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
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
3
Q
What guidelines are used when a person with mental disorder is in custody?
A
Police and Criminal Evidence Act
4
Q
Who do police send information to re charges against a suspect?
A
Crown Prosecution Service
5
Q
Who decides if prosecution against a suspect should continue?
A
CPS
6
Q
When will CPS continue a prosecution?
A
If public interest outweighs any other concerns
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
8
Q
Which courts can remand a suspect to hospital for assessment of MH?
A
Magistrates
Crown Court
9
Q
How long can courts remand suspect to hospital for assessment?
A
12 weeks under S35
28 days under S36 - Crown court only
10
Q
Purpose of S35
A
Provide court with a report on the persons mental disorder
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
12
Q
Outcomes after full trial or trial of facts
A
Absolute discharge (acquittal)
Probation or health supervision order (conditional discharge)
Prison
Hospital care
13
Q
What is a supervision order?
A
allows individual to receive support and treatment with aid os social worker.
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
15
Q
How long does guardianship order last?
A
6 months
16
Q
Who can renew S37?
A
RC
17
Q
Time limit of S41?
A
None
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
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
20
Q
Emphasis of community forensic teams
A
Step down in physical and procedural security
Stepping up in therapeutic care
21
Q
Models for care by community forensic teams
A
Parallel Care
Integrated Care
Hybrid Care
22
Q
What is the parallel care model?
A
Both IP medium secure care and community care provided in parallel with same service.
23
Q
Advantages of parallel care model?
A
Ensures full long-term community service that is continuous with IP care
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.
25
What is the hybrid care model?
Based on integrated services but includes period of shared care in weeks/months after d/c.
26
What is probation?
Serving a sentence in the community
27
How many supervised offenders are under probation when d/c from secure institutions?
70%
28
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
29
How many prisons in the UK have prison inreach service?
87%
30
What is National Offender Management Service?
Joins up prison and probation services.
| Conducts research and advises the UK govt on strategies and policies
31
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
32
What does MAPPA do?
Provides framework for interagency collaboration and communication to ensure successful management of violent and sexual offenders
33
What is used to determine level of security?
Weighing up need for safety vs therapeutic objective
34
How can observation levels be categorized
General obs
Intermittent
Within eyesight
Within arms length
35
What is general obs?
Location known at all times but not within eyesight
36
Who is placed on intermittent obs?
Risk of violence/attempting suicide
37
Who is placed on eyesight obs?
High & imminent risk of violence/suicide
38
Who is placed on arms length obs?
High risk of acting very quickly if opportunity arises
39
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
```
40
What should S17 leave forms state?
Purpose and conditions
41
What is the most significant cause of morbidity in prisons?
MH problems
42
How many prisoners have MH problems
90%
43
Mental disorders in sentenced male prisoners
37%
44
Mental disorders in men on remand
63%
45
Mental disorders in sentenced female prisoners
57%
46
Mental disorders in women on remand
76%
47
How many male and female prisoners receive 2+ diagnoses
25% - men
| 33% - women
48
Sentenced males who have psychosis
2.4%
49
Sentenced males who have neurosis
6%
50
Sentenced males who had PD
9%
51
Sentenced males who have substance misuse
22%
52
Sentenced females who have psychosis
1%
53
Sentenced females wo have neurosis
15%
54
Sentenced females who have PD
16%
55
Sentenced females who have substance misuse
30%
56
Remanded males who have psychosis
6%
57
Remanded males who have neuroses
15%
58
Remanded males who have PD
11%
59
Remanded males who have substance misuse
39%
60
Remanded females who have psychosis
4.5%
61
Remanded females who have neurosis
43%
62
Remanded females who have PD
15%
63
Remanded females who have substance misuse
41%
64
Most prevalent PD in prisoners (men)
Antisocial PD
Paranoid PD
(in that order)
65
In prisons how much of the psychosis is due to psychoactive substances?
25%
66
How many deaths in prison are self-inflicted?
