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Providing beds for children
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  1. Robert Wheeler
  1. Paediatric Surgery, University Hospital Southampton NHS Foundation Trust, Southampton, UK
  1. Correspondence to Dr Robert Wheeler, Paediatric Surgery, University Hospital Southampton NHS Foundation Trust, Southampton SO16 6YD, UK; robert.wheeler{at}uhs.nhs.uk

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An unfolding tragedy eclipsed by the pandemic has passed its most recent milestone. G was placed in foster care with her siblings when she was 4, living with them until the breakdown of her fostering arrangements in 2020, when she was 16. In January 2020, G started to harm herself to the extent that by October she had required 20 hospital admissions arising from the risk that she posed to herself. In May 2020, she was detained for assessment under the Mental Health Act (MHA) 1983. She was described as ‘incredibly complex, avoidant, very difficult to engage’; the psychiatrist considered that inpatient treatment was required, or in the absence of that, secure unit placement, ‘…at the very least a solo therapeutic bed provision’. Although the initial diagnosis was founded on post-traumatic stress disorder, subsequent assessments would reveal the development of an emerging personality disorder, rendering her vulnerable to self-harm.

At this stage, G was assessed as not meeting the requirements of a Tier 4 mental health admission.

Discharged from that detention after 28 days, she was placed in a residential placement where she was violent and aggressive to the staff, damaging property, applying effective ligatures to her neck and making many threats that she was going to kill herself. In the midst of this placement, punctuated by episodes of absconding and clinical assessments, she was again considered not to be suitable for a Tier 4 bed; rather, she was found to be mentally and medically fit to remain in the placement.

By the end of August 2020, the High Court authorised G’s continuing deprivation of liberty under its inherent jurisdiction, in the absence of available authority of the MHA. The court heard that G had written nine letters stating a desire to kill herself. Without subsequent consultation with the court, the local authority then arranged for a transfer to a specialist mental health inpatient home.

In the new facility, G continued her high-risk behaviour, self-strangling, cutting; swallowing inedible objects. Her violence and aggression necessitated further restraint. Ultimately, in early October 2020, she lit a fire in her bedroom, causing extensive damage. During the emergency building evacuation, she re-entered the premises and again set fire, this time to the curtains. She was not allowed to return following her subsequent arrest for arson.

G was detained again under the MHA, and admitted to an adult mental ward. A search for a Child and Adolescent Mental Health Services psychiatric bed followed. In court 3 weeks later,1 the judge was told that G was at significant risk of acting impulsively to end her own life, since she ‘…miscalculates the actions of others around her to preserve her safety’. The local authority submitted that the only placement available was unregulated; the proprietors were not prepared to apply for Ofsted registration. The multiprofessional team concluded that G had no diagnosable mental disorder that required clinical treatment in hospital. In line with the suggested diagnosis of emerging personality disorder the multi professional team proposed that she needed ‘…support from the appropriate mental health services’. Following this advice, a psychiatric report concluded that the treatment that G required could only be achieved through an adult mental health referral stemming from section 3 of the MHA, the criteria for which the psychiatrist believed were established.

During a further review by the same judge in December 2020,2 he was told that there were eight available beds in the secure UK estate for 26 referrals.

In the light of the disagreements as to whether G met criteria for compulsory admission (or suitability for a Tier 4 bed), the court invited the National Health Service England and the Trust to intervene in a hearing in February 2021, perhaps in the hope of expediting G’s placement.3 The court noted G’s inexorable deterioration in the unregulated non-therapeutic environment. It was agreed that detention in hospital was too risky for G. If there was an unplanned discharge, there would be nowhere to place her; and in any case, the therapy she required was not available in a hospital setting. Both parties reconfirmed their view that G’s welfare required a regulated placement in which therapy could be provided for her acute complex needs. In a separate setting, a psychologist came to the tragic conclusion that G was likely to ‘…experience overwhelming feelings of shame, leading to expressions of distress which manifest in her (now familiar pattern of) behaviour’. Her shame, it appears, is derived from her ‘insecure attachment style which impacts negatively on her internal working model’. The psychologist provided six therapeutic recommendations to be employed within a regulated non-secure placement. By the close of these judicially overseen negotiations, the local authority and the Children’s Guardian were in agreement with the other parties.

Thanks to this agreement, the court was no longer required to determine the nature of the placement, but the central problem of the lack of regulated placements remained.

To date, neither secure nor non-secure regulated accommodation could be found in the UK. Until such a placement can be found, G’s acute and complex emotional and behavioural welfare needs cannot be addressed, without the stability and security derived from long-term placement. While waiting for this accommodation, G continues to express a wish to end her life and to self-inflict physical harm. As the court observed, ‘…It is plain that G is at present in intense and enduring emotional pain, the accounts of which should move anyone reading them.’

Six months and 11 court hearings since August 2020 have elapsed, and the position remained that there was no regulated non-secure placement available. The judge reminded himself of the maxim that the ‘measure of a society can be obtained from how that society treats its most vulnerable members’; providing in addition Nelson Mandela’s formulation, ‘there can be no keener revelation of a society’s soul than the way in which it treats its children’.

The judge was once again left in the situation where he was unable to comply with his judicial oath. Having promised ‘…to do right by all manner of people according to the laws and usages of the realm’, Macdonald J found it very hard, if not impossible, to ‘do right’ by G ‘…to keep her safe and to work to relieve her enduring and acute emotional pain, when the tools required to achieve that end are simply unavailable to the court’. This placed him in the intolerable position of being required by the law to hold G’s best interests as his paramount consideration, but forced by circumstances to accept that he had no option but to endorse her continued placement in an unregulated environment, ill equipped to meet her complex needs. The judge once again directed that a copy of his judgement should be sent to members of the government and its relevant agencies; he noted that both Ofsted and the Minister for Children had provided ‘considered responses’ to his earlier judgements in G’s case but neither had resulted in any appreciable improvement in the situation.

Family courts have repeatedly highlighted the shortage of clinical provision and both secure and regulated placements for children requiring assessment and treatment for mental illness. The President of the Family Division described it as a ‘disgrace to any country with pretensions to civilisation, compassion and dare one say it, basic human decency…’4 Children’s doctors could support judges, demanding resources for children in G’s position.

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Footnotes

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Commissioned; internally peer reviewed.

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