Saturday 28 December 2013

The Capacity Games

As I walked into the room he was laying face down on the bed, arm hanging over the side and bleeding heavily. A constant stream of blood was trickling out into the ever increasing pool on the floor. He was seemingly unconscious and very pale. I applied some significant pressure to the wound in the bend of his arm whilst trying to find out what had happened. It turns out that he wasn't unconscious but just playing dead. Within a minute or so he was up and talking, full of bravado and attitude. I applied a pressure dressing to the wound and bound it up relatively tightly. 

In terms of numbers he was OK. His pulse and blood pressure were stable and was showing no signs of shock despite the blood loss. That said, he needed to go to hospital. Clearly this was a cry for help and I wouldn't be happy leaving him on his own. For a suicidal self harmer however, he was surprisingly up beat. Very chatty, very well spoken and extremely knowledgeable about mental health law. He quickly made it very apparent he was not going to be going to hospital under any circumstances and was well aware that currently the ball was in his court. I had hoped some well chosen words and my power of persuasion could have made inroads with him but he was as determined as he was smug. 

Plan B then. If I couldn't force him to go to hospital, then I had to bring the most relevant bits of hospital to him. I discussed options with him and we settled on getting an out-of-hours GP to visit to ensure the wound was clean and appropriately dressed and then contact a mental health crisis team who WILL visit within two hours. Well, that's what they are supposed to do! He was happy with the plan, his dad was happy with the plan and seemed in good spirits. I wasn't happy with the plan but that was probably fed by the compulsion to do something for someone in crisis and not getting my own way. The patient had capacity so this was the best I could do! At a stretch the fact he was drunk could effect his capacity but I was able to have a more than rational conversation with about the pros and cons of staying and going and depute my disagreement with his opinion, it was after all his opinion and ultimately, his choice.

*REMEMBER THIS MOMENT* At this point, no ambulance had arrived, so I phoned control, to tell them that the patient was refusing treatment so no ambulance was required. 

"We also have the police running on this CAD, would you like them cancelled too?"

"Rog, patient is compliant and isn't being aggressive. Cancel police."

"Rog, thank you, red base out."

I explained to the patient and his dad that I needed to go and get my paperwork and phone various people to arrange the referral. I needed to speak to our Clinical Support Desk, the GP and the Mental Health crisis team and that could take a little while to get the ball rolling.  What I did assure them of, was that I wouldn't be leaving until I knew exactly when someone would be coming.

I went down to the car and started my phone calls. Midway through my first conversation there was a knock on the window. It was the dad looking rather panicked.

"He's done it again, I can't wake him, it's bleeding everywhere."

*face palm* 

I hung up the phone and rushed (Ambulance Run - above average walk) into the house and back upstairs. As I got to the landing I could hear the blood pouring onto the wooden floor. He was now lying on his back, other arm hanging over the edge of the bed and blood was literally pouring out of him. He was white as a ghost and unconscious. Again, I applied pressure and held his arm as high as I could. I was now in an extremely awkward situation. *REMEMBER THAT MOMENT* 

I was on my own with a bleed I was struggling to control. I had cancelled the ambulance and considering I had already waited 40 minutes and one never arrived, the chance of getting one instantly was minimal. I had also cancelled the police, who in this situation could be of great use!

"You see the radio on my belt, twist it off, hold down '*' to remove the key lock, then hold down '#' (priority) for me."

His dad followed my instructions and within a couple of seconds the radio started ringing. 

"Hold down the button on the side for me."

"Red base, patient has cut himself again, I need the police and an ambulance as a priority, I'm struggling to control the bleeding." 

"Rog, will do that for you now, nearest ambulance is some distance away, sorry!"

"Right, take the key off my belt loop, in the boot is a big black bag with 'Paramedic' written on it. Bring me that bag please."

