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MRCPsych Part B > Forensic Psychiatry 2 > Flashcards

Forensic Psychiatry 2 Flashcards

1
Q

What are the options once a suspect is in custody?

A

Bail with conditions until court hearing
No bail - await court hearing

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2
Q

What should happen if someone in custody is suspected to have a mental disorder?

A

An appropriate adult must be informed and asked to attend the station

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3
Q

What guidelines are used when a person with mental disorder is in custody?

A

Police and Criminal Evidence Act

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4
Q

Who do police send information to re charges against a suspect?

A

Crown Prosecution Service

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5
Q

Who decides if prosecution against a suspect should continue?

A

CPS

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6
Q

When will CPS continue a prosecution?

A

If public interest outweighs any other concerns

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7
Q

Options for the suspect after first court hearing

A

Bail into community with conditions
Remanded in custody depending on severity of offence
Remanded to hospital for assessment of MH

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8
Q

Which courts can remand a suspect to hospital for assessment of MH?

A

Magistrates
Crown Court

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9
Q

How long can courts remand suspect to hospital for assessment?

A

12 weeks under S35
28 days under S36 - Crown court only

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10
Q

Purpose of S35

A

Provide court with a report on the persons mental disorder

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11
Q

What happens if the crown court finds someone unfit to plead?

A

There will be a trial of facts to decide if the individual committed the accused act

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12
Q

Outcomes after full trial or trial of facts

A

Absolute discharge (acquittal)
Probation or health supervision order (conditional discharge)
Prison
Hospital care

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13
Q

What is a supervision order?

A

allows individual to receive support and treatment with aid os social worker.

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14
Q

Purpose of guardianship order under s37

A

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

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15
Q

How long does guardianship order last?

A

6 months

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16
Q

Who can renew S37?

A

RC

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17
Q

Time limit of S41?

A

None

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18
Q

What does S41 mean for the RC?

A

RC needs the permission of the MoJ to allow leave or d/c from hospital
Hospital managers have no power to d/c

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19
Q

What happens if a prisoner was given a fixed term sentence which has expired while the prisoner is in hospital?

A

Section 49 restriction is removed and section is converted ‘notionally’ to S37

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20
Q

Emphasis of community forensic teams

A

Step down in physical and procedural security
Stepping up in therapeutic care

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21
Q

Models for care by community forensic teams

A

Parallel Care
Integrated Care
Hybrid Care

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22
Q

What is the parallel care model?

A

Both IP medium secure care and community care provided in parallel with same service.

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23
Q

Advantages of parallel care model?

A

Ensures full long-term community service that is continuous with IP care

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24
Q

What is integrated care model?

A

Upon d/c, general psychiatric services provide longer-term rehab. They will handle readmissions that do not require escalation in security.

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25
Q

What is the hybrid care model?

A

Based on integrated services but includes period of shared care in weeks/months after d/c.

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26
Q

What is probation?

A

Serving a sentence in the community

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27
Q

How many supervised offenders are under probation when d/c from secure institutions?

A

70%

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28
Q

Roles of a probation officer

A

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

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29
Q

How many prisons in the UK have prison inreach service?

A

87%

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30
Q

What is National Offender Management Service?

A

Joins up prison and probation services.
Conducts research and advises the UK govt on strategies and policies

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31
Q

Which offenders are deemed MAPPA eligible?

A

MDO convicted of a specified sexual or violent offence and sentenced for >12 months or detained in hospital setting or on conditional d/c

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32
Q

What does MAPPA do?

A

Provides framework for interagency collaboration and communication to ensure successful management of violent and sexual offenders

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33
Q

What is used to determine level of security?

A

Weighing up need for safety vs therapeutic objective

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34
Q

How can observation levels be categorized

A

General obs
Intermittent
Within eyesight
Within arms length

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35
Q

What is general obs?

A

Location known at all times but not within eyesight

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36
Q

Who is placed on intermittent obs?

A

Risk of violence/attempting suicide

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37
Q

Who is placed on eyesight obs?

A

High & imminent risk of violence/suicide

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38
Q

Who is placed on arms length obs?

A

High risk of acting very quickly if opportunity arises

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39
Q

What is decision for temporary leave from secure units based on?

