A doctor's dilemma: lock Susan up or let the streets claim her young life

She was a sex worker in her 20s with the health of an 80-year-old. Were we right to section her to stop her drug abuse?

We found our patient lying on a mattress on the floor of her room, naked and intoxicated with ketamine. Her speech was slurred and confused, her eyes roaming aimlessly, but she appeared happier than she had been for a while. Some other patients were with her, clearly substance affected. 

My colleague and I tried to remain composed, but I had that slow sinking feeling that we had already lost control of the situation. I couldn’t remember the part of our induction where all your patients take drugs and you have to pretend like everything is still normal.

It was my last day of my rotation on a locked female inpatient psychiatric ward, and a fitting goodbye to both our patient, Susan*, and to the four months I spent working there as a junior doctor.

Susan was one of our regular patients, and was such a troubling case that I had heard about her long before I met her. She was a sex worker with a personality disorder and polysubstance misuse, and had the physical health of an 80-year-old, despite only being in her late 20s.

Our plan had been to admit her not long before an important surgical appointment at a specialist hospital, so we could physically get her to the appointment, as well as keep her sober long enough to stabilise her mental and physical health for the assessment. Unfortunately, her mental state deteriorated to such an extent that we were left with no choice but to bring her in under section sooner than expected.

Unsurprisingly, Susan did not want this. What she wanted was to keep taking drugs. Her pimp had similar ambitions, and was persistent in his efforts. His preferred method for getting drugs on the ward was to throw them over the garden wall. These would then be picked up by one of our other patients and passed surreptitiously to Susan – although, inevitably, they would often end up taking them themselves.

We knew who her pimp was and had his picture up in the staff room, but the police declined to arrest him for reasons that were never clearly stated. In lieu of his arrest, our ward manager asked the hospital for CCTV cameras to discourage him from acting so brazenly. They refused, but offered to buy some fake cameras and a CCTV sign.

We closed the garden for the rest of Susan’s stay, but drugs still managed to make their way on to the ward. Susan could be quite charismatic, and was well liked by various patients, so it was unsurprising that a number of our more vulnerable women, often battling addiction themselves, could easily be persuaded to help her out, meeting her pimp when on leave from the ward and facilitating in other ways.

Our other method to prevent Susan from taking drugs was to keep her on eyesight observations – that is, watch her 24 hours a day, every day, for her entire stay. Sadly this wasn’t effective, as it only took a moment of inattention for the contents of a well-hidden drugs baggy to make its way inside her nostrils. It also took its toll on staff morale. Susan would often shout insults and try to persuade staff to look away.

This went on for four long weeks. No matter what we seemed to do, she still managed to take drugs on the ward. No matter what interventions we made, her mental state kept deteriorating.

With terminal cancer the hopeless inevitability is heartbreaking, but there is a framework by which we understand it. There is no such thing as a terminal mental illness. There is no palliative psychiatry. In spite of all our efforts, countless admissions, the input of every service available, we were failing to save Susan.

My last day on the ward was also her last day on section. Despite all our struggles, Susan’s attendance went off without a hitch.

We had got her to her appointment successfully, but there was no pride on our part; we were under no illusion that we had done anything to change the course of her life. After much deliberation, we decided that the purpose of her admission had been achieved, and that we couldn’t keep her on section indefinitely – it didn’t seem to be helping her, and was negatively affecting our other patients.

We took her off eyesight after our final morning meeting, to see how she would respond. She and a few of her peers were on a cocktail of drugs a short while after. With heavy hearts, we discharged her later that evening.

Whether Susan should have been allowed to take drugs and conduct her life as she wanted was raised many times, and we had innumerable meetings on the subject. Perhaps we were acting with the dreaded paternalism of doctors who feel we know what is best for our patients. Or perhaps it was our wish to try to save everyone, however hopeless.

I know that we all tried our hardest to do what we thought was right for Susan. We did our best, but sometimes that isn’t enough.

*Not her real name

If you would like to contribute to our Blood, sweat and tears series about experiences in healthcare, read our guidelines and get in touch by emailing [email protected]

Anonymous, Healthcare Network Blood, sweat and tears