Episode 3 Hospital

-Where is he?

-I thought...

-You need to shout for help. Where is he?

Which way did he go?

One of London's biggest hospital trusts...

He's having a heart attack, but we'll get him in straightaway

and we'll get him sorted out.

OK, on three. One, two, three...

..treating more than 20,000 people every week.

Flying over the enemy lines.

This is a place with some of the best specialists in the world...

I'm amazed he's alive. He had two blocked arteries.

..where lives are transformed.

Oh, thank you so much.

But it's under intense pressure.

We have a financial deficit of 41 million.

With growing patient numbers...

We are full. We're always full.

How long has he been here?

13 hours and 46 minutes.

I don't think that's best patient care.

..and higher expectations...

There can't be nothing in this day and age.

I want to look after him.

First ambulance is on the ramp.

..at a time where the NHS has never been under more scrutiny.

We're declaring a major incident at the St Mary's site.

If this was my sister, or a friend, or anyone,

this wouldn't be good enough.

Week by week, we reveal the complex decisions the staff must make...

Anybody else who hasn't gone knife to skin, they need to be sent home.

..about who to care for next.

Do you reach the point where you say, "Enough is enough"?

Yes. The family may not like that,

but we are stopping and this is where it ends.

This programme contains some strong language

and some scenes which some viewers may find upsetting.

-Good morning. Hammersmith?

-'Yeah, I'm here.'

Charing Cross, good morning to you.

'Morning, Judy.'

St Mary's, we have A&E with us.

Good morning. I think we've got 15 patients in the department.

Six are over four hours. Three of those are waiting for a psych bed.

One's been allocated, but she's waiting for transport.

Just to highlight,

the first psych patient has now been in A&E for 22 hours.

That patient has caused lots of disruption overnight,

has assaulted various members of staff.

The police have been called.

A woman is being cared for in Room Q -

a dedicated space in A&E for psychiatric patients.

She arrived in an agitated state

yesterday morning.

I'm just concerned about this mental health patient in A&E for 22 hours

who is difficult to handle because she's so aggressive and violent.

Going through the notes,

they've assaulted five members of staff throughout the night shift.

She's a very big lady and she's difficult to handle.

She...got seen by the mental health team,

they booked a normal mental health bed.

Eventually, she got so aggressive, when the crew turned up to take her,

they decided she needed a psychiatric intensive care bed,

which is in, like, a locked room.

There's very few of them in London.

The new bed was then identified, but now we're waiting on transport.

There has to be a secure vehicle that she can be secured in.

We've been waiting for that since 4:30, I believe.

I'll chase that up.

Does the patient need any cages or anything like that?

St Mary's, like most general hospitals,

doesn't have its own psychiatric beds on site.

We've got this lady - assaulted staff last night,

quite aggressive verbally and physically.

A liaison psychiatry team based at St Mary's

but employed by a separate NHS Trust

must assess and transfer mental health patients

to off-site psychiatric units

or arrange treatment for them in the community.

-She needed to be restrained as well?

-Yeah.

-Security or police?

-Security AND police.

It's the job of the team's deputy manager, Million Moyo,

to secure a bed for the patient.

The problem is the logistics,

because we don't have wards on site.

They need to be transferred elsewhere.

Where we transfer them, quite often there are no beds.

It's very unusual that we've got a bed ready for a psychiatric patient.

Hello.

We are giving her medication so that the transfer can go smoothly.

-Is she safe? Is she safe?

-Yeah.

OK. That's fine.

Oh, you're at St Mary's Hospital.

You came to the hospital yesterday.

When we met you, you seemed quite confused.

Do you drink alcohol?

Do you use any substances?

Crystal. When is the last time you used crystal?

You don't know.

Are you feeling sleepy?

Last year, 2,300 mental health patients attended St Mary's A&E,

an 8% rise on 2015.

Compared to maybe even six, eight years ago,

we're seeing more people showing up to our A&E departments in crisis.

It seems people don't know where to go to if they've newly become

homeless or are living on the streets or have newly been diagnosed

with a mental health issue, they might not always know where to go.

But everyone knows if you turn up to an Accident and Emergency department

that we will see you, regardless.

If they don't come to us, they're not going to get help,

and then things will turn out a lot worse for them.

It's getting to over 24 hours now. This is a very long breach.

12-hour breaches are considered very serious.

The Chief Executive gets informed.

The Government sets targets to prevent long waits in A&E.

If these are breached repeatedly,

the hospital can face financial penalties.

We do take breaches seriously.

We do strive to try and get our patients into beds

where we can, as possible.

Our mental health breaches, that's very difficult

to try and actually do anything about them,

because they're out of our control.

She's just as ill as our other patients.

She's iller than our other patients.

We can help them and look after them.

We can't do anything, other than wait and wait.

If this was my sister, or my mum, or a friend, or anyone,

this wouldn't be good enough.

