Teenager in secure care for six years needs to return to Ireland – 2018vol1#5

Video-link evidence was given in a High Court hearing regarding the progress and future of a 17-year-old teenager [A] in a UK psychiatric therapeutic hospital. The teenager, who would soon turn 18, had spent six years in total in secure care and his onward care package required evidence and discussion from his treating medical consultant in the UK, as well a consultant professor from the HSE who had been observing A and had written four court reports on his observations and opinion.

Ultimately, the court required evidence on possible timelines regarding the hospital order in the UK (made by his treating psychiatrist there). It was acknowledged by the parties that the section 37 UK order was controversial because it could only be discharged by the treating team in that jurisdiction, all sections of their mental health act were in fact indefinite. However on the other hand, the section 37 order could be discharged at any time.

The HSE professor, the first witness to give evidence, told the court that although A was being detained under the English Mental Health Act, it was more likely than not that he would be detainable under the Irish Mental Health act now having regard to his age. He said that diagnosis of mental illness in this age group was complex and while the standard WHO classifications were the diagnostic criteria applied in adults it was not uncommon not to see enough symptoms in a young person to make a firm diagnosis.

In A’s case, the professor had found evidence of an emerging bipolar disorder based on observations from interviewing the teenager and observing periods of withdrawal and irritation and negative mood which alternated with periods of sociability, openness, friendliness and then irritation again. Over a year and a half this had repeated as a cycle on a number of occasions, which suggested an emerging pattern of mood disorder and affective disorder, making him prone to periods of negative and elated mood. This was suggestive of bipolar illness but he could not go further with a diagnosis at the time of the hearing.

While it was suggestive rather than formal, within this age group prognosis was very good. The professor told the court that the majority of young people who might reach this point did well, his most positive feature was his age and he had had the benefit of learning to talk about his understanding of himself. On the other hand he was on quite a lot of mood stabilising medication and if he was not he would have fact crossed the diagnostic threshold by then.

On his return to Ireland although it was more likely than not that A would be detainable under the Irish Mental Health Act having regard to his age, this would be a decision made on the day. [A could only be detainable under Irish law if diagnosed with a mental illness, if diagnosed on the day of return with a personality disorder he could not be detained.]

With regards to his future care package in Ireland, the professor said there were two independent sector providers capable of providing a suitable placement for the teenager, both were in a community based setting.

Counsel for the CFA asked the witness had he considered the report of the treating psychiatrist in the UK who was in favour of a step down hospital placement in the UK for A and did not deem it appropriate for him to go to a community based setting.

The professor said that he felt a step down hospital placement was more difficult to arrange in the longer term, if a community placement was available in Ireland soon it would be better for A to go straight there, otherwise that placement could be gone by the time his hospital placement had finished.

While A had met the criteria for placement in the UK psychiatric therapeutic hospital at his time of admission, the HSE professor did not think that any further progress could be made by the teenager within that setting, he had some learning difficulties which had shown up in a neurocognitive assessment and these had caused him difficulty in availing of treatments. In the professor’s opinion the ability to benefit from treatment also depended on cultural matching and treatments available.

“With patchy cognitive impairment after a certain time no more progress will be made,” said the professor, “so a high support community placement should be the next step.”

However the treating psychiatrist in the UK did not agree, in evidence via video-link he said it was more appropriate to have a phased and gradual transition and if A progressed within a step down hospital placement (within the grounds of the psychiatric hospital) then he could eventually come back to Ireland and take up the community based type placement.

The treating psychiatrist told the court that A was currently in a 10 bedded male rehab ward and that a rehab ward tended to have patients who were nearer discharge and who had community leave. The ward also operated slightly different in terms of expectations of levels of functioning of patients and this gave the doctor a good sense of whether A could cope with relatively small change.

The change of ward did not signify a change of security level and it still had access to a seclusion room if required, although the psychiatrist did not anticipate A would need to move back to seclusion. It was now almost a year since A had required an episode of seclusion, progress had been made and the teenager was about to recommence unescorted leave in the hospital grounds.

“We know that progress continues to be made beyond someone’s 18th birthday, it is clinically not accurate that no more progress is being made, we would not want [A] to be moving to an adult secure service in the UK unless all other options have been exhausted,” the psychiatrist said.

He explained that the criteria for a section 37 order was that “a person has to have a mental disorder (in England we don’t have distinctions between personality disorders and a mental disorder) and unless it is necessary either for his own health or the protection of others that he be detained, there has to be a genuinely less restrictive option that can manage him, we can talk about community settings but he came to us from no community setting being able to manage him.

“He made progress and he can be managed now, we could never move anyone from a low security environment to a community setting of any security without it being tested, a concern raised that if he goes home he will abscond and not return [here].”

The psychiatrist told the court that there had to be some degree of testing his ability to cope outside of a low secure environment, an English patient would not be moved without some degree of testing, “I’m not quite sure why we should be doing anything different merely by virtue of the fact he’s not English.”

The move to his rehab ward was part of testing his capacity to deal with change, where he was to have a new responsible clinician. An active period of testing his capacity to deal with change with a provider would take three to six months and the psychiatric team were happy to maintain him in their adolescent services, so that he did not have to change to the adult one which would be disruptive.

If after six months A was deemed safe to return to the community there was no reason why he could not return to Ireland and cooperate with the process there. This testing period would give the psychiatrist confidence that he could discharge the section 37 as there would be enough evidence built up that A would be genuinely safe to himself and others outside a secure environment.

“We need to be careful about adopting a position that he can’t make progress in a hospital setting,” concluded the psychiatrist. His new treating psychiatrist on the rehab ward would decide at the end of May if the section 37 order should be renewed. All sections of the English Mental Health Act were potentially indefinite.