Suicidal teenage girl transferred to specialist unit abroad – 2017vol2#9

See also Case Histories 2017 Vol.1 No.5

A teenage girl [A], who had spent nine months in a Special Care secure detention unit without receiving a psychiatric assessment despite repeated requests from her mother, made a serious attempt to take her own life within one month of being discharged home.

After this she was placed in a mental health facility for four weeks during which time the court heard that it was the opinion of the psychiatrist that A needed psychiatric detention. Subsequently, orders were made readmitting A into secure care with the proviso that she would have immediate assessment by a psychiatrist on arrival but in fact she was assessed six days later.

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 the psychiatrist about and this event had led her to believe that she should not be alive. She was still actively suicidal after being admitted into secure care, “given the opportunity it is her intention to carry out her wishes”.

The social work department were looking at an out of State placement and a psychological report from the psychological service ACTS had stated that the therapeutic plan the child needed was not available in the State. There was a strong suggestion she had experienced child sexual abuse, there was no mental disorder, but she had very severe emotional and behavioural problems that in all likelihood reflected her childhood experiences. Her treating psychiatrist [who was available to the unit once a week] would also provide an up-to-date report to confirm that an out of State placement was correct.

Three very serious incidents of self-harm had occurred, one of which involved a ligature around her neck. The barrister for the GAL informed the court that secure care was not a suitable place for A, the guardian believed she was at a high risk of successfully completing suicide and there was no indication of the risk reducing.

The following month the court heard that an incident of self-harm had led to hospital admission during which time the treating psychiatrist had not been available to her. The judge remarked that she “was led to believe [in] his involvement, he would be available and he clearly isn’t.” Senior counsel for the CFA responded that the psychiatrist was a “HSE person, he provides consultative services to [the unit].”

The court then heard that A had assaulted staff while in a heightened state when she heard of the prospect of another minor coming into the unit. Eleven members of staff were injured, some quite badly who had to be hospitalised and would be out of work “and that was just the threat of someone moving in,” senior counsel for the mother said. Three out of State facilities were currently being looked at.

A solicitor for the HSE informed the court that the treating psychiatrist was providing a consultative service once a week to the secure care unit and A had refused to meet him on the last occasion he had attended there. He was due to meet with her again that morning. “He is a community psychiatrist with a busy case load and a lot of other patients,” said the HSE solicitor.

“I fully appreciate that,” replied the judge, “but is it appropriate for him to be the treating psychiatrist in this case? It ought to be reviewed, there had to be an admission to [an A&E] when no immediate psychiatric service was available to her.”

Within a few weeks the child was quite isolated in the secure care unit due to reasons of her personal safety. “She doesn’t see any future,” senior counsel for the mother said, “her situation now is that she’s being kept there in order to protect her from committing suicide, she is not able to engage with the ACTS team, there is very little psychological intervention and no therapy.”

One of the suggested placements in the UK had said they would not be able to offer the girl a place within their unit.

Counsel for the mother said that her client had understood that a wraparound psychiatric service would be provided for her daughter in secure care and yet the treating psychiatrist was available to her only once a week. There was very active suicidal ideation and a failure on the part of the Child and Family Agency to address the deficiency of a proper psychiatric system. They had written to the CFA and received no reply. The guardian’s position at this stage was that the court needed to be very concerned regarding the continued detention of A at the unit without treatment.

The HSE solicitor informed the court that her treating psychiatrist was providing a psychiatric service to the unit according to protocols, ACTS could provide DBT (Dialectical Behavioural Therapy) but she would not engage. Last week she would not engage with the psychiatrist on his arrival at the unit.

Senior counsel for the CFA did not accept the allegation of failure on the part of the CFA to provide psychological and psychiatric treatment support to A, “the different psychiatrists have not identified psychiatric intervention treatment or a psychiatric disorder.” The judge suggested an updated report from A’s treating psychiatrist would therefore be of benefit.

At this point senior counsel for the guardian told the court that at one point one psychiatrist was prescribing medication and psychiatric intervention but the treating psychiatrist had ordered all that medication to be withdrawn, his last assessment was that she did not need medication. Therefore counsel for the GAL was now seeking an independent review. “We were given a view of what would be provided by way of psychiatric intervention once A was in [the unit], then it wasn’t provided but [a visit] once a week was instead.”

The judge asked for the matter to be addressed as a matter of urgency.

The following week the court heard that the child’s mood was very low and she had been assessed by the secure care unit as being a very high risk to herself and others, she had been subject to a sedation due to violence and the staff were finding it difficult to cope.

It was being suggested that A would go to the out of State psychiatric hospital for a year or the prospect of a year. While her mother was unhappy with the idea of her daughter going out of the jurisdiction the judge felt the parents should keep an open mind as the success there was unprecedented and went over and above people’s expectations. Currently the CFA were waiting to hear back from the hospital if they could admit the teenager.

In September, seven weeks later, a place was ready for A in the low secure psychiatric child and adolescent therapeutic centre and the court used its inherent jurisdiction to transfer the minor out of State.

Senior counsel for the parents reported subsequently that A was feeling unfairly picked upon for punishment as currently she was in a room with a mattress and nothing else. The judge responded as she did not have the medical expertise to second guess treatment measures due to the complexity of her case where issues of self-harming arose. Counsel for the mother asked that the therapeutic centre communicate their reasons regarding the measures taken in order to assure the parents of the treatment.

When the girl was seven weeks into her placement in the psychiatric child and adolescent therapeutic centre the court heard that while A was still aggressive she was de-escalating herself and attending all of her therapy sessions. There had been no significant incidents for two weeks. Funding was being provided for her family visits and there was now a new system of information sharing between A and her guardian ad litem.

An indicator of particular progress for the teenager was that she had not taken part in a riot within the unit.

Note: ACTS is a small national specialised clinical service that provides multidisciplinary consultation, assessment and focused interventions to young people who have high risk behaviours associated with complex clinical needs. ACTS also supports other professionals in their ongoing work with young people and their families.