It's not good enough.

We have had patients here for 36, 48 hours -

young, vulnerable patients and elderly, vulnerable patients.

It is disgusting.

Sometimes we just feel like our hands are tied

and we can't do anything else.

All we can do is do our best for them.

Hi, it's Million. I've got a dilemma.

A bed has not been identified for this lady.

They actually refused the patient.

A few minutes ago.

Yeah, I know. I've been calling everybody.

We may be lucky to get a bed in the next few minutes.

I will call you back in the next 20 minutes.

Hopefully we can hold on to the transport.

A private ambulance is booked to take the patient to

an off-site psychiatric unit.

We're authorising hundreds of pounds worth of transport

for these people to go to a safe place.

Hi. I'm doing my best. We're just waiting for the go-ahead.

How long's that going to be? Cos we got told 10:30.

I think let's wait those ten minutes and see how it pans out.

Are you happy with that?

We're going to have to tell our controller,

cos we go straight in, straight out.

Transport are just waiting and they are just about to cancel.

Have you got a place for her yet?

-Not just yet. It is actually this phone call.

-He's on the phone now.

Can we leave it five minutes and then call you back?

Is that all right?

OK, they're standing here, so... All right, thank you. Bye.

Another five minutes...

I just want to check about this lady you're expecting.

What time we can transfer?

2:30?

Bad? It's not acceptable.

Why is it going to take two and a half hours?

But that takes two and a half hours, why?

I know it's not your fault, but I need an answer.

Everyone asks me why, and two and a half hours is...

OK, so this patient leaves here at two o'clock.

INTERVIEWER: What do people think of psych liaison in the hospital?

Those who understand how we work, they appreciate us a lot.

Those who don't, Um...are sort of...

lose confidence with us.

But I understand the pressure that they'll be going through.

It's not fair on her, ultimately, or anybody else here either.

We need a definite time for a bed,

and they can't keep changing it, so I'll rebook transport now.

A new crew for two o'clock. The patient goes at two, regardless.

They'll have staff and a bed at two o'clock.

-All right, two o'clock, yeah?

-Yeah, please.

I need to speak to someone regarding the mental health transfer.

INTERVIEWER: Whose fault is this?

-I have to let you guys leave.

-OK.

The possibility is that you might get a call back on it later,

but for now, I'm afraid we're going to have to cancel it.

No problem at all. Have you spoken to our office, or do you want me

-to do it?

-Yes, that's all been done, so we've made the contacts...

-Excellent.

-I am so sorry.

Hey, don't worry about it, things happen, don't they?

I had a lovely cup of coffee.

It's so frustrating and it becomes so ridiculous sometimes that we can

spend 12 hours of a shift, and then my colleague can spend

the next 12 hours of a shift trying to help these people,

trying to find them a bed where they can go to

so they can get the correct care that they need.

In the meantime, they're sitting in a cubicle

in a busy A&E department

with all hell breaking loose around them sometimes.

Three hours later, after 29 hours in A&E,

a bed in a psychiatric unit is found for the patient.

INTERVIEWER: Do you ever feel undervalued?

Occasionally I have felt undervalued...

..but not by patients.

I think let's leave that at that!

Get her mum's number.

Ask your colleague to get her her mum's number.

There's been just so many cuts in all areas

of our social care in this country.

It's just so frustrating that anyone in society that doesn't know

where to turn, they will come to us.

It's fine, that's what we're here for.

It just makes our job very, very frustrating.

It's also very frustrating for them and their families,

cos we're not the right people to help sometimes.

But in their eyes, we're seen as the only people that can help them.

We've got four patients with mental health issues in our department.

They've been here for rather a long time,

but they do all need a formal mental state examination

via our psychiatric liaison team, so...

INTERVIEWER: Referrals have been made, have they?

Yeah, yeah, they've been made. Many hours ago.

I've already had a barney with the A&E staff this morning.

I just basically told them, you can't keep bleeping

and asking about every single case.

I said I've come in to five cases, one of them's absconded already.

75-year-old Carl has dementia.

His family brought him to A&E after he became aggressive at home.

Yesterday morning, he walked out of the hospital

and was missing for 13 hours.

The police found him wandering the streets alone

and brought him back to A&E.

Three people to look after him at the moment,

he's needing security because he's in an unfamiliar environment,

it's noisy, it's bright, there's lots going on.

I suspect that that's really playing into his underlying diagnosis

and making things much worse for him.

For his own safety, Carl is being held in Room Q,

the space reserved for psychiatric patients.

-So we've just been asked to come and see that you're OK.

-Me?

Do you know where you are at the moment? Do you know where you are?

-Yeah.

-Yeah? Can you tell me?

Won't say anything.

He's very confused at the moment. He's got a history...

He's got a diagnosis of dementia already,

but it sounds like, from his presentation,

he's really deteriorated in the last month, really.

