CASE NOTES:
Practitioner: Chris Hadley, Derby City Care Line.
Field: Out of hours emergency social work.
Location: Derby, East Midlands.
Client: Paula Lloyd, 26, had her two children removed from her because of her inability to look after them safely. Lloyd had also assaulted social workers and police in the past. She lives alone in a first floor council flat and is insulin-dependent.
Case history: Pregnant again, the baby's birth was overdue. Lloyd was booked in for a Caesarean section but did not want to go through the ordeal and was threatening to kill herself and the baby by injecting herself with insulin and throwing herself out of a window. Lloyd's GP had been alerted to her situation and referred her to the community mental health team (CMHT) urging a Mental Health Act assessment to be carried out. However, given the imminent birth and Lloyd's history of postnatal depression the CMHT felt that an assessment would be better carried out by the mother and baby unit. The unit, however, was not convinced.
Dilemma: An informal admission to hospital was needed but Paula was refusing to go and threatening suicide. Compulsory admission might require force and damage both mother and baby also.
Risk Factor: Paula's heightened mental state was putting both her and the baby at serious risk.
Outcome: Through building rapport, Paula agreed to be admitted to a psychiatric ward, where she stabilised and later gave birth to a healthy baby.
Problems do not conveniently confine themselves to office hours. And so for social care we have emergency duty teams. However, given limited resources, such teams make no bones about only being able to provide a skeleton service.
Although change - in the shape of a move towards specialisms - hangs in the night air, EDTs tend to have skilled generic workers who have experience of all client groups. They handle precious little planned work; their job is to make situations as safe as possible until daytime services resume.
At the core is crisis intervention, and often in liaison with other services such as health and police. This aspect of the work is highlighted by the case of Paula Lloyd.
Heavily pregnant, Lloyd, whose other two children were in care, was threatening to kill herself and her unborn baby by overdosing on insulin and throwing herself out of her first floor flat window. Owing to her physical condition, the community mental health team that had been referred the case thought an assessment ought to be carried out by the mother and baby unit.
"However, the unit, of course, was not keen to do this," says service manager, Chris Hadley. "Daytime services negotiated over the best way forward and decided that a mental health assessment was required, but as time had elapsed, it would be left to the out-of-office-hours service to complete. So, my team was contacted to look into it."
In addition to Hadley, the team comprises two senior practitioners, three full-time and two half-time social workers, with a half-time admin worker. A group of daytime workers can also be called upon to help fill in gaps as required.
Hadley continues: "We got to the stage where the CMHT was liaising with my worker to sort out what was going to happen to Paula. The GP felt that she couldn't calm the situation down at home, and was not able to do anything productive to prevent Paula from jumping out of the window."
For Hadley, the task was to make Paula and her unborn baby safe.
Given Lloyd's expressed desire to kill herself, the immediate focus
was on tackling her mental health needs rather than her booked
Caesarean section. But with Lloyd refusing to attend hospital the
team might need to consider a compulsory admission.
"However, both the GP and the hospital consultant, who was to carry
out the Caesarean, felt that an informal admission to hospital was
needed rather than Paula being sectioned under the Mental Health
Act," adds Hadley.
A further challenge for the team was Lloyd's dislike and distrust of social services following the removal of her children. Indeed, given current circumstances, the plan was to remove the new baby as well.
But a slice of old-fashioned social work changed the momentum. "My colleague, who has a very approachable manner and is able to listen very well, managed to get hold of Paula by phone and succeeded in talking her down, building up a rapport," says Hadley. "Being a generic worker with many years' experience he was able to empathise while also being very practical: explaining what the implications would be for Paula for whatever course of action she chose.
"Ultimately, Paula was just getting scared because she was due to have her baby on her own, while knowing that it would be taken away. And that's scary. So we had to take the time to work through that with her."
It transpired that her negative relationship with social services was with daytime services, and certain workers in particular, who had removed her children. Thus, for Hadley's team, being able to be seen as not the same proved invaluable. "Paula eventually agreed to attend hospital to have an assessment," she says.
Nonetheless, given Lloyd's history of assaults on professionals there were concerns about how she would react when seen. "This is also partly why it was important to get her to leave her flat and be in a more open environment," says Hadley.
At the hospital Lloyd met with the senior house officer and the worker she had built up a rapport with over the phone. Says Hadley: "One of the beauties of out-of-hours working in a generic setting is that people can be dealt with holistically by one worker."
She adds: "It was explained to Paula that all we wanted was for her and her baby to be safe. She calmed down and agreed to an informal admission to a psychiatric unit, where she was kept for the remainder of the night."
Given space and time in hospital, Lloyd later gave birth to a healthy baby who for her own safety was taken into care. "It was a good outcome based on liaison between health and social services, and good involvement with the service user," says Hadley. CC Problems do not conveniently confine themselves to office hours. And so for social care we have emergency duty teams. However, given limited resources, such teams make no bones about only being able to provide a skeleton service.
