HoNOS-secure case study written vignette - Larry

Larry is a 24-year-old unemployed labourer of European descent. He was remanded to Waikeria prison two days ago, charged with threatening to kill his ex-girlfriend and trespass, in the context of a dispute whilst intoxicated. At the time of the offence, in Hamilton, he was seen at police cells by the MH Crisis team. He admitted to not sleeping for more than a couple of hours each night, and the presence of auditory hallucinations, not of a command nature but very derogatory and distressing.
There was no report of previous or current depression nor of intention to self-harm. He receives IM medication fortnightly, and displays some insight into his need for medication but does not understand the link between alcohol abuse and his mental state. Larry reported he felt stressed by his living arrangements, financial situation and the fact that his ex-girlfriend did not want to see him anymore. He said he had run out of money to buy food. He has found himself confused with simple decisions over the past fortnight.

He was recently involved in a street fight, with injuries (lacerations) that required an ED consultation following an ambulance review at the scene. Routine bloods were taken, and concerns about Larry’s liver function were identified and were being followed up. Larry said he has been feeling physically unwell over the past month and says he cannot ‘get out and about’ as he used to do.

He has a diagnosis of paranoid schizophrenia and was first admitted to a psychiatric hospital aged 18 after using excessive amounts of marijuana and alcohol. His diagnosis at the time was drug induced psychosis. He has denied any marijuana use since that time.

He had problems with alcohol and often used his benefit to access it to the detriment of his diet and wellbeing. He has always denied the use of illicit drugs and previous random urine tests have proved negative. Larry has struggled with his illness in the recent months due to his use and abuse of alcohol.

He has no dependents and has lived in supported accommodation, for the last six months, following his last discharge from hospital. Prior to this discharge, he was linked with a local social recreational men’s group. Post discharge his accommodation provider supported him to attend. He attended for three months, until he broke the group rules regarding intoxication and abuse of others.

He resided with two other mental health service users in a flatting situation which he found difficult. His accommodation provider has recently evicted him due to his behaviour and how he treats his flat mates. He has been told he can return to the accommodation when he has dealt with his drinking problem and the resulting aggressive behaviour. He is now of no fixed abode and reported 10 days ago he had been assaulted and robbed while sleeping rough.

Larry will need support to find a place to live and where his mental health needs can be met. His needs are complex and he requires input from a range of mental health professionals to support him to reduce his likelihood of reoffending, this may include community forensic follow up once released from prison.

He is known to the local Police and has a record of assaults and threats to harm dating back five years. For the past five years Larry has been supported by adult mental health services in relation to a diagnosis of paranoid schizophrenia.

His last admission to hospital was eight months ago, after a relapse of psychotic symptoms due to refusal to take medication, and he could subsequently not be located by his key worker. He seriously assaulted his girlfriend who needed sutures to her left eye and from that time forward, the relationship ceased.

When mentally unwell and/or when using alcohol, Larry ruminates about the past. He has been known to arrive at his ex-girlfriend’s house and threaten to kill her if she doesn’t take him back. He becomes suspicious of her actions and often thinks she has other men in her house. On two previous IPU admissions Larry has absconded and been found outside his ex-girlfriend’s home trying to break in. She informed the Police that she was going to move to Australia to live with her sister as she did not trust Larry to stay away from her.

Larry has been remanded into custody until sentencing next week. A referral has been sent to the Forensic Prison Team, an appointment has been scheduled for tomorrow for an initial psychiatric assessment.