In what was described as a “serious mental health case” heard over a period of three months in the Minors’ Review List a High Court judge was told that an Irish teenager, A, was being prescribed a specific medication in a medium secure psychiatric hospital in the UK. During this period her treating psychiatrist in the UK had deemed the girl fit for discharge and therefore believed it was unethical for the teenager to be detained for any longer in the facility.
Every week during the Minor’s List, counsel for the GAL reminded the court that the girl was being “detained in a place where the doctor said it is unethical to detain her”, and that the teenager’s views coincided with those of the doctor.
The court heard from counsel for the CFA that the drug which was being prescribed to the girl was normally only prescribed to adults for use as an anti-psychotic for schizophrenics and was described as “off-label” when being prescribed for a teenager. It required extremely careful management and if the teenager were to be brought down off it, it would take a period of years.
Counsel for the CFA also told the court that A’s medication would be prescribed into early adult life, it was quite specific and her doctor believed that it may have prevented another mental health aspect developing. The difficulty of sourcing the medication in Ireland could not be underestimated, he said, and it could only be prescribed if there was court authority.
Her treating doctors in the hospital had drawn up a template of what would be required for the teenager on her return to Ireland. Senior counsel for the CFA described the template as a “complex mental health arrangement under the supervision of a mental health psychiatrist.” There was no reality to the teenager returning to foster care, there was a risk to life and she required a bespoke package in a highly structured mental health residential centre.
The hospital in the UK had deemed A fit to be discharged and the question was how and when to implement a plan to bring her back to Ireland. Events leading up to her transferral to the UK were very risk taking and dramatic, and the hospital in the UK had crystalized a risk. A sensitive discharge was therefore required with safeguards put in place. An independent psychiatric review of the girl, with a risk assessment, was to take place prior to the discharge as well as a review by the CAMHS psychiatrist who had treated her prior to her transferral.
The judge remarked that a full clinical review was now needed in light of the hospital’s clinical report. She also directed the CFA to request an echocardiogram in the UK facility which was necessary in light of the side effects of the prescribed medication.
“The key here is to get a clinical pathway lined up carefully,” said senior counsel for the CFA, “and an education curriculum for the right exams.”
During the Easter recess the judge went to visit the facility in the UK and met with the girl who had asked her when she would be returning home and when a placement would be identified. The judge also said that the ECG would take place before the end of the week, this was necessary in light of the fact that a minor, who was also being prescribed the same medication and for whom an ECG had been deemed unnecessary, had died in the same facility.
However, when the case returned in the Minor’s Review List two weeks’ later the ECG had not taken place. The judge told the parties that she had been misled now on a number of occasions regarding the ECG, that she had been furnished a letter with a date on it and now she had another letter saying it was hopeful to have an appointment in mid-June. “The necessity for the test was identified months ago, it is to be rectified for once and for all,” she said.
“There was a reason for the ECG being identified because of the medication she is on, I want an answer next week. Matters are going to have to move along swiftly,” she told the parties.
Counsel for the CFA explained that the hospital where the ECG would take place had informed the UK hospital that A was not a priority patient, that she was not ill, that it was not urgent and that the referral had been made as a matter of best practice. She was currently receiving regular electrocardiograms and the ECG would most likely be done in mid-June.
Counsel for the GAL noted a further issue, that the consensus was her placement in the unit in the UK was problematic as she was considered ready for discharge and no onward placement had been identified in Ireland. The independent psychiatric review would be ready into two weeks’ time. In general terms the teenager was doing well, however, he was seeking to list the matter for hearing at the first opportunity in the next term in order to have an onward placement identified.
“Looking at it from a legal perspective,” said counsel for the foster parents, “how can it be lawful to continue detaining her in a psychiatric hospital when there is no therapeutic rationale. [A] herself is frustrated, it simply can’t go on for months and months and that’s what’s happened.”
Counsel for the HSE informed the court that an appropriate CAMHS unit had been identified for when A did return that would offer her a full Multi-Disciplinary Therapeutic Team Support (MDTTS).
A plan had been agreed on A’s mental health care on her return to Ireland. This plan had been agreed at a meeting by her consultant child and adolescent psychiatrist, the guardian ad litem and a psychologist from the Assessment, Consultation and Therapy Service (ACTS) who had known her while she was in secure care in Ireland. This plan set out that an emergency would be dealt with through the A&E department of a specified hospital and that instead of DBT (Dialectical Behavioural Therapy) a similar form of cognitive therapy called CAT would be commenced on A’s return home.
As regards her education, it was noted that the location of the school would depend upon her new placement as she would require a school close to where she would be living.
The judge listed the matter to return in two weeks’ time for intensive welfare review with updates regarding the ECG.