Thursday, 31 December 2009

Update - Harry

I last wrote about Harry in July 2009. Harry was an elderly man living alone in squalor, probably with Diogenes Syndrome, causing carers and other professionals (including the Fire Service) problems, whom on two occasions despite the risks I did not detain under the Mental Health Act. I concluded then that I had not heard the last of him, and I also speculated, tongue in cheek, that another AMHP might be asked to assess him.

Well, that’s exactly what happened. A couple of months later, while I was away on holiday, there was another request for a Mental Health Act assessment. This time, the AMHP concluded that it was appropriate for him to be detained under Sec.2 for assessment and he was admitted to the local psychogeriatric ward. I have no argument with that – AMHP’s act independently, and two AMHP’s may validly reach different conclusions from the same information. In any case, situations can change, risk factors may vary from day to day, and I am sure that the AMHP who detained him made the correct decision at that time.

A few weeks later I was asked to assess him again, this time for detention under Sec.3 for treatment. When I interviewed him in the hospital he was clearly in a much better physical condition than when I had seen him at home. He was clean, well groomed, had put on weight, and was obviously enjoying the comparatively salubrious environment of the hospital ward. But I had to decide whether, in all the circumstances of the case, it was most appropriate for him to be detained in hospital under the MHA.

There was some evidence of memory problem, he did not remember my visit to him a few months before, was vague about other facts, and he certainly did not regard his home conditions as in any way a problem. When I discussed the reason for my visit he became furious, swearing at me and threatening to harm me. But did this amount to anything significantly different from my previous assessment?

This time he did have a diagnosis of vascular dementia, so certainly had a mental disorder within the meaning of the Mental Health Act, but was it of a nature or degree to warrant his compulsory detention?

I thought long and hard about my decision. And in the end I applied for his detention under Sec.3 as requested.

I was covered legally. There were two medical recommendations. He had a mental disorder. But I still felt uneasy.

What swayed me in the end was the fact that circumstances had now irrevocably changed. My previous decision was about whether or not to remove him from his home. My decision now was about whether or not to allow him to return to his home. With this decision came even greater potential risk to Harry. He had already made it very clear to me that if he were not detained he would insist on going back to the squalor and fire hazard that was his house, and this time would probably be even more distrustful of authority that he had been before. His risks of being at home would be significantly greater now than they had been earlier. If he were ever to have a chance of surviving in a community setting, there would have to be considerable changes in his home circumstances.

And strangely enough, detention under Sec.3 could facilitate that, since any elements of his aftercare package would now have to be paid for by the local authority and/or the NHS. He would no longer be charged for home care, and indeed, any works to improve his home, through a major cleaning programme or even alterations to the house, could also be free of charge. He was wily enough to see that there could be advantages to his continued detention – although he would never admit it.

Tuesday, 22 December 2009

Sectioned on Christmas Day

Back in the days when I used to do out of hours on call duties, Christmas Day was generally considered a good shift to have – you got double pay for the bank holiday, and no-one ever called Social Services on Christmas Day – Boxing Day, yes, New Year’s Day, yes, but never Christmas Day.

Unless someone had chosen that day to go mad.

It was a snowy evening, very festive. I had had my Christmas dinner, and was settling down in front of the TV, confident I would not get a call, when my home phone rang. Robert was a 30 year old man who lived alone. He had only a minimal history of mental illness. He had been referred to the CMHT a few months before after having had an odd transient psychotic episode following general anaesthetic for minor surgery. I had actually seen him on one occasion, and although I had found him a little odd, he had not displayed any overt symptoms of mental illness and had not been seen again.

His father, who lived in a village some miles from Robert, had decided to invite him for Christmas dinner. Since Robert did not have any transport, his father had picked him up and brought him to his house. His father had found him rather quiet and subdued, but Robert had been like this for some months, so he thought nothing of it.

But as the day progressed, Robert’s father became increasingly worried about him. He appeared very stiff, as if his muscles were seizing up, and had to be helped to the dining table. His father would try to engage him in conversation, and got the impression that Robert was trying to reply, but no words would emerge. Robert had sat motionless throughout the meal, staring at his plate, but had eaten nothing. After the meal, his father had been unable to persuade him to leave the table. He called the duty doctor, who gave him a physical examination and found nothing wrong with him, but was equally unable to persuade him to talk or move. He came to the conclusion that mental illness was the only explanation, and called us.

I managed to locate the duty psychiatrist, who was surprisingly easy to persuade to attend – perhaps he had had a fraught day with his family – and we arranged to meet the GP at the house.

Robert was still seated in the chair at the table. The table had been cleared, and he seemed to be staring intently at the table cloth.

“Hi, Robert,” I began, sitting down at the table with him. “Do you remember me?”

