The High Court heard that an Irish teenager being detained in a psychiatric facility in the UK had been deemed ready for discharge, however there was no appropriate facility in Ireland to permit her to return home.
The history of the case: Case histories 2014, Volume 3, No. 3.
This case involved a teenage girl (A) whose mother had first written to a therapeutic clinic when she was four years old (when she had noticed her obsessive tendencies) but she had been told there was a five year waiting list. Her difficult behaviours had increased as she got older.
She was then diagnosed with PSSNOS, (Pervasive Developmental Disorder Not Otherwise Specified) by a team of seven psychiatrists, however after one year the clinic closed the file because she would not engage with the multi-disciplinary team and its psychiatrist.
Subsequently there was property damage at home and assaults. The mother went to the HSE herself and told them she could not cope with her daughter (who was now a teenager) and was not managing at home. However she was told it was not a child protection matter and sent home, she was advised to go back to the clinic.
Her daughter was making noises at night for five or six hours and neither of them were getting any sleep. She rang the clinic and told them: “I’m afraid I’m going to kill her or she’s going to kill me.” After that a social worker from the clinic got in touch with the HSE and they intervened.
The mother told the court that because she had asked for a residential temporary placement to help her she was accused by the HSE of giving up on her child and abandoning her. The HSE eventually referred A for a 12 week assessment and she placed her into voluntary care in a residential unit for the 12 week assessment which turned into seven months. However the behaviours became worse, she was urinating and throwing it at staff, thumping her head, writing all over the wall, she pulled doors off the cupboards and the fireplace off the wall.
“It was like something from a horror film going to visit her, she hadn’t washed in months, there were lice in her hair, she was sitting in urine in her bedroom, her clothes were soaked in urine,” the mother had told the court. She now sought a therapeutic residential centre for her daughter. “She has had no therapeutic intervention in the year she was in care, she saw a psychologist twice and a psychiatrist once,” she told the court.
Case Histories 2014, Volume 4, No.17.
When the case returned eight weeks later, the court had heard that no residential placement suitable for A’s needs was as yet available. A psychiatrist told the court that “it has reached the point where a Section 25 is needed; she needs to be in a place of safety.” Five weeks later, an application was granted under Section 25 of the Mental Health Act 2001 (authorising the detention of a person with severe mental health problems) due to A’s urgent needs for psychiatric care. A bed had been found after referrals to six adolescent psychiatric units. The HSE and its director of mental health services had found A the placement.
However the case returned three months later, this time to the High Court, where orders were sought pursuant to Article 56, authorising the HSE to place A in the UK. The existing Section 25 order would remain in place until she arrived safely at her new placement, whereupon it would be vacated.
Due to her extreme behaviour, her current residential unit had been in lock down, as it was not set up to deal with the extensive nature of her needs. Following an assessment of all suitable locations, the professional consensus was that the hospital in the UK offered the best prospect of care for A.
“At present there is no low support secure mental health facility in our state, the majority of hospitals are not secure hospitals, proposals to build one are there but it is not in place,” counsel for the CFA had told the court.
An independent psychiatric report found that A presented with a serious and immediate risk to herself and others and was unlikely to receive the treatment she required in her unit. The report was consistent in its summary and recommendations of the consultant child and adolescent psychiatrist in her unit.
The orders were made and A was removed from her unit the following week by government flight transport, using the assisted admissions team. An air ambulance then took her to the UK with a specialist team and she was accompanied by her mother. A had expressed a willingness to travel and understood she was in a situation of distress and her mother supported the application to move her daughter to the UK.
10 months later:
Ten months later in the High Court, the judge heard that A had been deemed ready for discharge from the psychiatric facility in the UK, however, there was as yet no appropriate facility for her in Ireland.
Counsel for the CFA told the court that “the time for discharge is fast approaching” and they were hoping to have a proposal from a private service provider in two weeks’ time. The barrister for the guardian ad litem (GAL) said: “The hospital say she is ready, the problem is there is nowhere in Ireland to put her, the only place available is not available until [spring 2016], so a [private service provider] was approached, the GAL would like a direction from the court for the CFA to seek a report for the court from [the private service provider] so we know what it is [they] can or can’t do and if they can do nothing the CFA will endeavour to seek alternatives.”
Counsel for the CFA said a direction was not necessary and the report would be provided.
Mother’s senior counsel informed the court that it had been the mother who had identified the third party private service provider; a facility that could provide a bespoke placement for her daughter [in absence of an appropriate HSE placement being available until 2016].
The CFA was about to make information available about A to that third party provider in order for a costing to be done up in relation to her particular needs.
As the teenager was due to reach the age of majority in 2016, counsel for the mother asked the court for the HSE to be brought back into the proceedings. She said it was appropriate as her future service provision must be looked at within the health and disability services in the HSE. The case was to return in two weeks’ time to inform the court as to whether the private service provider could facilitate a bespoke placement with appropriate therapeutic needs for A.
