Mr B (89): DoLS example from practice

Mr B, an 89-year-old widower living alone in a bungalow, was admitted to an acute hospital for a planned knee replacement operation. Following surgery he was transferred to a rehabilitation ward. He had a range of health problems, from chronic kidney disease to osteoarthritis, with some evidence of memory problems and confusion

Mr B was agitated and confused after his operation, trying to get out of bed and walk, when he was unable to. Subsequently he continued to demand to leave.

Since he was making repeated requests to leave and staff were preventing this, an urgent authorisation was issued followed by a standard authorisation. This was granted for three weeks, to allow time for a best interests decision and care plan to be put in place, ready for Mr B to leave hospital.

However, this did not happen within the three weeks and a further standard authorisation was requested.

Hospital medical and social work staff then told the best interests assessor that Mr B would be ‘unsafe’ to return home due to his cognitive impairment, and that a likely placement would be an elderly mentally infirm residential setting. Although Mr B had no previous contact with community mental health services, he was now prescribed drugs to reduce aggression and agitation. A capacity assessment, carried out by a medical student, had found Mr B to lack capacity, but there was no evidence of this relating to specific decisions as required in the MCA, and the diagnosis appeared to rely heavily on his score on a Mini-Mental State examination. 

When asked by the best interests assessor, his nephews stressed Mr B’s independent nature, and thought he would be much happier at home than in a care setting. They pointed out that Mr B had a supportive network of neighbours, and that his GP had no worries about him before this hospital admission.

The mental health assessor reported that Mr B was ‘better than they described’ and would have scored more highly on the Mini-Mental State examination when he saw him, despite some word-finding difficulties and cognitive impairment, probably caused by a dementia-like condition.

Mr B showed little insight into his needs, but expressed his strong desire to be at home rather than ‘fussed over’ in residential care: he told both assessors that he had gone into hospital to get his knee fixed, not to be imprisoned, and that he hated having no choice left in his life.

The best interests assessor concluded it was in Mr B’s best interests for the deprivation of liberty to continue in the very short term, while a discharge plan was being implemented. Conditions for the authorisation included a second opinion about the prescription of antipsychotic drugs, and that, in the light of the marked improvement in his mental state following the time immediately post-surgery, the hospital should make every effort to improve Mr B’s ability to decide for himself how he should live.

At a best interests meeting the following week, attended by Mr B and his nephews as well as staff from the hospital, the GP surgery and the local authority, a decision was made that Mr B should return home with a care package, which he successfully did.

Read more: Use of DoLS in hospitals