AF and MENTAL HEALTH REVIEW BOARD
[2014] WASAT 30
•18 MARCH 2014
JURISDICTION : STATE ADMINISTRATIVE TRIBUNAL
STREAM: HUMAN RIGHTS
ACT: MENTAL HEALTH ACT 1996 (WA)
CITATION: AF and MENTAL HEALTH REVIEW BOARD [2014] WASAT 30
MEMBER: MS D TAYLOR (SENIOR MEMBER)
DR G LIPTON (SENIOR SESSIONAL MEMBER)
MS K KEMP (SESSIONAL MEMBER)
HEARD: 22 JANUARY 2014
DELIVERED : 18 MARCH 2014
FILE NO/S: MHA 14 of 2013
BETWEEN: AF
Applicant
AND
MENTAL HEALTH REVIEW BOARD
Respondent
Catchwords:
Mental health - Involuntary patient order Mental illness - Detention authorised to protect patient's health or safety Patient applies to Mental Health Review Board for revocation of order Order confirmed Patient applies to Tribunal for revocation of order Decision affirmed
Legislation:
Mental Health Act 1996 (WA), s 5, s 26, s 66, s 142, s 145, s 148A
State Administrative Tribunal Act 2004 (WA), s 29(3)
Result:
The Mental Health Review Board's decision that the patient remain an involuntary patient in an authorised hospital is affirmed.
The application is dismissed.
Summary of Tribunal's decision:
The applicant applied for review of a decision made by the Mental Health Review Board under the Mental Health Act 1996 (WA) that authorised her continued detention in hospital as an involuntary patient for treatment of a mental illness.
The applicant sought revocation of the involuntary patient order. She denied she suffered from a mental illness for which treatment was required. She objected to treatment in a public hospital with antipsychotic medication in any event and favoured voluntary treatment in the private sector with alternative 'natural' medicine that would include naturopathy, reflexology and massage.
The Tribunal accepted the medical evidence that the applicant's current admission and detention as an involuntary patient occurred in the context of a relapse in her mental illness most likely caused by non-compliance with prescribed medication. It also accepted the applicant's evidence that if not detained for treatment as an involuntary patient, she would leave hospital and refuse treatment.
The Tribunal considered the written and oral evidence submitted by the applicant and her treating psychiatrist. It concluded that the applicant continued to display a number of profound and debilitating symptoms of a chronic relapsing mental illness into which she had no insight and for which she required treatment in the interests of her own health and safety.
The Mental Health Review Board's decision to continue the applicant's detention as an involuntary patient was affirmed.
Category: B
Representation:
Counsel:
Applicant: In Person
Respondent: N/A
Solicitors:
Applicant: N/A
Respondent: N/A
Case(s) referred to in decision(s):
R v Australian Broadcasting Tribunal; Ex parte Hardiman (1980) 144 CLR
REASONS FOR DECISION OF THE TRIBUNAL:
Introduction
We are required to determine an application brought pursuant to the provisions of the Mental Health Act 1996 (WA) (MH Act) for review of a decision made by the Mental Health Review Board (Board) on 27 November 2013 that authorised the applicant's continued detention in hospital as an involuntary patient for treatment of a mental illness.
The applicant seeks revocation of the involuntary patient order (IPO) and her immediate release from hospital and compulsion to receive treatment on the basis that she does not suffer from a mental illness for which any treatment is required.
The applicant also objects to treatment in a public hospital. She would prefer to initiate treatment of her choosing in the private sector that she describes as 'natural medicine', and explains that this would include, among other things, homeopathy, naturopathy, reflexology and massage. She proposes to take 'happy, healing herbs' in lieu of the medication prescribed to treat her illness, which she describes as 'degrading and poisoning toxic substances'.
Background
The applicant is a 43yearold Caucasian woman who resides with her parents at their home in the western suburbs together with her teenage son. She is an intelligent and articulate woman who was first diagnosed as suffering from a psychotic illness when pregnant in 1998. Since then she has been admitted to hospital and detained as an involuntary patient on many occasions.
The applicant's previous compulsory admissions to hospital have followed an established pattern of deterioration in her mental state over time whilst living in the community, secondary to non-compliance with prescribed medication and misuse of cannabis and alcohol. When her illness is relapsing she appears highly aroused and shows symptoms of florid psychosis that include paranoid and grandiose delusions, thought disorder, irritability and aggression. Once her mental state has improved and her symptoms abated in response to treatment in hospital with antipsychotic medication under an IPO, she has been discharged home on a community treatment order (CTO), having agreed to abide by its terms and conditions.
