Care Plan

Diagnosis: Paranoid schizophrenia; polysubstance misuse

Date of admission: 22/12/21, then went AWOL on 29/12/21, the ward obtained a S135(2) warrant and he returned to

Reason for admission/summary:
Concerns were raised by SIRRT social worker in early December about Israa’s self-neglect, decline in mental state and acting out erratically: ‘sleeping in the garden every other night’, ‘climbing the drainpipes to get into the property’ and ‘nailing his window shut’. A home visit by the SIRRT consultant on 13/12/21 found: "evidence of delusional systems, thought disorder, thought interference (thought broadcast) and ? auditory hallucination? passivity phenomena. He appeared low in mood and had lost weight and has no access to money and has lost keys to his home" and Israa was referred for MHAA. In the meantime, he presented to SWSC on 15/12/21. He expressed delusions with religious undertones and appeared changeable in his mental state, at times elated and at others paranoid and confused. An unannounced home visit took place on 17/12/21. "He seemed confused and reported that he’ wasn’t sure what was going on’. He appeared paranoid, spoke of ‘signs’ and of other’s being able to read his mind". At the planned MHAA on 22/12/21, he presented with thought disorder, paranoia and evidence of self-neglect. He was initially brought in under Section 135 to Laffan ward (because the 2nd Dr didn’t arrive for assessment) and following second recommendation he was placed under Section 2
IS went AWOL on 29/12/21
The ward obtained a S135(2) warrant and he was brought back to Laffan Ward on 14/01/2022

Section 3 (expires 17/7/22)
– 3 month period of treatment without consent expires: 21/3/22

Leave Status: No leave

Risk:
To self:
– Historic: In August 2020, Israa was admitted to hospital following a deep laceration to his left arm which required plastic surgery. This was thought to be driven by intrusive thoughts, in the context of a psychotic episode. Unpredictability of presentation means that suicide risk – or death by misadventure – is conceivable. Israa is also known to have suffered several falls when climbing on buildings (sometimes intoxicated, sometimes in context of psychotic episode). This has previously resulted in broken bones. Israa has recently misplaced his flat keys, which increases risk (SIRRT assisting him to get new set).
– Current: risk of self-neglect as he looks to have lost weight, has had no access to money for some weeks and there was no evidence of food in house on 10/12/21 home visit.
– At risk of absconding due to an episode of AWOL on Laffan Ward between 29/12/2021 and 14/01/2022

To others:
– Historic: During previous admission at UCLH had been sexually disinhibited, masturbating in front of others, smeared faeces on a staff member and poured water on staff
– Current: not voicing thoughts to harm others currently, stated he would never do this

From others:
– Historic: Israa has a history of being exploited by others, including those with connections to gangs. Physical abuse and financial exploitation from brother noted in 2016. Previously had flat used by others for drug use.
– Current concerns noted from community team: unknown individuals coming to his flat and pressuring him to return items – i.e. bike. Israa also could be receiving up to 2.5k backpayment of Universal Credit – which could lead him further at risk

Medication:
Current medication:
– Zuclopentixol 200mg depot fortnightly

Rationale for changes with dates:
– Previously on depot Zuclopenthixol 200mg – every 2 weeks Last administered 21/06/21
– 23/12/21 – started on risperidone 2mg (note as of 29/12/21 had only taken two doses – was declining previously)
– 29/12/21 – started clonazepam 1mg TDS
– 14/01/22 – restarted risperidone 2mg ON on return to ward. Clonazepam was not restarted.
– 19/1/22 – increased risperidone to 4mg ON
– 24/1/22 – clonazepam reduced to 1mg qds
– 29/1/22 – zuclopenthixol 200mg depot due.
– 31/01/22 – clonazepam stopped.
– 02/02/22 – zuclopenthixol changed to fortnightly

Physical health:
Medical History: No known long-term medical conditions; Not currently on any medication; no known allergies
– ECG: declining throughout admission and on return to ward from AWOL (14/1/22)
– Bloods: declining throughout admission and on return to ward from AWOL (14/1/22)
– Physical examination: declining throughout admission and on return to ward from AWOL (14/1/22)
– NEWS: 0 25/01/22
– Urinalysis + UDS: declining throughout admission and on return to ward from AWOL (14/1/22)
– Substance use: From CC: He continues to smoke marijuana (believes this is medicinal) on and off, but tells me he hasn’t used crack or cocaine since November.