Where is he?

You need to shout for help. Where is he? Which way did he go?

-That way.

-Right, chase him.

-Where is he?

Carl, look... Let's go into this room here where there's comfy seats.

Come and have a sit down, Carl. Please.

Come and have a sit down, please.

He's taking up quite a lot of resource in the A&E department

whilst we try and stop him from leaving,

because obviously, he doesn't really want to be here.

Carl.

Carl.

I'm Dr Matras, I'm a psychiatrist. How are you doing, sir?

Are you OK?

Are you OK? Are you doing well?

-Yeah.

-Perfect. Do you know where you are?

-Yeah.

-Could you tell me?

Say again.

Sober? I am sober, yes. I'm a doctor. I'm sober, sir.

We're finding it hard.

It is hard. It's stressful.

Just seeing him today

is just heartbreaking.

Really heartbreaking.

My mum's on respite.

She's gone on a two-week respite,

so myself and my partner are actually caring for Carl.

That's when we started finding more changes with him.

I don't know if it's the circumstances

that his routine's kind of changed, compared to when my mum's around.

I think that might be the cause of why he's in here today.

-Are you looking for your wife?

-Yeah.

-Yeah.

-Do you think he's missing her?

-He's definitely missing her.

He's definitely missing her, because he tries to ask for her.

He normally lives with his wife, who is away now.

She's due to return quite soon.

He doesn't have the history of aggression,

but he has become aggressive.

The daughter thinks that is has deteriorated over the last

three or four days. He's much more confused, he's much more jumbled.

He went to visit his daughter, but he confused the addresses

and tried to force entry to somebody else's home.

-That's not good.

-My concern is having him on this busy ward.

-Yeah, he needs to go somewhere else.

-I think he's getting agitated

-with all the people around him, the noise.

-Yeah.

The main problem will be he's wanting to leave and go,

because it's what he normally does.

INTERVIEWER: Can you just tell me

what's going on with this guy, what the dilemmas are?

First of all,

we are not entirely clear why there was a change in his behaviour.

The investigations that have been

carried out don't show the evidence

of a medical cause that could be attributable,

but, at the same time, it doesn't exclude that.

So there'll be a question whether he could be admitted medically

for further investigations.

That's something that I want to discuss with the medical team,

because they may say that, unfortunately,

it's not necessary for him to be admitted.

So then there'll be the question of who will be arranging

the increased package of care, because he's unlikely to be

able to return home without an increased package of care.

Psychiatrist Bart works for a different NHS Trust,

so he can't admit patients to St Mary's.

Instead, he must ask one of the duty doctors to find Carl a bed.

-Hi, how are you?

-Hi.

-There's a chap here called Carl.

He was brought in last night with increased confusion.

He normally lives with his wife, but she's away.

Communication with him was difficult,

but according to the daughter, he's even more jumbled up.

You know what I'm trying to say.

There's a Q on chronic confusion, there's a safeguarding issue

-and possibly...

-Well, not necessarily.

But might need an increased package of care or something.

He won't be capable of going back home at the moment.

-We'll get him admitted to AMU.

-AMU?

-AMU. There will be beds.

We'll get the whole story and we'll see what's chronic and what's new

and what's reversible and what's not.

-Awesome. Thank you.

-No problem.

-Thanks again.

Our longest waiting patient is going to go to the medical ward now,

so he's going to the Acute Medical Unit.

INTERVIEWER: How long has he been here?

13 hours and 46 minutes.

What do you think of that?

I don't think that's best patient care.

Is mental health given the priority that physical health is?

Yes, in terms of the care delivery within this hospital,

but no in terms of the budget that is has across the whole country.

-It doesn't have parity?

-No.

Get her away! Move away! No hands on me.

Please.

-Stanley, that's not nice.

-Please, don't let her touch me.

No!

OK.

85-year-old Stanley has vascular dementia.

This is his fourth admission in three months.

Push me back. About two feet backwards and then right.

OK, we're going now.

Around 25% of medical patients

treated annually by the Trust have dementia.

They're accommodated in a specialist ward

until their social care can be arranged.

STANLEY GROANS

Stanley, he remains medically fit.

In terms of discharge, actually,

the only thing that we need is the package of care.

What are we waiting for?

As he can no longer cope living alone, Stanley's family,

along with hospital staff,

have decided he needs a place in a care home.

He's under the care of the complex discharge team.

So I've spoken to the CCG.

They said that they still haven't heard from the commissioner,

so by midday tomorrow,

we'll hopefully get the answer for the funding that we're asking.

-Good stuff.

-Then we'll start looking for a care home.

If you get unwell, this is where you come,

and that's what we expect,

but I think there's probably more that we're seeing of people

whose social situation has just reached a breaking point.

I think, you know, we're just seeing more people in worse crises

as it gets more difficult to access social care

or to have your problems met in the community.

