Saturday, 14 August 2010

Anatomy of a Mental Health Act Assessment

Even though every assessment under the Mental Health Act is different, the actual procedure tends to be pretty much the same for all assessments. Assessments tend to have a similar structure, or series of steps, which have a logical sequence, and need to be followed if the assessment is to meet legal and professional standards. There follows a blow-by blow, step by step account of a recent assessment: Robina, a woman in her early 80’s living alone, with steadily worsening dementia.

• The Referral
1400 hrs
The referral came from the GP in the early afternoon. He spoke to the Social Services customer services, and they took down the basic details and then passed it to me for action as the duty AMHP. The GP had visited that morning with Robina’s social worker and the manager of a care home to try to arrange for an urgent admission to the home. However, she had been angry and aggressive, and had refused to consider this. They therefore decided to refer her for a formal MHA assessment.

• Gathering Information
I needed more information. I needed to know more about her personal circumstances. I needed to know what had led to this. Did she really need a formal assessment? Were there alternatives? I had several possible sources: the GP, Robina’s social worker, and any case notes that might be available through the Social Services computer system.

I rang the GP surgery, but the GP had finished his surgery and had gone home. He wasn’t available. This also unfortunately meant that he would not be available to provide a medical recommendation, if that turned out to be necessary.

I tracked down the mobile number of the social worker and rang her. However, her phone was sent to voicemail. I left a message for her to contact me urgently.

As it happened, there had been a request for a MHA assessment a week previously. I had a look at the assessment report. Robina had been known to services for several months. She was a widow who lived alone, and had home care, as well as considerable support from her daughter who lived a few miles away. Robina’s dementia had worsened considerably in the last few weeks. She had started to wander. Although she lived in a village a few miles outside the main city, she had been found in a garden centre several miles from home. She had become reluctant to accept the home care. The AMHP had assessed her with a psychiatrist, but had concluded that as Robina clearly lacked mental capacity, the powers to act in a person’s best interests under the Mental Capacity Act should be used, as she needed residential care rather than a hospital admission.

While I was reading this report, Robina’s social worker returned my call. She was able to fill me in on events since the previous assessment. The social worker had managed to find a bed in a care home and had organised an emergency admission. In the meantime, during the last week, things had got even worse. The police had had to rescue her from a large roundabout in the middle of a major interchange, and on another occasion had located her late at night walking down the central reservation of a dual carriageway 4 miles from her home. Her daughter was so concerned for her safety that she had spent the last couple of nights with her. Unfortunately, Robina was so hostile this morning that the care home were not prepared to offer her a bed, even if she could have been persuaded to go.

It was certainly looking as if all alternatives had been tried. There was no option but to arrange for an assessment.

• Organising the Assessment
1500 hours
The next step was to arrange to attend with two doctors. Robina’s own GP was not available. Since it is highly desirable to have at least one doctor who knows the patient (the AMHP has to explain on the section papers why they could not find a doctor who knew the patient if this is the case), I rang the surgery to see if they had another GP who had had contact with her and knew her. Unfortunately, there was only one GP now in the surgery, with a waiting room full of patients needing to be seen. And in any case, they had never seen her. I tried to contact Robina’s own consultant but they were on holiday.

This meant that I was going to have to get two Sec.12 approved doctors. These are doctors who may or may not be psychiatrists but who have particular knowledge of mental disorder and are therefore “approved” under Sec.12 of the Mental Health Act to act in this capacity. This is not always easy. AMHP’s have a list of Sec.12 doctors. They also have a list of Sec.12 doctors who are prepared and willing to come out to an assessment at the drop of a hat. This list is not so long, although there are always a number of doctors who are very keen to oblige and undertake these assessments, as they receive a fee in the region of £180 for each assessment they undertake.

My initial plan was to locate at least one Sec.12 doctor who specialised in old age psychiatry. I rang around other old age psychiatrists on my list; none of them were available. It took me over 30 minutes to obtain two doctors willing to come out; neither could attend before 1700 hrs.

