DM about to dangerously discharge

[DorsetCamping]

Apologies for the continuing saga but am at wits end.

To be brief DM (74) has been in hospital 3 times over the last month due to various conditions and the last admission being for 10 days and near deaths door. All pointing to her continuing decline and inability to cope independently.

She reluctantly agreed to go to a rehab unit last week and seemed to be making reasonable progress, no doubt due to be constantly monitored and with the 24/7 care.
Tentative Plans were being discussed for her to go home with an enhanced daily care package.

However, yesterday she had a fall, whereby her walking frame tipped and she banged her head. Thankfully she is ok but naturally it raised deeper concerns about her safety and needs when she goes home.

Onto this morning, she said she is self-discharging and that if I don't go and get her tomorrow she will call a taxi . Said that there is no way she is staying, hates it and is exhausted.
I have spoken to The nursing staff who are adamant that it is not safe for her to go home, especially with yesterday's fall and that her care package needs a new review. More worryingly is that no carers will even be available in the immediate future given COVID and calls on resource.
They have told DM all of this but she it's falling on deaf ears.

I am so cross her with, it's like dealing with a toddler. She has no clue about the worry this is causing or the implications with lockdown. All she keeps saying to the staff is that either I, or her elderly neighbours will help if need be.
I mean, WTF?!
They did ask me about her mental health as she seemed so low today but ultimately it is her decision.

I am so exhausted with her. All she is being asked to do it sit and recover - you'd think she was in a prison cell the way she goes on. I can pretty much guarantee that if she goes home tomorrow she will just end up in hospital again and we'll be back in the same merry go round.

Oh goodness, I’m really relieved so I can’t imagine how you’re feeling!
I’m really glad OP, for all of you x

@DorsetCamping

The house had been put on the market because we realised at that point she would have to self-fund care fees.

Viewings are happening but of course we don't currently have the authority to agree a sale.

If you don't have legal authority & she's too mentally unwell to sign, you can't sell her property.

You'd need deputyship in this case (if no POA)- look up how to apply on HMGov website

Right now she will be under a section 2 of the MHA (first 28 days for assessment), after then they will decide whether to detain her under s3 of MHA (up to 6 months) or a DOLs.
If she gets detained under s3 MHA she would be entitled to s117 aftercare planning and services which are free if related to her mental health needs for which she was sectioned. Ie. If Ward team feel she needs residential care home on discharge, it will be non chargeable (free) as under s117 aftercare arranged by adult services

If she does not go into s3 but instead her s2 lapses and she goes into a DOLs whilst in the ward, her future care remains chargeable (if not CHC level) . You'd need to talk to a hospital social worker anyway as you can see it's slightly complicated and around what lawful basis consent & needs for placement occurs

There are also different arrangements with some hospitals during coronavirus period

Thank you @Sparticuscaticus that is really useful information.

So I have a virtual 'admission meeting' with DM's consultant and hospital SW on a Tuesday. The unit liaison officer has contacted me to make sure I prep a list of questions to ask just in case anything is clear/covered.
Would this be a good opportunity to raise what happens when S2 expires and whether a S3 would be likely?

From what you say It seems like the decision whether to invoke S3 or go with DOL has a huge impact on the aftercare provided.

Hi @DorsetCamping I had no idea about the section 3 implications either until mum was put onto it and I asked on here! I would imagine if she has not been diagnosed within 28 days or needs further treatment in hospital then the will put her on s3. I don't know anything about DOLs and when that is used instead. You re right that is has a huge impact on aftercare though. I got the impression that our SW was not too impressed that mum had been put on a s3 but I could be over thinking it! It does mean as pp has said that all their aftercare is paid for altbeit only up to their local limit which in my mum's case is not a lot. If she does go into a home I would not want her to go to any of the ones the sw suggested.

We didn't get an admissions meeting so it sounds like they are on the ball. I would question what will happen when the s2 is up, I don't think at the moment they will be able to say whethe s3 or DOLs is more likely.

Hope all goes well, we have a ward discharge meeting tomorrow so hopefully will be able to move mum to somewhere more comfortable than the ward.