No, don't turn me right. Ahead. Ahead. No, you're turning.

-Stanley...

-I mustn't be turned.

-Stanley...

-What, darling?

Remember, I told you, no screaming.

I was assigned to look after only him,

cos he's quite confused and he's very demanding as well.

He's off and on, screaming, shouting.

Flip, flop...

STANLEY GROANS

Careful.

Asking for so many things that you can't really figure out sometimes.

Well, that's our job.

-Are you waving to everybody?

-What?

Are you waving to everybody?

INTERVIEWER: Do you think he knows where he is, Peter?

I've not got a clue. I can ask him.

Do you know where you are?

No.

-In St Mary's Hospital.

-Yeah.

-Do you know where you're going to after?

-Where?

Do you know where you're going to go to after?

No.

A nursing home.

-STANLEY GROANS

-My back!

Ohh!

-Thank you.

-It's cool, cool, cool.

Do you know where you are?

Me? I'm with you.

-Where?

-St Mary's Hospital, Paddington.

Dementia is not an illness, per se,

it's a series of different illnesses.

Like Alzheimer's, people tend to notice things like the memory loss,

but dementia is more than just memory,

it's also how you think, how you behave.

It can completely change someone's personality,

massively affect how they function.

Dementia is one of the worst things that can happen to you

or someone you care about.

He had about ten weeks in and out of this place,

because he keeps walking around the area - occasionally semi-clad,

shall we call it - on his electric scooter.

He broke down on the Westway once.

My brother Tony got a phone call to say, could he come and pick him up?

When he got there, he realised he was actually

in his electric wheelchair.

There's a rather large traffic jam, so he's just... He gets confused.

Three to six months ago, he would not have been like this at all.

He'd be totally, totally different.

Two years ago, he'd be like you and me, normal.

I don't know what normal is these days.

Because of the illness, he shouldn't be at home.

They're going to find you a nice home.

-Can't hear.

-They're going to find you a nice nursing home.

It'd be nice if you could find somewhere tomorrow.

But sometimes he actually thinks that he's already in a home.

The last time we came in here, he said,

"I should have come in here a long while ago," not actually

realising he's already three or four times in the last six weeks.

I don't know where he's going to end up.

They said there's a home for him eventually.

It's just when they can find a place.

Stanley is your patient. He's waiting nursing home placement,

I noticed that. He had all his documentation sent down to the CCG.

He was granted continuing care.

Yeah.

'Sometimes, patients that are challenging'

take a while to be placed.

Cos in the wrong place,

they will be back in A&E with people not able to manage them.

I think this is called acting natural.

The stocks for nursing homes are low

and the demands for people to go into them are high.

They may not... You see, like Stanley,

he has to be placed where they can meet his needs,

where his risks can be managed and where his challenges can be

managed, and also to protect him from harm and neglect.

He needs somebody around all the time to help him

and to provide some guidance and reassurance

and to make sure he doesn't get upset and agitated and angry.

Potentially, he's going to need a member of staff looking

after him quite a lot of the time. That's really, really expensive.

He's shattered, isn't he?

Remembering what he was like before and now is just...

It's heartbreaking. He's been like a dad to me, practically all my life.

He taught me how to do many things.

Taught me how to drive, that was one of the great things,

learning how to drive.

-Learning how to play cricket.

-Play cricket.

-He's always been there.

-Yeah, he's always been there.

It's quite sad seeing him in this condition.

INTERVIEWER: When he was a younger man, what was Carl like?

He loved his cricket. He always played cricket. He's a bus driver.

Even up to today, he talks about the buses.

-Those are his two main passions.

-Which route was it?

-182.

That's his bus. 182 to Harrow and Wealdstone.

So what's happening now?

It's going to be day by day, see how he gets on day by day.

Then we have to decide what we're going to do,

if he's going to come home.

My mum is the main carer. She's on respite.

She wanted to come back home straightaway,

but I tried to persuade her that it's in hand, we're dealing with it.

She's very upset. She'll be back soon.

Yeah, it's very sad.

I don't think she's come to terms

with what's happened to Carl, actually.

I think sometimes, she maybe tries to block it out.

Do you think she can continue to look after him?

To be quite honest, I don't think she can.

I think she'd like to believe she can, but I don't think she can.

Once he sleeps and revives, they'll just see how he gets on.

'She's not the same person as what she was.

'That's one of the reasons why she had to go on respite.

'She was drained.'

Do you have a tough decision to make?

I don't really want to make any decision, cos that'll be

in the hands of my mother when she comes back on Saturday.

I don't want to make wrong decisions,

so I'd rather just wait for my mum to decide what she wants to do.

OK, thank you.

Thank you. Thank you. Bye.

So, he was working four years ago, working as a bus driver.

They said it's been more like a year,

but the last two months have been worse.

Carl, come and wait here, please.

INAUDIBLE

There is no way out.

