Package of “elaborate” supports agreed for young Ward of Court amid concerns he may not take prescribed medication; order made under Assisted Decision-Making (Capacity) Act – 2023vol1#64

A package of care designed to support a young Ward of Court was described by a High Court judge as an “unusually elaborate and well thought out package.” The young man had been brought into wardship in mid-2022. However, the judge noted that the recent report from Psychiatrist Three, who had been engaged by the general solicitor, had expressed the view that A did not lack capacity, and so was not eligible for wardship.

The judge made the orders sought by the HSE pursuant to section 22 of the Assisted Decision-Making (Capacity) Act 2015 and granted the order to transfer A from his residential placement to the department of psychiatry in a named hospital. The 2015 Act has recently come into operation.

Evidence was heard from three psychiatrists, one from the department of psychiatry in a hospital, one who was treating the young man in his residential placement, and one appointed by the general solicitor. They differed in their assessments of the young man, but all agreed on the plan for him to move towards independent living, under the supervision of a mental health team.

In early 2023 the court had heard that Psychiatrist One from the department of psychiatry in Hospital Y, and Psychiatrist Two, A’s treating psychiatrist in his residential placement, were both of the opinion that the young man did not have capacity, while Psychiatrist Three, who had been appointed by the general solicitor to advise on placement, had formed the opinion that A in fact did have capacity. A fourth consultant was also of the opinion that A had capacity. Psychiatrist Two was seeking a cognitive assessment for the young man as he was “lethargic and not very spontaneous”. The social worker was seeking a forensic risk assessment report by a forensic psychiatrist in order to assess the risk in the community.

A’s current placement had served him notice as management did not think he continued to be appropriately placed there. His treating psychiatrist (Psychiatrist Two) “shared that view also,” noted the judge and the “HSE have been working extremely hard to see where he can be placed.” A had been in his current placement for more than a year and while it had not been a “happy placement in any way for him” his psychiatrist had reported that it had “benefitted him and he has remained stable,” said the judge.

The proposal from the HSE was that he would leave his placement and go to the department of psychiatry (DoP) in Hospital Y where his medication would be reassessed. When ready to leave the hospital he would then be placed in an apartment procured for him by the HSE as his step-down placement.

A community rehabilitation programme had been put in place which included a detailed plan as set out by a senior occupational therapist. Over a number of weeks he would move from a high level of supervision to a low level. A would be reviewed medically and overnight stays in the apartment would be trialled in order to establish full-time overnights there. The young man had never lived alone independently.

The agent for the general solicitor told the court that the A had been assessed by an independent psychiatrist engaged by them and it was “very much” his position that the young man did not meet the criteria of wardship “so we look to extract him from that.” For the time being they were supportive of the application to continue the orders maintaining wardship and then in “the coming months” it was hoped to discharge those orders, to see if it was possible to sustain the young man in the community with the critical input being delivered by the HSE. The agent for the general solicitor said that A’s mother would be “pivotal in this, they will be relying upon her in the community to safeguard (her son).”

A’s mother told the court that she understood that her son would first go to the DoP “to get his meds on an even keel, he’s going to come off some of it, then afterwards move into the apartment. I’m glad now that he can come off some of that in a place where people can deal with it. [His residential placement] couldn’t.”

The treating psychiatrist within the residential placement for A agreed with the proposal of Psychiatrist Three to move the young man to the hospital department of psychiatry and conduct the medical review prior to the transition into the community. However, he was of the view that the risk factor was that A “needed so much persuasion and encouragement to take his medication that he didn’t understand the significance of taking it and not taking it.”

The court heard that A’s treating psychiatrist had always viewed him as not having capacity to make decisions in his life, he viewed him as high risk and while he was currently mentally well, his psychiatrist was making sure he was compliant with his medication. Therefore it was put to the court that while the assumption on the part of the assessing psychiatrist, on behalf of the general solicitor, was that A was being compliant, in fact, the compliancy was due to his supports. However, all were agreeing on A’s transition from the residential placement to the hospital department of psychiatry and then to independent living in the apartment.

The agent for the general solicitor told the court that the DoP psychiatrist (Psychiatrist One) from the hospital was optimistic that A’s medication could be regulated on the psychiatric ward within two to three weeks. While A was on the ward, the staff would work with him in relation to discussing his move to the apartment. The occupational therapist had indicated he was thinking about a number of things to bring to the young man’s attention, such as exercise therapy in a gym, and an Active Life programme in the HSE, not to overwhelm him, but to talk to him about what he might be interested in, for when he permanently moved to the apartment.

The apartment was well furnished, said the agent. Initially A would do an overnight in the apartment from the hospital, then two overnights and then begin to live there permanently in eight weeks’ time. For now, the department of psychiatry would liaise with A’s residential placement in terms of admission in the next number of days, as the treating psychiatrist from the DoP had indicated there was now a bed available.

