Thursday 1 October 2009


I saw a lady on a medical ward. She is relatively young. She has diabetes, dementia and Down's syndrome. She was confused. She had fallen at home, her family explained that they couldn't manage her at home. Many meetings were held; she wanted to go back home.

The assessment of needs was clear. OT, social work and nursing assessments evidenced deficits that were pervasive (and progressive) throughout the 24 hours of a day, so couldn't be met through home care popping in to do specific activities. She needed ongoing care with appropriate, timely interventions to meet her needs. Her family had been doing this but were too burnt out and frazzled to sustain this, which in itself was a source of sorrow, guilt and abject misery.

The lady was an incapacitated adult, at that point in time, with respect to the specific decision on where she would reside. Best Interest meetings were held. All those involved in her care or interested in her welfare chirped up with their views. Everyone said the same thing. She now needed to be in a 24 hour care setting if her needs were to be appropriately met.

We gave our views to her medical team. She went in to permanent care.

It was a good outcome. On review she's very happy in her care home. She enjoys the company, she's warmed to several staff and really enjoys being around them, following them around and as she sees it helping in their duties (she spends ages in their laundry). Takes staff two to three times as long to get the work done with her help, but she enjoys it and it's meaningful activity for her. Staff see it as therapeutic time spent with her, not nuisance. Brilliant.

Her family visit daily and are very happy with things, too.

She didn't want to go in to care. The decision to place her in care was made within the section 4 framework of the Mental Capacity Act 2005, subsequently with necessary health and social care being delivered through section 5. There's no use of the Mental Health Act 1983. There's no free section 117 aftercare. She and her family pay for care. 10 years ago, requiring someone to reside in a care setting permanently when they didn't wish to be there, she'd have got this for free. Now she pays for it all.

A dismal consequence of the MCA 2005, methinks.


Cat said...

This is a matter that, unsurprisingly, we have discussed at great length both in our team, in my AMHP forums and in our BIA forums.

If she meets the criteria for the MHA she would still be placed under the MHA although there was a recent judgement which tackled the issue of whether someone who would otherwise have been placed under the MHA should be detained in a care home under DoLs because the care home is not a 'hospital' and of course, the MHA requires treatment in a hospital.

In some senses, the issue of 117 shouldn't change the decision being made but I've been asked to assess a couple of people who have failed the eligibility test of the DoLs with some vague suspicion that there was an attempt (and these were on in-patient wards) to bypass the MHA and avoid the need for 117 payments.

I am thinking on the run here but if she had been required to live in a care home 10 years ago, it would have been under the framework of Guardianship? When someone is placed under guardianship they are still liable to pay for residential care and are not subject to 117 aftercare (I'm dealing with just such an issue at the moment).
Of course, I understand that specific details might not be available and I know a lot of people that I work with are not aware of the implications and the right to section 117 aftercare.

The Shrink said...

10 years ago, without the community infrastructure, when home circumstances or placement breakdown necessitated placement in an EMI nursing unit, folks came in under the MHA 1983 on a s2 or s3. They'd be in hospital longer than 28 days, so most/all ended up on a s3.

The LA and PCT now have a full time funded s117 worker to review cases, as we've squillions they're still paying out for when, 10 years on, their care needs arguably ain't what the s117 meeting identified all that time ago.

Anyways, in my corner, I inherited oodles of folk who'd been admitted under s3 in the past so have s117 aftercare. So it used to be free. Now it isn't.