Don't open the door.

Why do you hit me?

I won't, don't worry. I'll be fine.

Can I get backup? Backup, please. Backup, please.

OK.

It may look heavy-handed,

but patients like Carl are very unpredictable.

The security is there, really, for his own protection.

Carl, look at me. It's all right.

-Carl.

-Be careful.

-Don't worry.

Yeah.

We need to find an assigned room.

INTERVIEWER: Did he hit you?

Yeah, he hit me.

Are you all right?

I'm OK. I'm OK.

Is this one of the risks of your job?

That's it. You must expect this.

You have to expect all that aggression, so...

You have to.

You can't blame him at all.

So, now they've put the care on two to one.

It's going to be two to one now, not just one person.

It's very difficult,

he just tried to kick the consultant in the face twice.

Yeah, yeah, yeah.

I mean, we're giving him more antibiotics now.

His inflammatory markers are non-exciting,

so there's no systemic illness going on, so, you know,

were it not for his deterioration, you know, we'd be discharging him.

There is nothing being done here that couldn't be done anywhere else.

Is there anywhere more appropriate on a different, you know,

within the mental health set-up?

Cos he's going to end up harming himself or someone else, you know.

He's medically fit, isn't he? There's no need to be in hospital.

We're making a guess, really, that he's got a unitary tract infection.

But the evidence for that is poor.

But, right now, he's someone who could come to harm

if he's not around people who can care for him.

His main carer is taking some respite care.

Quite clear that he needs to stay somewhere where he's safe,

and that place right now is a quieter a bit of the hospital.

So, we're not in a situation where we can send him home straightaway.

OK. Well, all the best.

-OVER PHONE:

-Thank you, bye-bye.

-Bye.

Carl's wife, Patricia, has returned from a respite break

visiting relatives in the Caribbean.

-Do you know where you are?

-Yeah.

Yes or no?

Where is there?

St Mary's Hospital.

-VOICEOVER:

-When I got the call,

everything just drained from my body. I started to cry.

I said to Sandra, "I'm going to try to get a flight to come back home."

She said, "Don't come, Mum," there's nothing I can do.

I felt so bad, you know?

You're... Hi.

-Hello. Hi.

-Kiss me.

Mmm! The other one.

Do you remember who I am?

Who? Tell... Hm?

No, I'm not Peter. I'm your wife.

I'm your wife.

Did you forget me?

Pat?

You remember me now?

You remember me?

Before I took the two weeks, I was at the edge.

I was at the edge of me breaking down.

Been a good boy last night?

No fighting?

I know you don't fight, I know. So that's what...

I did need a holiday because I can hardly cope.

Because his features changes.

In what way?

In a way like...

aggressive way.

In an aggressive way.

I can see when his features changes.

I have to tell him, "Let's go for a walk,"

because I get scared at home.

All right... You miss me? Kiss me.

-How many years have you been married?

-25.

Yes.

Good boy.

Do you think you can take Carl home?

Carl is still mobile. He's strong.

It is hard for me to put him in a residential home.

And at home, I cannot cope.

I don't know what's going to happen.

THEY LAUGH

I'll see you, yeah? We have to go now. Don't get upset.

They're looking after you and they care for you. Carl, please!

You stay inside. You're making me feel sad.

-You have to stay... You have to stay here.

-Who?

You. You cannot come out now.

-Just relax, watch some cricket, we'll come back.

-Yeah.

Watch some cricket. Cricket... You know cricket? West Indies?

-The West Indies.

-Yeah.

-Yeah. Watch them.

Watch them do bad again.

SHE SNIFFS

I don't know. I don't know what's going to happen.

Because he's talking about places he wants to go. I don't know...

Carl's case is passed to the complex discharge team,

who will assess his needs to see if he's able to return home.

Have you left my side up?

Yes, I'll do that. No problem.

Stanley has now been in hospital for 21 days.

His family are waiting for the results of a care home assessment.

All patients going into nursing homes have an assessment,

especially with complex needs.

What do you think they're going to say?

It would depend on the clients they have already got on board

in their nursing home, and would Stanley fit into their home?

Stanley's care home will cost £1,700 a week, plus,

because of his complex needs,

an additional 2,300 for one-to-one care.

It will be funded by the NHS continuing health care scheme.

Peter!

You all right?

STANLEY STUTTERS

Elizabeth!

You all right?

What a surprise!

I've got something for you, Dad.

Oh, what is that, eh?

I think that goes there.

We went... We went to view the home.

-What home?

-For you.

A different place for you to go in, with your own room.

It was nice.

Your own room.

Meet some nice new people.

Hello, is that the...home?

We came this morning regarding my father, Stanley.

She said there'd been an assessment done,

and she said she can't say anything to us until they hear back

from your person who came and assessed him this morning.

Would you like to get there?

Yeah.

It would... It wouldn't cost a lot?

