Mental health: Joseph’s summer on the streets exposes failings of system meant to help vulnerable

Numerous reports have highlighted the need to improve the response to vulnerable people

The gap between theory and practice of the services that should be available to someone with a mental illnesss left the family of one young man in despair and desperate for help, writes Special Correspondent Michael Clifford

Joseph’s summer on the streets began on the day he discharged himself from hospital.

For the following six weeks, he would be a missing person as far as his family as concerned.

Joseph (not his real name) is mentally ill. Over the summer, his family got various reports about him. On occasion, during that time, they located him and attempted to get help.

They received phonecalls about how he was arrested and charged with offences, how he had created disturbances in public places.

They heard how he had been seen for an extended period walking around without any shoes. And they made calls, to try to have him admitted to hospital, to ask members of the gardaí to keep an eye out for him.

To try to save him from his own, untreated, inner turmoil, and from the dangers that a vulnerable, ill person can be exposed to on the streets.

His family is exhausted and despairing. Their son, nephew, brother patently needs help but the mental health system appears incapable of meeting his needs.

What follows is how Joseph spent last summer in a wealthy first world country that in terms of treating mental health sometimes appears like an impoverished State ignorant of the most basic human rights.

Joseph walked out of Newcastle Psychiatric Hospital in Newtownmountkennedy, Co Wicklow, on June 8. He had been in and out of that facility and others over the preceding four years. Joseph is 22.

During his childhood, he had various issues with anxiety and missed extended periods of schooling. Soon after his 18th birthday, he had a psychotic episode. He thought the neighbours were talking about him and that his blood was flowing the wrong way.

He was treated initially in St Vincent’s Hospital in Dublin, and subsequently referred to two separate psychiatric hospitals. He was diagnosed with a form of paranoid schizophrenia.

According to his family, Joseph can and has been stabilised through medicine. But he becomes difficult and often refuses to take the medicine. Like others with the same condition, he can be violent and would not be suitable to live at home with his mother and siblings.

It was recommended that he get help in the community, as per the national policy on mental health. Since his diagnosis four years ago, he has received little help outside hospital settings.

Joseph is originally from Wicklow and his family live in south Dublin, but his aunt, with whom he and his mother are close, lives in Bray.

According to his family, Joseph can and has been stabilised through medicine but because he has poor insight into his condition, he often refuses to take the medicine, which in turn precipitates another psychotic episode. This is a common feature in people who suffer with schizophrenia.

The local psychiatric facility for Wicklow is Newcastle Hospital near Newtownmountkennedy. He has been in and out of Newcastle in recent years up until last June.

On November 16, 2017, he left the hospital. Later that day, his family was contacted. He was in Store St Garda Station in Dublin city centre after being removed from a cinema where he had caused a disturbance that resulted in the cinema being cleared. He was sent back to Newcastle that evening.

On another occasion, gardaí from Newtownmountkennedy, Bray, and Wicklow town, were all looking for him. He was finally located in Dún Laoghaire through his mobile phone.

On June 8 this year, he again left the hospital, this time for what would be an extended period. Eight days later, his mother and aunt went to the gardaí in Bray asking to keep an eye out for him. They received a call around midnight.

Joseph had been spotted in Bray. The gardaí could not detain him as he had done nothing wrong.

Five days later, his family contacted gardaí in Dún Laoghaire, where he had been sighted, and asked that an eye be kept out for him.

Throughout the summer, Joseph, his name or his family would come into contact with gardaí from a range of districts stretching from Wicklow to south Dublin into the city centre and even Dublin Airport.

According to his family, most members of the force were kind and understanding. They were dealing with a situation that is sensitive, difficult, and beyond the garda’s job description. The police force is designed to deal with law and order, not mental health.

In 2009, a joint report from An Garda Síochána and the Mental Health Commission recommended the establishment of critical intervention teams, a device that has been used successfully in other European countries.

Critical intervention teams combine police with health and social workers who are on duty outside normal working hours and able to respond at any time. No such teams were set up since the 2009 report.

The recently published Commission on the Future of Policing report referenced this failure to act.

“It is regrettable that, nine years on, the recommendation has still not been implemented,” the report stated.

Crisis intervention teams should now be established at divisional level, with round the clock response capabilities to serve every part of the country.

“The teams should comprise police, mental health, substance abuse, child service and other social workers who know their communities well and the vulnerable people within them.

“They should have ready access to a common pool of information about the people who need their services, so that actions and interventions may be taken rapidly when necessary and on a well-informed basis.”