I rang Robina’s daughter, who was with her mother in her mother’s home, introduced myself, explained what was going to happen, and outlined the legal process, including identifying her as Robina’s nearest relative (this is an important legal requirement, as nearest relatives have certain rights and powers under the Mental Health Act). I also asked her to tell me more about her mother. Her daughter was clearly very distressed by her mother’s deterioration. Robina’s outburst and hostility to the social worker, GP and care home manager that morning had clearly taken her by surprise and had shocked and upset her. Her mother was normally a very polite lady.

All of this was further useful information which I needed in order to conduct a proper assessment.

• The Interview
1700 hrs
I met with the doctors outside Robina’s house. I knew both of them. We often met in these circumstances.

We knocked on the door, and Robina’s daughter answered and welcomed us in. She seemed pleased to see us, but was obviously distressed by what was happening. Her husband was also there.

Robina was sitting in a conservatory at the back of the house. She showed no surprise or curiosity at our presence in her house, and at first was civil and polite. Her daughter sat in on the assessment. Robina had earlier taken some medication, but showed no signs of sedation. It very quickly became clear that her dementia was very advanced. She was unable to say what year, month or season it was, and seemed unclear whether her husband was deceased or not. She denied having had to be brought back by the police, said she did not have any home care and did not need it, and said that there was nothing wrong with her. She had only the vaguest memory of the visit she had had that morning, but when we broached the idea of going into a care home or being admitted to hospital, she became very hostile and refused to cooperate with the rest of the assessment, ordering us out of the conservatory.

• The Decision
1800 hrs
The two doctors and I went into the kitchen (this is often the place for these discussions – unless we have been thrown out of the house, in which case it will be around the wheelie bin or in my car, if wet). The decision this time was comparatively easy – there were patently serious risk issues, which appeared to be escalating. Her daughter was at the end of her tether, and was now afraid to let her out of her sight. It was not currently an option to explore residential care, and Robina was even denying the need to have home care. There had been significant changes in her mental state in recent weeks, and it therefore appeared reasonable to consider an admission for further assessment, as that assessment could not take place in her own home.

The two doctors completed a joint recommendation for admission under Sec.2 for assessment, and I completed my application. From that moment, Robina was formally subject to detention under the Mental Health Act.

The two doctors then left.

• Making the Necessary Arrangements
1830 hrs
My job was still very far from over. I needed a hospital bed. I rang the bed manager of the local psychogeriatric hospital. He informed me there were no beds. However, it was his task to find a bed, so he went off to do so.

I needed to inform Robina of the decision and of her rights. Even though I knew she would be unlikely to understand this, I still needed to do it. I went back into the conservatory. She did not recognise me, even though I had only been out of her sight for a few minutes. I explained to her that she was going to have to go to hospital, and offered her two options: she could go with me in the company of her daughter and son-in-law, or she could go in an ambulance. She listened to me, then chose option three: to stay at home, thank you very much. I tried to explain to her that this option was not available, but as there was nothing wrong with her, she did not need to go to hospital, and would therefore stay at home.

1900 hrs
I realised that I was going to need an ambulance and called Ambulance Control. They gave me an expected time of arrival: up to two hours from now. This is by no means unusual. Sometimes I have had to wait for up to 6 hours for an ambulance.

1915 hrs
The bed manager rang me back. He had at last found a bed for Robina. It was in a unit on the other side of the county, 50 miles away.

From time to time, I approached Robina to try to persuade her to go to hospital. She wasn’t having any of it and told me so in an extremely terse way (I won’t use the F word this time). This distressed her daughter, and I had to spend time with her, trying to reassure her.

2000 hrs
In view of her consistent antagonism, I decided that it was fairly likely that I would need police assistance to get her into the ambulance. I rang Police control and explained the situation and my need for assistance.

• The Admission
I was still on the phone to the police when the ambulance arrived, somewhat earlier than anticipated. The police officer asked me to keep the line open so that he could monitor what was going on and organise attendance if necessary.

I explained the situation to the ambulance crew, and followed behind as they entered Robina’s house.

It’s amazing what a uniform can achieve. Robina started to flirt with one of the paramedics, and within a few minutes walked out of the house arm in arm with him, a broad smile on her face, and entered the ambulance without fuss. Robina’s daughter accompanied her. I stood the police down.

