1. Introduction.
I am Andi Williams and I am a registered social worker and Approved Mental Health Professional with the Medshire Learning Disability and Mental Health Team; a specialist team working with adults who have a dual diagnosis of learning disability and enduring mental illness. The team consists of 3 registered social workers, 5 community learning disability nurses, a psychologist, 2 occupational therapists and a consultant psychiatrist.
I have known Ekam for 8 years. The information contained in this report was gained from the following sources: previous knowledge and working relationship with Mr Singh.
, case notes from the electronic records system, discussion with the Medshire Children’s Services, and discussion with Ms K Singh, Ekam’s sister.
2. Are there any factors that may affect the person’s understanding or ability to cope with the hearing?
Ekam has a borderline learning disability and autistic spectrum condition. He also experiences psychotic symptoms due to schizophrenia. All of these conditions may affect his ability to understand the tribunal hearing. It would help if all information is presented to him without the use of technical or legalistic language.
3. Are there any adjustments that the tribunal may consider in order to deal with the case fairly and justly?
See point 2 above.
4. Give details of any index offences or other relevant forensic history.
Ekam has never been charged with or suspected of committing a crime. There is no forensic history, although please see below information regarding his interactions with his sister’s niece and nephew.
5. What are the dates of the patient’s previous involvement with mental health services, including any admissions to, discharge from and recall to hospital.
Ekam was noticed to have delayed developmental milestones when he was a toddler. He was late to walk, and did not start to use verbal language until he was 7 years old. He was noticed to be significantly behind in his education attainment at primary school, and was moved to a special educational needs school at the age of 8. He was noted to present with aggressive behaviour at 10 years old, and his family were unable to manage his outbursts and challenges, many of which were directed towards his younger sister, Kamili. He was eventually moved to a residential school for children with learning disabilities and challenging behaviours where psychological assessments revealed moderate to mild learning disabilities, language delay and an autistic spectrum condition. He has remained in institutional care since that age, moving to a residential college at 16, and then into a residential care home at 23.
At 27 years old, Ekam showed sign of distress and increased aggression. His challenging behaviour intensified and he exhibited self-harming behaviour through cutting arms and legs and tying ligatures around his neck. He explained that a voice in his head was telling him to harm himself. He was detained under the Mental Health Act 1983 for assessment and then for treatment having been diagnosed with Schizophrenia. He has remained under the care of specialist learning disability and mental health services since with many admissions to hospital for treatment under the Mental Health Act 1983.
6. What are the patient’s home and family circumstances?
Ekam currently lives in supported living accommodation. He holds the tenancy to his flat, and he is provided with 8 hours of support each day from the Green Meadows services. He keeps his accommodation very neat, and is quite particular about this.
Both of Ekam’s parents are deceased. He has a close relationship with his sister, Kamili who lives nearby. Kamili has two young children, 9 and 11. Ekam often visits his sister’s home, and this is encouraged by her. Ekam has told me that he is sometimes allowed to babysit while his sister goes out for the evening. The children have disclosed to their school teachers that Ekam allows them to drink alcohol and sometimes leaves them on their own with no adult to supervise them. The youngest child has also claimed that Ekam has hit her several times, leaving bruise marks on her arms. The local social services children’s team is involved and currently looking into this situation.
7. What housing or accommodation is currently available to the patient?Given the incident that led to this admission, Green Meadows have withdrawn their care arrangements and are seeking to bring Ekam’s tenancy to an end. He currently has nowhere suitable to go if he were to be discharged from section today. The feeling is that the care package available to Ekam before admission is not appropriate or sufficient, and he requires a more intensive care arrangement, probably residential 24-hour care. I am currently working on an adult social care assessment of need and eligibility to ascertain the best way forward. Regardless of the outcome, Ekam’s sister would want to continue to be involved in his care.
8. What is/would be the patient’s financial position (including benefit entitlement)?
Ekam is not able to manage his own finances so his sister does this for him. She looks after all his bills and gives him a daily allowance.
9. Is the patient employed or is there any available opportunities for employment?
Ekam attends a local work project for people with learning disabilities where he does supervised grounds maintenance and landscaping for the local council, 2 days a week.
10. Is the patient subject to any conditions under Section 17B?
No, he is not subject to a community treatment order.
11. What was the patient’s previous response to community support or Section 117 after-care?
Ekam has always engaged with the care that he is given. He struggles with inconsistency of care, and works better with some carers than others. He needs reminding to take his antipsychotic medication, although he usually takes this with prompts. He has significant physical health issues from obesity and diabetes. This can cause conflict with staff members as is unable to keep a healthy diet, and often refuses to take his diabetes medication, believing that he is not diabetic. He needs a lot of prompting and persuasion to engage with healthy eating and weight management.
