QUEEN'S BENCH DIVISION
THE ADMINISTRATIVE COURT
B e f o r e :
|CELIA MARY HAMILTON||(APPELLANT)|
|THE NURSING AND MIDWIFERY COUNCIL||(RESPONDENT)|
Smith Bernal Wordwave Limited
190 Fleet Street London EC4A 2AG
Tel No: 020 7404 1400 Fax No: 020 7831 8838
(Official Shorthand Writers to the Court)
MR ROBERT LAWSON appeared on behalf of the RESPONDENT
Crown Copyright ©
Wednesday, 26th July 2006
"... we are persuaded that the weight of medical evidence indicates that you do suffer from a psychiatric disorder, and what gives us particular concern is that you lack the insight that would enable you to recognise and manage your condition, should you have a relapse. The medical advice is that it would benefit you to be in formal contact with the psychiatric service, and we consider this to be a minimum requirement before any further application for the termination of your suspension is made.
Having said that, we hope that in time you will be restored to full health and when you and your medical advisers believe that you are fit and ready, we should be very pleased to consider a further application to end the suspension of your registration."
"Miss Hamilton was suspended from practice in May 1999 for an unspecified period because she had been diagnosed as suffering from bi-polar affective disorder. ... The expert evidence about Miss Hamilton's mental state as it stood before the Health Committee in late 2001 was not unanimous, but it was not radically divided. It included four medical examiners' reports, together with a report from the claimant's treating practitioner and one from an expert independently instructed by her. Of the medical examiners, Professor McClelland had been brought in to resolve a difference between Dr Deahl and Dr Bergmann. He alone gave oral evidence to the Health Committee.
None of the doctors considered that the claimant was currently mentally ill. All of them considered that she was at risk of relapse. Professor McClelland concluded:
'... I have to be strongly of the view that whilst Miss Hamilton is well and it augurs well for the future, it would be better for her own self-interest in her health management and her illness management, just as with any other illness, even though the illness is in remission, to be in professional follow-up.'"
"On the evidence presented to us today we accept both Dr Moore's diagnosis and the opinion of the other medical examiners. The Committee therefore has concerns that you have a lack of insight into your illness and the effect this has on your behaviour. This lack of insight leads us to have grave concerns as to the practicality of being able to effectively monitor your progress should you return to nursing. We are further concerned by the lack of strong local supporting mechanisms that we believe you need to have in place. We note with regret that you did not take heed of the advice of the last Health Committee. We have further concerns about your ability to develop and sustain professional relationships. Our decision is made on these reasons and being mindful of our role in respect of public protection."
"1. On the evidence presented to us today, we accept both Dr Moore's diagnosis and the opinion of the other medical examiners.
2. The committee has concerns that you have a lack of insight into your illness and the effect this has on your behaviour.
3. This lack of insight leads us to have grave concerns as to the practicality of being able to effectively monitor your progress should you return to nursing.
4. We are further concerned by the lack of strong local supporting mechanisms that we believe you need to have in place.
5. We note with regret that you did not take heed of the advice of the last health committee.
6. We have further concerns about your ability to develop and sustain professional relationships."
"She has been examined by a number of psychiatrists appointed at her request and by the UKCC and the NMC. Each psychiatrist has formed the opinion that Miss Hamilton suffers from Bipolar Affective Disorder, although none have found evidence of acute illness at the time of the examination. However hospital records, notes and reports describe a variety of symptoms which are deemed to fit the diagnosis as identified below."
"Having interviewed Miss Hamilton and read through the extensive bundle of papers, I realised that whilst there were areas of disagreement and dispute between the family and the medical examiners, there were also many areas of agreement.
It is clear that on some occasions Miss Hamilton has recognised that life was difficult and she has been not functioning appropriately. It would appear that at such times she has asked for help from her General Practitioner. It is recorded that she believes that she was not offered appropriate help at the time of asking and that later when things deteriorated, it is her contention that the help that she was offered was disproportionate. On other occasions it is recorded that Miss Hamilton did not recognise that she was increasingly irritable and not coping as well as usual even though her parents were able to see the changes and had expressed concern. With hindsight Miss Hamilton had been able to acknowledge these episodes and agreed that she had, at times, been affected by life events. Once more however she thought that the reaction of the mental health service was disproportionate."
"At time of my examination I was unable to find any evidence of a mental illness. However, it is proven that Miss Hamilton is someone who is vulnerable to stressful life events and she may well encounter further stresses in the future which could affect her level of functioning. As in the past it is impossible to be certain that either Miss Hamilton or her parents will immediately recognise any changes. Consequently, should she return to nursing it would be essential that her health should be monitored by an appropriately qualified person.
In conclusion therefore it is my opinion that in considering this case the important issue is not labelling the illness but rather ensuring that the practitioner is able to perform her nursing duties at an acceptable professional level and to the satisfaction of her patients."
"The other episodes which have led to her being admitted [to] psychiatric hospitals, she feels have been a reaction to life events and her treatment has been exaggerated. She feels that she has never been offered the opportunity of working through the way she was feeling at any particular time, that people have very quickly diagnosed her as having a psychiatric illness and used the Mental Health Act. She feels that it has been inappropriate, she is very concerned that psychiatric services have been influenced by the original GP who saw her and mistakenly diagnosed her as having schizophrenia and she feels that once that label got on her notes, even though it was later rescinded, that that has influenced all the doctors who have seen her since then and they have over-reacted to her behaviour. She tells me now that she accepts that all the psychiatrists [who] have seen her have labelled her as having a bipolar disorder and although she does not agree with the diagnosis, she does agree that she has at times been hypomanic although she does not accept that she has been manic and that she has an episode of depression, so she sees those differently." Page 6, line 18.
