Friday 13 April 2012

Pass the Donkey - Part 2

"46 year old female, suicidal"


When we arrived at the hospital we were not greeted with open arms; in fact, quite the opposite. For the first time in my career the charge nurse refused to accept the patient. He didn't 'want her nonsense' in his department. As far as he was concerned she had been discharged from A & E and was not his responsibility. Obviously I didn't take this lying down but at the end of the day I have no power at all so we went and waited in the corridor like naughty school children until someone above my pay grade could decide what to do next. Obviously there were implications for our patients current mental state. I can only imagine what it must feel like to be taken somewhere you don't want to go and then be refused entry the place you have been assured will look after you. She did not take kindly to this rejection and despite the corridor being full of other ambulance crews and their patients she continued to scream, shout, swear and abuse. It was frankly embarrassing and something the hospital has a responsibility to avoid at all costs.

I felt it was important to get the hospitals view so invited Stuart Thomas, a charge nurse in a busy city hospital. I asked him how he felt about regular patients, suicidal patients and what he would do in this situation if presented to him and if there are circumstances in which a hospital refuses patients:

"From a nurses point of view, there isn't really a question of whether to accept hand over or not, the patient 'claims to be suicidal' so the patient stays to be assessed for suicide risk and medical clearance with an aim to refer to mental health services. Standard practice for any mental health patient. 

Capacity needs to be assessed and documented, if they have capacity then at least if they leave, your partially covered. 

So the treatment of the patient in question, isn't really an issue, it should happen, it needs to happen and clear discussion about the management of this patient should be carried out with the mental health team. 

What's more concerning in this case is the aspect of staff safety, without knowing why the police were called it's difficult to assess however standard practice can be carried out, nurse in two's, remind staff to look after personal safety, clear exit points for example. Request security to be nearby to maintain staff safety. If the patient kicks off then police get called, senior review and look at other options (section by mental health team or prison or sedation...but not too much or the mental health team won't be able to assess) 

What people often forget with frequent callers is that every episode should be treated separately, with respect and dignity, something I pass onto staff constantly. 

This case when broken down is simple and clear cut. Easy to manage with the right input."

Clearly, for the second time in an hour, the proper procedure was not followed and again we were left in a situation where I was unhappy and the patient was getting more and more aggravated. As we couldn't stay with her indefinitely and as the hospital would not accept her I had no choice but to call the police back. After 5 minutes we got the following message:

"No units to send, we will not be attending unless requested by the hospital. We have already attended this CAD"

So now we were stuck a corridor with nowhere to go and no plan ahead. I then asked the patient to get off our bed and sit on a chair. She refused. I'm guessing it was her chance to fight back and in a way I don't blame her. We had effectively been playing the kids card game 'Donkey' where the object is to make sure you are not left with Donkey at the end of the game. That was no different to this situation, as crude an analogy as it is, to look at the mental health patient as the donkey. As an ambulance service we want either the police to take charge or for the hospital to take her. The police didn't want to get involved as it would tie up officers for hours and the hospital didn't want to know because then they would have the responsibility. We were stuck with the 'donkey' with no one to pass it to. A cruel analogy yes, but despite knowing what should be done, no one seemed willing to do it on this occasion. We sat in that corridor for a further 2 hours, totalling 4 for the job. When she got off of our bed and used the hospitals toilet she became their responsibility so we left. Not ideal for the patient but what could we do? It is therefore only fair to get one more opinion on this. 

I'd like to introduce @Sectioned_ who has been a patient who's experienced the our ailing mental health system and has had dealings with the police, ambulance and hospital from a patients perspective. I asked her what it is like to be a patient in a similar situation. What is the mindset? Where no one wants to know, being forced to do things you don't want to do and having doors closed on you by the services supposedly there to help:

"When you’re suffering extreme emotional distress, let’s face it: you’re not at your best. You may not be great company or easy to deal with. That’s because you’re in pain. Not the bleeding-from-the-head-put-on-the-oxygen-mask kind, but pain nonetheless. And you want that pain to stop. But you don’t know how to make it stop. And you don’t necessarily pick the best options for making that happen because you’re not in an especially “resourceful” state of mind. (At least not in a helpful way: after all, swigging from strangers’ pints is a pretty resourceful way to get drunk and blot out the pain … but it’s never going to end in a good way.)