Off he ran (Non-ambulance run - Actual running - Weird phenomenon). I managed to apply a pressure dressing to the arm which seemed to do the trick. This time bound even tighter than the first! On his return I got his dad to hold the arm in the air, allowing me to do other stuff. His blood pressure was in his boots so I got a cannula in him (for the medical lot, an orange in the back of the hand, sadistic git that I am) and started running some fluids through. The patient gradually became more coherent and was soon back and telling me to go away and leave him alone. Unfortunately for him and luckily for me, the leaving alone option was no longer viable.

First to my aid was the police. They helped me with everything I was doing and also attempted to convince the patient that now hospital was a must. He was having none of it. 

"You can't section me, I'm old enough to make my decisions and I'm not going to hospital. There is nothing you can do to make me go."

"I think you'll find we can."

"What powers are you going to use to take me from my own home, a place of safety, right here and now. You can't do anything legal and you know it."

The poor copper looked a little stumped and unfortunately had no answer for him which somewhat undermined his authority.

Although the patient had apparent capacity to refuse treatment, on balance I now felt I had reasonable grounds to use the Mental Capacity Act to enforce treatment. As far as I was now concerned he lacked capacity to make an informed decision and didn't appreciate the severity of his injuries. Unfortunately for the patient, he came up against someone with greater knowledge of mental health law than him. I was able to quote section 4(B) of the MCA at him and outline why the deprivation of his liberty was necessary. My rationale was because my proposed treated was wholly or partly for the purpose of giving life saving treatment to him and that, as the medical professional currently in charge of his wellbeing, I was well within my right to ensure he got treatment.

I explained all this in quite a self gratifying speech which left the patient looking rather deflated!

"Aaaaahhh, you just got schooled on the law by a paramedic, aren't the police supposed to know more?! Embarrassing!"

I felt a little awkward but luckily the copper took it on the chin and seemed happy to follow my lead and confirmed to the patient that I could do what I was saying. I also backed that up by telling him that under section 6 of the MCA he could be retrained by the police to ensure said life saving treatment happened and to prevent further harm to himself or us. Faced with three people who were much more well read on mental health law than he was, he quickly got on board with what was going to happen and became compliant. 

When the ambulance arrived he came voluntarily and was most apologetic to all of us. His initial reluctance to go to hospital was easily explained......

5 hours earlier......

A 23 year old guy who suffers from bi-polar and depression, who has a history of self harm and suicide attempts, is feeling particularly low. He is feeling suicidal and wants some help. He tries but fails to get hold of his crisis team. They simply don't answer the phone. Because of these feelings, he has been drinking heavily but being self aware enough to know that he is likely to do something stupid, he self presents and his local A & E. He tells the triage nurse he has been drinking and is feeling very low and suicidal. He said he just wants to die. 

The hospital is very busy, majors and minor are full and the waiting room is at bursting point. The triage nurse listens to a young guy tell her he has been drinking and apparently takes no notice of his medical history and wish to die, so puts him in the waiting room where he waits.....and waits. After 4 hours he got up and left. His cry for help had been ignored by mental health services and his local hospital.  He got on a bus and went home where he carried on drinking. And drinking. 

He then smashed a glass, picked up a shard and rammed it into the crook of his arm. He then called his dad who was downstairs, to tell him what he had done. His dad phoned 999.

"My son has self harmed, he is bleeding from his arm quite heavily."

"OK sir, help is on the way."

"23 year old male, self harm, serious bleeding, access OK"

Luckily I was only round the corner so was on scene within a minute or so. I grabbed all my stuff and headed up the path for my first mental health of the night......

A patients outcome, positive or negative should not be based on luck. Luck that I was close by. Luck that his dad was in the house to find him bleeding when he did. Luck that the bleeding was stopped and he was quickly treated. This should be the basic of mental health care. There are services in place to not only treat this demographic of patients but to safeguard the risks that are associated with their conditions. A patient in crisis and at significant risk of harm should have instant access to their crisis team. Time and time again mental health services are impossible to access outside of 'Mon-Fri 9am-5pm'. It just isn't good enough. With the glaring failings in an understaffed, under trained and underfunded system, the safety net is always A & E. However, combine deep cuts, fed up staff and lack of training with winter pressures and a waiting room full of time wasters and the basics are simply overlooked. 

