Case 7 (Andre): 1993 then again in 2001

Andre was the subject of three guardianship orders, and only attended order one. His first order was made in 1993, and both the second and third guardianship orders were made in 2001. Andre had a very difficult childhood. He became a paraplegic following a suicide attempt at 18 years; this also heralded his involvement into the criminal justice system.

His administrator (a person appointed by VCAT to make financial and legal decisions) made the first Guardianship and Administration Board (GAB) application. At this time, Andre had received compensation following his suicide attempt and there was legal discussion regarding his ability to live independently. A guardian was appointed limited to decisions concerning health care and accommodation for 12 months. Andre received case management from a local psychiatric services team, home care and attendant care services. At the rehearing, the order was revoked. It appeared that Andre received appropriate mental health services to assist him in living in the community.

At the time of the second order, Andre was still residing alone. However, his medical and psychiatric condition appeared to have dramatically deteriorated. He had extensive pressure wounds to his buttocks and legs, which required urgent medical treatment; however, he refused to have them attended. Andre was receiving case management from a local community team and ongoing psychiatric assistance from the psychiatric services. The applicant was the manager of the care team. At the hearing, an urgent 21-Day Temporary Order was made limited to decisions concerning health care and accommodation and a power to enforce (GAA, s.26). The member’s reasons were to improve Andre’s quality of life.

It seemed that Andre was afforded many services but he vehemently refused to utilize most and was both aggressive and hostile when he believed his decisions were being ignored.

At the rehearing some 21 days later, Andre had refused to comply with the requests made by the police and ambulance officers to enable them to transport him to the Spinal Unit for medical treatment. They refused to “break his door down” without express legal advice. The tribunal was urgently contacted to address the question of seriousness of life threat, versus the use of excessive force. Given Andre’s level of hostility, the ambulance officers concluded his death was not imminent. Ten days later and with the assistance of his carer, Andre willingly admitted himself to the Spinal Unit for wound treatment.

The single, female member continued the order for three months with decisions limited to healthcare, accommodation and access to services. The member’s reasons were that Andre was exhibiting unreasonable behaviour and demonstrated a clear need for the appointment of a guardian. This decision was made despite the guardian’s provision of two medical reports. The first was from a Consultant Psychiatrist, who had previously treated Andre, and had recently visited him at his home. In correspondence to the guardian he wrote,

it is my opinion that he has the capacity to make informed decisions regarding his treatment for his health...it has been documented in the notes regarding his dislike for authority and in speaking with his treating doctors it would appear that he responds best when he is in control of his treatment....He became angrier when I informed him that I came there at your request....It is likely that any directive has the potential to make matters worse (Name withheld for anonymity).

A second Consultant Forensic Psychiatrist wrote a report based entirely on reviewing written material, as Andre refused him a home visit or any personal discussion. He added that his opinion must be cautiously viewed in this light, but wrote,

“the underlying ethical issue is obviously to do with control...he appears to react badly when too much control is taken away from him...” (Name withheld for anonymity).

During the order, Andre continued to remain non-compliant with the guardian’s requests. He was found at his home by a carer with maggot infested pressure wounds, two large wounds on his hips the size of a fist and deep to the bone, together with wounds on his heels and penis. While Andre willingly went to the hospital, he assaulted a doctor by spitting and punching him. The hospital sought his immediate discharge home, but the guardian refused, as no services would support him. Due to his challenging behaviours, Andre remained at the A & E Department, and five city hospitals refused to admit him.

At the third hearing, presided over by the Deputy President a plenary order was made, to enable the guardian to allow Andre to “die with dignity”. Due to his subsequent deteriorating health, Andre appeared to lose his ability to fight, and was then transferred to the palliative care unit in the hospital where he remained until his death some two months later. Andre died at 34 years of age.

3.3 Objective 3: To extend existing knowledge of system responses for