The Queen's Nursing Institute

A Service User Case Study

This is the story of a man who has had long term support from a homeless health service; details that could identify him have been excluded. However all health and social issues are genuine and not in any way exaggerated.

'John'

'John' is 39 years old; he is originally from the north of England but has lived in the southwest for the last 10 years. He has no known contact with his family and is very reluctant to enter into any discussion on this; he has referred to a strict Roman Catholic upbringing but not in any detail. Many professionals who have had contact with suspect that there is a history of abuse of some kind.

He has no disabilities and no history of serious illness or injury. He is of normal intelligence but states he never finished school and has no qualifications or work history of note.

He states he began using drugs (heroin) at the age of 27 and considers this the start of his addiction problems however he was a very heavy drinker from his teenage years which progressed to drug use during his twenties when he started using “recreational drugs” such as cocaine and amphetamine. Heroin use was a natural progression for him and he also has a very significant problem with benzodiazepines, codeine based drugs and continues to drink very heavily.

He has been in prison numerous times for petty offences such as affray and drunken criminal damage but also has convictions for burglary (committed to pay for drugs & alcohol).

He is currently homeless as he was evicted from social housing for non-payment of rent and anti-social behaviour and he is not eligible for housing in any other social housing as he has previous history of similar problems with all of them.

He has no GP and has been accessing healthcare via the Homeless Healthcare Team and other support at the Vaughan Centre, Gloucester. He is being prescribed low dose diazepam by them which he was previously getting via CSSMS. He was discharged by CSSMS when he stopped attending supervised consumption clinic for methadone and did not respond to contacts attempted by his Care Coordinator therefore was considered to have removed himself from active drug/alcohol treatment. He has missed several appointments with the GP at HHT; his most recent attendance was for chest pain and referral to Hepatitis Clinic as he has missed several appointments.

He has active Hepatitis C which was diagnosed approximately 6 years ago while in Prison, genotype 1A which requires 48 weeks antiviral treatment. He has not yet commenced treatment for this as he is never in Prison long enough to be in a position to start and be able to complete and by his own admission he would not be able to comply with the regime when out of prison due to his chaotic lifestyle therefore to start treatment repeatedly and not complete it would probably do more harm than good. 

Current Situation

Remanded to HMP Gloucester for 2 weeks prior to trial at Crown Court for criminal damage and assaulting a Police Officer. He was released from another prison the day before, returned to Gloucester and met up with friends, started drinking and went on to reoffend.

Does not require alcohol detoxification prescribing as only drinking for 24 hours but is on methadone and diazepam prescription (confirmed by previous prison). He is displaying some physical symptoms of opiate withdrawal as he missed yesterday’s methadone pick up at Pharmacy arranged by previous prison.

On assessment he is displaying some pressure of speech and is erratic and agitated. He has some short term memory loss and appears confused and vague at times, it is suspected that he may have early Korsakoff’s psychosis.

His BMI is 20, he has had Hepatitis B vaccinations, he has very poor peripheral veins and has a chronic abscess in his groin from injecting drugs. He also has chronic psoriasis which has several infected areas.

Problems

• No release date therefore difficult to make any plans for after release due to uncertainty
• Will remain homeless unless previous issues with housing providers can be addressed or alternative accommodation can be found (very unlikely and would usually involve outside of Gloucestershire which he doesn’t want – “I would rather be homeless”
• Evidence of severe, chronic liver damage due to high alcohol intake on top of Hepatitis C infection
• Infected skin lesions and general poor physical condition
• General deterioration in physical and mental state noted by staff who have known this man for many years
• Minimal insight or acknowledgement of his serious situation – either in denial, early Korsakoff’s or simply accepts his situation as he has known no different

Potential Outcomes for the Patient

• Very high risk of accidental overdose on release from Prison due poly drug and alcohol use (heroin, methadone, diazepam and dihydrocodeine are all prescribed or bought from illicit supplies and are all respiratory depressants)
• Liver failure is inevitable if he continues to drink alcohol and Hepatitis C infection is not treated
• Reoffending is highly likely after release due to combination of homelessness, continued drug and alcohol use, lack of insight into his own risky behaviours and general disinterest in addressing issues
• Physical and mental deterioration will continue if alcohol and drug use is not addressed particularly in view of the likelihood he already has early Korsakoff’s psychosis.

Potential Outcomes for Society

• Potential cost of nursing and medical care if he goes in to liver failure
• Costs to society of reoffending – individual as a victim, insurance, repairing criminal damage, Policing costs, Prison costs, etc.
• Risk of infection from Hepatitis C – unprotected sex, used needles, bleeding from injuries, etc
• Homelessness – street sleeping, increased drug & alcohol use, vandalism, etc
• Long term costs of being on benefits – sickness/incapacity, unemployment, housing

Actual Outcomes

What steps were taken / could be taken to help him to address his housing issues - where could he be referred to for support?