2015 hrs
The ambulance departed, with Robina and her daughter on board. The detention papers, as well as an authorisation by me for the ambulance crew to transport her (all legal requirements) went with the ambulance.

Since the duties of the AMHP are not discharged until the patient is formally accepted by the admitting hospital, and also because Robina’s daughter would need a lift back home, I followed the ambulance in my car, with Robina’s son-in-law.

Often this trip is a chance for the AMHP to relax a bit – it’s actually an incredibly stressful process being responsible for the safety and wellbeing of not only the patient but also the relatives – but this time, with a stressed and anxious relative on board, it was necessary to answer his questions, to explain exactly what was happening and also what was likely to happen in the future and reassure him that everything was for the best.

2115 hrs
We finally arrived at the hospital. Nurses took Robina and her relatives into a side room and gave them a cup of tea while I went into the nursing office to organise the formal acceptance of the paperwork by the hospital. I was offered a cup of coffee – the first refreshment since I had set off for Robina’s house nearly five hours ago. Unfortunately there was no-one on duty who was able to receive the paperwork, and I couldn’t leave until this had been officially completed. An authorised person had to come from another unit a couple of miles down the road.

While I waited for this, I set to work writing my AMHP assessment report – another requirement is that a formal report should be left on the ward before departure. I had already started to write this earlier, and had it stored on a memory stick, so this did not take too long to complete.

• The Aftermath
2145 hrs
At last the papers had been formally checked and accepted. It was time to take Robina’s relatives back to Robina’s house 50 miles away.

Extricating them was tricky. Robina was quite happy to be sitting with them drinking tea, but when she realised they were leaving and not planning to take her with them, she understandably objected. Although the nursing staff were experienced at handling this situation, it was still extremely distressing for Robina’s daughter, who started to cry once we were in my car. I spent the journey back attempting to reassure her that the decision was correct, that there was the prospect of improving or stabilising Robina’s condition, and that the likely outcome would be that she would be transferred to a care home in the near future.

2245 hrs
We finally get back to Robina’s house and I drop her daughter and son-in-law off. That is officially the end of the assessment.

2315 hrs
I get home. At last, after over 9 hours, I can actually relax, and maybe even get something to eat. And then I’ll have to be back at work by 0900 hrs tomorrow.

15 comments:

  1. It's very interesting seeing things broken down like that - especially as a comparison with how things might work in different boroughs. I tend to almost exclusively do assessments for over 65s as we have a separate rota between us (we will sometimes help out with others when they are short). I'm surprised though (although obviously there are a lot of details missing!) that someone with 'steadily worsening' dementia might need a MHAA that has to be arranged in an afternoon with little pre-planning and needing a bed so far away until of course, things have changed very very quickly (which I assume they did!).. especially if the GP referred her and obviously knew her and her background but I do know that sometimes things do need to happen quickly. I guess it's a part of the risk assessment that takes place. I suppose a care team that could have seen the situation emerging can sometimes arrange an assessment/admission less frenetically but that's an ideal of course. Especially as changes in routine are more distressing than usual for someone with dementia.

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  2. The assessment that took place the previous week suggested a mental capacity route. The SW spent the week trying to arrange this. Is the meantime she was becoming riskier and riskier, and the daughter could not longer cope. It was the combination of running out of options for alternatives and the risk to the patient that made a further MHA assessment inevitable.

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  3. Hi - I have a question for you, something I am curious about having had several MHA assesments in past and starting studying to be SW and then hopefully AMP. I had 8 assesments and never detained though I went voluntary once to avoid this.
    How often in your experience is hospital deemed necessary? and how often involunary under MHA?.
    Thanks.

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  4. Those are interesting questions -- so interesting, I will devote my next post to them.

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  5. Really, really interesting. I notice you say that you "completed your application" after the two Doctors recommendations and that the lady became subject to detention under the MHA.

    I'm a policeman and in my area, AMHPs who do not yet know which bed the person will be admitted to and therefore which hospital to make the application to, refuse to finalise the application, even though a person is in the cells without the police having a clear legal authority to detain them.