Whenever I’ve dealt with emergency services personnel, they’ve arrived at a time of crisis. Of course they’re human beings, good and bad; but in a crisis they interact in institutional ways, according to training, codes and protocols. They’re there to do a job, which is to somehow resolve the situation that presents itself to them in the moment.

They’re not there to fix your life. They’re not your mummy. They don’t love you. Similarly they’re not the housing benefit office that’s just written to say your benefit’s being cut; or the doctor’s receptionist who didn’t give you an appointment right away; or the hole in your pocket that meant you lost your purse. But it’s all these sorts of things and a million others that will be pressing on you in that one moment to contribute to your emotional distress.

Sometimes when you don’t know how to deal with these emotions you end up feeling completely worthless. Totally messed up. That you’re a burden. That people would be better off if you were dead. And that you’d be better off dead.

But here are the emergency services standing in front of you, trying to get you to do something you don’t want to, like move here, sit there, when all you want to do is cry out in pain. The priority of the emergency services is not to make your pain go away. Though they might well see you as a pain to be resolved, one way or another. 

This woman needs help with how she copes with her life. She needs coordinated mental health, physical health and social care services; pre-emptive measures. Each time she calls on the emergency services, it's an example of "failure demand": a demand generated by the failure to do something or to do it right ("Failure demand" is a concept invented by occupational psychologist Professor John Seddon and introduced to me by @MentalHealthCop.). It’s not about who’s going to transport her, or whose bed she sits on. These practical problems, which the emergency services are tasked with solving, are merely symptoms of a fragmented system that’s clearly been passing her around between different services for long enough for her to be seen as a right royal pain in the nether regions."

I decided to do this blog out of frustration. Frustration the patient didn't get the treatment she was entitled too. Yes, she drains resources, yes, she is often abusive and yes, she is an extremely difficult patient for us, the police and the hospital to deal with, but this does not negate anyone's responsibility towards her. Stuart Thomas summed it up perfectly. 'Easy to manage with the right input'. I think the one thing that is apparent after gaining a variety of opinions is that a lot depends on who you get. Like in every job there are good eggs and bad eggs. There are people at the start and end of their shifts. There are people who have passion about certain areas and not about others. There are good people on bad days. Luck has a lot to do with it. What that proves I don't know, but I think it does highlight the need for more communication between services, mental health teams AND patients. The patient's voice often goes unheeded but is one which I feel should carry the most weight. I think this is much more pertinent in mental health as we are not adequately trained to deal with it and therefor don't understand their mind-set and what does and doesn't help. If there was an open dialogue and agreements between services in place this job may not have escalated like it did. Personally, if the PRIVATE ambulance hadn't kicked out a vulnerable adult onto the street I probably wouldn't be writing this blog in the first place! Just saying! *cough NHS Bill

To be continued........

Part 3 - Click here


  1. I was agog for Pt II so...

    So many issues this raises!
    Who determines capacity? Because really and truly an adult ought to be allowed to make stupid decisions as long as they don't endanger others. I expect to be able to behave badly provided blah blah.

    OK, you decided she needed help even if she didn't want it. Then you have to accept she will be held in some kind of custody. That would be a secure unit until she was assessed (in my world).

    My main responsibility is to protect society as a whole. Individual liberty is thus imperilled. I see no other way.

    But really I'd want to tell her I'd tried my best to help and I was now going to assist someone else. Recommend a good place for a cuppa and disappear. We can't 'fix' everybody even if we wanted a robotic population of identikit workers.