No, it doesn't cost us anything.

I was just wondering if I can sort of pre-empt things a little bit

and wondered if there'd been a decision made.

It's just, we're sitting with my father and, obviously,

it would be good if we could give him some good news.

Thank you. Oh!

OK, then. Thank you very much.

She said...

It's all looking fine. As far as they're concerned, it's a yes,

but because he needs extra funding,

because he needs more one-to-one care than they are willing to

give him with the resources they've got, it has to be funded by the NHS.

And you won't know that until Monday.

You just have a man in the middle who has to say yes about funding.

Even though the funding's been agreed, but not for the additional care.

-OK, so the fact is we still don't know.

-No.

Everybody was full of, sort of, hope this morning.

You know, there's been a lot, a lot of stress over this.

People travelling from hundreds and hundreds of miles regularly

to come down and try and sort it and help it out and we're still here.

We still don't know.

And, erm...what if they say no?

Then we've got to find another place and start again next week.

And then, will we still have the same issues?

-Do you remember this?

-Hm?

-Your sideburn.

-Mm-hm.

See? Your sideburn.

Very proud of it.

Yeah, when you had your sideburn.

-And this one, I think we went away for a weekend.

-Yes.

I can't remember if it's... Yeah.

All right, let's start with Carl. So, he remains medically fit.

I think he seems a little better today.

We had a bit of a conversation about the cricket,

which was sustained, which was nice.

I haven't met his wife yet, but I think she's around this afternoon,

so I'll have a chat with her after the meeting.

In terms of discharge, the only thing we need is a package of care.

Yeah, it's all just social services we're waiting on,

and they want to make sure that there's something in place before he goes home.

Well, I'll have a chat and we can talk about various things.

-But, either way, should be getting out of here soon.

-Yeah.

-Good.

-Oh, we had our good times together.

-We used to...

Yeah, we had our good times together.

I know he would look after me. He would look after me the same way.

And I'm prepared to look after him as well.

But, in his condition, all I am asking for is a little support.

You know? Just to ease the pressure off me. That's all.

-Hello.

-Hello.

-Yes?

-Dr Mitchell. Nice to meet you.

-And you, yes.

-How are you?

I'm good, thank you.

So I've heard that there's been obviously quite a lot of challenge,

let's say, in terms of being able to cope and keep things going at home.

-Sounds like you've done a pretty remarkable job, frankly.

-Oh, I try!

We need another carer being there either during the day or at some

points during the week, so at least there's somebody around for a while so you can get out of the house.

-Yeah.

-Would that be of some use?

Well, yes, if I can get out, you know...

for even a day in the week.

You know, I could say, "Well, today's... Wednesday's my day."

-You know what I mean?

-Yeah.

I'll be honest with you - that's going to be difficult.

You won't get somebody there for a whole day.

Typically, what social services will do is they will get you a carer

for half an hour in the morning, half an hour in the afternoon.

Seven days a week.

It's not going to be able to do everything that you've been doing,

because what you've been doing, frankly, is incredible.

It's potentially going to be an ongoing challenge, I'm afraid.

If Patricia had known months ago that she could get some support,

then maybe it wouldn't have got to the stage where she is

so exhausted she can hardly imagine how she'll carry on.

But I guess that's what people often do.

They just sort of soldier on as long as they possibly can.

Listen... If you want to come home, you have to behave yourself.

Come here.

Are we set up to help somebody in her shoes?

No, these things are incredibly complicated.

I've been doing this, as a consultant, for five years,

and I still get baffled as to how some of these things get sorted out.

Are you OK? Are you OK?

Are you comfortable here?

Yes, thank you.

It's quite busy.

We came in this morning, there had been patients

in the apartment for over 12 hours.

Mostly psychiatric.

The problem with that is it takes up a quarter of the department.

Keeping an eye on them, keeping them safe, making sure

they don't abscond, making sure they're not too distressed,

looking after all the other patients in the department at the same time.

-RADIO:

-Trauma team to adult A&E resus.

56-year-old Stephen has been brought to St Mary's

by London Ambulance Service after self-harming with a knife.

He needs emergency surgery to repair his arm.

This is the psychiatric nurse.

She's basically explaining why he's done it.

Da, da, da, da, da...

He stated he deliberately did self-harm because his benefit,

he said, has been stopped.

According to him, he was unable to get support,

to have his voice heard, and this is the trigger, if you like.

How awful, if that's the only way you feel you can get attention.

Yeah.

Mental health patients are more likely to encounter trauma.

Illness that affects your behaviour and impairs your judgment makes them

more prone to accidents or, occasionally, self-harm.

So it does represent a significant proportion of our workload.

We're quite busy and we're quite stretched as it is, so in order to cover this,

I've had to take a very senior doctor out of another list to cover.

So we're stretched a bit thin.

I'm hoping for him that this is a sort of lucky escape, as it were.