It remains to be seen whether the commission’s report or any increased awareness of mental health will finally see this movement in this regard 

From early June to late July, Joseph presented himself at emergency departments in city hospitals on 16 occasions. Usually, he claimed an imaginary injury, including sometimes sustained in an imaginary road traffic accident.

On one occasion, he was referred from an emergency department to a homeless service. He never turned up. On another, his family claim he was allowed leave the hospital with no shoes. He was for a number of days seen without shoes in the Dublin 4 area.

There were a few occasions on which he was seen by a doctor and referred to a psychiatric hospital, but he was not admitted.

On June 27, for instance, he attended at the emergency department in St James’s Hospital in Dublin after his mother and aunt had come into contact with him.

A doctor was briefed on his history. He agreed that Joseph should be involuntarily admitted. Yet before the arrangements could be made, Joseph was out the door and back on the streets.

On July 8, his family reported him as a missing person. Three days later, gardaí in the Dublin 4 area found him. He was, reportedly, not wearing any shoes. He was released as there was no basis on which to detain him.

On July 19, he was brought from Pearse St station to Dublin District Court. He had been detained the previous evening after allegedly lashing out at a garda.

In court, solicitor Michael French was appointed to represent him on free legal aid.

The gardaí objected to bail. This was unusual for such a charge, but it may well be that the gardaí knew some of his history or considered him too unstable to release.

If he had been detained on remand, he would most likely have been sent to Mountjoy, no place for people with mental health difficulties.

Mr French succeeded in getting bail for his client. Joseph was ordered to reside at an address in Bray and sign on at Dún Laoghaire Garda Station on Mondays and Fridays.

His family knew nothing of this appearance and charge at the time. The first they would hear of it was when Mr French contacted them in September after Joseph failed to show up at a scheduled court appearance.

Residential care

In theory, there is an appropriate residential setting for people like Joseph. The HSE advertises that it provides residential settings for people with mental illness, and particularly for those who depend on collaboration between hospital and community services.

“Hospital and community services aim to function as partners in the delivery of services to individuals with a mental illness,” the HSE website proclaims.

“Some residential units serve as respite areas for those individuals who require support at different times.”

Joseph’s family has repeatedly attempted to have him referred to a residential setting in which they believe he would receive the most appropriate care. Their efforts have been fruitless.

The HSE’s residential service caters for high, medium and low support groups depending on needs. That’s the theory that unfortunately many people never get to see being put into practice.

By mid-July, the family was in intermittent contact with Joseph and growing increasingly desperate about his plight. They eventually managed to get a GP to examine him and determine that he should be admitted involuntarily. It took the best part of another week before everything was in place for him to be readmitted to Newcastle.

On July 22, his mother, aunt and uncle accompanied him to the hospital where he was readmitted.

Three days later, the Mental Health Commission published its annual report for 2017.

The report stated that major change was required or Ireland would “continue to provide a level of unsafe and substandard services, which are not aligned to best practice and breach fundamental rights of a vulnerable group of people who require such services”.

The commission’s chairperson, John Saunders, called on the Government “to initiate a major transformation programme to deal with the services issues highlighted in this and previous reports of the commission.

There is a glaring and inconsistent pattern of standards in service provision. The lack of any real progress and commitment on these matters undermines the fundamental human rights of people using mental health care services.

Joseph was in and out of hospital throughout August. On September 1, he was out again and found in Bray. Gardaí from the town brought him back to Newcastle.

On September 13, the involuntary order on Joseph was revoked or removed. This is not uncommon, particularly when somebody is suffering from a condition that can flare or ignite or alternatively quieten and stabilise for extended periods.

The following day he left the hospital. On September 17, he was arrested in Dublin Airport. He had apparently walked into a MacDonald’s outlet and demanded free food and created a disturbance.

A doctor saw him and a patrol car brought him back to Newcastle from the airport, a distance of around 56km. According to his family, staff at the hospital insisted that Joseph be assessed medically, particularly in terms of any drug or alcohol intake, in St Vincent’s, back in Dublin.

The gardaí refused to accompany him on the basis that their job was to deliver him to Newcastle. (The Garda narrative for the incident does not record any request about going to St Vincent’s).

The hospital called a taxi to take Joseph, but he had disappeared into the night before it arrived.

Later that week, as Storm Helene was lashing the country with high winds and torrential rain, gardaí in Bray spotted Joseph on the streets at 4am. They had no power to detain him.

A few days later, on September 21, he was detained in Pearse St station after causing a disturbance on Grafton St. Joseph’s family were contacted and a doctor called to the station to examine him. The doctor signed an order for his involuntary detention.

