Forensic Psychiatry 2 Flashcards
What are the options once a suspect is in custody?
Bail with conditions until court hearing
No bail - await court hearing
What should happen if someone in custody is suspected to have a mental disorder?
An appropriate adult must be informed and asked to attend the station
What guidelines are used when a person with mental disorder is in custody?
Police and Criminal Evidence Act
Who do police send information to re charges against a suspect?
Crown Prosecution Service
Who decides if prosecution against a suspect should continue?
CPS
When will CPS continue a prosecution?
If public interest outweighs any other concerns
Options for the suspect after first court hearing
Bail into community with conditions
Remanded in custody depending on severity of offence
Remanded to hospital for assessment of MH
Which courts can remand a suspect to hospital for assessment of MH?
Magistrates
Crown Court
How long can courts remand suspect to hospital for assessment?
12 weeks under S35
28 days under S36 - Crown court only
Purpose of S35
Provide court with a report on the persons mental disorder
What happens if the crown court finds someone unfit to plead?
There will be a trial of facts to decide if the individual committed the accused act
Outcomes after full trial or trial of facts
Absolute discharge (acquittal)
Probation or health supervision order (conditional discharge)
Prison
Hospital care
What is a supervision order?
allows individual to receive support and treatment with aid os social worker.
Purpose of guardianship order under s37
Ensure offender receives care and protection in community (rather than medical treatment) although guardian has power to require offender to live at specific place and attend specific places at specific times for medical treatment
How long does guardianship order last?
6 months
Who can renew S37?
RC
Time limit of S41?
None
What does S41 mean for the RC?
RC needs the permission of the MoJ to allow leave or d/c from hospital
Hospital managers have no power to d/c
What happens if a prisoner was given a fixed term sentence which has expired while the prisoner is in hospital?
Section 49 restriction is removed and section is converted ‘notionally’ to S37
Emphasis of community forensic teams
Step down in physical and procedural security
Stepping up in therapeutic care
Models for care by community forensic teams
Parallel Care
Integrated Care
Hybrid Care
What is the parallel care model?
Both IP medium secure care and community care provided in parallel with same service.
Advantages of parallel care model?
Ensures full long-term community service that is continuous with IP care
What is integrated care model?
Upon d/c, general psychiatric services provide longer-term rehab. They will handle readmissions that do not require escalation in security.
What is the hybrid care model?
Based on integrated services but includes period of shared care in weeks/months after d/c.
What is probation?
Serving a sentence in the community
How many supervised offenders are under probation when d/c from secure institutions?
70%
Roles of a probation officer
Assessing offenders prior to sentence
Monitoring progress of offenders sentenced to prison
Advising parole board
Supervision of offenders released on licence & recall
Supervising compliance with community sentencing & reporting breaches to court
Advising offenders on services/local resources
Directly providing support
How many prisons in the UK have prison inreach service?
87%
What is National Offender Management Service?
Joins up prison and probation services.
Conducts research and advises the UK govt on strategies and policies
Which offenders are deemed MAPPA eligible?
MDO convicted of a specified sexual or violent offence and sentenced for >12 months or detained in hospital setting or on conditional d/c
What does MAPPA do?
Provides framework for interagency collaboration and communication to ensure successful management of violent and sexual offenders
What is used to determine level of security?
Weighing up need for safety vs therapeutic objective
How can observation levels be categorized
General obs
Intermittent
Within eyesight
Within arms length
What is general obs?
Location known at all times but not within eyesight
Who is placed on intermittent obs?
Risk of violence/attempting suicide
Who is placed on eyesight obs?
High & imminent risk of violence/suicide
Who is placed on arms length obs?
High risk of acting very quickly if opportunity arises
What is decision for temporary leave from secure units based on?
Stability of mental state and risks Insight Rapport with staff Engagement with treatment and rehab Patients past behaviour when on leave
What should S17 leave forms state?
Purpose and conditions
What is the most significant cause of morbidity in prisons?
