Re PFA

[2012] QMHC 7

MENTAL HEALTH COURT

CITATION:	Re PFA [2012] QMHC 7
PARTIES:	APPEAL AGAINST DECISION OF THE MENTAL HEALTH REVIEW TRIBUNAL
PROCEEDING NO:	0284/11
DELIVERED ON:	Ex temp reasons given on 7 February 2012 Written reasons given on 14 February 2012
DELIVERED AT:	Brisbane
HEARING DATE:	7 February 2012
JUDGE:	Ann Lyons J
ASSISTING PSYCHIATRISTS:	Dr E N McVie Dr F T Varghese
FINDINGS AND ORDERS:	The appeal is dismissed; The decision of the Mental Health Review Tribunal dated 5 September 2011 is confirmed.
COUNSEL:	S Crofton for the Defendant J Tate for the Director of Mental Health L Syme for the Attorney-General
SOLICITORS:	Legal Aid Queensland for the Defendant Crown Law for the Director of Mental Health Crown Law for the Attorney-General

ANN LYONS J:

1. This is an appeal by the Attorney-General of a decision by the Mental Health Review Tribunal dated 5 September 2011 in relation to PFA.  I provided ex tempore reasons in this matter on 7 February 2012 and indicated that I would provide more extensive written reasons at a later date.  These are those reasons. 

1. On 5 September 2011 the Mental Health Review Tribunal confirmed PFA’s forensic order and approved limited community treatment (“LCT”). The conditions of the LCT allowed him to reside at his residence in suburban Brisbane and required that he not use alcohol or drugs and that he had to fully participate in random medical tests for those substances. The conditions contained a requirement that the LCT be implemented subject to the assessment of the treating psychiatrist that it was appropriate having regard to his mental condition at the time.

1. On 7 September 2010 the Mental Health Court had found PFA of unsound mind in relation to two offences both of which occurred on 25 November 2009. Those offences were one count of assault occasioning bodily harm and one count of obstructing or assaulting a police officer. The index offences involved allegations that PFA entered the caravan of another man holding a golf club, demanding money and swung the golf club, striking the other man on his leg when he refused. When police arrived PFA resisted arrest.

1. The notice of appeal is dated 27 October 2011. In the notice of appeal the reasons for appeal state:

1.          The patient continues to abuse drugs, particularly amphetamines, which leads to his mental health destabilising.

2.          The patient lacks insight and remains delusional.

3.          The current conditions of limited community treatment have not adequately safeguarded against the patient using illicit drugs and suffering deterioration in his mental health. A more appropriate condition mandating at least fortnightly random drug screening and providing for leave to be revoked in the event of the patient testing positive for illicit drugs, is warranted in the circumstances.

1. The real issue would therefore seem to be that PFA continues to use illicit substances, particularly amphetamines.

1. An appeal to this Court is an appeal by way of rehearing and the Court is to determine the appeal on the basis of the material that was before the Tribunal as well as any new information. The principal issue is whether the Tribunal should have approved LCT on the terms that it did.

1. The material before the Tribunal and the material before this Court indicates that PFA’s last hospital admission was in March 2001.

1. The report of the treating psychiatrist, Dr Parthasarathy, indicates that PFA has had a diagnosis of paranoid schizophrenia since the late 1990s which is complicated by multiple-substance abuse in the form of cannabis and amphetamines. His illness was stable between 2002 and 2009. In 2009 he relapsed following illicit drug use and needed treatment.

1. The reports indicate that PFA presents with a chronic systematised delusional system of grandiosity, persecution and control. He believes that organisations are out to steal his lyrics and that the Government owes royalties to him. It would seem that following his relapse in 2009 he was discharged from the Princess Alexandra Hospital and was managed under an involuntary treatment order until September 2010 when he was placed on a forensic order.

1. The evidence indicates that PFA has a long-term problem with illicit drugs and that his drug use started at the age of 13. The report of Dr Parthasarathy dated 12 December 2011 indicates that his use of drugs had declined in the previous eight week period. That report noted that in the two years from 2009 to 2011 his illness proved difficult to treat due to persistent chronic delusions.

1. Dr Parthasarathy indicated in his evidence to the court that since mid-2011, after the introduction of Clozapine in early 2011, there had been a definite improvement in PFA’s mental state. His delusions became less intense and less elaborate and associated with less distress. There were no further indications of self harm or aggression and he was engaging better with treatment.

1. The report also indicated that the index offence happened just prior to his admission to the Princess Alexandra Hospital, at a time when he was acutely psychotic with delusions of persecution by his neighbour. The evidence indicated that he believed his neighbour was tormenting him, stealing from him and sending messages to trouble him.

1. Dr Parthasarathy indicated that PFA attends his appointments and is compliant with his oral and depot medications. It was further noted that his delusions are reducing and Dr Parthasarathy stated that the most recent urine drug screen (“UDS”) was negative for illicit drugs. That UDS testing also indicated that PFA had not used amphetamines since October 2011. Dr Parthasarathy agreed with Dr Lawrence that it would be helpful if the UDS was done several days before his review with his psychiatrist so that the use of drugs could then be addressed by his psychiatrist and discussed with him in a more fully informed way. At the moment, if he has a positive UDS, he is brought in to hospital and his mental state is addressed at that point, which can be at a time which does not necessarily coincide with his psychiatric review.

1. Dr Parthasarathy did not believe that an inpatient admission would in any way mitigate the long-term risks given the severity of PFA’s illness. As Dr Parthasarathy noted, he has a well entrenched delusional system in place irrespective of drug use and there is no evidence that his psychosis would improve with hospitalisation. In his view it has been the introduction of Clozapine which has caused the greatest improvement in his wellbeing.  He noted that PFA has been experiencing a more severe form of his illness since 2009.

Should the appeal be allowed? 

1. The evidence indicates that PFA is currently well managed under the existing conditions of the forensic order.  He is being consistently monitored, particularly in relation to drug use and it is clear from Dr Parthasarathy’s evidence that the LCT is implemented subject to the assessment of the treating psychiatrist and only if it is considered appropriate having regard to his mental condition at the time.

1. Both Dr Lawrence and Dr McVie advise that PFA is currently well managed on the forensic order and neither supports an order other than in the terms of the existing order, which allows good management and oversight as well as the ability to return PFA to hospital if he became acutely unwell.  It is clear that PFA has been receiving LCT which has been appropriately managed by his treating psychiatrist. 

1. As the assisting psychiatrists have indicated, it is the monitoring of his mental state which is the vital issue. Intermittent use of cannabis may not even be affecting his mental state given how chronically unwell he currently is. As the MHRT indicated in its reasons, “There is no clear evidence linking this use to a relapse in his mental state.”

1. The current evidence indicates that PFA’s level of verbal aggression, distress and behavioural agitation are all reducing. There is no evidence that an inpatient admission would mitigate the long term risks. PFA has not had a hospital admission for almost 12 months and his condition is improving with the use of Clozapine.

1. I am satisfied that, at the time of the MHRT decision and at the time of the hearing of the appeal, the evidence clearly indicates that the current LCT conditions are appropriate. I am satisfied that the current LCT conditions are such that PFA does not represent an unacceptable risk to his safety or that of others.

1. The decision of the MHRT of 5 September 2011 is confirmed.

1. The appeal is dismissed.