There was no RAID (Rapid, Assessment, Interface and Discharge) or other liaison service made available or seemingly in place to allow a quick assessment of him. There was also no apparent risk assessment. After only 5 minutes with the guy and a limited knowledge of the Pierce scale of suicidal intent, I had him at a high risk of significant harm. His medical history and presentation alone raised enough Red Flags to warrant a rapid assessment. Instead he was left to his own devices in a waiting room of a busy hospital. Hardly the place for a vulnerable, suicidal young adult to be left. This job highlights the woeful inadequacies of mental health care from top to bottom of the NHS. When will this improve?! 

So, mental health care in the NHS. Discuss.


  1. Id like to say im surprised, im not. MH care is failing and badly thats from both personal experience and from the stories of others, were scared and vulnerable and ever so grateful to every professional that highlights this, thankyou. I dont know how the NHS can fix this, its not the only area of care thats failing and its costing money from other budgets such as the police, social services therefore its a false economics as well as costing the NHS's own budget extra as now hes going to need a bed which will cost more that CRHT and CMHT community treatment (im assuming).

  2. great blog entry as ever can see why MH Cop asked to repost it. Sadly I am not surprised by the lack of a response from the mental health services. The time for talking about priority with physical health has past it is way past time too that something is done about mental health services in this country too.

  3. We have a regular lass who calls, always outside that 9am-5pm Mon-Sat timeslot, and always with the same presentation. She feels down, has been drinking, wants to self-harm, and knows she shouldn't, so she calls us.
    If we don't get there quick enough, she will start self-harming. So far we have usually gotten there before she has a real good go.
    It breaks my heart every time we go pick her up, that she is having to call us because her mental health team isn't available (and there are no other options to get to the hospital at night, the buses don't run and the taxis don't come). We are not the people she needs. Instead we take her in, burdening the ED as they have to put her in a bed in plain sight for the night, and wait for the mental health team to be available in the morning to see her.

  4. I'm so glad I've retired, but wonder if these patients are "only" bipolar/depressed. Could there be some personality problems, too?
    Scotland based, I don't know how Enlish legislation coversthat.

  5. This blog hit a nerve.
    My foster brother suffered from depression. He self harmed and was taken by ambulance to a&e where the nurse told the ambulance crew to put him in the waiting room because he was a "frequent flyer".
    The reason he was a frequent flyer was because his crisis worker was on holiday and no alternative care had been put in place.
    After waiting for several hours he walked out amd threw himself under a train.
    The FAI laid partial blame at the feet of the triage nurse for telling the young ambulance tech to put him in the waiting room. Her reply was there was no one from MH on duty after midnight. She isn't MH trained. What else could she have done?

  6. This makese so sad. I've dealt with mental health as a patient lately and it really is a lottery. People end up in awful situations because of lack of support and assistance. It's not that people don't care, it's just that the system is stretched to the absolute max

  7. The lack of support for mental health in this country is sickening. I have mental health problems (including depression and OCD among others) and it shouldn't have to be paramedics who are dealing with us unless we have, as in this case, harmed ourself. I've needed to go to hospital once, crisis team weren't available (as per usual), my only option was to go wait in A+E which is about 14 feet from the MH hospital which has a large waiting room. I didn't want to be in the A+E and the other patients didn't particularly want me in the A+E either as I was very distressed. I ended up leaving because some guy started throwing up (very emetephobic!) and ended up staying with my parents! It's so wrong, you guys shouldn't have to do this for us.

  8. As a patient I've recently been discharged from my local MH treatment place after meeting 4 times with my pyschiatrist(s) and 4 with my therapist. I don't feel better, or 'normal' yet and it was as though they didn't really care and discharged me because I hadn't seen them in a while. Its the worst feeling, like my problems are no longer important.
    I admire you for what you do - we need more people like you in the health care sector.