His eyes flickered, as if he were straining to move them in my direction, and eventually they moved enough so that he could see me. However, his neck and body stayed absolutely still. I could see his throat quivering, as if he were trying to speak, but the only sound that came out of his slightly open mouth was a low gurgle.

We asked him a number of questions, but during the 20 minutes or so of the interview the only words he managed to utter, and clearly with much effort, were: “My heart.”

It was impossible to make a further assessment. Our impression was that it was a classic case of catatonic schizophrenia, which can be characterised by a complete inability to move or speak. He clearly needed further assessment, was unable to give any indication of consent, and we concluded that he needed to be detained in hospital under Section 2 for assessment.

When the ambulance arrived, the crew had to physically lift him, still in a seated position, into the ambulance, and he remained in that position all the way to the hospital.

He did indeed have catatonic schizophrenia, and in fact I was called on a number of occasions in subsequent years to assess him, frequently with the same presentation. But never again on Christmas Day.

Festive postscript:
As I was collating the paperwork and writing up my assessment at the hospital, I suddenly noticed his date of birth. It was the 25th December.

Sunday, 6 December 2009


It was 4.30 on a Friday afternoon in November. It was raining outside. I was looking forward to the weekend. Then the phone rang.

Miranda was 71. She lived alone in her own bungalow. She had never been married. She had a long history of involvement with mental health services, and had been transferred to the older people’s mental health service when she became 65. She had a history of detention under the Mental Health Act, had had many admissions over the years, and had variously been diagnosed with psychosis and bipolar affective disorder. She was currently on an interesting combination of an antipsychotic, two mood stabilisers and an antidepressant. She had been seen a month ago by her consultant, who had suggested an admission to hospital, which she had politely declined. Earlier in the week she had been seen by a GP who had diagnosed a suspected urinary tract infection and had prescribed her an antibiotic.

Her community nurse had been to see her earlier in the afternoon. She had found Miranda working her way through a bottle of wine, writing a list of music she wanted playing at her funeral. She passed her a suicide note, and asked for her favourite GP to sign her death certificate after the weekend. She was not prepared to go into hospital.

I spoke to the duty GP, who had not seen her today, but was prepared to come out if required. I talked things over with her nurse, and we decided to visit her together so that I could make at least an initial assessment. The nurse had arranged for a bed to be available if needed.

We stood outside Miranda’s bungalow in the November rain, waiting for her to answer the door. She looked at us both, then let us in, seeming resigned to a visit from mental health professionals. She had finished the bottle of wine, and now had a glass of ginger wine in her hand. Although her bungalow was cluttered and somewhat neglected, she had a high quality sound system in her living room, with piles of classical CD’s covering most available surfaces. Bach’s Mass in B Minor, sung by the Sixteen, filled the room. Tears were flowing silently down her face.

She was still working on the list of music for her funeral. It was tasteful but melancholy music: Bach, Handel, Fouré, and some solemn, mournful medieval plainsong for the most part.

“Miranda,” I said gently, “What’s happened? Why are you feeling like this?”

She told me she had been feeling bad for a few days and that she did not know why. She could not think of any incident or trigger. She subscribed to a postal CD company, and had received the CD she was playing that morning. “When I have listened to it to the end, I will end my life,” she said slowly and with the exaggerated dignity that only the intoxicated can manage. Since it spread over two CD’s and lasted nearly two hours, I estimated that we had some breathing space at least.

Things were stacking up against her. As I had gone through the bungalow, I had noticed that her bed was piled high with junk, and had clearly not been slept in for some time. I went into the kitchen to talk to the nurse, and she showed me Miranda’s empty fridge. There was evidence that she was neglecting herself. The nurse told me that Miranda did not usually drink, so her drinking today was perhaps a symptom of her underlying mental condition rather than the cause. I was unhappy about the odd assortment of medication she was taking, and thought that a review of her medication would be a good idea. I was also mindful of the effect a urinary tract infection might be having on her mood and general mental state.

What was clear was that she did need to be in hospital for assessment and treatment, and for her own safety. It was too dangerous to leave her over the weekend. She seemed to have every intention of killing herself before the weekend was out. I was prepared to use compulsion if need be, but wanted her to have the opportunity to preserve her dignity.

“Miranda,” I said to her. “I think you need to go into hospital for a while. You know what my function is. You know I can detain you under the Mental Health Act if I need to. But I really don’t want to do that. You will have more control over your admission and stay if you go in voluntarily.”

“Can I take my music with me?” she asked.

The nurse nodded. “Yes you can. There won’t be any problem, if you have a portable CD player and headphones.”

Miranda looked into my eyes. Then she looked down.

“Very well,” she said.

Her community nurse and I helped her pack an overnight bag and we found a portable CD player. She got into the back of the car, with her nurse sitting next to her. Miranda seemed relieved, if anything. She talked about the music she loved and gradually her tears dried. We took her uneventfully to hospital.