We get involved insofar as we obviously stitch them up

and repair whatever is damaged,

but this is clearly a manifestation of something more significant

in this poor gentleman's mind.

You know, I think it's no secret that we're having

a bit of a crisis with mental health at the moment in this country,

with the provision of care.

They won't present to hospital until things get really out of hand.

If they're at home, if they're having a psychosis,

if they've got lack of insight into what's going on with

their own health and not really taking control of it as well.

So that's why we need more support in the community, really,

to make sure that they get the appropriate care when they need it.

Who wants a banana?

After 24 days at St Mary's, Stanley is being discharged to a care home.

-I wish you all the best, my friend.

-Thank you.

-Yeah.

And you know what they say - I don't want to see you again.

Much as I love you, hope we don't have to see you again.

-I hope you're all right.

-All the best.

I've been hoping that this would happen

so someone else can have this bed...

because my dad's care could probably be taken out, done better elsewhere

and someone else can have this bed and I'm glad of that.

Thank you for everything and all your staff and...

Health visitors.

And thank you very much.

-You're a good girl.

-It's been a pleasure.

Right...

In a way it's sad that it takes so long

because we were adding up the amount of cost for somebody

like my dad to come in and out of hospital about four times.

Wouldn't it be great if we could cut that process down

so people could be moved more quickly

into a place rather than hospitals?

But we do appreciate everything the hospital have done.

Righto, here we go. Goodbye to every little one of you.

-Goodbye, young man. Take care.

-Bye!

See ya!

Super, Stanley, hello.

-We're back again.

-Super.

Are you OK, darling?

The wheelchair that he is sitting in, he fits in.

The wheelchair they've got

to take him in the ambulance, he doesn't fit in.

This wheelchair is not allowed to leave the hospital,

and if it does, they can't fetch it back cos they say they're going to another job afterwards.

So now they might need to find another wheelchair or change the ambulance.

HE MUMBLES

They're waiting for a wheelchair for you.

The problem is, he will get irritable

if he thinks he's not going.

Push!

-Push!

-Hiya, Stanley!

-Push.

One minute. We're going down, we're down to one minute now.

Right, we're going. Everybody!

One, two, three - go!

Excuse me.

-Push and push!

-Just got to wait for your wheelchair.

If you're not going, I'm going.

-You're fucking about!

-We're not.

-You've just got to wait.

-No, fuck off then!

SIREN WAILS

Get off! Get off!

An hour and a half later, a second ambulance arrives.

Let's hope we don't see him back in here again!

SHE LAUGHS

Bye-bye! Bye-bye, Alice. Bye-bye, everyone.

-I think...

-Let's get her off the scoop.

We can take her down and that will release you.

-Mags, love?

-Yeah?

Uh-oh! What are you doing?

-Huh?

-What are you doing?

MAN MUMBLES

-No, no, no.

-Oh.

I need you to sit down.

Cos otherwise you're going to trip up and fall over.

Do you need the...? Do you need the toilet? OK.

Step off the blanket.

OK, well done, we're on the run.

This morning we had a huge amount of psych patients.

Patients that have been particularly difficult...

We've got a patient in with quite advanced dementia who's needing a lot of attention.

-INTERVIEWER:

-What's he done this morning?

He's covered my department in poo... multiple times.

And so I now keep moving him

and the poor domestic, he's following me around!

So... But we're getting there.

ALL CHAT

How are you feeling? Are you OK?

So, all was fine for the operation.

Your cuts, we've stitched them up, so that's all OK.

Um... Most of the structures were all fine. How are you feeling?

-You feel good? Any pain in the hand at all, in the arm?

-No.

-Hello, hi.

-Hi.

I'm Dr Matras, I'm a psychiatrist.

My understanding is that you've been feeling increasingly stressed out

because of the problems with the benefits

to the point that you decided to cut yourself

because you didn't want to live any more with these problems.

A year ago,

Stephen lost his voice due to complications from throat cancer.

You are the shadow of the man you used to be

and is it because of your medical condition? OK.

And did they tell you about your prognosis as well,

what's going to happen in the future with your throat?

What did they tell you?

HE MOUTHS

That it's going to spread?

Now, when was the last time that you saw a psychiatrist?

Six years ago.

What did you see them about, about depression or about something else?

Anger. Anger issues, OK.

Did you have any trouble in the past, any trouble with the police?

OK, did you end up in prison at any point? A long time?

How long did you stay in prison?

20 years?

10 years? OK.

There's a question of whether you would need to have someone with you

all the time in the hospital.

Because you harmed yourself, in here, they are worried that you may

cut yourself or do something to yourself in the hospital.

No? What would stop you from doing it?

That's enough, that's it? OK.

How do you feel about being alive now?

Do you feel a relief or do you feel disappointed?

You are hopeful? OK.

Thank you very much.

-INTERVIEWER:

-So you cut your wrist to get some attention?

