1. MRCPSYCH COURSE 2014 MHA

2. Structure Part 1: brief, describes the purpose of the act Part 2: sections related to civil detention and compulsion Part 3: court and prison transfers Part 4: consent to treatment Part 5: tribunals

3. MHA : Part 2 S2, S3, S4, S 5/2, S7 (guardianship) S2 –Admission for Assessment  Requires: x2 RMPs, 1 S12 approved the other with prior knowledge of the pt (if practicable) and the applicant (AMHP or NR)  Duration 28/7 or earlier if discharged by ; RC, NR, Hosp Managers or Tribunal  Grounds: see S3

4. MHA S3-Admission for Treatment - Requires :as above & NR must not object to the application -Duration:6/12 or later if renewed or pt is AWOL; earlier if discharged by ; RC, NR, Hosp Managers or Tribunal Grounds: the individual must have or appear to have a mental disorder associated with some risk that cannot be managed or assessed in the community and there is a refusal to accept informal admission.(this can include a risk to their health) S117 aftercare: pts are entitled to this free of charge until it is decided this is no longer necessary

5. MHA S4 Requires: 1RMP, and an applicant (AMHP or NR) Duration:72 hours or earlier if discharged by RC. If is converted to S2 by the other appropriate medical recommendation the 28 days for the S2 starts at the commencement of the S4 Grounds: urgent requirement for detention in which the delay for a S2 would cause an unacceptable delay

6. MHA S5/2 S5/2 RMP or AC in charge of the pt or their nominated deputy Duration:72 hours or as soon as has been assessed for detention under S2 or 3 or is moved from the hospital where they are held Grounds: the RMP/AC/nominated deputy believes there are grounds for detention under S2/3

7. MHA S5/4 S5/4 (Nurses holding power) A qualified mental health or LD nurse may detain an I/P for up to 6hrs.

8. MHA Guardianship S7 (Guardianship) Requires: as for S2 Grounds: pt suffers from a mental disorder of a nature or degree that warrants this for their own welfare or the protection of others Authorises: a decision where the pt must live, a requirement to attend for medical treatment, work, training or education (although these may then be declined), access to the pt by the RMP,AMHP etc

9. MHA S135/6 S135 and 136 (not actually in part 2 of the act) S135 subsection 1: allows an AMHP to gain a warrant allowing a police officer to enter premises in order to allow an assessment where ‘ there is reasonable cause to suspect that a person believed to be suffering from mental disorder a) has been or is being ill-treated, neglected or kept otherwise than under proper control b) being unable to care for himself is living alone in any such place’

10. MHA s135/6 S135 subsection 2) allows a warrant to permitting a PO to enter premises to take or retake a person already detained under the MHA. S136 : enables a PO to remove a person found in a public place to a ‘place of safety’ who the PO believes to be suffering ‘from mental disorder and to be in immediate need of care or control’

11. MHA S135/6 S135&6 Duration: 72 hours or until assessed by an RMP or AMHP The pt may move from one place of safety to another in this time. If the pt hasn’t seen an AMHP after asst they should be offered the opportunity to see one. Purpose: ‘to permit assessment’

12. terminology Mental disorder ‘any disorder or disability of the mind’ Ie extremely broad! exceptions:- if the sole mental disorder is dependency on drugs or alcohol (intox’n or withdrawal though are not excluded) - for S3 people with LD and no other mental disorder may only be detained ‘if the disability is associated with abnormally aggressive or seriously irresponsible behaviour’

13. terminology Learning Disability ‘ a state of arrested or incomplete development of the mind which includes significant impairment of intelligence and social functioning’

14. terminology Nature or Degree: ‘‘nature’ refers to the particular mental disorder from which the patient suffers; its chronicity, its prognosis and the patients previous response to receiving treatment’ ‘‘Degree’ refers to the current manifestation of the patient’s disorder’ Both are ‘inevitably bound up’

15. terminology Medical treatment: includes ‘ nursing, psychological intervention and specialist mental health habilitation (learning new skills) and rehabilitation and care.’ ‘Appropriate treatment is available’ : applicable to treatment orders only This does not have to be the ideal treatment nor does it have to address every aspect of the pt’s condition. It is available even if refused by the pt. The ward milieu may be sufficient to qualify (in no cases yet has the court decided that appropriate treatment was not being provided)