The judge allowed for a motion to be brought to bring the HSE back into the matter, returnable for the next court date.
In the meantime A would remain in the UK in psychiatric detention, under an Irish High Court order, although she wished to return home.
Three months later, November 2015
Three months later the situation regarding an onward placement for the girl had not changed. Three clinicians were directed to attend the High Court to give their opinion as to her needs in the short and long term.
The first clinician, who was a consultant child and adolescent psychiatrist working with the HSE and a Professor of child and adolescent psychiatry, told the court the reality was that there was no existing placement in Ireland with the services she required. “It would have to be created for her,” she said and in her opinion the private placement option that was being put forward by the parents had some limitations.
She had first met (A) 8-10 years ago when she was referred to her with emotional and behavioural difficulties. She had also seen A in her low support in-patient adolescent psychiatric unit before her transfer to the psychiatric hospital in the UK with child and adolescent mental health services.
The three clinicians had recently held a strategy meeting regarding the girl and they had all agreed that what was needed in Ireland was a placement that could contain her and meet her needs and wishes. She had specific ideas about living independently into the future and before that she wanted to sit her Leaving Certificate and she had a huge interest in acting and theatre.
The environment she currently lived in was highly supported and she had severe and enduring difficulties. She needed to go on to a highly supported environment, if she were discharged now it would not be good for her, said the doctor.
The second clinician, a consultant child and adolescent psychiatrist for the HSE, was asked by senior counsel for the GAL if he could identify a unit in Ireland where A could now be placed. “What practical facility can be provided around meeting her needs?” he was asked.
The doctor told the court that a minimum timeframe of six months was needed in order to provide A with the private residential unit placement (proposed by the mother). To register the unit under HIQA would take at least six months and the building had to be located and purchased before that could happen.
The Nua Healthcare HSE option was not available until next March and that placement would be in Munster. The court had heard that A wished to live in Dublin.
Senior counsel for the GAL asked the doctor to identify the unit where she could be most appropriately placed currently. The doctor replied that her needs were being met “at this point in time, they are being met there now and it must be that she continue for the present in [the UK hospital].
“She is feeling frustration about the uncertainty of not returning to Ireland but there is a much less likelihood of a deterioration in her mental health where she is.” The GAL senior counsel asked if detaining her for a further period was being suggested, on foot of a High Court order, depriving her of her liberty. “I’m trying to identify what the judge is being asked to do,” he commented.
The doctor told the court that A had a psychiatric diagnosis and was a very vulnerable young girl whose mental state was at risk of deteriorating quite rapidly. She had been admitted to the low support in-patient adolescent psychiatric unit in Ireland last year under a Section 25 order of the Mental Health Act. She had severe emotional and behavioural difficulties, neurodevelopmental difficulties, Tourette’s Syndrome and a high risk of developing serious psychiatric illness into the future. She had a mental disorder within the meaning of the Mental Health Act.
“She has a severe and mixed disorder of conduct and emotions,” the doctor told the court.
“Within a supported setting a young person can be maintained, with a deterioration these difficulties become much more manifest and extreme.”
The judge said she had to think of the jurisdiction of the court when A turned 18 next year.
The third clinician, executive clinical director of a psychiatric unit told the court that in his view, the Nua Healthcare placement option had a lot of merit. Nua had a good working relationship with the HSE services and they had provided care for A before and they were an organisation that provided residential services and care services for people who had considerable support needs. Therefore the placement would be capable of meeting her needs.
He said that under her current arrangement A was reasonably stable and she had visits back to Dublin every fortnight. These elements could be continued. He had looked at the private placement proposals and he felt they did not sufficiently address the issues of HIQA certification.
Senior counsel for the child’s mother pointed out that the Nua option was currently a construction site.
The doctor agreed that there was nowhere available to A in Ireland, “if there was, she would be back,” he said.
Senior counsel for the GAL said that A did not want to go Cork, “if she says I’m not going, what happens then?” he asked.
“There are huge risks in any plan for [A],” replied the doctor. “Part of her difficulty is oppositional defiance, so it is likely she will object to the plan. It is part of the job of the people involved supporting her to help her understand that. Nothing is going to be ideal.” The judge remarked that after she turned 18 that A could only be detained under Irish law if she lacked capacity.
Senior counsel for the CFA said that if A had a mental health advocate, it could be recommended to A that she take a habeas corpus application to say that she wanted to return home. Alternatively, senior counsel for the mother could take an Article 40 application (seeking her release).
Senior counsel for the HSE retorted that “inviting the mother to take an Article 40 application was horrendous and irrational.”
In conclusion to the hearing, the judge stated that waiting for the placement to be ready in March was far too long. She asked the clinicians to meet again and come back with further proposals in two weeks’ time.