Half
67
Most common method of suicide in prison
Hanging
68
Prevalence of suicide in prison
8x higher than general population
69
When do majority of suicides occur in prison?
Within 6 months of imprisonment
70
Which prisoners have higher rates of suicide?
Life-sentence
Remand
Young offenders
Violent offences
71
Most common psychiatric common in prisoners who commit suicide
Alcohol and substance misuse
72
How did the Butler Committee describe dangerousness?
Propensity to cause serious physical injury or lasting psychological harm.
73
What has the term dangerousness been replaced with?
Risk assessment and management
74
Problems with predicting risk
Low base rate
Multifactorial
Unknown interactions
75
What does low base rate of violence mean?
Predictive value will be low
| False positive rate
76
How can risk factors be categorised?
Static
Stable
Dynamic
77
Who categorised risk into static, stable and dynamic?
Bouch and Marshall 2003
78
Describe stable risk factors
Long term, enduring but modifiable to some extent
79
What can happen to dynamic risk factors if not addressed promptly?
Can act synergistically and multiply the effect of static and stable risk factors
80
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
81
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.
82
How many clinical judgements have been found to be correct re risk?
33%
83
How does the actuarial approach work for risk?
Use of formal, algorithmic and objective procedures to quantify risk as probability of future outcome.
84
Advantages of actuarial approach to risk
Superior to other methods of predicting risk of violence and sexual offending
85
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
86
What is structured professional judgement?
Combines evidence base for risk factors with individual clinical assessment to complement psychiatric opinion.
87
What types of assessments are used in structured professional judgement?
Structured, scale-based assessment
88
Who created the stages of risk assessment and management
Bouch & Marshall
89
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
90
Name some structured risk tools
HCR 20
SARA
SCR 20
91
Who created HCR 20?
Webster
92
Advantages of HCR 20
Good inter-rater reliability
| Useful in predicting IP violence and community violence in d/c patients
93
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
```
94
Clinical items in HCR 20
```
Negative attitudes to health services
Active sx
Impulsivity
Treatment unresponsiveness
Lack of insight
```
95
Risk items in HCR 20
```
Management plan lacks feasibility
Exposure to destabilisers
Non-compliance
Stress
Lack of personal support
```
96
What does SARA stand for?
Spousal assault risk assessment
97
Structure of SARA
20 item set of risk factors for use of assessment of spousal assault
98
Structure of SVR 20
20 item guide to assess violence risk in sex offenders
99
How are actuarial instruments created?
Group data from high risk individuals is applied to patients in question
Gives group risk
100
Name some actuarial instruments for risk
```
VRAG
Violence Risk Scale
PCL-R
Static-99
SORAG
```
101
Who created VRAG?
Quinsley 1995
102
What does VRAG stand for?
Violence Risk Appraisal Guide
103
What is VRAG based on
Historical factors only
104
Where was VRAG validated?
Canadian prisons
105
Structure of VRAG
12 items including PCL_R as subscale
106
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
```
107
Structure of Violence Risk Scale
23 dynamic
| 6 static variables
108
Uses of PCL-R
To diagnose Psychopathy, informs risk assessment and treatment decissions
109
Scores of PCL-R?
0-40 score range
0-2 for each item
20 items in total
110
Cut off for psychopathy in PCL-R?
25
111
Who created Static-99?
Hanson and Thornton
112
Who is Static-99 aimed at?
Adult male offenders of at least 18 years of age at time of release to community
113
What does SORAG stand for?
Sexual Risk offender appraisal guide
114
Structure of SORAG
14 item instrument that incorporates PCL-R
115
What is actus reus?
Act of crime
116
What is mens rea?
Intent of crime
117
Psychiatric defence before trial
Fitness to plead
118
Psychiatric defences during sentencing
Psychiatric mitigation
119
Psychiatric defences during a trial
Not guilty by reason of insanity
Infanticide
Automatism
Diminished responsibility
120
What is fitness to plead?
Mental abilities to comply with trial proceedings
121
What is used to test fitness to plead?
