X (A Child) (No 3) [2017] EWHC 2036 (Fam)

“There are increasing concerns about [X]’s mental state … For much of the time [X] is actively expressing a wish to die and taking every measure available to harm herself. … there was no evidence to support a diagnosis of moderate to severe depression or a presentation with a mood related psychotic illness. [X] appeared to be in a “fugue” or trance like state during periods of restraint but she appears to be listening to conversations and able to choose to make requests … even at times where she does not appear to be responding to staff requests. … In my opinion, even if [X]’s current high level of emotional dysregulation is related to her underlying diagnosis of Emotionally Unstable Personality Disorder (EUPD) and ADHD … there are sufficient grounds for a period of further assessment under Section 2 of the Mental Health Act … … The diagnoses of ADHD (ICD10 F90) and Conduct Disorder (ICD F91) … remain valid. She does not fulfil the criteria for a diagnosis of moderate depression, generalised anxiety or psychosis. In trying to find a diagnostic label to best fit with her current presentation when there are long periods where she is either seriously attempting self-harm, with a view to committing suicide, or in a fugue, I think the most helpful diagnostic label would be that of a Reactive Adjustment Disorder (ICD10 F43.2). [X]’s trance-like behaviour is linked to her frustration, agitation and profound disappointment that her only wish is to return home to her mother … cannot be fulfilled and she is hopeless as to her future. Using this diagnostic framework, one could hypothesise that her current pattern of extreme behaviour is a mal-adaptive coping mechanism arising out of great distress, which provides a possible way forward in terms of psychotherapeutic support and gradual adaptation to a revised future. However, in order to help [X] adapt she needs to be in a setting that cannot only support her but gradually challenge her unhelpful cognitive beliefs and provide her with more adaptive coping strategies.”

“I understand that [ZX] have refused to keep [X] on welfare grounds because her needs are such that she often requires nursing over and above that which would normally be provided by [ZX] staff. … the team have no option but to primarily physically restrain [X], if she is threatening to self-harm and cannot be kept safe, as there is no ability to follow a process of rapid tranquilisation using a medication based approach since none of the staff have a nursing or medical background. … the emotional and behavioural distress exhibited by [X] through fugues cannot be adequately contained or managed in [ZX], despite the best efforts of a highly committed and caring staff group. … in her current setting the focus of care has necessarily been narrowed to that of keeping her safe.”

“It is undesirable, but it may be necessary, to consider a move to a suitable acute mental health bed before transfer (presumably under Section 3 MHA) to a longer-term placement in a psychotherapeutic unit which can adequately address her extensive therapeutic needs. I understand there are severe difficulties in finding a low secure adult bed and that [X] would not qualify for a medium secure adult bed. NHS England is involved in the search for a suitable alternative placement and [name of unit] have agreed to assess [X] although there is a long waiting list for beds. … I would support the longer-term plan to move her to low secure mental health unit that has a particular expertise in working with young people with EUPD that can provide her with a secure base to work through and come to terms with her experiences of trauma and rejection. I would agree with the view that therapy will need to be long term and of at least 12-18 months duration. Having spent so many months recently in institutionalised settings, [X] will require a very graded approach to rehabilitation and care in the community … … [X] requires a move now to an acute psychiatric unit with sufficient health staff in place to meet her needs and keep her safe. In my opinion, a transfer of care to a mental health unit is now unavoidable, even if it introduces an additional move of placement whilst [X] waits for an appropriate therapeutic unit to become available, a wait which could extend for at least six months. [X] should be transferred under the provisions of Section 2 of the Mental Health Act for further assessment of her current mental health needs. … [X] requires a fresh approach and additional mental health resources in order to make progress …”

“She is effectively nursed in her bedroom, but this bedroom has had to be stripped in order to make it secure, to the point where [X] has no personal items in the bedroom, no carpet, no mirror, her bed is a mattress on the floor and she has to be dressed in anti-ligature clothing. Even going to the bathroom or having a shower has to be closely supervised. There is a potential for concerns to arise about [X]’s consumption of food and drink, as the periods during the day when she is restrained become increasingly extensive. … she is now isolated from all her peers and no longer attends education, even on a minimal basis.”

“… she is not suitably placed at the moment in her current setting and … needs to be in hospital for further assessment. … although the nature of her behaviour has changed slightly …, we were not of the opinion that the level of security required to manage her had increased to meet the threshold for medium secure services. We therefore are in agreement with the psychiatrist who assessed her in June that she should be referred for a transfer to a low secure inpatient setting.”