That evening, gardaí accompanied Joseph down to Newcastle Hospital. Once more, there was an instruction that he be assessed in St Vincent’s. On the basis that the patient was to be involuntarily admitted, the gardaí agreed to accompany him this time.

At some stage the following morning he was admitted back to Newcastle. At the time of writing, he remains in the hospital.

His family has still not received any indication that he will be referred to an appropriate residential setting anytime in the near future.

‘Gardaí are having to deal with somebody because the health system is not doing its job’

Joseph’s mother is at her wits’ end. She has seen over the last four years her son being diagnosed with a form of schizophrenia.

That can be traumatic, but in theory diagnosis should be the first steps of the road to treatment. That hasn’t happened.

“We have been trying time and again to get him into a residential centre,” she says.

“That’s what he needs. That is what would be best for his treatment and it is what we are told that somebody in his condition should have. Yet, nothing has been done.”

Joseph’s father is not in his life. That increases the burden on his mother, but she does have the support of her sister, brother-in-law and Joseph’s two siblings.

Together they have done what they can but find themselves battling against indifference in a system where mental health is relegated to a low priority.

As outlined on these pages, Joseph is not a stranger to the State’s various agencies. He has attended at a number of psychiatric facilities in Dublin and in Wicklow.

He is know to gardaí in at least eight different stations. He has appeared in court. His case has been referred to politicians for help, including the former Fianna Fáil spokesman on heath and the current minister for health. Yet he cannot access appropriate care.

Whenever he leaves hospital the stress levels in the family home shoot up. He’s on the streets, vulnerable to all manner of dangers. As with many who suffer from Joseph’s condition, he is unsuitable to live at home, particularly as he could be prone to fits of violence.

“He rings me when he’s out there,” his mother says.

I try to help him get somewhere, but then he might go for days without ringing and that’s terrible.

“We are in constant contact with the guards. Once last summer, he was spotted by this husband and wife in Bray. They were concerned and rang the guards and kept their distance from him until the guards arrived.

“But then the guards can’t just arrest him. He hasn’t done anything wrong. But he can be a danger, to himself as much as anybody.”

His mother says that she knows she is not alone. Joseph’s plight is not unique. There are other families out there who are suffering in silence, spending vast reserves of emotional and physical energy attempting to get a loved one treatment.

What really galls his family is that the type of treatment that would help him is exactly what the HSE officially endorses.

“He does respond well to medication which is positive,” she says.

“But he won’t stay on it so he needs monitoring when he comes out of hospital. But instead he’s left to his own devices. He needs high support accommodation where there is access to some education or work of life skill-type classes and to make sure of basic things, like that he’s eating.” Meeting up with Joseph when he is on the streets can be heartbreaking. His physical health suffers when he does not have a routine.

“I remember meeting him at one point and he’d lost a load of weight in a short space of time. Another time he wasn’t wearing any shoes. Being confronted with that kind of thing, you son in that sort of condition. It’s hard.” She points to the misuse of resources in handling her son outside the appropriate treatment setting.

“Look at the guards. How much resources have they had to put on my son alone, not to mind others in the same situation,” he says.

“Even in Pearse St station alone, all they have done. Do you think they’ve nothing better to be doing?

It’s not fair on them but it’s a crazy situation that the gardaí are having to deal with somebody because the health system is not doing its job.

Haunting Joseph’s mother is the same nightmare known to all parents of adults with an acute disability.

“At the moment he has me and my sister, but what happens when we’re not around anymore?”

The obvious answer is that the State, with its duties to citizens, would take care of Joseph. All the experience of his family so far points to that being an unfulfilled, and even unacknowledged, duty.

Joseph has fallen between cracks in a broken service

The mental health system has failed Joseph, Fianna Fáil’s Billy Kelleher has warned.

In a letter to Health Minister Simon Harris, Mr Kelleher said Joseph has fallen between the cracks in a broken service.

He forwarded a sequence of emails from Joseph’s mother to Mr Harris to give him an insight into the nightmare they are facing every day.

The emails covered a three-week period in July when Joseph was on the streets — a situation the family described as “crisis territory”.

Joseph has been on the streets for 3 weeks and 3 days with no medication and no place to stay, his mental state is deteriorating by the day.

“I managed to get him to the A&E in St James’ Hospital, he was suicidal. The social worker there said there was nothing she could do and suggested he ring the homeless freephone number at 10.30pm and he might get a bed for one night.

“After an eight-hour wait he saw a psychiatrist who said he needed treatment in a psychiatric hospital and if he didn’t go voluntarily the doctor would invoke the mental health act. Joseph then left the hospital and the doctor said he had no power to stop him,” his mother wrote.