A

Stability of mental state and risks
Insight
Rapport with staff
Engagement with treatment and rehab
Patients past behaviour when on leave

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40
Q

What should S17 leave forms state?

A

Purpose and conditions

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41
Q

What is the most significant cause of morbidity in prisons?

A

MH problems

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42
Q

How many prisoners have MH problems

A

90%

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43
Q

Mental disorders in sentenced male prisoners

A

37%

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44
Q

Mental disorders in men on remand

A

63%

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45
Q

Mental disorders in sentenced female prisoners

A

57%

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46
Q

Mental disorders in women on remand

A

76%

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47
Q

How many male and female prisoners receive 2+ diagnoses

A

25% - men
33% - women

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48
Q

Sentenced males who have psychosis

A

2.4%

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49
Q

Sentenced males who have neurosis

A

6%

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50
Q

Sentenced males who had PD

A

9%

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51
Q

Sentenced males who have substance misuse

A

22%

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52
Q

Sentenced females who have psychosis

A

1%

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53
Q

Sentenced females wo have neurosis

A

15%

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54
Q

Sentenced females who have PD

A

16%

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55
Q

Sentenced females who have substance misuse

A

30%

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56
Q

Remanded males who have psychosis

A

6%

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57
Q

Remanded males who have neuroses

A

15%

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58
Q

Remanded males who have PD

A

11%

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59
Q

Remanded males who have substance misuse

A

39%

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60
Q

Remanded females who have psychosis

A

4.5%

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61
Q

Remanded females who have neurosis

A

43%

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62
Q

Remanded females who have PD

A

15%

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63
Q

Remanded females who have substance misuse

A

41%

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64
Q

Most prevalent PD in prisoners (men)

A

Antisocial PD
Paranoid PD
(in that order)

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65
Q

In prisons how much of the psychosis is due to psychoactive substances?

A

25%

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66
Q

How many deaths in prison are self-inflicted?

A

Half

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67
Q

Most common method of suicide in prison

A

Hanging

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68
Q

Prevalence of suicide in prison

A

8x higher than general population

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69
Q

When do majority of suicides occur in prison?

A

Within 6 months of imprisonment

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70
Q

Which prisoners have higher rates of suicide?

A

Life-sentence
Remand
Young offenders
Violent offences

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71
Q

Most common psychiatric common in prisoners who commit suicide

A

Alcohol and substance misuse

72
Q

How did the Butler Committee describe dangerousness?

A

Propensity to cause serious physical injury or lasting psychological harm.

73
Q

What has the term dangerousness been replaced with?

A

Risk assessment and management

74
Q

Problems with predicting risk

A

Low base rate
Multifactorial
Unknown interactions

75
Q

What does low base rate of violence mean?

A

Predictive value will be low
False positive rate

76
Q

How can risk factors be categorised?

A

Static
Stable
Dynamic

77
Q

Who categorised risk into static, stable and dynamic?

A

Bouch and Marshall 2003

78
Q

Describe stable risk factors

A

Long term, enduring but modifiable to some extent

79
Q

What can happen to dynamic risk factors if not addressed promptly?

A

Can act synergistically and multiply the effect of static and stable risk factors

80
Q

Problems in risk management identified by Homicide Inquiries

A

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

81
Q

What happens in a clinical approach to risk?

A

Clinicians subjective judgement informed by experience and knowledge is used to estimate risk and guide decisions about treatment.

82
Q

How many clinical judgements have been found to be correct re risk?

A

33%

83
Q

How does the actuarial approach work for risk?

A

Use of formal, algorithmic and objective procedures to quantify risk as probability of future outcome.

84
Q

Advantages of actuarial approach to risk

A

Superior to other methods of predicting risk of violence and sexual offending

85
Q

Disadvantages of actuarial approach to risk

A

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

86
Q

What is structured professional judgement?

A

Combines evidence base for risk factors with individual clinical assessment to complement psychiatric opinion.

87
Q

What types of assessments are used in structured professional judgement?

A

Structured, scale-based assessment

88
Q

Who created the stages of risk assessment and management

A

Bouch & Marshall

89
Q

Stages of risk assessment and management

A

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

90
Q

Name some structured risk tools

A

HCR 20
SARA
SCR 20

91
Q

Who created HCR 20?