Although change - in the shape of a move towards specialisms - hangs in the night air, EDTs tend to have skilled generic workers who have experience of all client groups. They handle precious little planned work; their job is to make situations as safe as possible until daytime services resume.
At the core is crisis intervention, and often in liaison with other services such as health and police. This aspect of the work is highlighted by the case of Paula Lloyd.
Heavily pregnant, Lloyd, whose other two children were in care, was threatening to kill herself and her unborn baby by overdosing on insulin and throwing herself out of her first floor flat window. Owing to her physical condition, the community mental health team that had been referred the case thought an assessment ought to be carried out by the mother and baby unit.
"However, the unit, of course, was not keen to do this," says service manager, Chris Hadley. "Daytime services negotiated over the best way forward and decided that a mental health assessment was required, but as time had elapsed, it would be left to the out-of-office-hours service to complete. So, my team was contacted to look into it."
In addition to Hadley, the team comprises two senior practitioners, three full-time and two half-time social workers, with a half-time admin worker. A group of daytime workers can also be called upon to help fill in gaps as required.
Hadley continues: "We got to the stage where the CMHT was liaising with my worker to sort out what was going to happen to Paula. The GP felt that she couldn't calm the situation down at home, and was not able to do anything productive to prevent Paula from jumping out of the window."
For Hadley, the task was to make Paula and her unborn baby safe. Given Lloyd's expressed desire to kill herself, the immediate focus was on tackling her mental health needs rather than her booked Caesarean section. But with Lloyd refusing to attend hospital the team might need to consider a compulsory admission.
"However, both the GP and the hospital consultant, who was to carry out the Caesarean, felt that an informal admission to hospital was needed rather than Paula being sectioned under the Mental Health Act," adds Hadley.
A further challenge for the team was Lloyd's dislike and distrust of social services following the removal of her children. Indeed, given current circumstances, the plan was to remove the new baby as well.
But a slice of old-fashioned social work changed the momentum. "My colleague, who has a very approachable manner and is able to listen very well, managed to get hold of Paula by phone and succeeded in talking her down, building up a rapport," says Hadley. "Being a generic worker with many years' experience he was able to empathise while also being very practical: explaining what the implications would be for Paula for whatever course of action she chose.
"Ultimately, Paula was just getting scared because she was due to have her baby on her own, while knowing that it would be taken away. And that's scary. So we had to take the time to work through that with her."
It transpired that her negative relationship with social services was with daytime services, and certain workers in particular, who had removed her children. Thus, for Hadley's team, being able to be seen as not the same proved invaluable. "Paula eventually agreed to attend hospital to have an assessment," she says.
Nonetheless, given Lloyd's history of assaults on professionals there were concerns about how she would react when seen. "This is also partly why it was important to get her to leave her flat and be in a more open environment," says Hadley.
At the hospital Lloyd met with the senior house officer and the worker she had built up a rapport with over the phone. Says Hadley: "One of the beauties of out-of-hours working in a generic setting is that people can be dealt with holistically by one worker."
She adds: "It was explained to Paula that all we wanted was for her and her baby to be safe. She calmed down and agreed to an informal admission to a psychiatric unit, where she was kept for the remainder of the night."
Given space and time in hospital, Lloyd later gave birth to a healthy baby who for her own safety was taken into care. "It was a good outcome based on liaison between health and social services, and good involvement with the service user," says Hadley.
Arguments for risk
Arguments against risk
Independent Comment
Daytime and out-of-hours social workers regularly face similar dilemmas, writes Glen Williams, and they must respond in significantly different ways when dealing with such risks.
For emergency duty team workers in the UK with an average 15 years' post-qualifying length of service, risk is very much their bread and butter. Providing a generic emergency service for about 128 hours every week of the year has meant EDT staff have developed an expertise in crisis resolution and risk assessment that is exemplified in the response to Paula.
EDT workers are the "last bastions of genericism" undertaking holistic assessments underpinned by a sound working knowledge of child protection and mental health.
EDT workers are expected to be able to prioritise quickly what needs to be done to make things safe until the next day. This means identifying a specific focus - in Paula's case, unspoken fears creating a risk to herself and the unborn baby.
EDT workers apply a "slice of old-fashioned social work", but this should not disguise or undermine the very real risks that existed in this scenario, the knowledge-base and skills of the worker, nor the systematic and sensitive manner in which a rapport was established with Paula and, ultimately may well have saved two lives with one intervention.
In the Victoria Climbie inquiry report, Lord Laming suggested child protection should not be part of generic EDT responsibilities. Based on the evidence of Paula and similar cases arising frequently out of hours, many disagree.
Dr Glen Williams is manager/practitioner, EDT for Sefton Council, Merseyside, and is chair of the Emergency Social Services Association.
