Page 1460 - 6. 2016 Diary 1st half New 26-05-21 No Table

-Insight: limited. Aware of reasons for admission but does not agree that he may have a
mental illness
Social and Personal Hx:
-Lives alone in 1-bedroom flat which he says he owns outright
-Mother lives nearby and provides support
-Simon says he has siblings and other extended family in the local area as well
-In a relationship, on and off with partner for 20 years (Katie). Simon told us that Katie lives
with him and is expecting his child. Declined to say when the baby is due to be born as he felt
this was too personal to share.
-Says he runs his own company at the moment (see details above)
-Past history of sexual abuse (from notes)
Family Hx:
-grandmother (? maternal) had BPAD and/or schizophrenia
66
Forensic Hx:
-frequent contact with police from a young age, says he has been to prison in the past but was
unable to say exactly when this was
-Says he is currently subject to an ASBO due to playing loud music
Physical Health:
-Previous notes state that Simon has Crohn's according to his mother. Simon denied this and
is not currently seeing anyone for this and is not taking any medication -Denied any other
physical health problems
-Simon was not fully examined as he was becoming increasingly aroused through the
interview -Obs noted to be NAD on admission -GCS 15/15
-Mobilising independently, normal gait
Risk Summary:
-to self: denied any thoughts of self-harm or suicide -to others: denied any thoughts to harm
others
-from others: vulnerable when unwell - need to explore whether he is being financially
independent.
-disengagement: highly likely to disengage
-Substance misuse: denied using drugs, cigarettes or alcohol
Plan:
1. Admit under Section 2 of MHA
2. 15 min obs
3. UDS to be done please
4. Physical and bloods to be done by day team please
Medication chart written

23
The Doctor’s Folder / pub Book Issue: 5!
Stage 5
Folder 5
Originator Details: 16 Aug 2016
Last Amended by Details: 16 Aug 2016
Hugh Briscoe
Page Numbers:66
Originator Details: 16 Aug 2016 04:44
Hugh Briscoe Social Worker
Originally Entered by Details: 16 Aug 2016 04:58