“… in accordance with guiding principles of the Mental Health Act, it is important that [X] is offered treatment and support in the least restrictive environment which is able to address her needs and risks. As her primary presentation is mainly driven by behaviours which are putting her own safety at risk, this would suggest that she needs access to a low secure facility which has the therapeutic facilities to manage her presentation, rather than a medium secure facility which typically has a different therapeutic approach.”

“this is considered with caution, given that the enclosed provision has been delivered whilst [X] has been resident within a secure environment, therefore procedural and environmental security has mitigated a number of risks, which may in fact be present in an alternate (for example community) setting, therefore consideration will need to be given to whether the identified management strategies may in fact need to increase further or be adapted within an alternate setting.”

“to send her back to any community setting, especially [her home town] ‘is a suicide mission to a catastrophic level’. Staff do not think it will take more than 24 to 48 hours before they receive a phone call stating that X has made a successful attempt on her life.”

“A central concern in this case, which cannot be ignored, is not only the complete inadequacy in respect of available child and adolescent mental health placement provisions, but also the apparent lack of availability of any suitable temporary placements. … To say the current situation in England and Wales for children with [X]’s (it is accepted unusually high) level of needs is of concern is perhaps an understatement. This is a child who is subject to a care order and who is accordingly owed support by the local authority pursuant to its duties to her as a looked after child. This is also a child who has significant mental health and emotional issues, which make her behaviours both dangerous and uncontrollable. More than this, she is highly vulnerable. Despite all of these factors, she has been placed in a situation where weeks and months have gone by with there being no placement available for her countrywide … The provisions for placement of children and adolescents requiring assessment and treatment for mental health issues within a restrictive, clinical environment is worryingly inadequate. One has to question what would have happened in this case had [X] not received a criminal sentence? Given the level of her behaviours, where would she have been placed? What provider would have accepted her given that secure units were unwilling to do so prior to her receiving a custodial sentence? This child has fallen into a “gap” in the system. Her behaviours are so extreme that no residential or supported living placement sourced by children’s services can meet her needs, whilst there is clearly inadequate provision from the NHS and health services of placements, which can manage her mental health needs. Her time at [ZX] has amply demonstrated that placement in secure accommodation cannot meet her needs and is inappropriate. … This case has demonstrated the inadequacy of the current secure accommodation resources in England and Wales (leading to this local authority having to place in Scotland) and has now gone on to demonstrate the inadequacy of suitable provisions for children with high level of mental health issues, which necessitate assessment and treatment in a secure setting. Placements for vulnerable children and adolescents, be it within secure accommodation of mental health provisions, are a scarce resource.”

“We strongly recommend that careful thought is given to services for vulnerable and high-risk children and young people. We welcome the Government’s recent announcement that they will ban the use of police cells as ‘places of safety’ for children. However, we urge the Government to prioritise investment in crisis care services for children and young people and urge NHS England, clinical commissioning groups and social services to ensure that adequate emergency care pathways are in place as a matter of urgency.”

“Accessing in-patient beds became much more difficult over 2013. Over 70% of respondents experienced frequent difficulties (‘often’ or ‘always’), and over 50% found the situation much more difficult than the previous year. … Bed access difficulties affected all types of bed provision, but predominantly generic adolescent beds … Overall, 79.1% of respondents reported safeguarding concerns while waiting for a bed; 76.5% reported young people with unacceptably high risk profiles having to be managed in the community because of a lack of beds; 61.9% reported young people being held in inappropriate settings such as paediatric and adult wards, police cells, Section 136 suites, and accident and emergency (A&E) departments. In total, 14% of respondents’ comments described patient suicide attempts while waiting for a bed, and 13% described episodes of violence.”

“The Government has recognised the need to provide more inpatient capacity in England, and to revise the geographical distribution of beds. This is an appropriate response to the current geographical disparity highlighted in this report. It is important, however, that there is now a sustained focus on the management of the inpatient estate across the country to make the best use of existing capacity and to monitor whether and where capacity should be increased.”

“… it is difficult to read the updates and not form the view that [X]’s care plan is being primarily determined by a lack of adolescent mental health resources. That appears most telling in respect of the now repeated failures to section [X]. The conclusion that the absence of a suitable bed within a hospital setting is the driving factor in the decision not to undertaken a mental health assessment of [X] is becoming irresistible. It cannot be right that such a vulnerable child with, a lengthy documented history of the most extreme and determined self harm, should have her medical care plan dictated by an absence of resources, as opposed to her identified needs. To read that the only available low secure bed identified within this jurisdiction [in fact no longer available] is the subject of competition from another child who is currently assessed as having greater needs than [X] is frankly alarming in respect of both children.”