    Someone has to make a decision and we should be employing people who are happy to take on that burden and are prepared to account for their actions. We should trust our emergency services to do their best, to be ready to explain themselves when they inevitably make a mistake and not to persecute them UNLESS it is clear that they were uncaring.

    1. In response to the post by "jaljen":

      Wouldn't it be lovely if offering someone a "nice cuppa" cured suicidal thoughts, mental illness and all manner of social problems. How remiss of the ambulance service, police and hospital to miss that one! Then, if the patient makes a “stupid decision” and takes her life anyway, well she’s only got herself to blame.

      I can see the attraction of such simplistic approaches but, er … they don't work. Otherwise instead of fleets of ambulances and police, we'd have mobile tea urns ready to be despatched at a moment's notice.

      This lady is known to mental health services and as such her undesirable behaviour has been diagnosed as being a symptom of mental illness, not merely bloody mindedness or attention seeking. As a special needs teacher, I’m sure you have some great skills to help your students gain coping skills, but sticking this woman on the naughty step for 46 minutes – nice cuppa or not - isn’t going to fix her.

      Killing yourself really is more than "behaving badly": it's terminal. Bear in mind she’s made serious suicide attempts before, ones that have left her permanently physically damaged (hint: wheelchair). She might try again. And this time she might succeed.

      In this country, we recognise that people suffering mental distress - just like those suffering physical illness - deserve assessment and treatment, not the naughty step. In my experience it's a shame there isn’t more compassion, kindness, coordination, early intervention and pre-emptive action in UK mental health care (which is why those of us who've been on the receiving end often have an ambivalent attitude to our beloved NHS; I myself am currently waiting for a response from my psychiatrist to a request for help made on 15th March … a month ago).

      However, if I were the patient in question, I would be glad it was Ella who turned up to this call not you, no matter how much I enjoy a "nice cuppa", especially when someone else makes it.

    2. Agreed - but I LOVE the idea of emergency mobile tea urns...

  2. I agree with some of what you say but on being told that she is feeling suicidal we have a duty of care to ensure she is taken to a place of safety regardless of her objections. We determine capacity using a Capacity tool. Its basic questions on whether the patient is being influenced by external influences, if they understand what is being proposed and why, and if they understand the consequences of not accepting treatment. In this case, she had capacity to refuse treatment but leaving her in a public place would be a danger to herself and others. Our place of safety options are simply a police station or A & E. We are not allowed to take a patient direct to a mental health unit so our options are limited. We are all prepared to account for our actions but the HPC and employers would not accept us leaving a suicidal patient in a public place who could potentially jump in front of a bus. It all comes back to a duty of care. Yes this patient is a burdon but why has she got like this? Failure Demand!

  3. Brilliant blog all....congratulations and thank you!
    I especially liked the explanation by @Sectioned_ and it proves that if one bad thing happens every few weeks, you can deal with it....but if all the bad things hit at once = OVERLOAD!
    Yes coping strategies and communication are key!

  4. Excellent blog as a AMHP have come across this type of patient many times and would have to agree with Stuart Thomas it matters not how many times a person has voiced suicidal intent they must be assessed afresh its not a waste of time its your job as a AMHP i have never refused a referral for assessment under the Act from A+E as i trust a fellow professionals judgement. Yes i might be annoyed n pissed off if i think its a waste of time but thats my problem not the patients or emergency staff its called been professional. Yes i have seen plans made up to refuse admission to certain patients but they are not worth the paper their written on if someone is saying they are going to kill themselves. So anyway apologies for the rant been one of those days if called in this situation i would attend A+E with medic possibly just 1 if person was likely to leave and assess under the Act and if appropriate detain under section 4 and if required would get this person referred back into services as part of the assessment if not detained


I love comments! All bloggers do! If you have something to say, agree or disagree I would love to hear it! I will reply to all! (or try my very best!) If however, you're a troll, save your breath!

Due to an increase in spam I moderate comments but ALL genuine comments will be posted. See above exclusions!