A

Webster

92
Q

Advantages of HCR 20

A

Good inter-rater reliability
Useful in predicting IP violence and community violence in d/c patients

93
Q

Historical items in HCR 20

A

Previous violence
Young age at first incident
Unstable relationships
Major MI
Substance use
Psychopathy
Employment issues
PD
Early maladjustment
Previous supervision failure

94
Q

Clinical items in HCR 20

A

Negative attitudes to health services
Active sx
Impulsivity
Treatment unresponsiveness
Lack of insight

95
Q

Risk items in HCR 20

A

Management plan lacks feasibility
Exposure to destabilisers
Non-compliance
Stress
Lack of personal support

96
Q

What does SARA stand for?

A

Spousal assault risk assessment

97
Q

Structure of SARA

A

20 item set of risk factors for use of assessment of spousal assault

98
Q

Structure of SVR 20

A

20 item guide to assess violence risk in sex offenders

99
Q

How are actuarial instruments created?

A

Group data from high risk individuals is applied to patients in question
Gives group risk

100
Q

Name some actuarial instruments for risk

A

VRAG
Violence Risk Scale
PCL-R
Static-99
SORAG

101
Q

Who created VRAG?

A

Quinsley 1995

102
Q

What does VRAG stand for?

A

Violence Risk Appraisal Guide

103
Q

What is VRAG based on

A

Historical factors only

104
Q

Where was VRAG validated?

A

Canadian prisons

105
Q

Structure of VRAG

A

12 items including PCL_R as subscale

106
Q

Items of VRAG

A

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

107
Q

Structure of Violence Risk Scale

A

23 dynamic
6 static variables

108
Q

Uses of PCL-R

A

To diagnose Psychopathy, informs risk assessment and treatment decissions

109
Q

Scores of PCL-R?

A

0-40 score range
0-2 for each item
20 items in total

110
Q

Cut off for psychopathy in PCL-R?

A

25

111
Q

Who created Static-99?

A

Hanson and Thornton

112
Q

Who is Static-99 aimed at?

A

Adult male offenders of at least 18 years of age at time of release to community

113
Q

What does SORAG stand for?

A

Sexual Risk offender appraisal guide

114
Q

Structure of SORAG

A

14 item instrument that incorporates PCL-R

115
Q

What is actus reus?

A

Act of crime

116
Q

What is mens rea?

A

Intent of crime

117
Q

Psychiatric defence before trial

A

Fitness to plead

118
Q

Psychiatric defences during sentencing

A

Psychiatric mitigation

119
Q

Psychiatric defences during a trial

A

Not guilty by reason of insanity
Infanticide
Automatism
Diminished responsibility

120
Q

What is fitness to plead?

A

Mental abilities to comply with trial proceedings

121
Q

What is used to test fitness to plead?

A

R v Pritchard criteria

122
Q

What are the R v Pritchard criteria?

A

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

123
Q

What Act is used for fitness to plead?

A

Criminal Procedures Act 1964

124
Q

What does the Criminal Procedures Act 1964 state re fitness to plead?

A

2 medical practitioners must give evidence in support of fitness to plead

125
Q

How must fitness to plead be proven if raised by prosecution?

A

Beyond reasonable doubt

126
Q

How must fitness to plead be proven if raised by the defence?

A

Balance of probabilities

127
Q

What are the components of the McNaughten Rules 1843

A

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

128
Q

Who does burden of proof for McNaughten Rules lie with?

A

The defence

129
Q

Who decides if the defence of McNaughten rules is suitable?

A

Jury

130
Q

What does diminished responsibility do?

A

Reduce charge of murder to manslaughter

131
Q

What is needed for diminished responsibility to be upheld?

A

Defending counsel must demonstrate absence of mens rea.

132
Q

Which group of offenders are more likely to get charge of manslaughter than murder?

A

Females
Those with no criminal records

133
Q

Legalities involved in intent for the crime

A

Mens rea for offence or recklessness
Specific jurisdictions e.g. obscurity of a violated law

134
Q

Sx that can prevent formation of relevant mental thoughts processes

A

Specific delusions relevant to situation
Abnormal mood state or associated psychomotor changes or impaired concentration
Severe cognitive impairment

135
Q

What occurs if diminished capacity is upheld?

