Girl discharged home from secure unit attempts suicide – 2017vol1#5

A teenage girl, who had spent nine months in a Special Care Unit, a secure detention unit, without receiving a psychiatric assessment despite repeated requests from her mother, made a serious attempt at suicide within one month of discharge home. The girl was subsequently admitted into a mental health unit for four weeks.

During her period in secure care, which began in mid-2016, the teenager was actively self-harming and at times was in a single occupancy unit. Within five months the High Court judge heard that her behaviour had deteriorated significantly and she was being impulsive. There was as yet no existing psychiatric assessment in terms of a formal diagnosis and the teenager was frustrated because no onward placement had been identified for her.

By the end of 2016 the court heard that a “large range of assessments and evaluations from ACTS (the Assessment, Consultation and Therapy Service)” had by now taken place and she had an individual therapeutic plan, despite this the young girl was still identified as high risk. By this point a psychiatric evaluation had not taken place and the ACTS team had made no referral for such an assessment to the attending psychiatrist, Psychiatrist A, who visited the centre on a weekly basis. Her mother was still endorsing the psychiatric evaluation as her daughter had talked of suicide. The teenager herself had asked to speak to someone in a specialist suicide NGO service in order to talk about historic issues.

In early 2017, the Child and Family Agency (CFA) made the decision that the teenager was ready to “be discharged directly home.” Counsel for the guardian ad litem told the court that there was no funding in place for items needed for the home, no extern worker had been allocated, her allocated social worker was leaving her role and the family would need a lot of support after the move home. The judge herself noted that the parenting capacity assessment was not as yet complete, she questioned whether there was a reality to the discharge within a week’s time.

The following week the court heard from counsel for the CFA that the issue of provision of psychological services was still outstanding. Prior to entering secure care the teenager had been treated by a psychiatrist, Psychiatrist B, however, this individual was on leave. Clarification was needed as to whether psychology would be part of a multidisciplinary approach for the child. The judge was told that “all the elements are in place” in relation to the issue of the parenting needs assessment, however there would be an ongoing assessment as things were developing. A newly qualified social worker would be appointed short term and the child’s bed in the secure care unit would be kept open for her first week of discharge home.

Two weeks later the CFA reported “one serious incident of self-harm”, there were “some setbacks but overall things are going very well [at home]. She is adjusting to the community and new situations and handling her anxiety in a very impressive way.” Counsel for the CFA confirmed that provision of psychological support for the child had been identified and seen as necessary. Psychiatrist B was still on leave.

A dialogue was underway to see if ACTS could provide support. The young girl also had speech and language difficulties. Counsel for the CFA asked for the detention order to be discharged and the case adjourned for two weeks’ for review.

The court heard from counsel for the GAL that there had been a turbulent period regarding the move home and she was very concerned in relation to the lack of psychological services for the teenager. Her treating psychiatrist needed to be confirmed and furthermore there was a lack of a multidisciplinary team.

Although the judge discharged the order, she remarked that time was of the essence, either Psychiatrist B, should be available or a private clinician would have to step in. She put the matter back in for review in one week. “All the good work will unravel unless the services are put in place,” she told counsel for the CFA.

The situation regarding an appointment with a psychiatrist remained unchanged over the subsequent two week period. During this two week period, a serious act of self-harm occurred and the teenager was admitted to hospital, where see was seen by the on-call psychiatrist. The on-call psychiatrist happened to be the teenager’s Psychiatrist B whom the court had been informed was on leave. The teenager had inflicted very serious wounds on herself and after her subsequent discharge from hospital with medication she had threatened to throw herself out the window. Thereafter An Garda Síochána were called and she was taken back to the hospital.

After this incident, the teenager was admitted to a mental health facility for one month during which time the court heard that in the opinion of Psychiatrist B (who was still on leave) the teenager needed psychiatric detention. There were conflicting views between Psychiatrist B and the locum, Psychiatrist C, who had attended the professionals’ meetings. Therefore the court requested an independent assessment as a matter of urgency on what was required for the teenager.

Subsequently, orders were made readmitting the adolescent into secure care with the proviso that she would have immediate assessment by a psychiatrist on arrival. However at the next sitting of the Minors’ Review List, the court heard that the girl had not been assessed on arrival because the psychiatrist had not gained entry to the premises. It had taken six days for her assessment to take place, which was the day prior to the hearing.

“The court was advised that she would be assessed immediately, in fact she was assessed six days’ later without any explanation, knowing how serious this case is that beggars believe,” remarked the judge. “That’s simply not good enough, serious questions would have had to be answered had an event arisen over that scale of time.”

It was not clarified exactly as to why this had happened but counsel for the HSE explained that it was believed that significant traffic had caused a delay in her arrival and she had not as yet been transferred to the premises when the psychiatrist had tried to gain entry for the assessment.

Counsel for the CFA told the court that a series of interventions were being proposed and the teenager was still expressing suicidal ideation. There were suggestions that a specialised mental health unit in the UK was suitable.

The court was informed of an historic event that the teenager had told Psychiatrist B about, and that this event had led her to believe that she should not be alive. “This child is clearly in a great amount of pain, the likelihood of a crisis becomes more apparent, this is a terrible impasse for her to be in, steps must be taken,” said the judge. She requested an explanation for the delay in the psychiatric assessment which had been agreed to on the teenager’s arrival to the secure care detention unit.

The teenager was currently stable and was waiting to see the Psychiatrist A in five days’ time, during his weekly visit to the secure care unit. Counsel for the CFA informed the court that in the opinion of Psychiatrist A the teenager’s mental health was good.

The following week the court heard that there had been very serious concerns in relation to the teenager’s behaviour and well-being in the last week. There had been an incident of self-harm that had required 20 stitches and she was still in a very precarious state. Counsel for the CFA told the court that the teenager would need an individual therapeutic plan and that the causes of her current difficulties needed to be looked at. There was a possible need for an out of State placement.

Psychiatrist A was visiting her weekly and it was his view that she needed psychotherapy to assist and it was not a psychiatric situation.

It was the opinion of the GAL that while secure care was keeping the young girl safe it had no particular therapeutic benefit. The teenager was no longer sharing her views regarding the incidents of self-harm with the GAL but she was meeting with Psychiatrist B. Her DBT (Dialectical Behaviour Therapy) work was of great assistance.