M is a 22-year-old woman with a history of EUPD. She has been known to child and adolescent mental health services (CAMHS) since the age of 14 with multiple characteristics of EUPD including impulsivity, lack of consideration of consequences of her actions, unpredictable and capricious mood, outbursts of emotion, incapacity to control behavioural explosions, quarrelsome behaviour and conflict with others, poor self-esteem, unstable interpersonal relationships, self-destructive behaviour, and suicide attempts. Her presentation to secondary mental health services was precipitated by sexual abuse by her brother when aged 10 and subsequent bullying at school due to her weight. She typically presented to the ED with extensive self-harm and suicidal intentions triggered by auditory hallucinations involving the voice of her brother. She was a psychiatric inpatient between 2011 and 2016 and responded well to a combination of clozapine and levomepromazine. She was subsequently discharged to supported accommodation.
She had 14 admissions to the local acute psychiatric unit in the calendar year before the admission discussed here. The factors influencing her presentations were considered to be multifactorial, including being the victim of a sexual assault in May 2018 and nonconcordance with medication.
In September 2018, she was brought to the ED by police under section 136 of the UK Mental Health Act with self-harm wounds and disclosing to police officers her intention to walk to a nearby motorway to commit suicide. She was extremely agitated, handcuffed to the bed trolley, and restrained for prolonged periods by four police officers and two members of the hospital security team. The police stayed in the hospital with her for nine hours, and subsequent restraint was carried out by six security staff. Staff support and various forms of sedation were used during the initial hours in ED to try and reduce her agitation and step-down restraint.
Her medication on admission was clozapine 250 mg/day, paliperidone depot 75 mg/month, sertraline 150 mg/day, pirenzepine 50 mg/day, omeprazole 20 mg/day, atenolol 50 mg/day, ferrous fumarate 420 mg/day, desogestrel 75 micrograms/day, and an etonogestrel contraceptive implant.
She had deep lacerations on her left arm and both legs, 12-14 cm in length, exposing subcutaneous fat. Surgical review concluded that the injuries required exploration and closure under general anaesthesia, but that the wounds did not pose a risk to life or limb, nor did they require emergency surgery or admission to a surgical bed.
As she was detained under section 136 of the MHA (Mental Health Act) and there was no readily available alternative place of safety, she was admitted to facilitate a psychiatric assessment. She consistently refused treatment and was threatening to complete suicide on a local dual carriageway; twice earlier that year she had been removed from walking along the carriageway of the same road.
A Mental Health Act (MHA) assessment took place 18 hours following admission. M was detained under section 3 of the MHA. She was scheduled for surgery to repair her self-harm wounds. She remained suicidal and continued trying to remove her lines and dressings.
This was the start of a 128-day admission to the acute hospital where several life-threatening iatrogenic complications arose (Table 1). M was restrained at least 17 times, and intramuscular (IM) medication was used in nine of these incidents. She was intubated and transferred to the intensive care unit (ICU) four times to manage her behaviour.
Various members of both the medical and liaison psychiatry (LP) teams involved determined on at least a daily basis that she did not have capacity to make decisions about her medical care and treatment. This opinion did not alter throughout her medical admission.
M was finally transferred to Springbank ward, a specialist personality disorder unit in Fulbourn Hospital, on the morning of her 128th day of admission. At the point of transfer to Springbank, the liaison psychiatry and medical teams considered her mental state to be similar in terms of distress, attempts to self-harm (in frequency and severity) and statements of intended suicide as those throughout her acute hospital admission, including her first presentation to the ED. At the point of discharge, she was in ICU on 2 : 1 special observations. Her mobility was limited to 80 yards with a Zimmer frame and two members of staff assisting her. She required rapid access to the toilet because of urinary and faecal urgency. She had difficulties speaking or lying flat. Her leg wounds required ongoing dressings, and she required outpatient follow-up by cardiologists, ENT surgeons, and respiratory physicians.
Springbank ward is the only specialist personality disorder unit in the NHS that accepts patients detained under a section of the MHA. It offers a one-year treatment pathway for women with a personality disorder who have not benefited from acute and community services or who are still considered to be at high risk of completed suicide. The use of the MHA is avoided, and detained patients are expected to set a discharge date from their detention early on in their admission.
M was discharged from section 3 MHA after 18 days at Springbank. She was redetained under section 3 MHA on day 238 of her admission, due to a suspected psychotic episode when she was threatening to jump in front of traffic. The detention was followed by a series of severe self-harm incidents. The detention was rescinded after two days when it was established that her behaviour was not secondary to psychosis, but part of her personality disorder. When given the option of leaving the ward, she opted to stay, and her self-harm stopped.
There were 26 significant incidents during her 372-day admission to Springbank (Table 2). The severity of the incidents on the ward was of equal or greater severity than those at first presentation to the ED. She frequently refused any interventions. The general approach adopted was to ask her to stop the self-harming behaviour, ask her to remove any inserted foreign bodies (or offer help in doing so), and ask her whether she wanted any treatment. Her wounds would typically require suturing, but she would often refuse this and refuse to go to the ED. Control over and responsibility for her treatment was given to her.
She was never restrained and rapid tranquillisation was never given. She was never physically violent towards staff. The complications arising from not enforcing treatment (usually skin infections and large scars) were minimal in comparison to those that had arisen at the acute hospital and the general psychiatric ward (Table 1). Medication was not enforced. She was discharged into supported accommodation after completing the one-year treatment programme.
Eight structured outcome measures were used to monitor her progress at Springbank. M showed improvement in nearly all outcome measures (discharge versus admission; supplementary data Table 3).
On discharge, her regular medication included olanzapine depot 405 mg/fortnight, lithium carbonate 1000 mg nocte, prazosin 3 mg nocte, levomepromazine 50 mg tds, promethazine 50 mg tds, pregabalin 300 mg bd, levothyroxine 100 mcg od. Pro re nata (PRN) medications included levomepromazine 50-100 mg every 4 hours, diazepam 5 mg (up to 40 mg/day), salbutamol, Peptac, and codeine phosphate 30-60 mg qds.
At the time of writing (September 2020), M has been discharged for 248 days. She has not had any further hospital admissions. Supplementary data Table 4 summarises her service use before and after her admission to Springbank. She is currently living in supported accommodation, engaging in voluntary work, and has been self-harm-free for over one year.