The DoP psychiatrist said in evidence that the initial few days on the ward for A would give them an idea if the young man was experiencing adverse effects from his meds. “I think they can be reduced anyway, when someone is stabilised sometimes they don’t need the same amount of meds. He hasn’t had a relapse and definitely benefited from his time in [his residential placement], it’s allowed him to stabilise from a mental health point of view, in the initial week we’ll make a plan and look at what we can reduce.” The consultant added that “with regard to the sedated aspect we are going to monitor him for the first couple of days and get a baseline, and then see if there is a noticeable effect.” He said that the doctors would expect to see quite quickly if he was over-sedated.

The judge accepted the evidence of Psychiatrist Two that A had an established diagnosis [of a mental illness] and there were a number of issues getting him to take his medication in a timely and appropriate manner. A team of experienced mental health professionals would attend daily at the apartment to supervise the young man taking his medication.

“I’m satisfied that a very extensive proposal has been put in place by the HSE to that effect. It will be possible for the [mental health nurses] team to supervise him at home. It will allow oversight in the community context,” said the judge. An allocated social worker was also involved in A’s care and there would be input from psychology and family therapy.

The independent psychiatrist, who had assessed A on behalf of the general solicitor, identified in his report that the risk A posed to the community had two elements. As the young man currently presented, stable and cooperating, he was a low category risk. However, his treating psychiatrist from the residential unit was of the opinion that that Psychiatrist Three had not reported A’s limited understanding of his medication.

It was Psychiatrist Two’s opinion that if A’s compliance with his medication was not good then he would not agree with the opinion that he was of the low risk category. Therefore compliance was critical. A “core concern,” said the judge, was to ensure there was a plan in place to “ensure compliance with the medication and a plan in place for spotting when he was not.” The judge said that he was satisfied with the plan as the treating psychiatrist had said the team supervising daily compliance with medication were mental health nurses and would identify if A was becoming unwell despite taking his medication.

Psychiatrist One, from the DoP, explained that the young man’s antisocial behaviours were a separate matter that had occurred in the past in the absence of illness. Therefore, if A had medication and was stable as regards his illness, “he is no risk.” However, “the risk of him becoming unwell is that he becomes disinhibited, that will accentuate a lot of undesirable behaviours and severely affect his judgment and in that sense he would be a high risk then if he was off his meds.”

The consultant added that he did not believe that the young man had insight into his illness, “that he believes he’s unwell and needs to take his medication or continue taking it. His concerns are limited to putting on weight with it or that it would make him tired. I have no sense that he appreciates that he has an illness and that in order to remain well he has to remain on medication or he will relapse.” He stated that A’s treating psychiatrist was in agreement that the young man lacked insight into his illness.

The mental health team would supervise him taking the medication once he moved into the apartment. However, they would not be able to “stand around” and wait for him to be compliant with the medication, said the consultant, they would have about 15 minutes so “long stand offs”, such as the four hours it had previously taken, were not going to be possible.

The consultant told the court that he was not fully convinced by the arguments of the psychiatrist engaged by the general solicitor that the young man had capacity. However he did believe that some antisocial behaviours were under his control, such as targeting less experienced members of staff. However, he added the proviso that if A became mentally unwell or psychotic then he could come under the influence of delusions. Blood tests of the main mood stabilisers would be the markers of compliance. Antisocial behaviour would within the remit of An Garda Siochana.

A number of key supports would be available to A in the community, two male community health nurses would visit him once a week and would be available on the telephone otherwise. A critical part of their role would be to assess his behaviours and his risk management. He would be visited daily by the mental health social worker who was very committed to A’s transition.

The proposed team had said they would be very dependent on A’s mother and other family members in the area to communicate concerns to them. The young man was not going to be detained in the apartment, he would be free to come and go, he was not going to be under prescriptive orders from the court, so critical needs would have to be identified by his network.

The judge said he was satisfied that there was a plan in place with the mental health team to ensure compliance with the medication and a plan in place for spotting when there was not. Furthermore, the team would be able to identify when A was becoming unwell despite taking his medication.

There would be liaison between the HSE and An Garda Siochana “in relation to how the Gardai might identify concerns regarding his behaviour (not related to his mental illness). It seems to me that risk can’t be eliminated,” said the judge. He noted that support from his family would be vital. A had not lived with his mother for a very long time but he saw her as an “absolutely vital part of his life”, she had attended all of the court reviews and participated and spoken out for her son and identified her concerns for him.

“I’m very happy that she’s committed to helping him when he returns,” said the judge. It was in A’s best interests to move, and to go first to the DoP for stabilisation, in order to give him the absolute best chance for maintaining himself in the community in the apartment.

The judge continued the orders sought by the HSE pursuant to section 22 of the Assisted Decision-Making (Capacity) Act 2015 and granted the order to transfer A from his residential placement to the DoP, agreed that the orders of restraint should be made and would assist the hospital staff in managing the young man and his best interests. The case was listed to return within a month and the judge said that he would very much welcome A if he would like to participate.