The most recent instance in this recurring cycle occurred in 2011 when the applicant was detained in hospital on an IPO for an extended period, before being discharged home in June 2013 on a CTO that required her 'to take all medicines as prescribed' and to keep regular appointments with her psychiatrist and other members of the community mental health team. The CTO appears to have achieved its purpose to ensure that the applicant's mental illness was treated on discharge so that her mental health remained stable as it was revoked on 1 August 2013 by the applicant's treating psychiatrist at the time as he no longer considered the applicant to meet the criteria under s 66 of the MH Act that justified the making of such an order with its consequent restrictions upon the applicant's freedom to make her own good and bad decisions about treatment and any related matters.
The current admission
On 29 October 2013 the applicant was admitted to Graylands Hospital following her forcible removal from her parents' home by the police. In the weeks prior to the admission a marked deterioration in the her mental state had been noted by family members and other people with whom the applicant came into contact. She was believed to be experiencing a relapse of her chronic psychotic illness due to noncompliance with prescribed medication and possible use of illicit substances including cannabis.
On 30 October 2013 the applicant was detained in hospital for treatment as an involuntary patient following an assessment of her mental state by a psychiatrist. She was diagnosed as suffering from paranoid schizophrenia and a schizoaffective disorder.
According to the integrated progress notes kept by the hospital regarding the applicant, her demeanour at interview soon after her admission was angry and demanding. She is described as having several grandiose delusions that included her strongly held belief that she is the Queen of Australia. She appeared to have no insight into her illness and need for treatment. She rejected the less restrictive option of being discharged home on a CTO on condition that she accept treatment in the community. She denied having a mental illness and declined treatment because she believed that she did not need it.
In the opinion of the psychiatrist who assessed her, the applicant was experiencing a relapse in her psychotic illness due to non-compliance with medication in the preceding months. As the applicant had declined treatment in the community that would of necessity require her to accept medication, detention in hospital as an involuntary patient was the only means by which effective treatment could be delivered.
The applicant opposed the decision to detain her as an involuntary patient and applied to the Board (s 142 of the MH Act) for the order to be revoked.
The hearing before the Board
On 27 November 2013 the Board convened at Graylands Hospital to hear the application.
The Board's powers when determining a new matter coming before it for consideration are broad, as it may make such order in respect of the matter as it thinks appropriate (s 145 of the MH Act). It may substitute a CTO for an IPO if circumstances indicate a less restrictive approach to treatment is warranted and feasible.
The essence of the applicant's case was that she did not suffer from a mental illness and so did not require treatment. She described being forced to have treatment for an illness she did not have as being 'purely ridiculous'.
The Board accepted the medical evidence from the applicant's treating psychiatrist, Dr John, that was given in a written report dated 20 November 2013 and at the hearing. According to Dr John the applicant suffered from a chronic, relapsing mental illness that was currently of both a nature and degree to justify detention in hospital for treatment.
The Board rejected the applicant's submissions and decided that the IPO made on 23 November 2013 should continue to have effect.
In its written reasons for decision dated 14 January 2014 the Board noted the following:
The Board finds that [AF] is a person with a mental illness requiring treatment which can be provided through detention in an authorised hospital and is required to be so provided in order to protect her health. The Board finds that [AF] has refused treatment and due to the nature of her mental illness [AF] is unable to consent to treatment and that an involuntary patient order is the least restrictive means of treatment at this stage.
In reaching this conclusion the Board has had regard to the objects of the Act set out in s 5 and in particular, s 5(c), namely 'to minimize the adverse effects of mental illness on family life'. [AF] wished to be discharged from hospital to live with her parents and son. However the evidence was that she was currently refusing to speak to her mother; and has asked her father to eject her mother from the family home; her parents were unable to cope with her recent relapse and that her parents could not have her at home at this stage because it would be disruptive to her 14yearold son (T p 14). The Board is satisfied that [AF's] detention in hospital for treatment until she has recovered will minimize the adverse effects of her illness on her family life at this time.
The review proceeding
Section 148A of the MH Act enables a person dissatisfied with a decision of the Board to apply to the Tribunal for a review of that decision.
On 6 December 2013 the applicant applied to the Tribunal for review of the Board's decision. She gives her title as 'Queen Majesty' and says that she identifies as being of Aboriginal or Torres Strait Islander descent. In the box on the form relating to identity she wrote:
I am on a dreamtime songline. I am called Nanga. This means TOP ONE.
In response to the question 'What decision do you want the SAT to make?' the applicant wrote the following:
[T]o decide to free Queen Majesty [AF] from mental health treatment and torture so she may be allowed to be treated privately without suppression, degradation and poisoning by toxic substances promoted by mental health practicioners [sic]. Queen Majesty [AF] seeks to use natural medicine; naturopathy, homeopathy, reflexology, chiropracting, aromatherapy, craniosacral massage[,] happy, healing herbs at her own expense and asks to promote holistic medicine and the campaign for nuclear dissarmament [sic] and moral rearmament.
