She Moved Off The Radar

CASE STUDY

Situation: Maria Baker is 36 and has a history
of significant mental health problems – she had experienced
psychosis to such a degree that she has spent nearly 10 years of
her life in and out of hospital and secure accommodation. She also
has mild learning difficulties and her weight – she is over 20
stone – causes physical problems.

Problem: Last year Maria moved out of the area to
be near her step-brother Barry, and had consequently slipped
through the net. However, a referral from a landlord alerted her
presence to the community mental health team. A social worker
visited and found her living conditions – she had become
incontinent – to be a health risk. She also smoked but if she
dropped a cigarette she was physically unable to pick it up. She
had a number of cigarette burns on her arms and legs. The landlord
said that Maria should be locked away because of the mess she
makes, because she is seeing things and hasn’t paid her rent for
five months. The social worker discovered that Maria had entrusted
all her benefits and money to Barry, who brought food and
cigarettes “whenever he could”. Maria disclosed that her recently
deceased mother – who left a substantial insurance amount to her –
had appeared before her and told her to give all the money to Barry
so he could look after her properly, a request she has complied
with.

Practice Panel Mental health team, Milton
Keynes
Panel Responses

Jane Ross

This is not an untypical situation for a long-term mental health
client. Maria has spent much of her life in and out of hospital and
will have become increasingly dependent on her support network as
her confidence is affected by successive admissions.

The combination of her mother’s death and moving away from a
familiar area has contributed to the relapse in Maria’s mental
health leading to her possible disengagement with the
services.

The main areas of concern seem to be:

• Maria is severely obese. Apart from the problems she is
  experiencing with mobility this excess weight has obvious health
  risks. Her care plan would look at health screening and the
  possible input of a dietician, encouraging Maria to gain insight
  into these issues.
• Maria has become incontinent and it is not clear if this is
  because of her mental state or a physical condition. It may be that
  she is depressed and the incontinence could be an associated
  symptom; she requires a urine screening test and possible referral
  to the incontinence nurse for advice.
• I am concerned about the cigarette burns as they might be signs
  of abuse, self-harm or neglect. A full risk assessment would need
  to be completed and these concerns discussed with Maria and,
  possibly, Barry.
• Maria believes that her mother has asked her to entrust her
  savings to Barry. Although he has accepted responsibility for this
  he appears to be unable to appropriately attend to her needs. This
  may be due to his misunderstanding of her circumstances or his own
  inadequate skills. With sufficient support Barry could become a
  valuable member of Maria’s support network. This would not be the
  case if it became apparent he is abusing and exploiting Maria;
  appointeeship or power of attorney may be necessary to secure her
  future financial situation.

In the long term I would encourage Maria to look at relapse
prevention and life skills, assisting her to develop insights into
her mental health needs. I would undertake joint work with a social
worker to help Maria look at her social care issues of unpaid rent,
suitability of accommodation and possible legal issues relating to
her finances.

Mike Varney

With a lengthy history of hospital stays, a clear assessment of her
needs, a care plan and care programme approach care co-ordinator
should be in place. Services should be aware of Maria’s needs and
able to ensure effective transfer of information to new services in
the new area. Continuity of care is what the care programme
approach should be all about.

Awareness and details of Maria’s physical needs, her learning
difficulties and support needs are equally important to services in
the new area.

The social worker who recently visited should ensure that there is
a thorough assessment (incorporating past history and risk
information) to help establish Maria’s current needs and risks. At
the moment, we don’t even know whether Maria is registered with a
GP.

Maria appears to be a vulnerable woman, likely to be in need of
ongoing support from a range of services. It may have been better
for her to have moved closer to her step-brother, particularly in
the context of the recent loss of her mother, but Maria seems to be
unable to adequately care for herself, and risks possible
eviction.

I’m concerned about her financial situation: if she has entrusted
her benefits and money to Barry, she may well be at risk of
exploitation. From the limited information we have, Barry does not
appear to be able to adequately support Maria or manage her
finances. There is also a possibility that Maria’s decisions to
give the financial power to Barry are based on psychotic or
delusional ideas.

Maria may benefit from medication and support from the community
mental health team. Hospital admission or support from a crisis
team are other possible options. At the very least, there should be
a co-ordinated assessment to urgently determine Maria’s mental
health and practical needs, and agree with her how those needs can
be met.

Guardianship (section 7, Mental Health Act 1983) may provide the
legal framework to ensure that Maria has appropriate access to
support and services if she is unwilling to engage with them
voluntarily. A consideration of guardianship may be the least
restrictive means of enabling her to obtain support in the
community, while reducing her vulnerability, and risk of
readmission to hospital.

USER VIEW

It is important not to make any assumptions about this
situation. It would be easy to jump in and arrange a whole manner
of interventions that would seem to benefit Maria. I can imagine
words like “vulnerable”, “risk” and “abuse” being banded about with
only a passing acknowledgement of what Maria might think or want,
writes Kay Sheldon.

The focus of any approach should be on self-determination and
offering Maria the support to make her own decisions. This support
should ideally be provided by an independent organisation that
specialises in self-advocacy and supported decision-making. It may
take time to establish trust and understanding between Maria and
anyone who becomes involved in her care.

It is very worrying that someone who appears to be in significant
need of help from services has slipped through the net simply by
moving to a different area. It would be worth contacting Maria’s
previous providers of health and social care (with Maria’s
permission) just to find out what caused such a failure of
communication. Efforts should be made to ensure various systems and
procedures are tightened up to try and stop the same thing
happening to other service users.

There is no suggestion that Maria does not want to receive any
input from health, social or non-statutory services. Or in fact
that she intended to lose contact with the services when she moved
area. It would be worth discussing with Maria what input she had
previously received and what was particularly helpful.

This could form the starting point of creating a supportive
structure for Maria. For example, it may be that more suitable
accommodation – either supported or with support – would be
something that Maria would particularly value. Alternatively, Maria
may appreciate some time in hospital to sort out her immediate
mental and physical health difficulties and to plan for a more
supported return to independent living.

Maria’s relationship with her step-brother should be handled
sensitively. Here, time, trust and independent advocacy are vital.
This would be preferable to a heavy-handed approach that could take
away Maria’s right of self-determination and jeopardise the
relationship between Maria and her step-brother. Attempts should be
made to engage with Barry (with Maria’s permission) to find out
what his views on the situation are.

Kay Sheldon is a mental health service user