MH problems
How many prisoners have MH problems
90%
Mental disorders in sentenced male prisoners
37%
Mental disorders in men on remand
63%
Mental disorders in sentenced female prisoners
57%
Mental disorders in women on remand
76%
How many male and female prisoners receive 2+ diagnoses
25% - men
33% - women
Sentenced males who have psychosis
2.4%
Sentenced males who have neurosis
6%
Sentenced males who had PD
9%
Sentenced males who have substance misuse
22%
Sentenced females who have psychosis
1%
Sentenced females wo have neurosis
15%
Sentenced females who have PD
16%
Sentenced females who have substance misuse
30%
Remanded males who have psychosis
6%
Remanded males who have neuroses
15%
Remanded males who have PD
11%
Remanded males who have substance misuse
39%
Remanded females who have psychosis
4.5%
Remanded females who have neurosis
43%
Remanded females who have PD
15%
Remanded females who have substance misuse
41%
Most prevalent PD in prisoners (men)
Antisocial PD
Paranoid PD
(in that order)
In prisons how much of the psychosis is due to psychoactive substances?
25%
How many deaths in prison are self-inflicted?
Half
Most common method of suicide in prison
Hanging
Prevalence of suicide in prison
8x higher than general population
When do majority of suicides occur in prison?
Within 6 months of imprisonment
Which prisoners have higher rates of suicide?
Life-sentence
Remand
Young offenders
Violent offences
Most common psychiatric common in prisoners who commit suicide
Alcohol and substance misuse
How did the Butler Committee describe dangerousness?
Propensity to cause serious physical injury or lasting psychological harm.
What has the term dangerousness been replaced with?
Risk assessment and management
Problems with predicting risk
Low base rate
Multifactorial
Unknown interactions
What does low base rate of violence mean?
Predictive value will be low
False positive rate
How can risk factors be categorised?
Static
Stable
Dynamic
Who categorised risk into static, stable and dynamic?
Bouch and Marshall 2003
Describe stable risk factors
Long term, enduring but modifiable to some extent
What can happen to dynamic risk factors if not addressed promptly?
Can act synergistically and multiply the effect of static and stable risk factors
Problems in risk management identified by Homicide Inquiries
Failure to take carers view into consideration
Undue emphasis on civil liberties of patients
Failure to implement MHA properly
Tendency to take cross-sectional rather than longitudinal view of risk
Failure to share information
What happens in a clinical approach to risk?
Clinicians subjective judgement informed by experience and knowledge is used to estimate risk and guide decisions about treatment.
How many clinical judgements have been found to be correct re risk?
33%
How does the actuarial approach work for risk?
Use of formal, algorithmic and objective procedures to quantify risk as probability of future outcome.
Advantages of actuarial approach to risk
Superior to other methods of predicting risk of violence and sexual offending
Disadvantages of actuarial approach to risk
Does not inform clinician about risk factors that need to be targeted
High false positive
Historical aspects given more importance
Difficult in generalisation
Too much focus on static and stable risk factors
What is structured professional judgement?
Combines evidence base for risk factors with individual clinical assessment to complement psychiatric opinion.
What types of assessments are used in structured professional judgement?
Structured, scale-based assessment
Who created the stages of risk assessment and management
Bouch & Marshall
Stages of risk assessment and management
Identify need for full structured risk assessment
Assess static, stable, dynamic and future risk factors and consider protective factors
Individual formulation of risk applied to context of current presentation
Consider possible interventions and level of support required
Anticipate impact of possible interventions
Develop management plan with specified short and long term implications
Review and revise management plan with variations in risk factors
Name some structured risk tools
HCR 20
SARA
SCR 20
Who created HCR 20?
Webster
Advantages of HCR 20
Good inter-rater reliability
Useful in predicting IP violence and community violence in d/c patients
Historical items in HCR 20
Previous violence Young age at first incident Unstable relationships Major MI Substance use Psychopathy Employment issues PD Early maladjustment Previous supervision failure
Clinical items in HCR 20
Negative attitudes to health services Active sx Impulsivity Treatment unresponsiveness Lack of insight
Risk items in HCR 20
Management plan lacks feasibility Exposure to destabilisers Non-compliance Stress Lack of personal support
What does SARA stand for?