The grounds of the application are given as follows:
I, [AF], have been forcibly overmedicated
treatment has not been upon free and informed consent
unwanted force used and physical and mental damage has been sustained from unwanted medication
15 years of pharmaceutical testing by Mental Health department has achieved no benefits for Queen Majesty [AF].
original diagnosis incorrect
[AF] does not suffer 'voices' as B Zawadaski first wrote in 1998. This has also damaged her son.
- foreign interference in Australian nature.
On 12 December 2013 the Tribunal issued standard directions for the filing of documents and material relevant to the review, and listed the matter for hearing on 22 January 2014.
On 15 January 2014 the Board indicated that it intended to play no part in the proceeding and would abide by the Tribunal's decision in order to preserve its impartiality in case of any future application made by the applicant: see R v Australian Broadcasting Tribunal; Ex parte Hardiman(1980) 144 CLR 13 at 35 and 36.
On 21 January 2014 the Tribunal received a short report from the applicant's treating psychiatrist to supplement the information set out in her report dated 20 November 2013.
On 22 January 2014 the Tribunal convened to hear the application. The applicant and her father attended the hearing in person. Dr John attended via a telephone link to the hospital.
The applicant's case
The applicant told the Tribunal in clear terms that she had been wrongly diagnosed as suffering from a mental illness several years ago, since which time she had been treated on a number of occasions against her will with medication she did not need or want and to which she was allergic. She described her recent compulsory admission to hospital following her removal from her parents' home by the police as being the result of a case of mistaken identity for a woman who had been fraudulently using her identity. Her plan on discharge was to return to live with her parents and to stop taking any prescribed medication.
According to the applicant the admission was unnecessary and highly inconvenient, not least because it prevented her from continuing with her work promoting indigenous rights and nuclear disarmament and as an international peacekeeper.
According to the applicant she had been made Queen of Australia in 1974 and had negotiated with foreign governments at a high level. She supported the Secretary General of the United Nations, Ban KiMoon, and said that she had spoken directly to Benjamin Netanyahu and the Australian Prime Ministers, Abbott, Rudd and Gillard, among other government leaders, to promote a total moratorium on uranium mining. She said that her status as Queen of Australia had been kept a secret for reasons that were not entirely clear.
In her final submission to the Tribunal the applicant said the following:
I just like to remind you that I have degrees in political science, journalism, public relations and engineering and I am a PhD in philosophy. I reject the doctors suppressing my brain power because of the misdiagnosis that Zadawski made when I was pregnant in 1998. As Queen I am protectress of Crown Lands and I seek to protect the National Parks. I am preserver of the faith and I recognise that in Australia we must embrace multiculturality and I wish to support and develop environmentally friendly industries.
I recognise my place in the constitutional monarchy of Australia and I wish my presence to be acknowledged as a fair and loving Queen and to keep the peace for Australia in its region and I reserve the right to be treated privately by less damaging and less invasive means. If I could leave you with a quote from the Bible Isaiah 52:15:
So she [sic] will sprinkle many nations and kings will shut their mouths because of her [sic] for what they were not told, they will see, and what they have not heard they will understand.
The medical evidence
According to Dr John, the applicant is experiencing a relapse of her schizophrenic and schizoaffective disorder in the context of noncompliance with recommended medication prescribed to treat her illness.
At paragraphs 2 and 3 in her report dated 20 November 2013, Dr John says the following regarding the period leading up to the applicant's most recent admission:
[AF] … has a long standing history of Paranoid Schizophrenia/Schizoaffective disorder complicated by alcohol and cannabis use. She lives with her elderly parents at their home in [C].
[AF] has been followed up by [D] CMHS for many years. Historically she is known to have very limited insight into her illness and hence medication non compliance leading to multiple relapses. For this reason she was treated on a CTO multiple times. [AF] was recently on a CTO until August 2013 which was allowed to lapse. Following this she continued to attend the clinic for some weeks and received her fortnightly depot of 20mg Flupenthixol. However she managed to skip the recent depots leading to acute deterioration in her mental state. [AF] started to become very delusional and physically aggressive towards her mother, which is one of the first symptoms of her relapse. In between she had one depot on the 14/10/2013 but failed to attend the one due 29/10/2013. In between, several attempts has [sic] been made to assess [AF] and to place her back on the CTO which all failed.
In her short report dated 21 January 2014 Dr John wrote the following (at paragraphs 2 to 4) regarding the applicant's current mental state and medication:
At present she is on oral antipsychotic Olanzapine 20 mg at night and Depot Flupenthixol decanoate 40 mg once in two weeks. Her mental state is improving and she is now accepting medication as she is aware that she is an involuntary patient.
