Air ambulance to take child with complex needs to specialist unit in UK – 2014vol4#17

A case where an Emergency Care Order (ECO) had been refused in the District Court for a teenager with complex needs returned to court for mention eight weeks later.

At the ECO application stage the teenager [A] had been in voluntary care but had kept absconding from her residential unit. She had gone back and forth to live between her paternal and maternal grandparents since leaving the unit and picked up criminal charges. An up-to-date psychiatric assessment had been sought and she had been found to have severe ADHD with Asperger’s Syndrome.

The judge had ruled that the threshold in terms of immediacy and necessity for an ECO – to place the child back in the residential unit from which she had absconded – had not been met. “I’m quite satisfied [the CFA solicitor] has established on the evidence it’s a chronic situation for a considerable number of years, which has not enormously escalated in the last six months, but the immediacy has not been established.”

When the case returned for mention eight weeks later, the court was told that no residential placement was as yet available, due to the nature of [A’s] needs, which were significant. However a placement proposal had been received that morning which was currently designated as a disabilities unit, a separate facility would have to be created which would take six to eight weeks, it was a de novo placement. The solicitor for the CFA told the court that the entire family would have to buy into the package in order for the placement to succeed.

The mother’s solicitor told the court that the teenager’s behaviour had escalated in the past few days, she was back living between her mother’s house and maternal grandparents’ house and had assaulted her mother again. “She can’t wait much longer, something needs to happen very soon,” said the solicitor.

The psychiatrist told the court that he had spoken to the maternal grandmother and the situation in terms of her safety was quite grave. [A] was out on the road in the middle of the night, distressed and agitated, there had been a breakdown with her peers and her mother had received a substantial number of assaults in the last 24 hours.

Psychiatrist: “[A] is not in a place of safety, she slept in a car for a few hours last night; there is a complete break with reality which is obvious during the day. Section 25 [of the Mental Health Act] is relevant, we can’t continue and stand by to leave her with the risk she’s at; she’s so vulnerable, unpredictable, uncontrolled, unprotected, it’s a tragedy waiting to happen – we’ve no excuse to let it go on. I don’t say that lightly, I’m caught in the middle because I’m a HSE employee first and foremost, but I have grave concern for her safety.

It has reached the point where a Section 25 is needed; she needs to be in a place of safety. The application under Section 25 can be made by a variety of people, it will be up to the court to decide on that. Regardless of her long term placement she needs to be somewhere safe, the only safe facility is the designated child psychiatric units, they are often full but you could get lucky and have a bed in [a named unit]. They have a system on a Wednesday where all four child unit services contact each other with availability of beds.”

It’s rather grim,” said the judge. She directed a report on the welfare of the child under Section 27 of the Child Care Act 1991, nominating an appropriate neutral. Although it was listed for mention within three weeks, the judge felt the case needed to come in sooner. Liberty was given to bring the matter in any day during the vacation as necessary in the circumstances.

Five weeks later – the District Court

Five weeks later an application was granted under Section 25 of the Mental Health Act 2001 due to the girl’s urgent need for psychiatric care. A bed had been found after referrals to six adolescent psychiatric units. The HSE and its director of mental health services had found [A] the placement.

Three months later – the High Court

Three months later the CFA brought an application to the High Court seeking orders pursuant to Article 56, authorising the HSE to place [A] in the UK. The existing Section 25 order would remain in place until she arrived safely at her new placement, whereupon it would be vacated.

This is a case that involves a mixture of behavioural, social and mental health issues,” said counsel for the CFA. “[A] is currently an in-patient, in [a high support residential unit- an approved centre under the Mental Health Act], her behaviour is very extreme, there have been a series of assaults and property damage.” The residential unit was in lock down due to her extreme behaviour and it was not set up to deal with the extensive nature of her needs. Following an assessment of all suitable locations, the professional consensus was that the hospital in the UK offered the best prospect of care for [A].

The affidavit from the consultant child and adolescent psychiatrist in her unit said that [A] had refused medical assessments. There had been sporadic interactions between her and the consultant, there were times when [A] was in a position to engage in discussions, but in general her behaviour had been very distressed and was at the higher end in terms of extremity of behaviours.

The CFA counsel told the court that the affidavit and psychiatric reports supported the general proposition of the CFA. The clinical director of her high support residential unit had visited the hospital in the UK and was impressed by it.

At present there is no low support secure mental health facility within our state, the majority of hospitals are not secure hospitals, proposals to build one are there but it is not in place,” said the CFA counsel. An independent psychiatric report found that [A] presented with a serious and immediate risk to herself and others, and was unlikely to receive the treatment she required in her unit. The report was consistent in its summary and recommendations of the consultant child and adolescent psychiatrist in her unit.

The hospital in the UK showed a willingness to provide the service required.

The CFA counsel told the court that the Central Authority in England and Wales had confirmed the consent required by an Article 56 placement from one institution to another. If the court made the order in the terms sought by the CFA, the CFA then would make an application in London for a mirror order.

The place was available from the following Monday. It was proposed that [A] would be removed from her high support unit by government flight transport, using the assisted admissions team. Air ambulance would then take her to the UK with a specialist team and she would be accompanied by her mother. [A] had expressed a willingness to travel and understood she was in a situation of distress.

Counsel for the mother told the court that the mother supported the application. A dedicated liaison person needed for the mother in relation to the removal and placement of her daughter.

She was most concerned that there would be a track of the clinical care in the UK unit.

Unfortunately there is no such unit in Ireland,” said her counsel. In term of the present situation, the mother would travel on air ambulance with her daughter. In totality, she was cautious in terms of clinical interventions.

The barrister for the guardian ad litem told the court that the child did want to move to the UK, she wanted to a new start somewhere else. There had been 100 incidents in her unit since September and her quality of life was extremely poor. She was limited to one room for most of the day. The guardian was recommending an organic assessment of the child to rule out any physical cause for the behaviours as well as a review by an expert in the field of Tourette’s Syndrome. There was no facility that met the low secure criteria in Ireland, said the GAL barrister.

The judge made the orders – under notice of motion, 27.1, Civil Law Miscellaneous Provisions Act 2008. There were 21 orders in total, including a declaration that A was in need of specialised care and to be detained temporarily in a secure place. One order authorised the CFA to remove A from this jurisdiction and place her in the control of the Institute in the UK.

An assessment of [A] was to be completed within six weeks of admissions.

See Volume 3, 2014, Order refused for child with very complex needs