Iatrogenic Complications of Compulsory Treatment in a Patient Presenting with an Emotionally Unstable Personality Disorder and Self-Harm

Table 2

Summary of incidents and interventions during Springbank admission. There were no major complications from any intervention (or lack of intervention), apart from the pain, bleeding, and scarring from the wounds and limited skin infections that responded to antibiotics. A&E refers to the accident and emergency department.

Significant events	Day	Incident description	Intervention
Admission	1	Scratching an old wound on her left leg, making it bleed	Asked patient to stop and to redress wound.
	4	Picking at a wound on her leg until bleeding slightly, 2 inches in length	Refused to have wound cleaned, but accepted dressing. 1 : 1 support provided.
	16	Reopened wound on lower left leg using fingers	Wound cleaned and dressed. 1 : 1 support provided.
Discharged from s3 MHA	18	Three-inch laceration to her left forearm using a pair of nail scissors	Wound cleaned and dressed. 1 : 1 support provided.
	24	Inserted finger into old wound on left lower leg and then inserted an implement from nail kit into wound (7-9 cm long, inserted half-way)	Verbal support provided. Duty doctor called. Wound cleaned and dressed.
	47	Superficial scratches to face and left forearm	No intervention needed
	53	Cut with a piece of ceramic	Wound cleaned and dressed. 1 : 1 support provided. Safe held whilst cleaning.
	53	Self-harmed after smashing a ceramic bowl (cut 5 cm long and 2 mm wide)	Refused all first aid. Eventually allowed gauze and dressings, but no steri-strips.
	53	Inserted a wooden stick (2 inches long) into a wound on her arm	Duty doctor called. Refused to go to A&E and refused to have wound cleaned. Accepted dressings.
	74	Patient re-opened old wound on left arm	Wound cleaned, dry dressing applied.
	116	Self-harmed using aerosol spray. One-inch burn in her arm	Refused to see duty doctor. Advised to clean skin.
	116	Further self-harm using aerosol spray. Small red area on forearm	PRN medication and verbal support.
	205	Verbal altercation with another patient. M was punched on the nose by the other patient. No fracture	Staff support and safeguarding raised.
	224	Whilst on leave to supported accommodation, left property and told staff she was going to the motorway to end her life because she was not able to cope with the voices	Police informed. Patient called repeatedly by staff. Initially refused, but eventually agreed to return to the ward. No police involvement needed.
	237	Mania-like behaviour (poor sleep, overspending, and elation) with auditory hallucinations and paranoia. Requesting to leave the ward to jump in front of traffic as instructed by voices. Detained under s5(4), then s5(2) of the MHA. Series of incidents followed. Smashed a bowl, made multiple lacerations on her arm in the dining room in front of staff (up to 6 inches long and 1-inch deep, fatty tissue visible). Began inserting pen into laceration wounds	Staff verbally de-escalated, but did not stop her. Eventually allowed steri-stripping, but refused A&E.
	237	Inserted a pen and a hair clip into her arm through wound made earlier. Inserted on the horizontal plane through fatty tissue	Refused to go to A&E and to let staff remove objects. Unable to close wound. Dressed with gauze and bandages.
Detained s5(2) MHA	237	Reopened wound on the right arm. Inserted a piece of emery board	Refused steri-strips and A&E. Allowed cleaning with saline.
Detained s3 MHA	238	Removed dressing and inserted fingers into wound. Some pooling of blood on the floor	Allowed steri-strips only.
	238	Reopened wound on the left forearm and smeared blood on the wall	Refused steri-strips. Refused physical observations.
	238	Inserted plastic foreign bodies into cuts on left arm. Sprayed aerosol into wounds	Refused to have wounds cleaned, verbal deescalation, wounds dressed. Refusing medication and antibiotics.
	239	Smashed a glass and made 3 lacerations. One laceration made to the upper left arm, 13 cm in length, 4-5 cm wide. One laceration made to the left wrist, 6-7 cm in length. One laceration made to the left leg	Refused A&E, refused medical review, minimal first aid allowed by patient.
Second opinion from a psychosis specialist; Discharged from s3 MHA	239	Made three incisions to her right bicep. Two cuts 7 cm in length 3 cm wide, one cut 10 cm in length 3 cm wide. All cuts showing fatty tissue	Refused A&E and wound dressings, but then allowed dressings. Allowed removal of plastic foreign bodies inserted before. Second opinion sought after incident. Discharged from section 3 MHA. Patient asked to leave ward. Backed down when allowed. Allowed removal of foreign bodies. Began accepting medication and wound care.
	244	Used pen to reopen lacerations to her right arm and left leg and inserted pen into her arm	Refused A&E. Allowed dressings only. Accepted PRN medication.
	247	Reopened wound on the left upper arm	Refused all interventions and 1 : 1 support. Accepted cleaning and dressing of wounds.
	247	Inserted a wooden skewer into the wound on her left forearm	Refused A&E, unable to extract foreign body, wound dressed.
	258	Inserted wooden cocktail stick into arm wound from previous self-harm	Agreed to attend A&E the following morning for removal of foreign body.
Discharged from hospital	372