Case 25 Own worst enemy

The duty consultant chemical pathologist contacts the medical SHO on-call at 19.40 in the evening to inform him of an abnormal serum potassium (1.8 mmol/L) taken from an outpatient. The laboratory has been unable to contact the referrer (a GP) and asks the SHO to contact the patient and manage the situation. The clinical details given with the request state ‘bulimia nervosa’. The SHO attempts to contact the patient, 21-year-old Ms Barnes, and speaks to her mother on the telephone. Ms Barnes refuses to talk to the SHO.

Should the SHO speak to Ms Barnes’s mother?

The SHO explains the situation to Ms Barnes’s mother and she agrees to accompany Ms Barnes to the hospital.

In taking her history, the SHO discovers that Ms Barnes has had an eating disorder since the age of 15. She attended the hospital three weeks ago following a first episode of self-harm (cutting), having split up with her boyfriend. She has been vomiting (self-induced) since discharge from hospital. There is no history of laxative use. Ms Barnes complains of intermittent muscle cramps, particularly affecting the calves. On examination, Ms Barnes’s body mass index is in the range of 16-18 kg/m2. She has some lanugo hair on the cheeks and bilateral parotid swelling. She has been managed by her GP, Dr Green, and has blood tests performed fortnightly. She is withdrawn and avoids eye contact.

Repeat blood tests confirm profound hypokalaemia and Ms Barnes agrees to intravenous fluid administration but refuses oral potassium supplements. After 3 litres over 10 hours, Ms Barnes’s serum potassium is measured at 3.4 mmol.

What would you do now?

Ms Barnes suddenly becomes agitated and insists that she be allowed to go home. She says that she is fed up of people looking at her as if she was a circus animal. Ms Barnes’s mother is tearful but seems resigned to Ms Barnes’s outburst. She says that she will remain in the house with Ms Barnes during the afternoon and overnight.

How would you decide whether Ms Barnes should be allowed to go home?

Ms Barnes appears to be orientated in time, place and person. The SHO allows her to go home and advises her to seek assistance from her GP the next day.

Three days later, the SHO comes into work and discover that Ms Barnes had thrown herself from a multi-storey car park the previous night. She has transected her spinal cord at C3 and is quadriplegic.

Six months later, Ms Barnes’s mother takes legal action against the hospital claiming that the suicide attempt and resulting injuries could have been prevented had a formal risk assessment been undertaken.

Expert opinion

Ms Barnes presented with an acute medical problem which was corrected appropriately. The SHO recognized that the discharge was risky but ensured that she would be accompanied and advised her to seek further help from her GP. The SHO felt that Ms Barnes was an adult who had been orientated and was communicating coherently. She had not expressed any suicidal ideation and the primary issue, bulimia, appeared to be chronic.

The SHO acted reasonably in the circumstances and the absence of a formal mental health and competency assessment is acceptable.

Legal comment

There is an assumption that a patient of 21 years of age has capacity. One of the five core principles of the Mental Capacity Act (MCA) 2005 is that a person is assumed to have capacity unless it is established otherwise. The consent of the patient is required before personal information can be shared with a third party. If this patient had impaired capacity due to the abnormal serum potassium, then the doctor could take steps in her best interests so that she is brought to hospital quickly.

The conversation with Ms Barnes’s mother would have to be carefully worded so that the urgent need for Ms Barnes to obtain emergency treatment was imparted without disclosing unnecessary confidential healthcare information. 

The SHO would have had to have overriding evidence of a psychological condition requiring sectioning under the Mental Health Act 1983 in order to prevent Ms Barnes from taking her own discharge. It would have been important to elicit her past medical history and any desire to self-harm. To prevent Ms Barnes from taking her own discharge, the SHO would have to have evidence of a psychological condition which justified her being sectioned under the Mental Health Act.

In the absence of a documented assessment of the patient’s capacity at the time of the decision to self-discharge, this case will be difficult to defend.

 When where restraint needs to be used, staff will be protected from liability if certain conditions are met. These conditions are set out in Sections 5 and 6 of the MCA. They must reasonably believe that the patient lacks capacity to consent to the act in question, that the act needs to be done in the patient’s best interests and that restraint is necessary to protect the person from harm. The restraint used must be a proportionate or reasonable response to the likelihood of the person suffering harm and to the seriousness of the potential harm.

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