However, she doesn't believe that she is having any mental illness that requires treatment. She still remains hostile toward her mother. When her mental state is stable, [AF's] parents are ready to have her back at home.
Since she is unlikely to comply with oral medications due to lack of insight, based on the past history also, the treating team is planning to taper off the oral Olanzapine and adjust the dose of depot and discharge her on Community treatment order. The treating team has explained this to [AF].
At the hearing Dr John said that the applicant's mental state had improved because she was responding successfully to medication prescribed to treat the illness, and for no other reason. She explained that in the absence of the IPO the applicant would refuse treatment and her mental health would deteriorate as before. In Dr John's opinion the applicant continued to require treatment in hospital under an IPO as she was not yet well enough for discharge on a CTO or otherwise.
Relevant legislation
Section 26 of the MH Act sets out the criteria that must be met if a patient is to be detained in hospital for treatment against his will:
Persons who should be involuntary patients
(1)A person should be an involuntary patient only if
(a)the person has a mental illness requiring treatment; and
(b)the treatment can be provided through detention in an authorised hospital or through a community treatment order and is required to be so provided in order
(i)to protect the health or safety of that person or any other person; or
(ii)to protect the person from selfinflicted harm of a kind described in subsection (2); or
(iii)to prevent the person doing serious damage to any property;
and
(c)the person has refused or, due to the nature of the mental illness, is unable to consent to the treatment; and
(d)the treatment cannot be adequately provided in a way that would involve less restriction of the freedom of choice and movement of the person than would result from the person being an involuntary patient.
(2)The kinds of selfinflicted harm from which a person may be protected by making the person an involuntary patient are
(a)serious financial harm; and
(b)lasting or irreparable harm to any important personal relationship resulting from damage to the reputation of the person among those with whom the person has such relationships; and
(c)serious damage to the reputation of the person.
The Tribunal's powers on review are set out in s 29(3) of the State Administrative Tribunal Act 2004 (WA) (SAT Act):
(3)The Tribunal may
(a)affirm the decision that is being reviewed; or
(b)vary the decision that is being reviewed; or
(c)set aside the decision that is being reviewed and
(i)substitute its own decision; or
(ii)send the matter back to the decisionmaker for reconsideration in accordance with any directions or recommendations that the Tribunal considers appropriate,
and, in any case, may make any order the Tribunal considers appropriate.
Tribunal's findings
We accept the medical evidence that the applicant suffers from mental illness. She is diagnosed as suffering from both paranoid schizophrenia and a schizoaffective disorder. The illness is chronic and relapsing in nature and currently severe in degree. It is characterised by a plethora of debilitating symptoms that include grandiose and paranoid delusions and thought disorder.
We accept that at present the applicant believes to be true what she told us about her antecedents, her status and her activities as an international peacekeeper and human rights advocate. However, we find that these beliefs are delusional and symptomatic of the applicant's chronic, relapsing mental illness.
We find that the applicant is in need of ongoing treatment for her psychotic illness with prescribed medication and that this treatment can only be provided against her will in an authorised hospital. The applicant's plan to leave hospital and stop taking medication is logical in the context of her firmly held belief that she has no illness and so does not need treatment. In our view, a premature cessation in treatment is likely to see the applicant's mental state deteriorate further and hope of recovery from the most recent relapse abate. Treatment in hospital may result in improvement in the applicant's mental state. It is required to prevent the applicant's health, safety and reputation from being compromised further.
We find that due to the applicant's lack of insight into her mental illness, she is unable to consent to treatment. This is because she does not recognise that she is unwell and in need of specific treatment in the form of medication, if her mental state is to improve. It is the applicant's lack of insight into her illness and need for prescribed medication that prevents her currently from seeing the advantages of being discharged on a CTO. Had she not rejected this option, she could have returned to live at home with her family and enjoyed greater autonomy and freedom.
Conclusion
We are satisfied that the criteria are met for the continued detention of the applicant at Graylands Hospital for treatment of her long standing mental illness.
In reaching our conclusion we have regard to the objects of s 5 of the MH Act that require us to ensure, among other things, that persons having a mental illness receive the best care and treatment with the least restriction of their freedom and the least interference with their rights and dignity.
Orders
1The decision of the Mental Health Review Board of Western Australia made on 27 November 2013 whereby the applicant remains an involuntary patient in an authorised hospital is affirmed.
2The application is dismissed.
I certify that this and the preceding [41] paragraphs comprise the reasons for decision of the State Administrative Tribunal.
___________________________________
MS D TAYLOR, SENIOR MEMBER
0
1
2