    I'm of the view, that you can finalise applications, despite not yet knowing whether a bed is available, and that s13 and s140 of the MHA may be of application, to assist the AMHP or to allow them to manage their relevant hospital.

    Is it your view that where bed is not yet available, the AMHP can nevertheless make the application (thereby, allowing the police to detain the person in their own interests or for the protection of others, under s137 MHA)? ... perhaps because it obligates the hospital to which the application is addressed, to start thinking of Plan B and Plan C to release a bed?

    Michael./

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  6. You were very observant, Michael. Actually, I realise I got the order a little wrong. In this case, I had confirmation of the bed before I completed the application. Generally speaking, the AMHP does have to know where the patient can be admitted to before they can complete their application -- this is especially the case with Sec.3.

    I do know that in extremis AMHP's and ASW's before them have put the name of a hospital on the application and then turned up with the patient, on the basis that the hospital has a duty to find a bed for the patient. But I have had at times a frustrating wait having made a decision to admit but not having a bed, and having to keep the patient calm in the meantime.

    I remember one occasion when an elderly lady had been summoned to the magistrates court and then bailed, but was clearly so unwell that the court had kept her on the premises, without any real authority, until a MHA assessment could be made. There then followed a nerveracking 2 hours while two different areas decided who had the responsibility to accept her admission. During that time, I could not complete my application, and the patient was in a legal limbo where she could have left at any time. Such situations have also arisen in police stations, where a patient who has been detained under Sec.136 has then been assessed, but there has been a delay in actually finding them a bed to take them to. During that time there is no real authority to continue to keep them at the police station. Custody officers are genrally aware of this, and understandably get very twitchy!

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  7. Thanks, very helpful indeed to know that. Really enjoy your blog.

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  8. Good article and interesting to read the differences between your patch and mine.

    The responsibility for finding beds here is down to the doctor from the relevant Trust, not the AMHP.

    In office hours, that would be the RC (likely delegated to a junior to actually liaise with the wards) but out of hours, it would typically be an SpR/equivalent from the Trust.

    The reason is that here there are still Higher Trainees on the out of hours rota and they are expected (though not formally obliged, due to EWTD issues) to attend any MHAAs. So they're the ones who have to argue with the wards to find a bed!

    This is good for both the AMHPs and the SpRs, so nobody wants to rock the boat. The AMHPs don't have the hassle of bed-finding, and the SpRs claim the statutory fee for the MHA, so boosting their income (and also learn how to find beds which is something they'll need to do as RCs anyway). Plus it encourages more of a collaborative approach to the process I think.

    I know a neighbouring county uses the same system as yours, and I don't think the AMHPs there like it as much as ours. I'd be interested in which system you think is better?

    As an independent S12 doctor, I no longer need to be involved in the bed-finding process, but since I used to work as an SpR in the same region, new trainees in the area doing their first MHAAs often ask for a bit of advice! :)

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  9. Although the AMHP in our area will have to contact the hospital, either before the assessment, or once a decision has been made to admit, it is up to the hospital's bed manager to actually find the bed. However, frequently, the Crisis Team will have already been consulted, and may have already made an assessment that the MHA is likely to be needed. In those cases, as they are the gatekeepers to beds, they should have already earmarked a bed.

    I must say, in recent months it has become increasingly hard to find beds -- the wards are blaming "bed blockers" -- patients who no longer need to be inpatients, but do not have anywhere to go -- but I think it's rather more complicated than that.

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  10. I have only just come across your blog, hence late comment.
    What a fascinating and well-written post, showing your obvious compassion for those you work with in their times of need.
    I've been on both sides with mental health services - a situation similar with my late Nan, my Father couldn't cope with how she lost her mental capacity, it was tortuous.
    I have since had my own mental health problems and if I ever need admission to a ward I hope I am dealt with in such a professional and caring manner.

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  11. I was amazed to read your description of Robina and her behaviour, you could have been describing exactly my own mother's behaviour a couple of months ago when we went through the same thing. Thank you so much.

