and diagnosis, and the social and community background of the patient.

The Hearing was fairly informal, with the managers introducing themselves and explaining what was happening. They then discussed aspects of the reports with their authors. The patient’s legal representative is also able to cross examine each participant and question their report, and will present the wishes of the patient to the Hearing.

The patient is able to make direct representations to the Managers as well. Denise took full advantage of this, pointing out that the reports did not make sense, that her medication was not real medication, that she did not really have schizophrenia or indeed any other mental illness, and that it was the world itself that was ill. I detected a note of desperation in her lawyers summing up at the end.

After due consideration of the merits of her case, the Managers declined to discharge her from detention.

One task down, another to go. It was all going quite smoothly. However, on arriving at Bluebell Ward, I was told that there was an urgent assessment under the MHA back in town, and was given the mobile phone number of a health visitor. Intrigued, since health visitors (community nurses who look after the welfare of preschool children) do not usually get involved in Mental Health Act assessments, I rang her.

She had just visited a new mother, a young Latvian single parent who had only been in this country for a couple of months. She had arrived heavily pregnant and had duly delivered a baby a few weeks ago. The health visitor was very concerned about both mother and baby. She feared the mother had post natal depression, and was not coping with the baby. She also had no money, and no entitlement to state benefits because of her nationality. To top it all, she had no other relatives in this country, and did not speak any English. The health visitor had spoken to the patient’s doctor, who had told her to arrange an assessment under the Mental Health Act.

This was when my sometimes almost supernatural ability detected an opportunity to avoid getting involved. The doctor had not actually seen the patient. She was not known to the local psychiatric services. There had been no exploration of alternatives to compulsory admission, such as informal admission, or home treatment. In any case, Woodland House did not have facilities to accommodate a mother and baby, so maintaining her in the community in some way would be likely to be in the best interests of both the patient and her baby. Children’s Social Services needed to be involved. I pointed all this out to the health visitor, and suggested that the doctor should see the patient himself first, and then ask the local Crisis and Home Treatment Team to make an initial assessment.

Having dealt with that, I attempted to clear my mind and get into an appropriate state of relaxed alertness for my planned assessment.

Terry also had a diagnosis of paranoid schizophrenia. He was reported to be creating considerable management problems for the nursing team because of his erratic and at times disturbed behaviour. His symptoms included paranoid delusions that he was being poisoned, severe thought disorder, and flight of ideas.

I saw him alone in an interview room. Terry smiled amiably at me as I explained who I was and why I was there.

“I see,” he said, “Only a genius or professor can section me.”

“I’m afraid I’m neither of those. Terry, can you tell me something about how you came to be admitted?”

“I open the box of Pandora – that means that I am nothing, but aware.”

I left him time to elucidate, but he subsided into an amiable silence.

“Er, Terry, do you think you are unwell at present?”

“It is because my National Insurance number belongs to the parliament of Scotland. You see, the angels of the world are flying over my house, and although I am wise, they can see me for what I am.”

“Right… Do you think the medication you are taking is helping you?”

“I have a high level of testosterone because of my proximity to women. The tablets help me to discharge my energy. It is all the same in the cosmos.”

He continued in this vein for several minutes, warming to his incomprehensible topic. I had not the faintest idea what he was talking about, and at the soonest available opportunity I thanked him for his cooperation and told him I had to now go and consider my decision.

“You are not part of the blue circle. Nobody speaks for a moment. There are millions of people. They implanted two chips in my shoulder. Two veins go from these chips into my heart,” he said to me, smiling, as he left.

I confess that it did not take me long to reach a decision.