"Cos they were going to evict me from my flat -

"what was not my fault."

And is that what's been upsetting you?

HE MOUTHS

You'd rather be dead than lose your flat?

Why... Why did you think this was the best way to make a point?

"Cos they don't listen to reason."

What's quite clear, had he not had the financial problems,

we wouldn't have met today.

Housing problems with benefits are a recurrent theme

and quite often the major source of stress

that leads to patients presenting in crisis.

And quite often, yes, we have to pick up the pieces.

Hello!

Hello, hello!

Hello, hello!

Good boy!

Hello, I'm Alice. How are you?

I'm good, thank you.

Hello.

And how are you?

How are you coping?

Very hard, I couldn't... I can't cope.

How long have you been looking after your husband with this condition?

-From December 2015.

-So...

-The whole of 2016...

-Yes, yes.

And when I... I was going down... I was breaking down...

-Right.

-..when I called my GP.

I said I cannot do any more,

-I feel I'm going downhill and I've got health issues as well.

-Yes. Yes, yes.

-You know?

-So you felt burnt out?

-Oh, Alice, to be honest, I was on the breaking point.

-Right.

I want to look after my husband the best I can

and I always promised to look after him.

But there's a limit or else I'll go down before him.

-So I just feel I'm going down, I'm going downhill.

-Of course.

-SOBBING:

-It's too much for me!

Yes, but you just remember that we try to look after the carers.

-I want to look after him!

-Of course.

But we do understand the stress and strain that you are under too.

I look after him for one year, all they gave me -

which I think is unfair - a pile of papers to read and they left me...

-That's all they left me. I didn't know where to turn.

-Yes.

I didn't know where to go.

So you feel that you've been in the wilderness with no support?

-In the wilderness. No support at all.

-Right.

Well, I will try my very best to get a meeting together with

-a social worker at the hospital here, all right?

-Yeah, that's fine.

-All right, and lovely to meet you.

-Thank you, Alice.

-Thanks for your help.

-Take care. That's OK. Thank you.

-OK, thanks.

And are you all right, Carl? You've had a nice wash?

ALICE LAUGHS

-All right, Tricia.

-Yeah, thank you, Alice.

-All right.

-Nice to meet you.

-Goodbye.

-Have you been to the toilet then?

-Yeah.

-Number two?

You had a number two?

You look nice in that, Carl.

Carl has been in St Mary's for 11 days.

Today, he's going home.

Let's go.

Social Services have agreed to fund a carer for two hours a day,

seven days a week, to help Patricia look after Carl.

-INTERVIEWER:

-Patricia, how are you feeling this evening?

A bit anxious, you know? Excited.

But my concern is at night, when I'll be with him alone.

I don't know, I might not sleep tonight.

I'll just have to wait and see his reaction and how he behaves.

If he wants to get out, I cannot stop him.

Carl, stay still, please.

You need to stay...

You need to stay still, Carl. Please.

Where are you going? You need to stay still, please!

-No, no, no, don't push me, Carl. Please, please.

-Wait and stay here.

Please, don't push my shoulder.

INAUDIBLE

-Yeah? Yeah?

-THEY CHAT

You're welcome, sir. On you go.

-PATRICIA:

-Probably when he gets home, you know,

he might be a bit back to himself.

-INTERVIEWER:

-You're hopeful?

Yeah, yeah, yeah. That's all I can do, live in hope.

Bye!

Things are looking up. I know where to go now for help.

-Aw, you OK?

-Hello, darling. Hello, welcome home, welcome home.

-You all right?

-You're home again.

-You're home again.

-You're home again. Yeah?

-You all right?

-Yeah.

-How are you?

-It's this way, is it?

-LAUGHTER

-All right?

-I'm all right, I'm all right.

Happy to see me, huh?

-INTERVIEWER:

-Are you happy?

-Of... Of course.

Carl's in a mental health unit. I visit him every day.

I wish a miracle could happen and get back to normal.

You know? And that's all I can do, is to pray... Pray for him.

I need some atropine, please. Quick, quick, quick!

At Hammersmith Hospital,

the heart attack centre is treating more people than ever before.

We've just had an emergency call.

We just need to get the other patient done.

We're getting busier and busier

and the staff are extremely stretched,

but we have to keep going.

There's an ongoing drive to make cost savings across the trust.

So, last year our challenge was £2.3 million... This year, £3 million.

It gets to a point where actually there is no more meat on the bone.

And two young patients test the skills

of Imperial's specialist teams.

It's not fair, but it's happening, so get on with it.

There's the tumour there, look.

Well, he's going to come through it. He's still got a lot to do in life.

It's one of the most challenging things we treat.

If you don't get the timing of surgery right, the patient will die.

What choices would YOU make

when faced with complex health care decisions?

Visit our interactive pages to find out how you would respond. Go to...

..and follow the links to the Open University.