His relationship with his carers recently broke down recently. Ekam had refused his physical and psychiatric medication for several days and was showing signs of increased self-harm, irritability towards carers and his sister, going out for long periods without telling carers where he was all day, and his flat was becoming untidy and cluttered. The situation culminated with the carers finding Ekam with a ligature tied around his neck one morning. They were able to remove it and then they called an ambulance. He was taken to Medshire Hospital A & E where he told the nurses that he was hearing voices telling him to harm himself. He was detained under the Mental Health Act for assessment on the 25th November and taken to the Acute Psychiatric Inpatient unit on the hospital site.
12. What care pathway and Section 117 after-care is being or could be made available to the patient?
As noted above, this is still being assessed..
13. Details of current care plan.
See previous answer.
14. Are there any issues to funding the current or future care plan?
This depends on the outcome of the adult social care assessment and the level of assessed need once his mental health has stabilised.
15. What is the current adequacy and effectiveness of the care plan?
The care plan as it stood before the incident in November appeared to be adequate, but the information regarding potential risk towards niece and nephew, as well as the relapse of mental illness would suggest otherwise. The plan is being reviewed with the possibility of new care arrangements when Ekam is ready to leave hospital.
16. What are the strengths or positive factors relating to the patient?When well, Ekam is gentle and thoughtful man. He collects joke books and likes to refer to them at any occasion. His autistic spectrum condition and learning disability, whilst mild, still present significant challenges to his daily life, but they are generally manageable with the right support and care, and he has developed coping strategies that he employs to good effect. He enjoys listening to Indian classical music, and plays the tabla drums to a high level.
17. Give a summary of the patient’s current progress, behaviour, compliance and insight.
The ward staff tell me that Ekam is still experiencing voices and seeking out ways in which he can harm himself. These are not as serious as upon admission, but he has managed to cut his legs on several recent occasion using items he has found around the ward.
18. Give details of any incidents I hospital where the patient has harmed themselves or others, or threatened to harm others.
See para 17 above
19. Give details of any incidents where the patient has damaged property, or threatened to damage property.
Ekam has tried to kick through the ward door to leave. No damage was noted.
20. What are the patient’s views, wishes, opinions, beliefs, hopes and concerns?
I am not allowed to visit Ekam on the ward due to the coronavirus restrictions. I attempted to speak with Ekam on the telephone, but he declined. I have bee unable to ascertain his views. The ward staff tell me he wants to live with his sister, who he claims is willing to allows this.
21. What are the views of the patient’s Nearest Relative?
Ms Kamili Singh spoke to me on th 2nd December. She is disappointed that Ekam is back in hospital, and states that this is due to his carers not understanding him or his needs. She is willing for Ekam to move in with her when he is ready to leave hospital as he is always fine with her and her children. She believes she will be able to care for him adequately at home, but only once his mental health has been stabilised. She minimised the involvement with children’s services, and suggested she had never allowed Ekam to babysit her children.
22. If (having consulted the patient) it was considered inappropriate or impractical to consult the Nearest Relative, what were the reasons for this, and what attempts have been made to rectify the matters?
23. What are the views of any other person who takes a lead role in the care and support of the patient but who is not professional involved?
24. Is it necessary for the patient’s own health or safety, or for the protection of others, that the patient should receive medical treatment? If yes, why?
Yes:
Own health: Prior to admission, Ekam was inconsistent with taking his psychiatric and physical health medications. This represents a risk to his own health.
Own safety: Ekam has a history of significant self-harm when unwell. He tied a ligature around his neck prior to this admission, and is currently seeking methods of self-harm on the hospital ward.
Protection of others: The risk towards the niece and nephew is being investigated by children’s services.
25. If the patient was discharged from the detention, would they be likely to act in a manner dangerous to themselves or others?
Yes, see historic and current incidents of self-harm above. Also see information relating to Ekam’s niece and nephew.
I believe that the current detention for assessment, and possibly eventual treatment, is the only way to manage the risks that Ekam presents to himself, and possibly towards others. The prognosis appears to be good in that Ekam recovers well when his symptoms are treated effectively with medication and hospital care. There is every hope that this admission will not last long, and that he can be discharged once recovered and suitable care arrangements have been put in place. It might be useful for Ekam to be subject to conditions when he does leave hospital to ensure engagement with treatment and a quick recall should he show future signs of relapse.
26. Do you have any recommendations to the tribunal?
I would ask the tribunal to uphold detention for assessment.
