After the fire

October 20, 2005 in Mental Health

The names of the service user and his family have been changed

Case notes

Practitioner: Chris Hadley, practitioner-manager, Derby City Care Line.
Field: Out-of-hours emergency social work.
Location: Derby, East Midlands.
client: Howard Godfrey is 34 and lives with his mother, June, 54, and his younger brother, Frank, 29.
Case History: Howard was brought to hospital at 6am under section 136 of the Mental Health Act 1983 which makes provision for a place of safety for “mentally disordered persons found in public places”. There had been a fire at the family house and the fire officers who attended the scene were concerned about how he was behaving, not least because he had to be persuaded to leave the property so the fire could be tackled safely. Police officers at the scene agreed that Howard did not seem well and felt he would be better off being assessed. They took him to the psychiatric unit of a local hospital.
Dilemma: Although Howard’s behaviour and conversation were worrying, a compulsory admission into hospital was felt excessive, but to permit him to return home also appeared the wrong course of action.
Risk Factor: If informally admitted he could discharge himself at any time, thus putting himself and his family at risk of harm.
Outcome: Howard agreed to be informally admitted into a psychiatric unit where he remained while his social and mental health problems were investigated

Risk is the bread and butter of emergency out-of-hours workers. Providing a generic service every evening, night, weekend and bank holiday has given them an expertise in crisis resolution and risk assessment.

With an average 15 years’ post-qualifying service, workers can assess quickly what needs to be done to remove imminent dangers. With planned work a rarity, each shift starts with a clean sheet and nothing but the unexpected is expected.

After a fire at his mother’s house where he and his brother lived, Howard Godfrey, 34, became a cause of concern. Although distressed by smoke, he refused to leave the house at first. His behaviour and hallucinatory conversation led police to believe that he may have mental health problems and they decided for his own safety that he needed care and control. They took him to a place of safety under section 136 of the Mental Health Act 1983, which allows a person to be detained for up to 72 hours.

However, this section requires the “mentally disordered person” to be in a public place. Howard was still in his house – so the police, although recognising he needed help, had no legal recourse to remove him. So they spent some time persuading him to leave the property. He finally agreed and was taken to the psychiatric unit at a nearby hospital, where he could be examined by a consultant psychiatrist and interviewed by an approved social worker for the place of safety to be recommended.

Chris Hadley, practitioner-manager of Derby Care Line, the city’s out-of-hours emergency team, says: “We have a local protocol if someone is placed on a 136. Provided they do not need urgent medical attention or are aggressive, they are taken to the psychiatric unit as that is felt to be a less threatening place for them to be rather than a police custody suite. The hospital arranged for the duty consultant psychiatrist on call to visit jointly with the social worker.”

Normally for a Mental Health Act assessment to take place there is a need for two medical recommendations as well as the approved social worker recommendation. “However, on seeing Howard, the psychiatric unit felt that if he needed admission it would require only one medic because he might agree to come to hospital informally,” Hadley says.

As Howard was unknown to both social services and the hospital there was no previous history to hand. “The only information we had was what he gave us at the time,” says Hadley. “He was quiet and calm. He was smoke-damaged – and he said he had gone to sleep with a lit candle at the side of his bed, which had then caused the fire.”

Despite the calm exterior, it was the content of his “bizarre” conversation that was causing concern. Hadley says: “He was heavily into witchcraft and said he possessed extra sight. He claimed some marks on his body had been caused by a witch war in a previous life. He seemed very underweight and admitted that he wasn’t eating properly and was hearing voices. His mother was concerned and said she felt his mental health had been deteriorating.”

Howard disclosed that he was suffering significant trauma as a result of being sexually abused as a child, and that a member of his family was a “schedule 1 offender” – someone who had committed a crime listed in schedule 1 of the Children and Young Persons Act 1933, although the term “risk to children” is preferred now.

As more of a picture was built up and, indeed, a rapport, it became clear that home life for the Godfreys was less than ideal. “People in their thirties tend to have their own independent accommodation but he still lived in his mum’s house, along with his adult brother,” says Hadley. “His mother was also physically unwell and needed to be on oxygen. And Howard was a chain-smoker who sat next to her – we did worry about the possibility of an explosion.”

However, Hadley believed that compulsory detention was unnecessary. She says: “Although his behaviour was bizarre he was offered an informal admission. Thankfully he agreed. It could have been argued that compulsory admission would have been over the top for him and perhaps would have damaged him further. He was looked after and fed, and received some medical help for the mental health problems. Daytime services also looked into his social care needs: it was a good outcome for him.”

Arguments for risk

Although the content of much of Howard’s conversation prompted concerns over the state of his mental health, he appeared calm and controlled. He did have insight into his condition. He provided all the information needed to build a picture of his social circumstances and, although a spell in hospital was clearly required, it would be better for the admission to be informal rather than compulsory.

The on-call consultant psychiatrist, police officer and approved social worker (“approved” to carry out assessments under the Mental Health Act) all agreed and spoke to Howard hoping to persuade him to be admitted into hospital informally. “This would also buy time and space to look at accommodation issues and his relationship with his family,” says Hadley.

It was felt that a compulsory detention under the Mental Health Act 1983 could be potentially more harmful to Howard.

Arguments against risk

Although Howard’s behaviour at the hospital was calm, he presented as clearly unwell. His beliefs that he was injured in a witch war in a previous life and his claimed extra sight suggest a metal health problem that even his mother agreed was deteriorating.

Equally worrying was his behaviour: he remained inside the house during the fire, which he started by falling asleep and presumably knocking over a candle beside him; a chain-smoker he seemingly has scant regard for his mother’s health – she needs oxygen and cannot be tolerant towards cigarette smoke. Indeed, there is also a cited fear of a possible explosion of the oxygen container.

An informal admission depended on Howard’s intention to remain in hospital – but his behaviour suggested that he did things for himself with little acknowledgement of the potential consequences. It would have been no surprise to see him discharge himself and then put himself and family at further risk.

Independent comment
For all social workers, the concept of “risk” is central to their practice, writes Glen Williams. But the situation is complicated because the context of “risk assessment” in social welfare has been driven in conflicting directions and there remains a balance between “risk taking” and “risk management”. The nature of risk entails elements of the unknown, improbabilities and uncertainty.

For emergency duty team (EDT) workers, risk assessment often involves making significant decisions quickly with sparse information – as was the case with Howard. The risk to police for removing Howard from within his home illegally under section 136 seems outweighed by the need to protect him from harm. The risk of him refusing to remain an informal patient seems outweighed by the EDT worker’s justifiable preference for avoiding statutory admission. The risk of Howard’s health deteriorating in the short term is balanced against the likely long-term impact of a stay in a psychiatric unit and chronic prescription of anti-psychotic medication. Risks to Howard’s mother, brother and neighbours have to be weighed against Howard’s right to exercise choice.

All EDT staff will recognise that on any shift the greater the number of referrals, the greater the risks that are taken. Balancing competing generic priorities often reflects the autobiographical template of the worker and the risk tolerance of the organisation.

EDT workers balance relative merits whereas society demands absolute answers. Collisions are, then, inevitable.

Dr Glen Williams is EDT manager-practitioner, Sefton Council, Merseyside, and is chair of the Emergency Social Services Association