16. terminology RMP Registered Medical Practitioner; need a licence to practice from the GMC (unless acting solely as a medical member of a tribunal) AC Approved Clinician: An RMP, nurse, psychologist, OT, SW who has been approved as an AC and thus may be ‘in charge of the treatment of an informal in-patient and so may make a recommendation under S5/2’

17. terminology RC Responsible Clinician: An AC who has a detained or CTO patient under their care. A patient may only have one RC at any one time but may have more than one AC looking after different aspects of their care at any one time Nominated Deputy: an RMP or AC who has been nominated by the RMP or AC in charge of an INF to act on their behalf with respect to S5/2

18. MHA terminology Nearest relative: defined by a set list; spouse/civil partner> child over 18 (oldest first)>parents (oldest first) etc SOAD : second opinion appointed doctor, appointed by CQC to provide a second opinion for medical treatment for a detained pt (or CTO pt)

19. MHA Process RMPs must ‘make a direct personal examination of the pt’ If neither RMP has previous knowledge of the pt it is recommended that both are S12 approved No more than 5 days between the med recs. (days of the recommendations aren’t counted) AMHP has 14 days from the last med rec to make the application (tho within 24 hrs for S4) Should avoid RMPs and AMHPs with conflicts of interest eg all in same team etc

20. Process For admission to private units; only one RMP may be employed by that hospital (England, neither may be in Wales)

21. MHA Transfer between hospitals. May be transferred if they are detained via use of an applicant ie ; this is allowed therefore by S4, 2 & 3 but not 5/2. Detention in general hospital. To be a detaining hospital there needs to be an RC in that hospital (which could occur via a SLA agreement with the local MH hospital) a general hospital can receive pts on S17 leave and use S5/2 A patient cannot be ‘nominally admitted’ to a Psych hosp and be given immediate leave.

22. MHA S17 leave Leave from the hospital granted by the RC ( may leave the ward without S17) Does not apply to S5/2,5/4, 135 and 136 for which leave cannot be granted or to forensic sections eg S35,36 and restriction orders etc If leave exceeds 7 days, CTO must be considered

23. MHA S17 leave & AWOL Only RCs can grant leave thus senior trainees cannot. Only the RC can rescind leave, this must be in writing S18 Returning Patients who are AWOL May be brought back by hosp staff, an AMHP, police : S135 still required to enter private property If s3 pt has been absent >28/7 they must be examined by the RC within 7/7 to record that ongoing detention is required

24. Community Treatment Orders (CTO) Code of practice: consider if ;history of rpt adm’ns, failure to follow the Rx plan, taking into account the pt’s attitude and insight to treatment. Can only be applied from a non restricted Rx order ie S3 or 37

25. CTO Conditions: -they make themselves available for exam’n by the RC or SOAD if they are required to take medication -they make themselves available for exam’n by RC for renewal of the CTO. Other conditions may be added eg where they live, supervision, medication etc as long as they do not constitute a Deprivation Of Liberty And Are necessary to- ensure the pt receives Rx, -prevent the risk of harm to others or to the pt’s health or safety

26. CTO Breaches of conditions: Recall: must be In writing Can only be by the RC (cannot be delegated) Pt must immediately return to hospital if handed the recall; will be formally AWOL the next day if placed through letter box or on 2 nd working day if posted (1 st class)

27. CTO May be recalled to any hospital May not need to be admitted to a hosp bed Duration up to 72 hrs. RC can cancel the recall at any time. If detained under S2, CTO continues, under S3 CTO is cancelled.

