Wednesday, 21 April 2010

A Little More on Section 4

(This assessment took place before the Mental Capacity Act 2005 came into force. Had the MCA been in place at the time, the outcome might have been very different.)

Ernie was in his late 80’s. He lived alone and had no known relatives. In recent months the GP had become concerned about possible dementia, and he had been seen by a psychiatrist on one occasion.

It was the middle of winter. The GP had visited Ernie and found him crouched in front of a one bar electric fire, surrounded by squalor, and with a strong smell of excrement in the air. She was very concerned about swelling in his legs, and had arranged for an ambulance to take him to hospital. But when the ambulance had arrived, Ernie had refused to leave his bungalow, and so the ambulance went away. The GP then made a request for him to be detained under the Mental Health Act.

In view of his frailty and the possibility of a life threatening condition, I went out straight away and did a home visit with the GP. His bungalow was pretty much as she had described it. There was evidence of many years of neglect: plastic carrier bags filled with junk and rubbish filled his hallway, his kitchen was filthy, with little evidence of food, the walls were black with grime, and spiders’ webs hung from the corners of the rooms. Ernie himself was sitting in his armchair in front of his fire when we came in (his front door was not locked).

It took him a few moments to register we were there. He seemed quite moribund. He was clearly worse than he had been an hour or so ago when the ambulance had come. He barely recognised the GP. He would not allow the GP to give him a proper medical examination. The only coherent thing he said to us was: “I’m not going to no fucking hospital!”

We went back to the GP’s surgery.

“This isn’t a case for the Mental Health Act,” I began. “He’s physically ill. He needs to be in hospital. This is an emergency. He’s getting worse by the minute. We need to get an ambulance out again and bundle him into it, whether he likes the idea or not.”

“But we can’t,” she replied. “He has a diagnosis of dementia. He’s been seen by a psychiatrist. He has a mental disorder. That means we can only admit him under the Mental Health Act.”

“The Mental Health Act really doesn’t come into this. We’re not admitting him for his dementia, we’re admitting him because he’s dying.”

But the GP wasn’t having it. She was convinced that the existence of a diagnosed mental disorder meant that only the Mental Health Act could be used to remove him from his home. Continuing to argue about it was just wasting time, time that Ernie did not have. We had to get him to hospital somehow, and as soon as possible. And we really didn’t have time for a psychiatrist to come out and assess him. So I decided we had to go for admission under Sec.4.

But this only made things much, much worse.

I rang Ambulance Control.

“I need an ambulance for an elderly man detained under Sec.4 of the Mental Health Act. He needs to be admitted to the general hospital. He’s very ill and frail physically. It’ll be a blue light job.”

“We can’t admit someone under Sec.4 to a general hospital. In any case, we’d have to take him to Accident and Emergency first, and if he’s on Sec.4 he could only be taken directly to a ward that will admit him,” the controller helpfully told me.

I could see his point.

“OK,” I eventually said. “We’ll admit him to the psychogeriatric ward. But we need the ambulance as soon as possible. This is an emergency. He’s really very ill.”

“If he’s detained under the Mental Health Act we can only classify your request as urgent, not as an emergency. We will try to get an ambulance to you within an hour.”

I tried to argue this point. But as I have found on many occasions before, arguing with Ambulance Control is invariably futile. And neither is pleading, begging and crying any more effective.

When I rang the hospital to arrange a bed, the bed manager understandably wondered why Ernie wasn’t being taken to a general hospital. I tried to explain. I recognised that almost as soon as he was formally admitted to a psychiatric ward, he would need to be transferred to A & E – a further hurdle to getting him the appropriate medical treatment, but it seemed I had no option. The bed manager reluctantly agreed, and the GP and I completed the application under Sec.4.

I went back to Ernie’s bungalow to wait for the ambulance. In the event it came within half an hour. By now Ernie was so weak, he put up no struggle at all when the ambulance crew lifted him onto a stretcher and got him into the ambulance.

He did not put up any struggle when they took him by stretcher into the psychiatric ward. The ward sister looked askance at Ernie as he was wheeled past her.

“What the hell have you brought him here for in this state? He needs to be on a medical ward!”

I miserably tried to explain yet again why I had taken the decision. By now, I wasn’t even able to convince myself.

He was transferred to A & E within minutes of his formal admission under Sec.4 Mental Health Act, and was then admitted to a medical ward. As he should have been hours previously.

And three days later, he died.

Sunday, 18 April 2010

When To Use a Section 4 (and When Not To)

Detention under Section 4 of the Mental Health Act only requires one medical recommendation. It should be used “only in a genuine emergency, where the patient’s need for urgent assessment outweighs the desirability of waiting for a second doctor.” (5.4 Code of Practice). There should be evidence of “an immediate and significant risk of mental or physical harm to the patient or to others; danger of serious harm to property; or a need for physical restraint of the patient.” (5.6 CoP).

