Breda O’Brien: Questions remain about detained pregnant teenager

In recent times, Brian O'Connell of RTÉ's Today with Seán O'Rourke programme has been looking at the experience of people who feel suicidal and who present to emergency departments, and the difficulties they have in accessing acute services.

In one case, a suicidal woman in her 40s with mild special needs who looks after her elderly mother was accompanied by a family friend and a city councillor to an emergency department, but was discharged home without any support.

These cases cause outrage and are examples of how our mental health services often fail vulnerable people

In another, a medical team was proposing that a man who had a substantial wound after a suicide attempt be discharged into the care of his brother, while also saying he would need 24/7 monitoring to keep him safe (except when he was asleep).

These cases cause outrage and are examples of how our mental health services often fail vulnerable people.

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However, the case that caused most outrage this week was one where a psychiatrist assessed a child under 18, judged that it was in her best interests to admit her to an acute care psychiatric unit and then did so.

There are hundreds of families around the country who have sought admission for a family member to an acute unit and have failed to receive it and who live in fear of tragedy.

Acute unit

Admission to an acute unit is not always the best solution, but sometimes it may be the only solution if the person is acutely suicidal and their families cannot cope. Every effort will be made to support the person through the crisis while keeping them in the care of their family and community but it may not always be possible".

If the person is deemed to be experiencing active suicidal ideation or has made concrete plans, the correct approach is admission to an age-appropriate acute psychiatric unit. At times, this may have to be compulsory.

The gold standard is the minimum necessary intervention to protect the person from harm, particularly in the case of a child. Or, in the case that caused all the controversy this week, a child and her unborn child.

The young woman was in acute crisis and, according to the reports, the psychiatrist made a professional judgment that an abortion would not solve all her problems. This hints that the crisis was not purely because of the pregnancy. It rarely is.

Compulsory admission in the case of acute crisis is regularly used. It is often wrong not to use it, as tragic cases in the past have illustrated.

There are many unanswered questions about the case of the pregnant teenager that the media seems uninterested in pursuing.

If she was 24 weeks or beyond, she would not be given an abortion even in Britain, not least because it is an acutely distressing procedure

It has been reported that the young woman and her mother thought that they were travelling to Dublin for an abortion, and had no idea that the young woman might be sectioned.

Family consent

If this is true, it is both highly unusual, very disturbing and completely unacceptable. A decision to make a compulsory admission to a psychiatric unit normally does not happen without the active involvement and consent of family. Was there a language barrier? If so, was an interpreter provided? How could such a misunderstanding arise?

Here’s another question. What gestational stage was the pregnancy? If she was 24 weeks or beyond, she would not be given an abortion even in Britain, not least because it is an acutely distressing procedure. (Unless, of course, the baby had a disability like Down syndrome or cleft palate. In that case, it would be legal until birth in Britain.)

The second psychiatrist in the case determined that the young woman did not have a mental illness, and neither was she actively suicidal and therefore should not be detained.

However, people who do not have a mental illness but who are in acute crisis, can often make irrevocable decisions such as suicide or abortion.

I have seen no reference among commentators to the fact that it is well-documented in psychiatric literature that young women who feel unsupported in a crisis pregnancy are among those who are most at risk of mental ill-health after an abortion.

Other options

Was the young woman offered counselling to help her? Was she given space that might have allowed her to reframe pregnancy not as a complete disaster, but something with which she could cope, given the right support?

If she did have the baby, what approach was taken by the obstetric unit that dealt with her?

Was adoption presented as an option? Or fostering?

Did the young woman go on to have the baby? If she did have the baby, what approach was taken by the obstetric unit that dealt with her?

If, for example, a consultant obstetrician encouraged her to continue with the pregnancy until a stage when the child might be safely delivered and taken into care, and the young woman freely consented to that and is now well, what would be wrong with saving both a child and a little, helpless baby?

Surely an obstetrician and care team would be commended for compassionately handling a case in that way?

Perhaps the lack of interest in pursuing many of these questions lies in the fact that they will not advance the cause of introducing widespread abortion in this country, but they are important questions, nonetheless.