Doctors’ orders overruled

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