In 27 years of working within the Mental Health Act, I have used Sec.4 on only 17 occasions (and only once in the last 7 years). Most of those took place in the early years of the Act, when it was often impossible to get a second medical recommendation within a realistic time frame, especially in a rural area; when hospital bound consultants would still say: “Be a good chap and bring them in under a 4, and I’ll convert it to a 2 when you get here.”

I’ve written on this blog about the first time I used Sec.4 (Emma, posted on 11th July 2009) and the most recent time I’ve used it (Mavis, 24th April 2009). Here’s another example.

William was 40. He had learning difficulties and had been placed in a care home in our area for about a year. He had a history of impulsive and aggressive behaviour, and this had been getting worse over the last few weeks. He had assaulted two staff members and had been arrested, then bailed back to the home. Two days later, he assaulted three more staff members and was again arrested. He had again been bailed, but this time the home was no longer prepared to accommodate him. His Consultant Psychiatrist had arranged for a bed in a low secure private hospital and made a request for assessment for admission under Sec.2 Mental Health Act.

One might have imagined that this was a comparatively straightforward assessment of a man with learning difficulties (at least there was a bed – sometimes a bed for a patient with learning difficulties can take weeks to obtain, leaving the AMHP unable to complete an application because there is no hospital to put on the form, and sometimes having to obtain further medical recommendations because the first ones have run out of time).

But as I obtained more information, my heart sank. Firstly, the Consultant had not actually provided a medical recommendation, and was not currently available. Secondly, William was not at the police station, since he had been bailed and the staff had picked him up. And he was not at the care home, because they were refusing to take him back, and he was refusing to go back. At the time I received the request, he was being driven round the county in the home’s minibus, in the company of four of the staff. It was the only way to keep him happy and prevent him from beating them all up.

So somehow I had to arrange for the assessment of an aggressive and impulsive man with learning difficulties (and epilepsy and diabetes) who was only being managed by taking him wherever in the county he had a whim to go, otherwise he was going to assault even more staff. The Consultant, who had seen him and who could have furnished a recommendation, was unavailable. It did seem to be a matter of “urgent necessity” to admit him to hospital. It seemed logistically impossible to get two doctors in one place at the same time as the patient, and would involve unreasonable delay.

So I arranged for the assessment to take place at the GP’s surgery. I contacted the staff in the minibus on their mobile, liaised with the GP, and we all met up in the car park within an hour of receiving the call. The GP and I persuaded him to come into the surgery, where we interviewed him. Although he remained calm with us, this was probably more because of the novelty of the location, and the fact that he was supplied with a plate of biscuits. He did, however, become touchy when asked anything about the care home, and we felt we needed to finish our assessment at that point. With the GP’s lone recommendation I made an application under Sec.4 and rang the hospital to inform them that he was on his way.

But that was too easy, wasn’t it?

“We’re a low to medium secure unit,” the admitting nurse told me. “We only take patients who are detained under Sec.2 or Sec.3, or under Part III of the Act [relating to mentally disordered offenders].”

“What do you mean?” I asked. I explained the situation to the nurse as clearly as possible, aware that, now William was back in the minibus and expecting to go to hospital (which he said he preferred to the care home), he was again getting twitchy, because he liked to be in a moving vehicle, not in a car park. “If a patient has a lawful detention, I think it is immaterial what particular section they’re detained under.”

“We’ve never had anyone here on a Sec.4.”

“There’s always a first time for everything isn’t there? A Sec.4 was the only way I could see of getting him to a safe place. Once he’s admitted, we can get it converted to a Sec.2 within hours.”

This conversation continued for several more minutes. At one point the nurse transferred me to a social worker. I had a similar conversation with her, stressing that the longer the delay, the more agitated the patient was likely to become. In fact, I was myself beginning to get an inkling of the agitation William might be feeling. However, the social worker did seem to have a better grasp of the Mental Health Act, and of my predicament, and eventually she conceded that a section was, essentially, a section, and he could be admitted.

And within minutes of William’s arrival at the hospital, the Consultant miraculously made an appearance and supplied a second medical recommendation.

Wednesday, 7 April 2010

Some Notes for Readers of this Blog

When I started writing this blog, it was intended to consist purely of reminiscences of my present and past practice as an Approved Mental Health Professional (and previously Approved Social Worker). Cases were frequently chosen to illustrate the dilemmas and problems with which AMHP’s have to deal. I imagined that the readership (if any) would consist mainly of other AMHP’s or aspiring AMHP’s, and hoped it might be of interest to them.

From the feedback I have received from readers’ comments (which I really appreciate), I am building up a picture of the readership of this blog. As well as other mental health professionals, I am aware that there are also people who have been on the receiving end of the Mental Health Act, as well as others with a wide range of mental illnesses and disorders. This is making me aware that my accounts of assessments under the Mental Health Act might give to those readers an unduly alarming and possibly distorted picture of the consequences of having a mental disorder.