A

Acquittal or conviction for lesser offence may ensue

136
Q

What is automatism as a plea?

A

Plea by defendant that his actions were not under the control of his conscious mind

137
Q

What happens if plea of automatism is successful?

A

Will negate the conduct element of actus reus of any offence with which defendant is charged

138
Q

Legal classification of automatism?

A

Sane automatism
Insane automatism

139
Q

What is sane automatism?

A

Act is one off

140
Q

What happens if sane automatism is held?

A

Complete acquittal is possible

141
Q

What is insane automatism?

A

Likely to recur

142
Q

What happens if insane automatism is held?

A

Likely to lead to psychiatric disposal

143
Q

What is another name for sane automatism?

A

Automatism simpliciter

144
Q

Examples of sane automatism

A

Hypoglycaemia
Night terror
Dissociative states

145
Q

What can counsel plead if insane automatism is held?

A

Not guilty by reason of insanity

146
Q

Examples of insane automatism

A

Night walking
Epilepsy
Hypoglycaemia due to recurring condition

147
Q

How have the courts limited the defence of automatism?

A

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

148
Q

What happens if insane automatism is upheld for a charge of murder?

A

Indefinite stay in a psychiatric unit

149
Q

Who created the list that supports sleep walking as an automatism defence

A

Fenwick, 1990

150
Q

Features that support sleep walking as an automatism defence

A

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

151
Q

What can lead to outcome of culpable homicide?

A

Diminished responsibility

152
Q

What does culpable homicide mean?

A

Lack of specific or evil intent to kill but murder has taken place

153
Q

What is voluntary culpable homicide?

A

Death resulting from intentional reckless act but because of provocation or diminished responsibility

154
Q

What is involuntary culpable homicide?

A

Death is unintended but occurs as a result of an assault or negligence.

155
Q

What is involuntary intoxication?

A

Someone unwittingly taking a ‘spiked’ drink or automatism occurring as SE of medical treatment.

156
Q

Examples of involuntary intoxication

A

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

157
Q

What can involuntary intoxication be used as?

A

Mitigating factor to reduce sentencing or acquittal

158
Q

What factors are mitigating i.e. reduce culpability of the defendant

A

Being provoked
Age or vulnerability
Mental disorder or LD
Involuntary intoxication
Showing remorse
Having limited role in the offence

159
Q

Factors associated with claims of amnesia during defence

A

Violence - especially homicide
Extreme emotional arousal
Alcohol abuse and intoxication
Depressed mood

160
Q

Which disorders may be relevant to claims of amnesia?

A

Psychosis
Epilepsy
Hysterical personality traits
Parasomnias
Organic brain disorder
Hypoglycaemia
HI

161
Q

What type of amnesia has no legal implications?

A

Amnesia in the absence of automatism

162
Q

What is used to assess test for fitness to give evidence?

A

Understanding the question
Applying their mind to answering them
Conveying the answers intelligibly to the jury

163
Q

What types of false confessions are there?

A

Voluntary
Coerced-compliant
Coerced-internalised

164
Q

Factors influencing false confessions

A

Situational
Individual

165
Q

How to assess whether a false confession has been made

A

Reviewing transcripts
Assessing vulnerabilities, cognitive status, intelligence and mental disorder

166
Q

Tasks of the psychiatrist in the criminal justice system

A

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

167
Q

Good medical practice in writing reports

A

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.

168
Q

Types of witnesses in court

A

Ordinary (witness of fact)
Professional (to comment on clinical state)
Expert (write reports or statements to court regarding specific issue)

169
Q

What type of expertise do expert witnesses provide to court proceedings?

A

Advisory
Actuarial
Clinical
Experimental (evidence)

170
Q

What is Article 2?

A

Right to life

171
Q

How is Article 2 linked to forensic patients?

A

State has positive duty to safeguard prisoners and others in custody

172
Q

What is Article 3?

A

Prohibition of torture and degrading treatment

173
Q

What is Article 5?

A

Right to personal liberty

174
Q

Which Article brought about the creation of DOLS?

A

Article 5

175
Q

What is Article 8?

A

Right to private and family life

MRCPsych Part B (64 decks)

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