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M ental I llnessC oncernsA ll | Is all as well as it seems? All is not as clearcut as the headlines convey. APPENDIX CHELD 5th NOVEMBER 1999 ... ' Christopher Watts is not now suffering from mental disorder or from mental disorder of a nature or degree which warrants the detention in a hospital for assessment (or for assessment followed by medical treatment at least for a limited period ). The patient was discharged from the liability to be detained forthwith. The reasons given by the members of the Tribunal were: ...
' The patient has a longstanding mental illness, diagnosed as paranoid schizophrenia exacerbated by alcoholism. He also has cognitive impairment and suffers from marked jealousy and has an inadequate personality. This illness is episodic and his numerous admissions are related to stress and his inability to cope with events in his living (sic). [ bold = ed.] It is not clear what 'basic assessment' means here. Basic risk assessment ? Nor what is meant by 'an episodic illness' taken with above 'a longstanding illness. In the continuing presence of schizophrenia it is better accepted as being an expression of that illness The Inquiry says ...' Dr Mylonakis gave evidence that further assessment in hospital was needed' - there is an appropriate form for this - but the Inquiry goes on to be dissatisfied that the reasons given for that could be convincing to the Tribunal. The content of what the locum consultant put to the Tribunal is not given. He appears before the Tribunal to convince them - to be ready to answer any questions the Tribunal may have. We are not told how he described that interview to this Inquiry and what came up in it. The Inquiry Panel does not seem to have interviewed or heard directly from the Tribunal, the medical member of which is expected to examine those notes relevant to the appellant. The voice of the medical member is not heard in this Report. [ the Tribunal have the power under Rules to obtain any information they think necessary, including the power to subpoena witnesses. The medical member will in all cases be required to examine the patient or.. (?ed.).. to take such other steps as he consides necessary to form an opinion on the patient's mental condition. ] Is it the degree of illness which the Tribunal considered insufficient to need further assessment? [ an Assessment detention is ...'ought to be detained ...a Treatment detention is 'necessary to be detained ' (can't be done outside). Blom Cooper in the Robinson Inquiry ( The Falling Shadow ) was less reticent, and was given access to personal notes of Tribunal members. The function of the Tribunal medical representative at a Tribunal review is not clear. Discoverer, evaluator, interpreter, judge? It is certainly adversarial. Why should the Tribunal prefer the Tribunal medical view of Watts - a point in time viewpoint - rather than the view of the clinician who has been seeing him over months. The Trust clinicians put their case for detention. The medical member has to interpret its degree of conviction to the other members of the Tribunal Panel - as well as having to assess and put in his own view of the lawfuness of the detention. There is no serum schizophrenia here. It is a matter of grading degree of illness and degree of risk, weighing the evidence presented by the Trust, through the consultant representative, balanced by that obtained and illuminated by the Tribunal medical expert. If the scrutiny of the clinical appraisal of the medical member finds worrying matters for concern, over and above what is put to them in the content of the psychiatric and social Reports, what does the Tribunal listen to ? In one of the first Tribunal exercises [ The Falling Shadow: Blom Cooper; Robinson ] the medical representative was denied access by the patient, and the Tribunal just accepted - wrongly - the content of the hospital Trust consultant Report to that Tribunal. Here the Inquiry report points out the Reports ( here commenting on the Social work report in particular ) to the Tribunal are not advocates for the position of the patient but provide the foundation for the Tribunal to say whether detention is legal. If the remarks in the paragraph describing the compulsory admission were in the clinical notes underpinning the recommendations, then did they include that a neighbour reported hearing threats to kill during the preceding two weeks and that a friend heard talk of suicide. This editor would describe his long held jealousy - as related in the Inquiry - as not just marked, but in the context of other behaviour indicating the presence of schizophrenia - abnormal, insubstantiated, persistent and morbid i.e. a manifestation of continuing delusional illness, and showing the persistence of the absence of insight. Insight in accepting the title of schizophrenia is not to be equated with an understanding of its implications, or even that treatment will therefore be followed. It is often just a recognition of the given name. It is never clear that it persists. It can endure for a point interview, but other observation may confirm that the illness escapes. As for risk assessment - which was one of the the reasons behind the Section 2 admission requested by the locum Consultant - schizophrenia, alcoholism,abnormal sexual jealousy, protestations of impotence with the companion treated (presumably with viagra) , threats to kill, a close-by companion a potential victim, and one could add the provoking stress of the current uncertainty in the mental condition of the potential victim - all add up to giving a basis for just the period of further close observation required by the locum Consultant - who did not have any longstanding personal contact with Christopher Watts to draw on, but who felt Watts needed more observation. The Inquiry responds to the relatives by saying the Inquiry has to react legally to the case put by the Trust for continuing detention, and here it was to respond to the reports put in by the consultant psychiatrist, and the social worker. The Tribunal does not say the risk assessment is finished according to the consultant and the social worker. [ The Inquiry Report is in a muddle here ...Commenting on the Tribunal decision the Inquiry report says ..(p.46; line21) ... 'If there were anxieties about Eunice's safety, they must have been lessened by her admission to Bridge Ward in the Brooker Centre on the evening before the Tribunal ...' But earlier - p21,para2, line9 - the Inquiry says ' Eunice was seen at the Centre with Christopher and showed the apprehension of Christopher listed earlier as -' offered admission,which she then refused' . Earlier - for the same incident - the Inquiry report says- p18, para4, line7 - she was admitted informally, but discharged herself against medical advice - on the following day. Then under the section headed 'Findings and Conclusions' referring to the same incident - about the decision of the Tribunal p38,para3,line9 ...' A report from Dr.Riedel ( if Eunice was admitted, surely it would be in the notes ? ) who encountered Chris and Eunice on the previous day, when she seemed frightened of him, was not available to the Tribunal'....? If the Tribunal knew she had been admitted ? ] The Inquiry cogently remarks that as Christopher Watts was allowed home during his detaining Order the risk to Eunice could not have been assessed or presented to the Tribunal as a high risk. Is on short day leave - under the Order - not perhaps a low risk, whereas complete discharge would bring more imponderables, over more time, more chances for 'difficulties ' to arise.? The Inquiry is less convincing to me where it deduces that the Tribunal could see the incidents of threats to kill, and rage abuse - and the detail in the jealousy ?