Rapport in a Storm

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

• Naturally, this case raised issues about the safety of the
  unborn baby. But it also raised issues about the safety of the
  mother. And in this situation having generic workers handle the
  case meant that a more holistic approach could be taken. As Hadley
  says: “From our point of view, our staff are all generic, we can
  see the bigger picture: seeing the case from a mental health
  perspective as well as a child protection one.” 
• The medical advice – from GP and consultant – was consistent.
  It was preferable, given the lateness of the birth and Lloyd’s
  mental state, that she opted for an informal rather than a
  compulsory admission.
• The emergency out-of-hours worker managed to get through on the
  phone (where a lot of EDT work is conducted) and by using excellent
  listening skills was able to build up a rapport with Lloyd that
  would lead to her trusting the advice about attending hospital for
  an assessment by her own free will

Arguments against risk

• Lloyd was known to social services. She had her two other
  children taken from her and her unborn child would follow suit.
  This is, for her, not a situation where one can expect her to
  behave reasonably – even if she wasn’t convincingly threatening to
  commit suicide.
• As is often the case, having children placed in care causes
  resentment. Add to that Lloyd’s record of assault on social
  services staff and police officers, and the dangers of trying to
  engage with her are very apparent.
• A mother threatening to kill herself and her unborn baby (and
  one who had already tried to take an insulin overdose to do so) is
  not a situation in which there is time to consider options. Even
  the GP had visited and had admitted defeat in trying to place
  productive barriers in the way of a woman intent on throwing
  herself out of the window of her first floor flat.

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.