QUEENS BENCH DIVISION
London, WC2A 2LL
B e f o r e :
| THE QUEEN (on the application of HP and KP)
|- and -
|LONDON BOROUGH OF ISLINGTON
Mr Bryan McGuire (instructed by the Director of Law & Public Services) for the local authority
Crown Copyright ©
Mr Justice Munby :
"For community Care Assessments a judgement must be made about the level of need, Higher, Medium or Lower. These do not necessarily relate to the CPA levels."
A diagram illustrates how, if there are severe and enduring mental health needs, it will be the adult mental services which will be responsible for future care, whilst otherwise the responsibility will be that of generic health or social services. Eligibility for Community Mental Health Team services is dealt with as follows:
"CMHTs must concentrate on working with people with severe and enduring MH problems …
1 Clients diagnosed as suffering from Schizophrenia, Manic Depressive Illness or any other persistent Psychotic Illness unless a high degree of stability has been achieved with their symptoms …
2 Depressive Illness, Anxiety Disorders and Obsessive Compulsive Disorders where the risk of self-harm or harm to others has been sufficiently serious to consider a hospital admission within the past two years.
No challenge of any kind is made to the lawfulness or propriety of this policy.
"He was generally unwilling to be interviewed and much of the history therefore, was from the wife and son. Mr P had expressed his concern that he was not happy to be seen by a Doctor, because he believed he was going to be killed. He however volunteered a history of hearing voices, which he did not elaborate upon, before deciding he was not interested in being interviewed …
He sat on the bed with his head down most of the time. He had poor eye contact and [was] generally uncooperative and unwilling to be interviewed. He believed we had come to kill him. He was tearful when discussing his six-year son who was killed in Kosovo. His speech was retarded and he was depressed and irritable in his mood, but not suicidal. He had persecutory delusions as previously mentioned. It was impracticable to elicit any abnormality in his perception, or cognition, in view of his lack of co-operation he seems to have poor insight into his condition.
The impression is that he has presented with symptoms suggestive of a depressive episode, with psychotic symptoms, with a background of chronic grief reaction and unpleasant life experiences in Kosovo. It may well be that he has had symptoms suggestive of Post Traumatic Stress Disorder in addition."
"Mr P speaks no English and it was necessary to work with an interpreter. Mr P was unwilling to answer questions other than to say he was all right. According to his family he has always been "slow" and apparently never functioned at a very high level. He had occasional, casual labouring jobs whilst living in Kosovo and only ever had 2 years formal education and is unable to read a newspaper. However, his family felt that his condition had deteriorated since coming to the UK and following the death of one of his sons in Kosovo. He had appeared low in mood and forgetful. However, on questioning, there appears to be no suicidal ideation and no psychotic symptoms.
My assessment was that he was suffering from reactive depression and possible the early stages of dementia, although this was very hard to assess properly in the circumstances. As noted above, it would appear at best that he has only a fairly low level of function. His family were of the view that the housing situation exacerbated his condition and we will obviously do what we can to help with this, although in view of his current indeterminate immigration status, there may not be a great deal that can be done in the short term. I note he is currently on Paroxetine 40mgs daily and Amisulpride 200mgs mane, 400 mgs nocte. I would recommend continuing with the Paroxetine but the Amisulpride should be tailed off over the next few months."
"I completed a home visit with Jackie Social Worker, a translator and Mr P's social worker. I visited Mr P at home with his wife and found him resting in bed upstairs. Initially Mr P did not respond to any questions at all and lay on his side staring at the wall. Most of the initial history was taken from his wife who was still also lying on the bed but was not asleep. His wife mentioned that her husband had always been "slow" and had never functioned cognitively at a high level.
She described how Mr P had been taking his medication but she had been giving her husband Paroxetine 60 mgs a day and Amisulpride 200 mgs once a day for the last year. He had been compliant with this and an improvement in his medical symptoms of aggression, suicidal thoughts and paranoid ideation had been noticed by her. However she remained concerned that her husband continued to spend most of his day in bed and appeared agitated and tremulous for most of the time. She would describe how he would often sit next to the window and stare out of the pane of glass occasionally appearing tearful.
However she did not say that he described any auditory hallucinations or paranoid ideas which had been a clear part of his symptomology one year ago. He continues to eat and drink, but at times this can be variable.
