Civil Admissions Flashcards
section 72
discharge by a tribunal (every detention period)
section 2 + days
application for assessment (28 days)
section 3 + days
application for treatment (28 days) usually in a home, can be prison or doctors
section 4 + time
emergency application for assessment (72 hours)
section 5 + time
Doctors 5(2) and nurses 5(4) holding power - 6 hours, 7 to hours
Winterbourne View and Bubb Report
led to increased calls for scrutiny over decisions to remove people with learning disabilities in their homes.
Winterborne View
showed the perils of taking seriously the principle of LR, scandal of warehousing 10,000s learning disabled people receiving no care or support but each had a review prior to being detained. Patients must be continuously assessed.
Connor Sparrowhawk
drowned in a bath whilst having a seizure unsupervised, death contributed to by negligence in the hospital trust.
convicted of breach of 3(1) health and safety at work act 1974
No Voice Unheard no Rights Ignored 2015
2 recommendations
Recommended:
1. introduction of regulations to require more explicit recording of why P cannot be looked after at home
2. exploring whether there should be increased right to challenge decisions to admit
Gov responded positively in green paper but no change yet
Assessment section 2
The disorder is ‘of a nature or degree which warrants the detention of the patient in a hospital for assessment’ (followed by treatment)
Treatment section 3
The disorder being ‘of a nature or degree which makes it appropriate for him to receive medical treatment in hospital’ treatment cannot be provided unless the patient is detained
Phil Fennell relapsing patient
if the p’s history indicates a strong likelihood of relapse, p’s should be re-admitted before relapse occurs. It is not necessary to wait for p’s psychosis to ‘ripen’ before admission
R v MHRT for South Thames Region ex p Smith
where p has episodic and relapsing condition, entirely legitimate to preventatively detain, conflict between this and human rights
CM v Derbyshire
following convictions for violence and paranoid schizophrenia, hospitalised. free from psychosis symptoms for over 10 years, no relapse following discharge but returned for drug use alone. the nature of the disorder did not mandate the return or continued residence.
Lawful section 3 detentions showing “no magic in a bed”
CS v MHRT
attendance at the ward round every four weeks
B v Barking
inpatient monitoring and assessment every week, lived at home Thursday to Monday
KL v Somerset
attendance at a community mental health ‘base’ fortnightly and meetings with a key worker for outpatient reviews
criteria for admission s3, renewal s20, discharge s72
“medical treatment which is appropriate in his case, taking into account the nature and degree of the mental disorder and all other circumstances” s3(4)
definition of medical treatment s145
“Includes nursing, psychological intervention and specialist health habilitation, rehabilitation and care”
key focus of section 3
“the purpose of which is to alleviate, or prevent a worsening of, the disorder or one or more of its symptoms or manifestations”
Code of Practice 23.13
Medical treatment must always be an appropriate response to the condition
Code of Practice 23.14
Medical treatment must be actually available to P
Code of Practice 23.17
may be patients whose particular circumstances mean treatment may be appropriate even if it consists only of nursing and specialist day to day care
Code of Practice 23.18
simply detaining someone, even in hospital does not constitute medical treatment
Conflict between section 23.13, and 23.14 with 21.17
How can treatment be an appropriate response and actually available whilst not being proper treatment beyond day to day care?
MD v Nottinghamshire Health Care NHS Trust
MD detained for violence, claimed detention was unlawful as no appropriate treatment was available. held he benefitted from care and milieu therefore apt treatment was available
Article 5
the patient must reliably be shown to be of unsound mind, of a kind warranting compulsory confinement, validity of such depends on the persistence of the disorder (Winterwerp)
Reid v UK
argued by being a psychopath he was untreatable therefore unlawful to detain, P must be established as suffering from a mental disorder of the kind warranting compulsory confinement, this may be necessary even when P needs control and supervision to prevent harm to himself or others.