  9. Fantastic points made from start to finish in your blog. I've had bipolar for most of my life ( I'm 42) and have been through similar situations.

  10. Woah, woah, woah!!

    'Unfortunately for the patient, he came up against someone with greater knowledge of mental health law than him. I was able to quote section 4(B) of the MCA at him and outline why the deprivation of his liberty was necessary. My rationale was because my proposed treated was wholly or partly for the purpose of giving life saving treatment to him and that, as the medical professional currently in charge of his wellbeing, I was well within my right to ensure he got treatment.'

    Section 4B MCA says that D is authorised to deprived P of his liberty WHILST A DECISION AS RESPECTS ANY RELEVANT ISSUE IS SOUGHT FROM THE COURT. It ain't a general power to deprive a person of their liberty to administer life sustaining treatment, unless that is linked to an application to the Court. Was there a Court application here? It doesn't look like it, and it seems unlikely.

    'I also backed that up by telling him that under section 6 of the MCA he could be retrained by the police to ensure said life saving treatment happened and to prevent further harm to himself or us.'

    Section 6 MCA can indeed be used to restrain, but not to authorise deprivation of liberty. So if this amounted to deprivation of liberty, then it cannot be used. Please check with your Trust's legal team - it looks like you've been given some bad advice.

    1. If you were stood in front of someone with an active arterial bleed, decisions compromised by alcohol and significant blood loss, do you think it appropriate to sit around requesting a court application? Have you ever tried getting a court application during a bi-lateral active arterial bleed? I would argue that removal under the MCA was indeed the least restrictive and most appropriate action. The restraint can be used to protect the patient from further harm from themselves i.e. to stop him pull off the pressure dressing stemming the bleed and also to prevent harm to ourselves from a combative patient.

  11. great blog as always Ella. Suffer from MH issues myself.

  12. I have borderline personality disorder, which is basically seen by MH services as attention seeking. I have been suicidal in the past, but I wasn't seeking attention. Quite the opposite, I wanted to die and thought that the world would be a better place without me in it.
    I was diagnosed 2 years ago, but only found out last year. Nobody bothered to tell me I had it, let alone offer help. I've been on the waiting list for a CPN since February and there's still no sign of anything happening. As a whole, I'm extremely proud of the NHS, but mental health services leave a lot to be desired.

  13. Sadly an all too familiar scenario.
    **potential trigger below**
    I am a carer for someone with significant mental health issues (Borderline Personality Disorder, which as Petrolhead above me says, is often seen as "manipulative, attention seeking behaviours" (those were the words used by the psychiatrist assessing the person I care for and major depressive episode.)
    Last year, one night at around 10pm he decided he wanted to end his life. He became delusional (there were people watching him, I was plotting to poison him, the world would be better without him as I would be "free", I was "speaking in code"). I didn't know what to do. I had never seen him so bad.
    He had, at this point, been on the waiting list for an "urgent assessment" for 3 years. THREE YEARS.
    I phoned the out of hours doctors. They told me they couldn't attend for mental health issues and take him to A&E. I have no car. He clearly isn't driving anywhere. No taxi driver is going to pick up the large, angry, deluded, aggressive, terrified, sweating, shaking, desperate man, even if I could somehow carry him into the cab.
    I phoned NHS Direct (as was). They said it was not a "medical emergency" and so could not help.
    I phoned 999. I asked for ambulance. I explained the problem and was told this was a police matter as it was "domestic violence" as it was happening in the home, and they could arrest him. He needed medical help, not arresting!
    I phoned his parents and sister (it was almost midnight by now, somehow he was sweating, naked, angry, irrational, gone. I had hidden everything of danger I could find - knives, scissors, pills, cleaning products, alcohol. I tried to convince him to take one of the sleeping tablets the GP prescribed for emergencies. He eventually took it but it had barely an effect.
    His family live 3 hours away. it was the middle of the night but they got into their car and set off driving.
    I text a friend, who went online, and found, buried somewhere in an online forum, a phone number for our local crisis team. I rang them....and got an answerphone saying they were open Mon-Fri 9-5.
    I will admit, at this point I considered dialling 999 again and saying he had chest pains and difficulty breathing, I was desperate. he was desperate. I left a message on the "crisis team" answerphone which informed me I would be phoned "within 48 hours".
    Eventually his family arrived. They relieved me so I could eat something, rest a little.
    In the morning I phoned the "crisis" team again. "we don't do visits out of hours" they said "it is a health and safety risk. In future you should have him arrested so he is safe". I was flabbergasted.
    They eventually came that afternoon. He was calmer, doped out on sleeping tablets and diazepam. They asked him how he was. "fine" he slurred. They told us he was fine, there was no crisis, and left.
    It is now 4 years since he went on the waiting list. He was seen 3 months after that night for an assessment (where he received the diagnosis and comments above). He was then discharged as he "did not need intervention". I wrote to our MP who intervened and got him back on the waiting list. At the bottom.
    This is the state of mental health "care" today.