Barriers to discharge:
– mental state;
– ensure flat is safe given history of exploitation (on 23/12/21, Israa said his flat was fine for him to return to without any problems)

Objectives for admission received from community team:
See email on carenotes 23/12/21
– One objective of admission, would be for Israa to be well enough to sustain a relationship with Kayden (which has been historically his wish).
– Everyone that works with Israa has a lot of time for him. It would be fantastic to see him well enough to get back on track with his relationship his son and to begin to reconnect with the community.

Follow up on discharge/community team: SIRRT

Care coordinator: Robert Durant

Capacity to consent: Does not have capacity to consent to medication (23/12/21)

Estimated discharge date: 28/2/22

Sharing information: has not given permission to share information as of 29/12/21

Does this service user have contact with children? Yes, has a son, Kayden. Around November 2021 he stopped attending contact arrangements for his son, Kayden (who is incredibly important to him). – Israa has been too unwell to engage with the Solicitor or Social Worker involved in the Children and Families Proceedings. One objective of admission, would be for Israa to be well enough to sustain a relationship with Kayden (which has been historically his wish). Whilst on AWOL, the notes suggest that Israa had been to the Children and Families Centre in Hackney to see his son Kaiden on Friday 7th:

Fit for discharge: No

Delayed transfer of care: No

***

MDT Discussion:

General impression:
– Remains guarded
– Very suspicious of unfamiliar staff e.g. bank staff
– Mood seems low

–Mental state during past week:
—-Appearance:
—-Behaviour:
—-Mood: objectively low
—-Thoughts & perceptions:
—-Cognition?

–Where are they spending their time?
–How do they make their needs known?
–Engagement with other service users?
–Engagement with staff? Does he have 1:1s?
–Sleeping, eating and drinking? No concerns
–Ward activities?
–How are they keeping their room space? Sometimes tidy, sometimes very littered

Risk incidents
– Was there a risk incident during the week? No
– Was the Carenotes risk assessment updated? n/a

Medication
– Is the service user concordant with medication? Has received depot medication
– Is the service user reporting side effects? No

Leave
– How is the leave going? Is the service user using their leave? None at present
– Has leave been stopped for any reason? n/a

Physical health
– Any concerns about the service user’s physical health? Not engaging with any vitals, bloods or PHE

***
Interview.

PATIENT VIEW
– Doing "good", says trying to get outside, wants to get out in community ("London, universe, global community")
– He "speaks to the eternal creator" – otherwise he says noone else
– He says ‘definitely’ others know what he is thinking – did not elaborate

MEDICATION
– He says he doesn’t like the medication/injection – makes him lethargic, sleep all day
– Repeatedly asked why we have changed his medication – explained it was a change in name, not the actual medication. Says he would rather have clopixol than zuclopenthixol. He would take clopixol
– Repeatedly said we injected him with ‘liquid coshh’ – turned out coshh is control of substances hazardous to health. Explained it was zuclopenthixol.

– Says he hurt himself previously because he wasn’t happy the way he was treated in his community. Says he was neglected and abused but did not expand on this.
– Says he wanted to punish himself, but then on pressing says he did not want to punish himself

LEAVE
– Explained we are concerned about him getting leave as he previously broke out of a window/door and went AWOL – we are worried he might run off and this would be unsafe for him
– Explained we will keep it in mind and can rediscuss later this week

PHYSICAL
– He says he has no physical health issues

***

MSE
Appearance & Behaviour: Young Caucasian gentleman. Casually dressed. Backpack kept on.
Speech: conversational rate, tone, reduced volume.
Mood: objectively flat/low
Thoughts: quite disordered, would go over same answers and questions multiple times. Some evidence of thought broadcasting – thinks others ‘definitely’ know what he is thinking
Perception: nil abnormal elicited
Cognition: orientated in TPP
Insight: does not consider has MH problems, does not think he requires treatment

***

Impression/Summary:
– Young man with history of recurrent psychosis. Presentation and history indicative of relapse. Likely related to extended period of medication non-concordance. Difficulty in ensuring concordance has been present throughout illness. Was AWOL between 29/12/21 – 14/01/22.
On return he has been declining all engagement with staff. May require depot medication but we are persevering with oral medication today top encourage engagement.

***

Care plan:

Medication
– Depot due 11/02/22
– Changed zuclopenthixol to fortnightly instead of weekly

Leave and legal
– Section 3 (Exp 17/7/22)
– No leave yet

Physical health
– NEWS weekly
– Continue to offer bloods/phe/ecg/uds on an ad hoc basis

Discharge
– EDD: 28/2/22
– Community team: SIRRT
– CC: Rob Durant
– Discharge destination: Home visit prior to return to ensure is safe prior to discharge due to previous exploitation
– CC suggests Floating Support on discharge may be helpful – Rob Durant is helping with financial guardian, bank account access

Misc