Spousal assault risk assessment
Structure of SARA
20 item set of risk factors for use of assessment of spousal assault
Structure of SVR 20
20 item guide to assess violence risk in sex offenders
How are actuarial instruments created?
Group data from high risk individuals is applied to patients in question
Gives group risk
Name some actuarial instruments for risk
VRAG Violence Risk Scale PCL-R Static-99 SORAG
Who created VRAG?
Quinsley 1995
What does VRAG stand for?
Violence Risk Appraisal Guide
What is VRAG based on
Historical factors only
Where was VRAG validated?
Canadian prisons
Structure of VRAG
12 items including PCL_R as subscale
Items of VRAG
PCL-R Elementary school difficulties PD Younger age Separated from parents before 16 Never married Absence of schizophrenia Victim injury Alcohol abuse Female victim Failed conditional release/supervision order Hx of non-violent offence
Structure of Violence Risk Scale
23 dynamic
6 static variables
Uses of PCL-R
To diagnose Psychopathy, informs risk assessment and treatment decissions
Scores of PCL-R?
0-40 score range
0-2 for each item
20 items in total
Cut off for psychopathy in PCL-R?
25
Who created Static-99?
Hanson and Thornton
Who is Static-99 aimed at?
Adult male offenders of at least 18 years of age at time of release to community
What does SORAG stand for?
Sexual Risk offender appraisal guide
Structure of SORAG
14 item instrument that incorporates PCL-R
What is actus reus?
Act of crime
What is mens rea?
Intent of crime
Psychiatric defence before trial
Fitness to plead
Psychiatric defences during sentencing
Psychiatric mitigation
Psychiatric defences during a trial
Not guilty by reason of insanity
Infanticide
Automatism
Diminished responsibility
What is fitness to plead?
Mental abilities to comply with trial proceedings
What is used to test fitness to plead?
R v Pritchard criteria
What are the R v Pritchard criteria?
An individual is found unfit to plead if found incapable of: understanding charge Deciding whether to plead guilty or not Exercising right to challenge jurors Instruct solicitors and counsel Follow course of proceedings or Give evidence in their evidence
What Act is used for fitness to plead?
Criminal Procedures Act 1964
What does the Criminal Procedures Act 1964 state re fitness to plead?
2 medical practitioners must give evidence in support of fitness to plead
How must fitness to plead be proven if raised by prosecution?
Beyond reasonable doubt
How must fitness to plead be proven if raised by the defence?
Balance of probabilities
What are the components of the McNaughten Rules 1843
Defect of reason (impaired)
Due to disease of mind
Leading to loss of appreciation of nature and quality of act
So accused did not realise what he was doing was wrong
Who does burden of proof for McNaughten Rules lie with?
The defence
Who decides if the defence of McNaughten rules is suitable?
Jury
What does diminished responsibility do?
Reduce charge of murder to manslaughter
What is needed for diminished responsibility to be upheld?
Defending counsel must demonstrate absence of mens rea.
Which group of offenders are more likely to get charge of manslaughter than murder?
Females
Those with no criminal records
Legalities involved in intent for the crime
Mens rea for offence or recklessness
Specific jurisdictions e.g. obscurity of a violated law
Sx that can prevent formation of relevant mental thoughts processes
Specific delusions relevant to situation
Abnormal mood state or associated psychomotor changes or impaired concentration
Severe cognitive impairment
What occurs if diminished capacity is upheld?
Acquittal or conviction for lesser offence may ensue
What is automatism as a plea?
Plea by defendant that his actions were not under the control of his conscious mind
What happens if plea of automatism is successful?
Will negate the conduct element of actus reus of any offence with which defendant is charged
Legal classification of automatism?
Sane automatism
Insane automatism
What is sane automatism?
Act is one off
What happens if sane automatism is held?
Complete acquittal is possible
What is insane automatism?
Likely to recur
What happens if insane automatism is held?
Likely to lead to psychiatric disposal
What is another name for sane automatism?
