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Case notes  (the name of the service user has been changed)
PRACTITIONERS: John Gatefield, professional development co-ordinator and approved social worker (ASW); and Dave McGarry, ASW, community mental health team, Halton Council.

FIELD: Mental health.

LOCATION: Runcorn, Cheshire.

CLIENT: Arnold Snow, 87, was not previously known to social services.      

CASE HISTORY: Late one Friday afternoon a request to complete an assessment of Snow under  section 2 of the Mental Health Act 1983 was received by the duty ASW, John Gatefield. If granted this would lead to Snow's compulsory admission into hospital where he could be detained for up to 28 days for assessment. For him to be "sectioned", the law also requires two medical recommendations - and both of these had already been completed. However, neither of the doctors (a consultant psychiatrist and a GP), who both felt Snow had depression and dementia, had made any attempt to discuss the case with an ASW beforehand. Given this, Gatefield contacted an off-duty ASW colleague, Dave McGarry, to accompany him on the visit. 

DILEMMA: The medical recommendations in part hinged on Snow's dementia but, despite Snow's lack of short-term memory, Gatefield was not convinced of the diagnosis.

RISK FACTOR: Despite an incomplete risk assessment, the decision was taken to allow Snow to remain at home all weekend, where he might not receive any food or support.

OUTCOME: A community care assessment later took place and Snow now has a formalised care  package at home.

The Mental Health Act 1983 devolves remarkable powers to detain people against their will for up to three days for an emergency assessment (section 4), up to 28 days for an assessment (section 2) and up to six months for treatment (section 3). It gives relatives, approved social workers (ASWs) and doctors the right to have a person detained for their own safety or the safety of the community.

Although two doctors and an approved social worker must agree to "section" a person (although just one doctor and an ASW is sufficient for an emergency assessment), it is not an action to be taken lightly. And certainly it takes conviction to be the one of the three to decline the application.

The case of second world war veteran, Arnold Snow, required duty ASW John Gatefield to disagree with the medical recommendations for Snow's compulsory admission to hospital under section 2.

"Normally, doctors talk things through first but not this time," says Gatefield. "In effect, they had signed the papers, dropped them off and said 'go and get him'. I took the pragmatic decision to ask a colleague to come along."

Within 10 minutes, Gatefield and ASW Dave McGarry from the community mental health team were at Snow's one-bedroom flat in a deprived area of the borough.

"He welcomed us in, was very cheerful and soon took to talking about his wartime experiences," says Gatefield.

The flat was comfortable, clean, well-furnished and warm - it was winter and extremely cold outside. There was a large plasma TV and no shortage of videotapes. McGarry says: "There was evidence of food having been prepared recently as there was a tray left on a kitchen work surface, laid with cutlery and condiments. Although Arnold could recall his personal details, he could not remember who had done the cooking or cleaning."

There were several telephone numbers written on scraps of paper and postcards piled on the telephone table. Again, Snow was unsure to whom these all referred.

"Doctors were concerned about Arnold's diagnosed depression and dementia," says Gatefield. "I tend to work from a social model of disability - and concluded that here was someone who was physically and mentally active: he was hopping about from one foot to another - he had been a boxer - and was graphically describing his wartime experiences."

Neither worker identified any diagnosed symptoms. "Admittedly, he did have short-term memory loss - he couldn't name the person or people caring for him, but crucially he knew that somebody was," explains Gatefield.

Despite being unable to complete a full risk assessment, it seemed clear that Snow was expecting food and support over the weekend.

"Looking around the flat it was apparent that he was receiving a high standard of care," Gatefield says. "He was coping remarkably well within the community with support from unidentifiable sources. We could reasonably expect that, come Monday, this man would be alive and well. On that basis I took the decision not to make the application for section 2."

Snow also made it clear that he did not want to go to hospital. Apart from the shrapnel in his legs, which the district nurses tended, he believed there was nothing wrong with him. "Another factor was that police assistance would have been required to remove him from his home," adds Gatefield. "He took up boxing stances and said that he would fight anyone who tried to take him away."

The workers decided to leave Snow at home, brief the emergency duty team and place an urgent needs-led assessment with older people's services on Monday morning.

"This, I believe, is the business of self-determination," says Gatefield. "Acting in someone's best interest sometimes means having to treat them compulsorily or sometimes means having to use the powers of legislation, but not in this case."


Snow's community care assessment was completed and he now has a care plan - which is prominently placed on his wall - and a care package. Gatefield says: "It turned out that a variety of neighbours, friends, relatives and even wartime buddies were involved in providing support. Indeed, so comprehensive was the care and support that social services only needed to chip in with a few hours of home care."

Arguments for risk

• Given his good physical state and that he was in a comfortable, warm and clean home and that he seemed cared for (although he couldn't remember by whom) a section was unnecessary. Gatefield says: "The issue for us was to decide whether Arnold was presenting as a risk to himself or others. He wasn't. And could he safely be left in his own accommodation over the weekend? We concluded he could."
• Snow was clear in his own mind that he did not want to go to hospital.  
• Equally, the social workers were in no doubt that he would have physically fought any attempt to move him from his home. Gatefield says: "We would have had to  use force. There was no way that Arnold was simply going to walk out of that flat. Could we justify the ignominy of having a war veteran dragged screaming and fighting from his home? On balance, that course of action would have posed a threat to him and others."
•    
  
  Arguments against risk
• The medical recommendations for compulsorily admitting Snow to hospital were signed. Despite the ASWs' scepticism two separate doctors - a psychiatrist and Snow's own GP - believed Snow's depression and dementia made him a danger to himself and others if permitted to remain in the community. It is a big call to overrule such medical concerns.
• Because of Arnold's short-term memory lapses any attempts to complete a full risk assessment would have been thwarted. This means that a decision was taken without full disclosure or all the facts being known. 
• For all the workers knew, Snow's support might have been for weekdays only and he could have been left with no food or support at weekends.
• More effort might have been made to contact people whose numbers were by the phone. "None of the numbers tried were answered," says Gatefield. "It was the twilight period of early Friday evening when people are on their way home or out shopping."
• 
  Independent comment 
  This case provides a good example of how an assessment of social circumstances should be considered alongside a medical diagnosis when holistically balancing the risks inherent in a service user's perceived needs and vulnerabilities, writes Martin Smith.
  
  Arguably, the primary task of an approved social worker is to consider whether any "less restrictive alternative" to hospital admission is possible or desirable; and in this case the decision that there was a preferable alternative turned out to be the correct one.  
  
  The emergency duty team were "briefed" but I wonder with what expectation? It seems Snow would not have been able to use the telephone numbers available to him should there have been an emergency. Nor is it clear that the assessing workers could be sure that any one of the "unidentifiable sources" would be checking on him over the weekend.  
  
  The nature and strength of Snow's anticipated resistance and opposition to being sectioned is not, in itself, sufficient reason not to proceed with such a course of action. His dignity is important but so, too, is his safety. The crucial determinant in these cases is that approved social workers should act in "good faith and without negligence" (Mental Health Act 1983, section 139).  The "reasonable expectation" of the workers is critical in this respect. Enlisting the help of a trusted colleague to make the assessment and subsequent decision, as was done in this case, is one of the most effective steps workers can take.
  
  Martin Smith is practitioner-manager, Buckinghamshire emergency duty team, and author of The Heart of the Night about the work of EDTs