R v Pritchard criteria
122
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
```
123
What Act is used for fitness to plead?
Criminal Procedures Act 1964
124
What does the Criminal Procedures Act 1964 state re fitness to plead?
2 medical practitioners must give evidence in support of fitness to plead
125
How must fitness to plead be proven if raised by prosecution?
Beyond reasonable doubt
126
How must fitness to plead be proven if raised by the defence?
Balance of probabilities
127
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
128
Who does burden of proof for McNaughten Rules lie with?
The defence
129
Who decides if the defence of McNaughten rules is suitable?
Jury
130
What does diminished responsibility do?
Reduce charge of murder to manslaughter
131
What is needed for diminished responsibility to be upheld?
Defending counsel must demonstrate absence of mens rea.
132
Which group of offenders are more likely to get charge of manslaughter than murder?
Females
| Those with no criminal records
133
Legalities involved in intent for the crime
Mens rea for offence or recklessness
| Specific jurisdictions e.g. obscurity of a violated law
134
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
135
What occurs if diminished capacity is upheld?
Acquittal or conviction for lesser offence may ensue
136
What is automatism as a plea?
Plea by defendant that his actions were not under the control of his conscious mind
137
What happens if plea of automatism is successful?
Will negate the conduct element of actus reus of any offence with which defendant is charged
138
Legal classification of automatism?
Sane automatism
| Insane automatism
139
What is sane automatism?
Act is one off
140
What happens if sane automatism is held?
Complete acquittal is possible
141
What is insane automatism?
Likely to recur
142
What happens if insane automatism is held?
Likely to lead to psychiatric disposal
143
What is another name for sane automatism?
Automatism simpliciter
144
Examples of sane automatism
Hypoglycaemia
Night terror
Dissociative states
145
What can counsel plead if insane automatism is held?
Not guilty by reason of insanity
146
Examples of insane automatism
Night walking
Epilepsy
Hypoglycaemia due to recurring condition
147
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
148
What happens if insane automatism is upheld for a charge of murder?
Indefinite stay in a psychiatric unit
149
Who created the list that supports sleep walking as an automatism defence
Fenwick, 1990
150
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
151
What can lead to outcome of culpable homicide?
Diminished responsibility
152
What does culpable homicide mean?
Lack of specific or evil intent to kill but murder has taken place
153
What is voluntary culpable homicide?
Death resulting from intentional reckless act but because of provocation or diminished responsibility
154
What is involuntary culpable homicide?
Death is unintended but occurs as a result of an assault or negligence.
155
What is involuntary intoxication?
Someone unwittingly taking a 'spiked' drink or automatism occurring as SE of medical treatment.
156
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
157
What can involuntary intoxication be used as?
Mitigating factor to reduce sentencing or acquittal
158
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
```
159
Factors associated with claims of amnesia during defence
Violence - especially homicide
Extreme emotional arousal
Alcohol abuse and intoxication
Depressed mood
160
Which disorders may be relevant to claims of amnesia?
```
Psychosis
Epilepsy
Hysterical personality traits
Parasomnias
Organic brain disorder
Hypoglycaemia
HI
```
161
What type of amnesia has no legal implications?
Amnesia in the absence of automatism
162
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
163
What types of false confessions are there?
Voluntary
Coerced-compliant
Coerced-internalised
164
Factors influencing false confessions
Situational
| Individual
165
How to assess whether a false confession has been made
Reviewing transcripts
| Assessing vulnerabilities, cognitive status, intelligence and mental disorder
166
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
167
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.
168
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)
169
What type of expertise do expert witnesses provide to court proceedings?
Advisory
Actuarial
Clinical
Experimental (evidence)
170
What is Article 2?
Right to life
171
How is Article 2 linked to forensic patients?
State has positive duty to safeguard prisoners and others in custody
172
What is Article 3?
Prohibition of torture and degrading treatment
173
What is Article 5?
Right to personal liberty
174
Which Article brought about the creation of DOLS?
Article 5
175
What is Article 8?
Right to private and family life