National law greater degree of protection than ECHR
Partnerships in Care v W
antisocial personality disorder, string of convictions, difficult to distinguish between appropriate treatment from mere detention, key lies in 145(4)
145(4)
Purpose of treatment must be to benefit the patient, if the purpose is to prevent a worsening of symptoms or manifestations likely to constitute apt treatment likely to amount to this
Cheshire and wirral NHS trust v Z
definition of treatability is to alleviate or prevent a worsening of the disorder or one or more of its symptoms or manifestations, here not best interests to treat
Why are patients admitted?
Mental Health Act Commission 11th Biennial Report 2005
of 111 patients at risk to themselves, 25% self neglect, 75% self harm/suicide.
of 133 patients risk to others, 1/3 property/people and 2/3 threatening behaviour NO violence reported.
Code 4.8 assessing risk, must take into account..
not always possible to differentiate risk of harm to patient to others, reliability of evidence, willingness/ability of people living with P to cope
R ex parte IH
mutilated son, convicted criminally, moved to hospital, tribunal eventually agreed to discharge, nobody would take him. Tribunal only a recommendation
Adshead et al (r ex parte IH)
“risk to public welfare consisted only that Mr H might not cooperate, and this may lead to a breakdown in therapeutic alliance, might lead to future violence”
Art 5 Reid v UK
protection of others is a legitimate basis for detention
Art 5 winterwerp
existence of mental disorder of a sufficient degree must be established on the basis of objective medical expertise
MacArthur study
1 in 4 of the ‘highest risk category’ not dangerous in 12 months following discharge
Hare’s PLC-R study
2 in 3 ‘highest risk category’ had not violently reoffended in 7 years
Quinlivan et al
assessment tools are no more effective at predicting risk of self harm than psychiatric intuition or patient’s self-evaluation
Gunn et al 1999
No increased rates of incapacity for blood test for those with schizophrenia and those with no disorder
Okai 2007
Frequency of incapacity in psychiatric in patients does not differ greatly from that for general hospital in patients
Cairns 2005
43.8% of psychiatric patients lacked capacity for treatment decisions for mental disorder
Code of Practice 1.8
A patients past present wishes and feelings should be considered as far as reasonably ascertainable, should be encouraged and supported to develop advance statements
Code of Practice 14.14
Informal admission is usually appropriate when a patient with capacity is consenting
Code of Practice 14.16
compulsory admission should be considered where a p’s current mental state with evidence likelihood they will change their mind regarding informal admission
Code of Practice 14.17
threat of detention should not be used to coerce a patient to consent to voluntary admission or treatment
The Richardson Approach
- Capacity can be overridden but only with substantial risk of serious harm to themselves or others
- Reference to positive clinical measures, disagreed being in a clinic alone is treatment, preferred empowerment!
Mental Health (Care and Treatment) (Scotland) Act 2002
disorder, decision ability significantly impaired, necessary for assessment or treatment, significant risk to patient or another, detention certificate is necessary
Northern Ireland Mental Capacity (Northern Ireland) Act 2016
Fused MC and MH legislation. Civil admission for ‘impairment or disturbance in functioning of the mind or brain’ only facilitated if lacking capacity or with capacity and agrees. No admission for those with refusing.