When I examined him today he appeared thin and withdrawn but he was not anaemic, dehydrated or jaundiced. His pulse was of a normal rate and rhythm of 80 beats per minute. He initially lay in bed and ignored my questions but after a while did eventually sit up in bed. He appeared to have some psycho motor retardation with minimal eye contact. He was extremely tremulous: both hands had bilateral tremor which was fairly marked. There was evidence of poverty of speech but no other formal thought disorder. His mood objectives appeared to be depressed but on questioning he said he felt fine. He denied any suicidal ideas, homicidal ideas, or any thoughts of self harm. He continued to eat and drink but this can be variable according to his wife. There is no loss of weight according to his wife. Although he remains in bed for much of the day it is difficult to assess how much quality sleep he gets as his wife is not able to tell at times whether he is asleep or just resting.
He denied any paranoid thoughts, and there was no evidence of any disorder of thought possession. In addition there was no evidence of abnormal perception or any auditory hallucinations which had been a feature previously.
Although Mr P continues to be compliant with his medication, I feel that his wife or Mr P has confused the fact that Amisulpride was meant to be given twice a day and Paroxetine only once.
I have re-addressed the balance of Paroxetine 30 mgs od and Amisulpride 200 mgs a day and would like to review Mr P in two or three weeks time.
It is very difficult to assess but I feel that Mr P probably has experienced some improvement on his medication with regard to the previous paranoid ideation and depressive symptomology and aggressive out bursts. However, there remains to be some evidence of ongoing depressive symptoms which may also in a context of some paranoia and/or cognitive limitations. This was difficult to assess given the history of Mr P."
"Mr P does not have a firm psychiatric diagnosis. He may be suffering from reactive depression resulting from traumatic events whilst living in Kosovo. Members of his family say he did not function to a high level before these events. There may be an organic root to his problems but it is not clear whether a neurological assessment has been arranged.
Mr P appears to be suffering from a form of depression known as "reactive" ie it is reasonably appropriate to his circumstances (lost his son in traumatic circumstances and is culturally and socially isolated). This is not a severe and enduring mental illness."
It was said to be "not possible to assess" either thought content (hallucinations, delusions, preoccupations, obsessive thoughts) or thought interference (withdrawal, insertion, broadcast), though there were said to be no hallucinations known. Mr P was assessed at being at "risk" of "severe self-neglect" and "vulnerable to deterioration in his mental state particularly if he stops taking his medication."
"1 Mr P requires prompting to attend to all aspects of daily living including personal care.
2 Mr P requires reminding to take his medication.
3 Mr P needs treatment with depression and bereavement issues.
4 Mr P needs safe accommodation with more privacy for himself and his family.
5 Mr P requires support and prompting to go out and socialise."
The 'outcome of assessment' was that the answer "no" was given to the question "Does the service user meet the eligibility criteria for care management?"
"With such severe impact upon his daily functioning, and his stated vulnerability and adverse social circumstances, he should fulfil the eligibility criteria for Care Management, and should be allocated a Care Co-ordinator forthwith to help access and provided an appropriate support package for him."
"My clients do not accept that Mr P has not had a proper community care assessment. As assessment was completed and following that assessment the decision was made that community care services will not be provided as Mr P does not have a severe and enduring mental illness. As you will see … your client was seen by two psychiatrists as part of the community care assessment that was undertaken (emphasis added)."
"My diagnosis is that he is suffering from severe depression with psychotic symptoms. This is a very severe mental illness".
In his report he described his interview with Mr P:
"When I asked Mr P whether or not he had any problems he would like to discuss with me, he initially did not reply. After a while he mumbled that "my friends are in the dark and I am going to provide light for them. I won't leave my friend in the dark". He said little else that was comprehensible throughout the two hours I was with him, apart from this reply. He sat crossed-legged on his bed, fiddling with an electric cable and plug. On several occasions he got up from his bed and walked in an agitated manner in the corridor."
"Mr P was of slim build and dressed casually. He exhibited three behavioural phases. The main one was sitting on his bed fidgeting with his clothes and wrapping and electrical cable around a plug. He acted as though he was trying to fix the plug or attach the wire to it. He would vigorously rub his face and frequently fidget with his fingers and wring his hands.