Automatism simpliciter
Examples of sane automatism
Hypoglycaemia
Night terror
Dissociative states
What can counsel plead if insane automatism is held?
Not guilty by reason of insanity
Examples of insane automatism
Night walking
Epilepsy
Hypoglycaemia due to recurring condition
How have the courts limited the defence of automatism?
Where the defendant exercised some control
Where the condition can be brought within the ambit of the rules on insanity
Where was prior fault on part of the defendant
What happens if insane automatism is upheld for a charge of murder?
Indefinite stay in a psychiatric unit
Who created the list that supports sleep walking as an automatism defence
Fenwick, 1990
Features that support sleep walking as an automatism defence
Family or childhood hx of sleep walking
Occurring within 2 hours of sleep onset (non REM)
Inappropriate behaviour with element of confusion witnessed
Presence of trigger factors
Substantial amnesia
No attempts to conceal crime
Lack of sexual arousal if crime is sexual in nature
What can lead to outcome of culpable homicide?
Diminished responsibility
What does culpable homicide mean?
Lack of specific or evil intent to kill but murder has taken place
What is voluntary culpable homicide?
Death resulting from intentional reckless act but because of provocation or diminished responsibility
What is involuntary culpable homicide?
Death is unintended but occurs as a result of an assault or negligence.
What is involuntary intoxication?
Someone unwittingly taking a ‘spiked’ drink or automatism occurring as SE of medical treatment.
Examples of involuntary intoxication
Drink being spiked
Taking drug px by medical practitioner
Using substance that is not dangerous but in a reckless manner
Using substance as a result of irresistible impulse
What can involuntary intoxication be used as?
Mitigating factor to reduce sentencing or acquittal
What factors are mitigating i.e. reduce culpability of the defendant
Being provoked Age or vulnerability Mental disorder or LD Involuntary intoxication Showing remorse Having limited role in the offence
Factors associated with claims of amnesia during defence
Violence - especially homicide
Extreme emotional arousal
Alcohol abuse and intoxication
Depressed mood
Which disorders may be relevant to claims of amnesia?
Psychosis Epilepsy Hysterical personality traits Parasomnias Organic brain disorder Hypoglycaemia HI
What type of amnesia has no legal implications?
Amnesia in the absence of automatism
What is used to assess test for fitness to give evidence?
Understanding the question
Applying their mind to answering them
Conveying the answers intelligibly to the jury
What types of false confessions are there?
Voluntary
Coerced-compliant
Coerced-internalised
Factors influencing false confessions
Situational
Individual
How to assess whether a false confession has been made
Reviewing transcripts
Assessing vulnerabilities, cognitive status, intelligence and mental disorder
Tasks of the psychiatrist in the criminal justice system
Assessing suspects brought under custody who may be mentally ill
Advising on MH diversion and attending to medical needs
Advising on fitness to be interviewed and need for appropraite adult
Advising on fitness to plead and stand trial
Arranging hospital transfer whilst on remand
Providing solicited advice regarding sentencing options
Good medical practice in writing reports
Must be honest and trustworthy
Do your best to make sure any documents written or signed are not false or misleading.
Take reasonable steps to verify information in documents.
Must not deliberately leave out relevant information.
If you have agreed to prepare a report, complete or sign a document or provide evidence, you must do so without unreasonable delay.
If you are asked to give evidence or act as a witness in litigation or formal enquiries, you must be honest. You must make clear limits of your knowledge or competence.
Types of witnesses in court
Ordinary (witness of fact)
Professional (to comment on clinical state)
Expert (write reports or statements to court regarding specific issue)
What type of expertise do expert witnesses provide to court proceedings?
Advisory
Actuarial
Clinical
Experimental (evidence)
What is Article 2?
Right to life
How is Article 2 linked to forensic patients?
State has positive duty to safeguard prisoners and others in custody
What is Article 3?
Prohibition of torture and degrading treatment
What is Article 5?
Right to personal liberty
Which Article brought about the creation of DOLS?
Article 5
What is Article 8?
Right to private and family life