Readers need to be aware that my work as an AMHP is only a comparatively small part of my overall work as a social worker in a community mental health team, and by definition it only deals with crisis situations where people are acutely mentally disordered and may need compulsory detention for their safety and/or the safety of others. I have not written about anyone who has not been subject to an assessment under the MHA.

The people I see in my day to day work have a wide range of mental health problems, including depression, bipolar affective disorder, schizophrenia, personality disorders, anxiety, obsessive compulsive disorder, post traumatic stress disorder, and the long term psychological effects of childhood abuse. The vast majority of them will never find themselves needing to be assessed under the MHA or admitted to a psychiatric ward. Believe it or not, as a team we try to keep people out of hospital. What’s more, the vast majority of the people I see will improve, reach mental equilibrium and stability and be able to manage their disorder, or even recover completely, and will in time move on and cease to require support from mental health services.

I hope that service users and people who might have been detained themselves who read this blog will find it interesting and informative to see the process of assessment from the other side. I hope that they may recognise that AMHP’s are only ever trying to do what is in the interests of the patient and their carers, and that they must comply with the law and adhere to the highest standards. The fact that the AMHP, who makes the actual application for detention, is not a medical professional, is designed as a safeguard against undue medicalisation of the process of assessment in those acute circumstances.

I am aware that some of my accounts appear to have sad or unfortunate endings. I am, of course, only writing about the most severe and difficult situations I have come across in my career.

However, since this is my blog, I can write what I want, so I may also include some accounts of people I have worked with who did not need to be assessed or detained under the MHA, and whose stories have unequivocally happy endings. There are plenty of them.

Thank you all for reading.

Thursday, 1 April 2010


I was contacted first thing one Monday morning by our Criminal Justice Liaison Worker. Part of her job is to liaise with the police and the courts and to identify and assist with mentally disordered offenders.

She was ringing from Charwood Magistrates’ Court. There was a 15 year old boy in the cells, waiting to be charged with robbery and aggravated vehicle taking. The more she told me about the circumstances, the more appalled I became.

Shane had been a perfectly unremarkable boy until a terrible thing happened to him when he was 14. He was seduced and sexually abused by the mother of one of his friends. Since then he had become increasingly depressed and suicidal. He began to self harm. Three months before, he had cut his wrists quite badly and was assessed under the Mental Health Act and detained in a children’s psychiatric ward for about two months. He was a patient of the Child & Adolescent Mental Health Service (CAMHS).

A week previously Shane had taken a serious overdose and received medical treatment at the local Accident & Emergency Department. He had then run off, taken his parents’ car and was arrested and charged with aggravated vehicle taking. He was on bail when he was arrested again late on the Friday evening. He had stolen a car from a woman at knifepoint and had then crashed it, with the explicit intention of crashing it into a tree and killing himself. It was only the car’s insistence, through an annoying and persistent warning noise, to put on his seat belt that had saved him from serious injury. He was found by police wandering down the road in a very distressed condition, and had asked to be arrested. The police duly obliged.

What should then have happened:
The police, knowing his previous record of attempted suicide and self harm, should have arranged for a formal assessment under the Mental Health Act without delay. He could then have been detained under the Mental Health Act and admitted to a children’s ward for appropriate treatment.

What actually happened:
He was seen by a Forensic Medical Examiner, who unaccountably decided that he was fit to be interviewed. He was then interviewed, cautioned and remanded in custody until the next available court. Which was on the Monday. A suicidal, severely mentally ill child had been held in the cells for over 60 hours.

We attempted to retrieve the situation as much as possible. A social worker from the Youth Justice Team came to the court. We contacted the CAMHS consultant psychiatrist who also came to the court. His parents were already there with him, understandably extremely anxious and distressed about the entire situation.

We interviewed Shane. He presented with a range of symptoms of depression and Post Traumatic Stress Disorder, including nightmares and flashbacks relating to the abuse, loss of appetite and weight loss, and severe sleep disturbance. He was experiencing auditory hallucinations. He told us that he kept hearing an external male voice telling him to do things he didn’t want to do, such as cutting his wrists, taking tablets, and crashing the car. He said he had tried to use distraction techniques, but these did not always work. He cried. He wanted to die. He wanted it all to end. It was very clear from this interview that Shane was genuinely mental ill, and desperately needed to be in a safe environment.

In conjunction with the clerk of the court and Shane’s solicitor, we devised a plan. It was too late to use Part II of the Mental Health Act (Sec.2, Sec.3 etc), but we could use Part III of the Act, relating to the powers of the courts to detain mentally disordered patients. A bed was found in a secure children’s psychiatric unit. The Consultant gave evidence of Shane’s mental state to the magistrates. The Court agreed to detain Shane under Sec.35 for assessment. The police duly took him to the unit. Justice, at last, was done.