- as within the acceptable range of personality variation rather than typical of illness. The Tribunal sat unusually long - three hours. If the people invoking the Section 2 detaining Order had seen what the visiting social workers saw in the home two weeks later - thousands of unused tablets belonging to Christopher Watts - would matters have been different? Steps were subsequently taken to see that Christopher Watts took medication at the day centre We are left with a feeling of dissatisfaction. What would the Tribunal have decided if they knew of the hoard of untaken medication. How was it the many, many, home visits never uncovered the hoard. Why is it that the Inquiry has so little to say about the apprehensions that Eunice showed once - but only once ? Were they ever aired when she was on her own - not seen together as an appendage of Christopher. We hear very little of her view of the accusations made against her by Christopher. Did she share any of her worries about her own at risk assessment with the support worker, ward nurses, fellow patients - maybe her mother - noted as visiting the home with the social workers who found the hoard, and being nearly hit the next day on the ward, whilst visiting and when Christopher Watts pushed a stool about the ward. None of her independent community contacts seem to have been interviewed. Not even her mother. She may have been invited - but by the Trust people - involved parties -and declined - but, an explanatory invitation from the Tribunal for help ? We are left somewhat in the dark. This editor is left wondering whether supportive home visits to Christopher were ever used challengingly, to bring out his inner illness driven convictions - the persistence and strength of his abnormal jealousy. Building up trust can mean overlooking and putting aberrations on one side. A patient in these contacts is set to impress and convince. Trust in openness can never be unreserved when dealing with the illness schizophrenia. Their own account of what has happened 'in between' is unreliable information. It is the outspokenness in the presence of naive observers which discovers abnormal talk. The Inquiry somehow leaves this editor with the feeling that in the precis presentaton of the Report the final headline has been arrived at, and the Report then shaped around the conclusion. What is to be made of these two paragraphs ? ' From the day when he took his own discharge from hospital on November 5th until Eunice's death 4th December Chris was seen frequently by a range of clinical and social work staff. But when two people living together both have continuing severe and enduring mental illnesses any untoward behaviour suggests full review to consider whether it is evidence of franker illness. Earlier, when both were at home -after Christopher Watts is released by the Tribunal from his Order and before Eunice was admitted on hers 'both had telephoned the on call worker at the Day Unit'. 'There was a report that one of them had a knife' Dr. Mylonakis reported a Care programme Review meeting on November 16th,attended by himself, ASW, CPN, Deputy Sister Pine Day Unit and Outreach Care Worker.Christopher Watts was described as having become very withdrawn in recent days, to have talked of stopping clozapine and to be suggesting that Eunice might be having an affair with one of the patients on Bridge ward where she was now an in-patient "He has said he would smash the face of this fellow patient". ... on 19th November he angrily pushed the stool during an abusive meeting with Eunice - still an in-patient - and nearly hit his mother-in-law. The finding of the large quantity of medication in the house the previous 18th November day was 'reported to the team' [ the only 'team' listed is the mental health Social Worker Team ? ed.] ....( was the family doctor informed ) .... and on that same day .. 'They ( who ?- the whole team - psychiatrist, nurses on Eunice's Ward : or the Social worker team. Who?ed. ) wondered about detaining him ( was the family doctor contacted ) but decided there were not enough grounds to use the Mental Health Act ..." [ did they know or remember that a substantial part of the reason of the Tribunal release on 5th November was because he is compliant and agreed to take medication. ] [Recommendation 4. ... that decisions about the risk of violence or self harm should wherever possible be shared by all members of the multi-disciplinary team ] The Department of Health does give guidelines and a conclusion here is that these were met. The caveat from the Department is that these are guidelines and how they are met is down to the local commissioners and those who are to deliver the services - the local people best know the conditions at the workface which decide the implementation practice. The Inquiry delivers twenty-eight recommendations that will help in the lessons that can be learned. It resolves the missing tablet question by suggesting blood level testing. Mandatory ? The Inquiry Report has a curious sentence under National Issues....'We hope that Ministers and the Department will be able to acknowledge the case as illustrating the need to seek to find blame where there is none to be found.' Professor Louis Appleby might understand it . He has called together some of the great and good in the mental health service .. Membership of the working group
... and concludes. This Dick; Watts' Inquiry recommends ;- Responsibilities. 13. 'There should be a review of the role and responsiblities of the consultant psychiatrist in a modern community based mental health service' Another recommendation is that locum Consultant appointments should be avoided. This when there are 500 vacancies in the mental health service. The Inquiry is surely correct in that a locum appointment needs closer and stronger management mentor support. Hindsight cannot become foresight. Carers, particularly family carers, remain hopeful, that looking for ' weaknesses ' will remain a proper objective, that the findings will lead to an ackowledgement in practical response that the lessons have been learnt locally, and those lessons that have wider resonance come to the consideration of other local mental health service NHS management , and generally feed into planning and funding. Nothing from the Department shows any active response to the one hundred Inquiries that have been reported. No advice to local management. |
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