    Sorry for the long post. Not opened up to anyone about it, this post seemed to trigger it and I needed to get it out. Thank you if you read this far.

    1. It definitely helps having friends in the same position. I met my friend Charlotte in a mental health unit I June 2012, and were both diagnosed with BPD. In December 2012 I took an overdose and was admitted to MAU for observation because I also have a cardiac condition and pacemaker. When the staff opened the curtains in the morning I was shocked to see Charlotte in the bed next to me. The mental health liaison nurse who we both knew from previous occasions decided after the doctors medically cleared Charlotte for discharge that she would try and have her admitted to the mental health unit. I was admitted to CCU and didn't get to speak to her until I was discharged under the 'care' of the 'crisis team'. She then told me that she was discharged from the mental health unit the day after she was admitted, proceeded to take another OD and was sectioned that night! Worst case scenario she could have died, she was obviously crying for help but where was it? Where will it be next time any of us need it?

  14. I'm a Paramedic in Queensland, Australia and we have the same problems with lack of support for mental health patients.
    Although in the Ambulance Service here, we have the ability to detain and transfer patients against their will to hospital if they have attempted suicide or are 'at risk' of significant harm to themselves or others. Once at hospital they are held for up to six hours for mental health review.

    Makes it nice and black and white. Tell me you're going to kill yourself or try.... You're coming up to hospital!

    But there definitely needs to be more invested into MH. The problem is just getting worse here and more patients are reaching out to us cause there's no other support.

  15. There are problems with mental health care in the UK at all levels- right down from the GPs to the MHUs as well as the hospitals treatment of MH patients.
    I am very young to be suffering with depression, the kind of young where people turn around and patronisingly ask what I could possibly be depressed about? [Yes, because I'm making myself depressed, I deliberately chose to have a broken brain and thinking patterns(!)] And I was fortunate to have an understanding GP the first time I went for help, he put me on antidepressants and referred me to several local counselling services. He was fantastically supportive and brilliant but he was also only temporarily at my local surgery. The next doctor I saw was quite frankly a b*tch. I turned up for my check up to get my repeat prescription continued and this is what she said when I walked through the door.
    "You've been on the antidepressants for eight months now, we don't like people to be on them for more than ten. We're going to take you off them."
    She didn't get me to fill in an assessment of recent symptoms (the 'on a scale of one to ten have you had difficulty sleeping within the last two weeks' one) And to be quite blunt I outright panicked.
    "But I can't cope without them!" My mind was screaming while I was couldn't quite get the words out.
    "We'll cut the dose slightly and ease you off." She informed me.
    I appreciate that she is the medical professional and I am not but she didn't ask how I was coping, if I thought I would be okay without the tablets, she didn't even ask if I had stopped self harming- I wasn't okay. I've been off the tablets for a year now and I still self harm. I won't go back to a doctor to get a referral for more help because irrationally it worries me that the next doctor will be the same as her and I will feel humiliated.
    And all the while I'm a statistical success for their "we only like to give patients antidepressants for ten months" campaign....


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