“Joseph has presented 10 times to St Vincent’s Hospital, Elm Park with delusional beliefs for example that he was in a car crash. Every time he has been allowed to leave, including yesterday which was the first time they got a psychiatrist to see him.

“Joseph refused to engage with her and left the hospital at 1.30pm. I just found out that he was in there again at 1am last night and left at 6am this morning.

“The social worker in St Vincent’s has been talking to Joseph and she is very concerned about his suicidal ideation and psychotic symptoms.

“The gardaí have picked Joseph up twice and let him go despite it being flagged on their system that he is a danger to himself and others. We contacted them again today to ask them again to flag him and if he comes to their attention to call a doctor and have him admitted to hospital involuntarily.

“All of this could have been prevented if Jospeh had gotten the care and support he needs. My priority now is to get him admitted to a psychiatric hospital for treatment.

“He may not survive long enough for that to happen which is my biggest fear. He also poses a significant danger to the public which will increase as the days go on.

I am on the verge of a nervous breakdown myself, I am barely getting through every day and I am sick and tired of asking for help for Joseph knowing that the likelihood is that he is going to die before any help comes.

Mr Harris replied to Joseph’s mother saying he had requested an update from the HSE.

“I have followed up with the HSE and requested an urgent update regarding Joseph’s treatment. I will revert back to you as soon as I receive a response. In the meantime please continue to keep me updated.” 

Patient confidentiality precludes any health service or hospital commenting on an individual. This newspaper, however, submitted a number of questions to the HSE about policies and procedures at Newcastle Hospital.

Is there a closed ward in Newcastle psychiatric hospital?

Avonmore Unit in Newcastle Hospital is a closed unit. It provides continuing care to patients over 65, predominantly with dementia. Glencree, the acute admission unit, is an open unit except during night time hours (20:30hrs-08:00hrs).

Would patients be discharged without their belongings being assembled? If, for instance, a patient was being discharged and he appears not to have any bag at the time would this be addressed?

It is the policy of Community Healthcare East Mental Health Service to ensure on admission that a detailed property checklist is compiled and that all property is returned to the patient on discharge.

In the event of a patient simply walking out, is that patient’s family informed?

If a patient is absent from the hospital without leave, the patient’s next of kin is contacted where the patient has given consent to contact the next of kin and if they have provided contact details on admission.

Are there occasions when Newcastle turns a patient away, even if that patient has papers certifying he should be involuntarily admitted to hospital?

All patients referred to Newcastle Hospital under the Mental Health Act 2001 are assessed and managed in accordance with the Mental Health Act.

Is it policy to refer patients to St Vincent’s Hospital for medical clearance if there is a suspicion that patient has been ingesting drugs or alcohol? If so is there no way of checking this at Newcastle?

It is the policy of Community Healthcare East Mental Health Service that the admitting NCHD (non-consultant hospital doctor) will ensure on admission that a full physical examination of the patient is completed, and that all findings are documented and acted upon where necessary. It is the policy of the service that patients referred/assessed for admission with mental health disorders co-morbid with intoxication or withdrawal may be referred to the local emergency department (ED) at St Vincent’s University Hospital for assessment, diagnosis and treatment. Where medical clearance is required, a patient is referred to St Vincent’s University Hospital.

On what basis is a patient released if he or she has been admitted involuntarily? What is the approach in this regard if it concerns a patient who has been admitted multiple times, voluntarily on some occasions and involuntarily on others?

It is the policy of the Community Healthcare East Mental Health Service that all patients in the approved centres are discharged at all times in accordance with the terms of the Code of Practice 33(3) Admission, Transfer and Discharge 2009 and in accordance with the Mental Health Act 2001.

As outlined in the Mental Health Act 2001: Where the consultant psychiatrist responsible for the care and treatment of a patient becomes of opinion that the patient no longer fulfils the criteria for detention under the Mental Health Act, he/she shall revoke the relevant admission order or renewal order, as the case may be as specified in the act.

Where an admission order or a renewal order has been referred to a tribunal under section 17, it shall review the detention of the patient and shall either:

(a) if satisfied that the patient is suffering from a mental disorder, and (i) that the provisions of sections 9, 10, 12, 14, 15 and 16, where applicable, have been complied with, or (ii) if there has been a failure to comply with any such provision, that the failure does not affect the substance of the order and does not cause an injustice, affirm the order, or (b) if not so satisfied, revoke the order and direct that the patient be discharged from the approved centre concerned.

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