Referred to Offender Management Unit for assessment & referral to community agencies however as he is on remand it is very difficult to plan as he has no definite release date and his not under mandatory supervision by OMU/Probation therefore low priority. Referral will be sent to housing provider for consideration but unlikely to be actioned until release is imminent or has already happened.
It is very possible, and happens frequently that he will go to court, be sentenced and released from court as he has served time on remand.

Most likely scenario is that he will be released as NFA, which he is used to, therefore will be street homeless and would normally end up at Night Shelter or on friend’s floor if he was lucky (I believe Night Shelter is closing/closed).

Will probably access referral to housing provider at Vaughan Day Centre but may be using drugs/drinking again by this time meaning he might miss appointments, etc. This sounds very cynical and stereotypical however it is an endlessly repeated scenario as people like this are “trapped” to a certain extent within a system that is supposed to help them but in effect is at times impossible to manage due to unpredictability, availability of housing stock, money problems and arrears and the lack of any agency having overall responsibility.

There is a very significant cohort of people (male & female) who are in this situation – their offending is usually low level but constant however they do not meet threshold which would meet criteria for Prolific & Other Priority Offenders program which would allow for more coordination and priority in providing support following release. Integrated Offender Management System should begin to address this but will still require significant input from many agencies. 

What happened re: addressing his health problems (beyond prescription of methadone / diazapam) - was he referred to the IDTS?

All of these patients are referred to IDTS; subsequently he was assessed and prescribed methadone maintenance, alcohol detoxification and diazepam stabilisation programs. He then remained under IDTS team who continued to monitor response to treatment and mental health. He has stabilised physically but remains erratic in his behaviour with unrealistic expectations of himself and the treatment he is offered, i.e. one day he wants to detox off everything and another he wants to transfer from methadone to dihydrocodeine.

Whilst as the patient he should always be able to make his own choices the IDTS guidelines and protocols, plus staff experience suggest that he is not making sensible suggestions and ultimately is probably not capable of such decisions due to potential mental health issues and underlying organic damage. Detoxifying off everything sounds ideal within the “Recovery Agenda” but in reality would place him at enormous risk of overdose and death if he were to be totally opiate & benzodiazepine free and then return to using after release with his usual group of friends. He would need to be in a much safer and supportive environment following release to make this a realistic treatment option – which would need concrete plans for release which we have already seen are very difficult to put in place.

Whilst there is often no question that the individual is motivated to be drug/alcohol free when they are in custody, return to using circles, comfortable behaviours, familiar environments usually means return to previous behaviours and requires support to prevent via different environment, rehab programs, etc.

What other services was he / could he be offered?

He was offered access to psychosocial programs & support via the Substance Misuse Team including 1 to 1 sessions looking at drug use, relapse prevention, harm reduction, etc which are patient led using problem solving techniques’ (following ITEP Node Link Mapping). However he finds group situations difficult due to reduced attention span and poor short term memory, he responds better to 1 to 1 where they can be offered – difficult at times due to limited availability of therapeutic environments.

Ongoing physical health observation by healthcare staff and referred regarding Hep C infection however this will only involve monitoring of liver function and viral load at present due to no possibility of accessing and completing 48 weeks antiviral treatment plus drinking behaviour.

How is the issue of short-term or indeterminate length of stay addressed in terms of planning care?

This makes planning and delivering care difficult but as we can have little or no influence on changing this we work with what we have and offer services as described within our capacity. All patients are referred to community teams as appropriate at the earliest opportunity and prescribing arranged to follow on in the community. Community agencies such as housing providers will offer assessment before release where possible. Offenders are only supervised by Probation where they are released having had a sentence of over 12 months unless they are subject to a community order therefore there is no mandatory support and supervision available to him. There is a new initiative called the “Atlas Project” locally that would be ideal for him as it involves intensive support, housing, access to healthcare, etc in a coordinated system, however places are limited.

What impact could these steps have on his outcomes, compared to the worst scenario?

It would be hoped that he would engage with services and work to prevent relapse to drinking and drug use however it would take a determined, coordinated and reliable service for him to truly engage. The issue of motivation is enormous with patients such as this as they have often attempted to address their problems in the past with variable results both due to their own capacity and that of services in being able to deliver what is needed where such complex issues are evident.

Where all plans come together effectively the ideal scenario would put him in supported accommodation, he would not be drinking or using drugs which should mean less likelihood of reoffending. Once stability was established Hep C treatment should help prevent further deterioration in his health with the resultant liver problems that are currently almost inevitable.