Dr’s holding powers under s5
- must already be an inpatient
- Dr, must be of the view application ought to be made
- Max 72 hours
Nurses holding powers
- Must be receiving treatment for disorder as an inpatient
- Suffering from disorder
- To such a degree necessary for health/safety/protection immediately restrained from leaving hospital
- Not practicable for dr to exercise power
- Max 6 hours
Emergency s4
- Made by AMHP or NR
- Urgent necessity for patient to be admitted under s2
- Compliance with 2 med prof unnecessary delay
- Max 72 hours detention
- Can be converted to s2 if second recommendation is supplied in 72 hours
Assessment s2
- AMHP or NR
- Patient suffering from disorder
- Of a nature or degree warranting detention in hospital for assessment and
- P ought to be detained in interests of own health or safety with a view to protect others
- 28 days (can also be treated against their will)
Treatment s3
- AMHP or NR
- Suffering from disorder
- Of a nature or degree appropriate to receive treatment in hospital
- Treatment cannot be provided unless P is detained
- Necessary for health or safety or protection to receive treatment
- App treatment available
- Automatic referral to MHRT within 6 months - longest period under civil powers
14.27 S2 only used if:
this is controversial, just because someone has had several episodes doesn’t mean they wouldn’t benefit from full assessment
- the full extent of nature and degree of condition is unclear
- need to carry out initial inpatient assessment in order to formulate a treatment plan or judge if they will accept voluntary
- need to assess for a new treatment plan or acceptance on voluntary basis
14.28 s3 only used if:
- already detained under s2
- nature and current degree, essential elements of a treatment plan to be followed and likelihood of acceptance are already sufficiently established to make it unnecessary to undertake a new s2 assessment
Renewal of detention s20
renewal for 6 months, 6 months, 1 year, responsible clinical reports to hospital managers a P has a mental disorder making it appropriate to receive treatment in hospital, necessary for health/safety/protection, appropriate treatment is available
AMHP nearest relative objections under s2 and s3 after duty to consult
does not invalidate admission under s2
does invalidate admission under s3
Peay 2003 nearest relative objection acts as
brakes
Nearest relatives
can veto applications for treatment, have to be consulted about admission, can apply for discharge but can be vetoed or displaced by court for unreasonable objections, P can now petition for the removal of an NR
Nearest relatives
Spouse, couple living as such for 6 months son or daughter father or mother brother or sister grandparent grandchild uncle or aunt nephew or niece unrelated living for 5 years
TW v Enfield BC
AMHP does not consult with NR about s3 as P didnt want them to, AMHP concluded it wasn’t reasonably practicable, hadn’t considered art 5 therefore £23,000 settlement
MH v UK unreasonable objection
P downs syndrome, mother objected under s2, sought to displace her, P unacceptable level of risk at home. If this happens then s2 can run indefinitely over 28 days
Code of Practice guidance deciding whether to apply to displace NR
Any reason to think they have or will suffer abuse by NR, whether P is afraid of NR or seriously distressed at them being the NR, or unknown/ distant relationship
Ontario
No patients may be treated without his or her informed consent
Committee for the Prevention of Torture, established by the Council of Europe
The admission of a person to a psychiatric establishment on an involuntary basis should not be construed as authorising treatment without his consent. Every patient voluntary or involuntary should be given the opportunity to refuse treatment.
Lady Hale in Broadmoor dissenting
Our threshold of capacity is rightly a low one. It is better to keep it that way and allow some non-consensual treatment of those who have capacity than to set such a high threshold for capacity many would never qualify.
Bartlett
Believes need a new mental health act … and we should ensure incapacity is the criterion for compulsory treatment.
Capacity cannot provide the sole legal framework for psychiatric detention.
Article 5 ECHR
“Everyone has the right to liberty and security of person. No one shall be deprived of his liberty save in the following cases and in accordance with a procedure prescribed by law; … (e) the lawful detention of persons of unsound mind.”
Four things to consider prior to making admission
- LRA
- Dangerousness/risk
- Treatability
- Capacity
MHA commission relapsing patient
Must be reliable evidence of a continuing unsoundness of mind, the nature of which warrants compulsory detention, evidence would need to be sufficiently compelling that it could properly be said that the individual ought to be deprived of his or her liberty in the interests of h/s/p
Stojanovski
Breach of art 5 when his condition was no longer of the nature or kind warranting compulsory confinement
Ramsey et al 1999
P’s with anorexia nervosa sectioned under the act did less well than those who were not sectioned. Using compulsion can damage the trusting relationship between dr and p
M v SOS for health
High Court ruled the Act’s provisions concerning the patient’s nearest relative breached Article 8 of the EU Convention. The fact that a patient has no means of challenging the appointment of a person as NR was in violation of a person’s right to respect for their private life.
St George’s self-neglecting behaviour
There has to be some concern with a degree of confidence the self-neglecting behaviour is symptomatic of the mental disorder. Taking someone to hospital is for the disorder not the treatment