At times Mr P would freeze. He would make no bodily movement for approximately thirty seconds.
The third characteristic behaviour he exhibited was pacing up and down in the corridor with his arms folded. He walked in an agitated manner and at times would stop and try to remove an invisible mark or object off of the floor.
Mr P only spoke three or four sentences when I was in his flat. There was marked poverty of speech, and at times he muttered incomprehensibly.
When I enquired about his mood, he did not reply. In the past he has expressed suicidal ideation but has not done so recently. His family is concerned that if left unsupervised he might harm himself, because he repeatedly tried to cut and strip electric cables with his teeth. Objectively, he appears severely agitated and depressed.
I was unable to elicit any delusional ideas because of his lack of communication. He appeared severely withdrawn from reality and was constantly preoccupied with his own concerns. He did not appear to notice my presence or that of his family. In the past he has exhibited paranoid delusions that his family are trying to kill him.
At times he appears to be responding to auditory hallucinations. I was unable to test his cognitive abilities.
Mr P appeared to have no insight to his state of mind."
"Mr P fulfils the ICD 10 Diagnostic Criteria as suffering from a severe depressive episode with psychotic symptoms (Category F32.3). My reasons for this are that for over two years he has exhibited symptoms of low mood, suicidal ideation, severe agitation, anorexia, insomnia, inability to care for himself, paranoid delusions, auditory hallucinations and withdrawal from reality.
In my opinion Mr P suffers from a severe and enduring mental illness, as his depressive symptoms are of a psychotic intensity and he has been unwell for over two years.
I am also concerned that Mr P might be suffering from an organic brain disorder. There is a history of head injury from the beginning of his illness. I also observed times when the body became "frozen" which could be due to an absence attack, which is a type of epilepsy.
In my professional opinion Mr P's mental disorder has come about as a consequence of his maltreatment by the Serbian authorities and most important of all, the killing of his son. Even though Mr P, prior to these incidents, was of below average intelligence, he did not suffer from a psychiatric disorder, which could be the reason for his present problems. It is likely though that his low intelligence would have made it more difficult for him to cope with the tragic death of his son and contributed to his flight from reality.
Noise from Mr P's neighbours is exacerbating his depressive disorder, as it is responsible for making his insomnia worse and increasing his restlessness and agitation.
In view of the severity of Mr P's mental disorder, I think he is in need of regular supervision by mental health services. I would agree with his present care plan for treating him in the community. However without the support of his family, he would be at risk of self-harm and self-neglect and would require in-patient care. It is therefore necessary that his family is well supported and, if possible, given some respite. Unfortunately, respite might be difficult for the family, as so far, he has not accepted help from non-family members. It might be possible for carers to support him if they were involved regularly and consistently over a long enough period."
He added that, in view of the possibility of an underlying organic disorder, he would recommend detailed neurological investigation, including an EEG and CT scan.
"Discussion Dr McK (consultant) and AD (Team Leader)
They have read and discussed the report from Dr H – the doctor appointed by B&P to assess Mr P. The advice given is that there is insufficient evidence to suggest that we change our assessment of Mr P. I am advised by AD that I should now prepare to close this case. Therefore the carers assessment should be cancelled."
"we do not propose providing services to HP and his family – the family are aware of his needs and, from what they've told us, they are willing to meet them as best they can."
"holding to its decision that Mr P does not have severe and enduring mental illness thus warranting Community Care provision (emphasis added)."
i) Islington cannot reasonably maintain its reliance on what are said to have been Dr McK's and Dr B's "admittedly uncertain diagnoses" when faced with what, in contrast, is said to have been the "detailed and definitive … clear … careful diagnosis" of Dr H: given that, so it is said, Dr McK and Dr B had "stated that they could not reach a clear diagnosis" there was no reasonable basis for Islington to reject Dr H's diagnosis and in all the circumstances it was irrational to do so.
ii) Islington's decision is devoid of reasons: it is said to be impossible to tell whether Islington has concluded that Dr H's diagnosis is wrong or that, despite his diagnosis being correct, Mr P is nonetheless not eligible for services.
"… community care services will not be provided as Mr P does not have a severe and enduring mental illness …
… Mr P does not have severe and enduring mental illness thus warranting Community Care provision … "
Islington's misunderstanding – misdirection – is patent.