Thanks @flygirl767
I suspect there are differing agendas at play when deciding whether to invoke S3. The aftercare is clearly expensive and I suspect SS might be very mindful of budgets.

As an aside one of the MH nurses rang me earlier saying DM keeps throwing herself out of bed and her wheelchair. Unfortunately the last time she did it she really banged her back on the metal footplate. The nursing home also said she'd been doing this - I just don't get why? She refuses to talk about it when anyone asks. It's so sad
It pains me to write it but I really hope they S3 DM, there is no way she can come back from all this within 3 weeks.

Hope all goes well with your DM's discharge meeting @flygirl767

@DorsetCamping

Thanks *@flygirl767* I suspect there are differing agendas at play when deciding whether to invoke S3. The aftercare is clearly expensive and I suspect SS might be very mindful of budgets.

As an aside one of the MH nurses rang me earlier saying DM keeps throwing herself out of bed and her wheelchair. Unfortunately the last time she did it she really banged her back on the metal footplate. The nursing home also said she'd been doing this - I just don't get why? She refuses to talk about it when anyone asks. It's so sad
It pains me to write it but I really hope they S3 DM, there is no way she can come back from all this within 3 weeks.

Your poor mum, I really hope they can calm her down and stop her injuring herself. From the sound of it, she won't be going anywhere anytime soon so in which case it will be a S3. The first couple of weeks are using spent observing anyway and there is no way a nursing home could cope with her the way she is now.

Thanks for the good wishes, I will update my post after the meeting. Funnily enough Mum has stopped asking to go home now, not sure she really remembers it as home anyway as when she was there, she wsa always asking to go home (common in dementia patients apparently).

Had DM's assessment meeting today with her consultant, hospital SW and warns nurse.

All very informative although still early days. Consultant says delirium seems to be the overriding symptom at the moment but could take a long time to diagnose the cause. Nothing is being ruled out.

I gave a potted history of what's been going on but stressed that she has no history of mental illness or confusion and that all this came in very suddenly.

When S2 runs out on 17/8 one of 3 things will happen, going for the lightest touch approach

1 voluntary inpatient
2 DoL
3 S3
Tbh I'm still not totally clear in the difference between DoL and S3 but certainly can't see DM volunteering to stay. Apparently she is very cross at being labelled 'insane'

*ward nurse

Sorry for multiple posts. Seems to me the only difference between S3 and DoL is that aftercare is funded with S3? If that's the case I guess most people would push for S3?

My nans carehome applied for DoL in April 2019. It was finally granted in January 2020.

I'd push for the section as then you won't have any costs to pay.

Just read back over the whole post and this stood out:
I can't help but think there is some sort of connection with the 'mild seizures' she had durjng the longest hospital stay. The brain scan came back clear but all I can say is that she has been 'changed' since then.
She's like a truculent, obstructive toddler; won't cooperate and confused. She also had a varying hold on reality. Her eyesight has also rapidly deteriorated

This is exactly the same as my Nan. She had a massive stroke and within a fortnight she was like this. She was also suicidal and self-harming. Lost sight in one eye and was hallucinating and accusing people of raping her. She lost all inhibitions and became very self centred.
It was vascular dementia and it is very rapid. The change in her personality was so fast and so shocking.
She had a few TIA and started having seizures too.
The hospital reckoned she was fine and it was a fight to get them to listen to us. Fortunately, SS were brilliant and the SW got her out of there and into a lovely home.

Hi Dorset I'm glad the meeting was helpful. My cousin who's mum was sectioned under DOLs said it was used when hospital treatment was not needed for her mental condition but she was unable to look after herself and unwilling to go voluntarily to a care home. So if after 28 days they can do no more for your mum in hospital but she can't go home it would be DOL but if she needs further treatment and assessment it will be S3. (I think, I am no expert and have been thrown into this situation just as you have!)

As you know my mum has delirium too and she has been in a MH hospital 6 weeks and they still do not know the cause so I would think it likely your mum will be staying in unless they find the cause quickly.

