Ravi’s Mental Capacity Assessment during Lockdown
13th May 2020
As with most polytrauma cases, Ravi’s injuries were complex and cumulative in their effects. Most obviously, his reduced mobility and eye patch were the most visible ‘scars’ of the assault he had experienced whilst out socialising with friends in the run up to last Christmas.
When I met Ravi last month he was a strikingly confident and personably 20 year old with little overt evidence of the invisible scars. He described his need to recover some normality and resume responsibility for his financial affairs. However, the extent and nature of his brain injury had inevitably forced his legal team to question whether an interim payment should be paid directly to his account; the conundrum of capacity was encapsulated in the contrast between the severity of his brain injury (a Glasgow Coma Scale of 5 at the accident scene, post traumatic amnesia of almost 4 weeks and neuroradiological evidence of diffuse axonal injury) and his obvious progress in inpatient rehabilitation, reflecting Ravi’s strong work ethic, determination and infectious positivity.
Unfortunately, Ravi’s return to the family home coincided with the outbreak of COVID19 and at the time of my capacity assessment a team of community based neurorehab professionals overseen by a case manager were ‘sat on their hands’, yet to begin their assessments and detail their treatment plans.
Ravi had been working as a security guard at the time of the injury, earning excellent money for his age; moreover, it appeared that his experience of handling money extended back to his early-teens when he had regularly helped in the family’s chain of convenience stores. He demonstrated a strong commitment to supporting his family and at assessment, expressed his frustration at his inability to contribute to his parents’ rent and the strong desire to pursue his rehab goals in earnest in order to secure the purchase of a property where he could live with his parents and younger siblings.
On psychometric assessment Ravi’s memory was clearly impaired as he struggled to effectively retain the details of information provided verbally. His attentional processing and ability to switch his thinking between different tasks also presented as impaired although, more positively, his performance on other tests of executive functioning was better, placing him within the levels expected given his educational and occupational history. Taken overall, his psychometric ‘profile’ offered some positive evidence of preserved functioning in key areas of executive functioning yet to be adequately tested by the rigours of daily life in view of the limitations imposed by lockdown.
This assessment raised so many issues, not least those related to undertaking assessments of such import with unfamiliar clients by ‘FaceTime’. Moreover, Ravi’s relatively very early stage of recovery from such a substantial brain injury underlined the potential for (and indeed the likelihood of) ongoing neuropsychological recovery yet to be realised following his discharge to the community. The case also generated questions regarding the extent to which we can infer from psychometrics to people’s day to day functioning and in the absence of behavioural evidence, how we appraise the balance between protecting and empowerment. On balance, Ravi’s history suggested a sound ‘working knowledge’ of finances and an associated ability to engage in decision making with the support of his extended family. The question remained as to whether or not there was enough evidence to support a decision not to give him responsibility for a sizable interim payment. The Mental Capacity Act is clear in its emphasis on the ‘assumption of capacity’, the need to identify unequivocal evidence to displace this assumption before introducing active support, intervention, professional oversight and application to the Court of Protection.
Ravi was yet to realise the potential benefits of further community based assessment and rehabilitation which would have afforded us greater information regarding his functional abilities, augmenting the psychometric evidence and providing a clearer view of his potential vulnerability secondary to the noted cognitive changes. On balance, the question of Ravi’s capacity to manage his financial affairs needed to be treated with caution and left open to future review and reassessment, dependent upon broader behavioural evidence, his further progress with rehabilitation and ability to manage the increasing responsibilities associated with his own ‘new normal’.