"When I examined Miss Hamilton back in July and again today, like my predecessors, I was not able to find any evidence of active illness at the time. She was able to talk with me very rationally and coherently and we spent a lot of time together."
"At the moment the only symptom that she has is that she has clearly become quite stressed and she is hyperventilating from time to time which she accepts is something that she has experienced in the past."
"Does Miss Hamilton now recognise the sorts of things -- the trigger symptoms for her, for what happens to her? Does she now recognise when things are not going quite so well?
Dr Moore: No. She accepts that life events and changes in her behaviour are connected but she does not or certainly has not in the past recognised when things were starting to go wrong. She recognised that [she] was stressed and hyperventilating but there are not any other issues. What I am saying I guess is that there is not any evidence to show that if she was to go into another depression or into another hypomanic episode that she would realise it was happening."
"The other question I wanted to ask was clearly there has been a lot of discussion between the practitioner and the medical experts around about the labelling of being suggested that there is a mental health issue here. I wondered if it was part and parcel of having the bipolar disorder that makes you have no insight into that and perhaps more likely to deny the existence of that.
Dr Moore: I think that it is more most people lack insight who have a psychotic illness. If you have a psychologist you may have the insight into the fact that you have got an illness. There is also the stigma and there are lots of people who just do not want to accept that they have got a psychotic illness so there is that issue. I think for Miss Hamilton there is a big issue. She does see mental illness as a big stigma and really finds it very difficult to accept that it applies to her. She does not recognise quite how seriously changed her behaviour has been over the years. Whether that is part of her or whether it is part of the illness I think is difficult to say but as I have talked more to her she has become more able to accept that her behaviour has changed and has been -- she has behaved in a way that other people would not find acceptable or normal behaviour."
"Dr Collingwood: You have given an account, Dr Moore, which is very much from Miss Hamilton's point of view, what she believes. I felt that in the papers there is a lot of evidence of ill health which I felt that you almost disregarded. You just tell me about all these opinions from other people.
Dr Moore: I certainly have not disregarded them. There is an illness here without any doubt. She has an illness and I have told her that that is what I believe. What I was trying to get across is the way that she has seen her behaviour as opposed to the way the doctors have seen her behaviour.
Dr Collingwood: You talked just a minute or two ago about insight that she was now recognising some change in her behaviour. But coming through again from the papers, there seems to be very little insight from her.
Dr Moore: Indeed.
Dr Collingwood: Again, an example you gave was of taking these people into her home. I am just wondering, from your definition that you have put in and from your report, you are saying that she has a relapsing condition.
Dr Moore: Yes.
Dr Collingwood: In relation to that then, our function is to protect the public and how safe can she be looking after vulnerable people.
Dr Moore: I think that is a difficult decision. What I can say is that between each episode she appears to have made a very good recovery, appears not just when I examined her but when other psychologists have examined her, she seems to be able to function at quite a good level so although this is a chronic relapsing illness it is not one that between episodes has affected her ability to function. The episodes themselves are very damaging to her and to her surroundings."
"Dr Robson: Sorry to keep on about this point about diagnosis, but do you yourself agree with your colleague's diagnosis that this history is consistent with one of bipolar affective disorder? Dr Moore: Indeed."
"Ms Hamilton is not suffering from mental illness at the present time. Her medical records suggest she has previously suffered from hypomania although she steadfastly denies this and has taken steps to seek redress of this perceived injustice. Ms Hamilton has a blunt direct manner and she admits that she becomes irritable and easily upset under stress. It is conceivable that her behaviour may have been misconstrued and perceived in terms of mental illness particularly once she had received a psychiatric 'label'. It is however likely that she did suffer affective disturbance particularly as several different psychiatrists have reached the same conclusion and that apparently these views have been endorsed by a Mental Health Review Tribunal during her various periods of involuntary admission into hospital."
"A) I believe it is unlikely that Ms Hamilton suffers from bipolar affective disorder as such. If this were the case, I would expect her to have had more frequent episodes of depression or hypomania, particularly bearing in mind the fact that she does not take mood stabilising or other psychiatric drugs, and the fact that her life contains a good deal of stress."
"It is likely that she has had stress-related psychotic episodes, which have resulted in her admission to psychiatric hospital."
"My opinion with respect to her diagnosis must be regarded as tentative, due to limitations in receipt of some background information."
"The Health Committee had concluded in May 1999 that the Claimant did then suffer from a mental condition. Mr Lawson's submission that she was not entitled to challenge that decision is not now contested. Moreover, the medical evidence before the Committee and now before me overwhelmingly supports the finding. There were several episodes of serious mental illness, although the actual diagnoses had sometimes differed."
"In my view there was sufficient evidence before the Committee that the condition was one that seriously impaired her fitness to practise. They were entitled on the evidence to find that the Claimant lacked the insight to recognise and manage her condition if she had a relapse. She made it plain in answer to sympathetic questioning that she was unlikely in fact to recognise a relapse or, unless obliged to do so, to seek or follow psychiatric advice."