Is she calmer now or still hurting herself?

Actually I'm sure it is a lot more complicated than what I have said above! Perhaps ring the helpline of either Mind or the Alzheimer's society, they have expert advisors who will be able to give you the correct information.

If the doctors think it's more appropriate to place her under a DOLS in a carehome would she qualify for CHC funding, you can ask them this.

I can assure you, for an elderly parent (and sometimes a child), being in hospital is like being in prison.

There will be carers available to help your mother at home. You say you are worried about her mental health but once she gets home, you may find she is better. There's a tendency to give unnecessary medication to elderly patients which often doesn't work very well and makes their mental state worse.

www.gov.uk/government/publications/nhs-continuing-healthcare-checklist

Quick update as I've just spoken with DM's Psych.

DM is still in throes of delirium and until that subsides there is no further diagnosis. She has a few lucid moments but soon descends into confusion. What is causing the delirium they don't know although all the various medical conditions she has are likely to be impacting. It is also too early to diagnose whether the self harming is due purely to delirium or depression is present as a separate condition.

The S2 comes to an end on the 17th and DoLs is being suggested as an impatient. I've been advised DM could be there a while. Still not sure why this would be enforced instead of S3 or the differences between Mental Health Act and Mental Capacity Act but I have been told that any aftercare would be carefully planned and she would only go somewhere with specific care.

Not Sure whether this means it would be funded though 🤷‍♀️

They are meant to find the least restrictive option to detain someone. It means however that OPMHs in hospital sometime use DOLs instead of moving into a s3 of MHA at end of s2 MHA. Ask them for what reason? as if she needs to stay in a while for Further treatment in the same psychiatric unit then she would have far greater protection and rights under a s3 MHA (AND her aftercare related to her needs would be free (under s117 aftercare services) when she is discharged, which it would not be under s2 MHA then under a DOLS. )

As nearest relative you get a say, I strongly advocate for s3 MHA to be considered in these circumstances if it is a fairly balanced choice between the two, because IMO it supports persons rights far more clearly and their aftercare needs . Talk to her current IMHA (independent MH advocate) and ask her views. They will support what is best for client too

Thank you @Sparticuscaticus that is so helpful.

I will try and find out who DM's advocate is as I haven't as yet heard that role mentioned.
It certainly sounds like S3 would be the better option especially as she will be in the same unit for sometime and lacks capacity but I don't want to seem grabby regarding aftercare (although obviously it would be great is she didn't have to pay!)

Sorry need to have a mini rant...

I was going through DM's paperwork yesterday and looking at her home insurance there are several clauses stating no coverage if the house is unoccupied for 30+ days.
So I rang Halifax insurance to tell them the situation but of course "computer says no" because of GDPR and I need to get her to contact them 🤦‍♀️🤦‍♀️. I stressed that is not going to happen nor likely to happen anytime soon and just wanted to let them know the house is unoccupied.
Hit a brick wall, no help whatsoever or even any empathy. Only thing the guy said he would do was log my call but without any detail.

Brilliant, if anything happens to her house before I can either get LPOA or Deputship we are screwed.

Times this call by every other company I'll have to also deal with and I'll be telling DM to shove over and make space for me!

Rant over !!

Can you go and stay overnight in her house to reset the clock on her insurance? It is all very stressful but you are being an absolute star for your Mum. How is she today?

Unfortunately even though I'm family, to class her house as occupied overnight stays must be someone who normally resides there.

When I visited DM yesterday (1st time since being moved) I was really shocked. If anything she has declined even more, both psychically and mentally. What is most upsetting is how scared and distressed she is but they won't give her any meds until the 'observation period' is over. Really hard to witness but at least she was pleased to see me.

Is she receiving any treatment at all. Does someone need to be diagnosed with a treatable mental health condition to be on a section 3.

No she is still being assessed. When I spoke to her psychiatrist last week she said she was reluctant to prescribe any meds at this stage before they have a clearer picture because of DM's multiple health conditions.

My understanding of section 3 is that it is more a case that a person needs to be treated in hospital even if diagnosis is not yet clear.