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  12. Please advice as i am in the final year of my AMHP training and am currently up late completing an assignment which is based on a MHA assessment i recently shadowed.You have written in this blog (By the way what an excellent resource your blog has been to me)that the duties of the AMHP are not discharged until the patient is formally accepted by the admitting hospital, and also because Robina’s daughter would need a lift back home, you followed the ambulance in your car, with Robina’s son-in-law.Had it not been for Robina's son-in-law requiring a lift home couldn't you have instructed the person authorised to convey to present the paperwork to a member of the hospital staff receiving the patient as per Code Of Practice 11.25 or is there an actual duty upon the AMHP to be present. You suggest that the duties of the AMHP are not discharged until the patient is formally accepted by the admitting hospital but in my experience of shadowing, some AMHP's have not always attended when the patient arrives at hospital especially when the hospital receiving the patient is out of area. I would appreciate some clarification/guidance on this, many thanks, Coach, TRiamhp.

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  13. There are circumstances when the AMHP could fax the papers to the receiving hospital so that they could do a preliminary check of their validity, especially if said hospital was a very long way away -- although the physical papers do have to go with the patient -- but most AMHP's would prefer to discharge their duties by being physically present when the patient and papers are received.

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  14. You talked about reports. Is the AMHP outline report a statutory requirement under the MHA? The CQC visiting one of our wards with detained patients noticed a lot of the sections did not have an AMHP outline report. This is surely an AMHP duty do the Hospital Managers have a legal duty to actively chase this from the AMHP?

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  15. Trying to prove that s12 committed fraud by claiming fees for assessment he did not attend. We are alleging the other S12 doctor involved and the AMHP were complicit in forging sectioning papers stating the s12 doctor was present for the assessment. Police corroboration that second doctor was not at the assessment. SAR only contained sectioning forms. What documents are used/created when an AMHP books s12 doctor? Believe the fraud was committed every time one of the doctors was out of the country...Believe AMHP used same s12 doctors and fees were split. AMHP's handwriting matched printed address of absent doctor on sectioning document. The addresses of both s12 doctors were redacted--not in black ink but just blank. Trust told solicitor document was redacted because patient had contacted one of the s12 doctors then proved patient only contacted s12 doc after sectioning forms were already sent in SAR. Trust then said the redaction was an oversight. AMHP was aware of allegation withheld 135 warrant that had his handwriting on it, had to ask twice for the warrant. AMHP also destroyed hand written copy of AMHP report..stating that copious notes were destroyed. Request for Police assistance also withheld...Finally received it and proved he did not book ambulance for assessment although he said he did. Called ambulance service and they confirmed no booking. Also just found out that 135 warrant has supplemental document in support of warrant. 135 warrant was not obtained via emergency situation. Was obtained the day before the assessment. Repeatedly asked for this document or any document supporting warrant. Never received a reply. Also GP confirms that AMHP did not attempt to contact GP for assessment. AMHP just wrote GP Unavailable. Also, AMHP called GP's office 4 hours after patient was admitted to ward for patient details. Challenged S12 doctor to volunteer access to his mobile phone records..allow examination of possible enhanced data that might show his geographical location. Trust did everything but properly investigate. Believe they don't want to open can of worms...if allegation true then every patient these guys sectioned would be reviewed.
    Solicitor waiting for funding for civil case. Police did not want to take criminal report. Asked for MP's support. Called police and asked them to put reason for not taking report in writing...police called back and were told to go to station and make report. Also trainee social worker was present for assessment. Trainee social worker not cited as corroborating witness for either doctor in GMC complaint. It's a mess. 2 cops at assessment corroborated that only accompanied 3 members of assessment team not 4 as stated by Trust. AMHP only name they both recorded. Doctor who was absent has obvious accent. No one with such accent present at assessment. Family member also present throughout assessment. Family member absolutely adamant that second dr. was not present and only three members of team present. Unfort. family member been in hospital for 3 months in critical condition. Called embassy of country the second dr. from. Said if he was out of country would have record but could only disclose to police. Catch 22 regarding making crim report...As above have no documents re: booking of either doc. Must be documents/phone records to prove case...Any help would be appreciated.

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