28. CTOs Revocation If the pt requires admission for > 72 hours AND pt meets criteria for detention under a treatment order Treatment order starts again (ie 6/12) Requires RC and AMHP Requires ref to Tribunal

29. Part IV Consent to Treatment for detained pts Medical Treatment includes, nursing,psychological intervention, specialist mental health rehabilitation and habilitation and care S57 Treatment requiring Consent and a second opinion-psychosurgery- surgical implantation of hormones to reduce sex drive in males 2 nd opinion from :2 non-medics to check capacitous and consenting and SOAD

30. Part IV S 58a ECT ECT requires capacitous consent or SOAD Cannot be given if capacitous refusal (except in an emergency under S62) SOAD authorisation for ECT required if pt lacks capacity. Requested by RC. SOAD consults the written Rx plan, 2 professionals involved in the pts Rx (not the RC)and examines the pt. Cannot override advanced directive or objection from court or health and welfare attorney.

31. S58 Treatment requiring Consent OR a 2 nd opinion Required for medication for mental disorder after 3/12 of treatment (prior to this is authorised by S63) capacitous consenting pt: RC certifies the medication categories, max doses and route including ‘prn’ If RC is not an RMP or nurse prescriber the AC for medication certifies.

32. S58 Capacitous refusing or incapacitous pts. SOAD certification of Rx is required SOAD may amend the Rx plan of the Rc but should discuss. There is no appeal against the SOAD Rx plan

33. S62 Urgent Rx Can override the requirements for S58 or 58a Any RMP or Ac who is a nurse prescriber may authorise Urgent means: Immediately necessary to; save a pts life, or prevent a serious deterioration (mustn’t be irreversible) or to alleviate serious suffering or is the minimum intervention to prevent the pt behaving violently or being a danger to themselves.(mustn’t be irreversible or hazardous)

34. S63 Rxs that don’t require the patients consent. 1 st 3/12 of medication for mental disorder Broad definition of medical Rx; nursing, care, psychological Rx etc Medical Rx can be given for the ‘causes or consequences’ of mental disorder being treated under pt IV of the act (S2,3 etc) This includes necessary Ix Can also include eg medical Rx of a paracetamol OD

35. Pt IV and CTOs Medication for mental disorder CTO pts in the community (after the 1 st month in the community) require -Part4a certificate signed by RC if pt capacitous and consenting or SOAD if incapacitous. Meds not on the list can only be given with consent and in an emergency SOAD authorisation required if become incapacitous (but can continue with the meds if consenting whilst waiting if stopping would cause serious suffering) Cannot be prescribed meds without consent or with an advanced refusal

36. Pt IV and CTOs CTO pts on recall No certificate required if <1/12 since start of CTO, otherwise: Capacitous and consenting, can be treated with authority of RC Capacitous and refusing: requires SOAD or S62 if urgent Incapacitous can be required to take meds from Part IVa SOAD certificate

37. PtIV and CTOs Pts whose CTO has been revoked Are subject to Part IV as for any other detained pt If Part IVa is relevant this can be used pending a part IV certificate

38. Part III (Courts and Prisons) May be admitted to hospital under Pre-trial orders S35, 36, Post trial orders 37/41, 38, Transfer Orders 47/49, 48/49

39. Part III S35 -Remand to hospital for report on accused's mental condition Duration 28/7, renewable up to 12 /52 Requires x 1 RMP to give evidence to the court Rx: cannot give Rx without consent Disposal: returns to court (cannot be moved, given leave or discharged)

40. Part III S36 Remand for Rx Requires x 2 RMPs, 1 S12 approved Rx can be given under pt IV RC cannot move, give leave or discharge Dur’n 28/7 can be extended up to 12/52 Disposal: return to court

41. Part III S37 (Treatment Order) Like a S3 imposed after conviction instead of imprisonment Restriction order (S 41) may be imposed by the court ; movement, leave and discharge can only be granted via the Home Office. Often a ‘conditional discharge’ will be made.

42. Part III S38 Interim Order; used following conviction when it is likely but not totally clear that a S37 will be required Duration : 12/52 renewable to 12/12 Disposal: return to court

43. Part III Transfer from Prison S47 Transfer for Rx (inevitably with a S49 restriction) Temporary Rx out of prison (prisoner returns to prison) RC cannot move, grant leave or discharge S48: temporary transfer from prison for Rx when on remand,can be used only for prisoners in need of urgent treatment for mental illness or severe mental impairment

44. MHA Ref: A Clinician’s Brief Guide to the Mental health Act Tony Zigmond,RCPsych Publications Recommended reading See also Code of Practice