Joint Committee on Health and Children
Public Hearings on the Protection of Life during Pregnancy (Heads of)
Bill 2013
Dr Eamonn Moloney – Opening Statement
Monday 20th May 2013 at 12.15
I am clinical director of the mental health service which has its inpatient unit/approved
centre base at Cork University Hospital (CUH) and Cork University Maternity Hospital
(CUMH), one of the busiest maternity hospitals in Ireland with over 9,000 deliveries per
annum. There are over 600 people seen for emergency psychiatric assessment following
suicidal behaviour at CUH on an annual basis and many more with suicidal ideation.
As clinical director of a busy, community mental health service serving a catchments area of
190,000, I have overseen the implementation of new legislation in the form of the Mental
Health Act 2001 within the service over the past six years and have an ongoing responsibility
to ensure that the appropriate legislative procedures are followed. My comments on the
Heads of Bill are from the perspective of a clinical director/consultant psychiatrist and
primarily relate to the practical application of this proposed legislation. The current
operation of the Mental Health Act 2001 leads me to believe that this legislation could be
practically implemented but I will suggest some areas where amendments would ensure
that a suicidal woman with a crisis pregnancy is managed in the most appropriate, humane
and timely manner. The relevant care pathway is described.
Head 4:
Two Medical Opinions/Possible Care Pathway
The requirement for two psychiatrists and an obstetrician/gynaecologist to certify that a
woman is eligible for a termination of pregnancy is excessive. Two medical opinions should
suffice.
One of these medical opinions should ideally be the pregnant woman’s general practitioner.
The importance of the general practitioner is recognised in the explanatory notes on
(2)(a)(1) by virtue of his/her “long-term and in-depth knowledge of the woman” and he/she
will have a unique perspective of the woman’s particular circumstances in relation to, for
example, her social supports, relationships, previous pregnancies, any history of sexual
assault or abuse and family background.
It is likely that the woman will consult her general practitioner in the first instance for
confirmation of pregnancy and discussion of the options for what may be a crisis pregnancy.
The woman’s general practitioner can carry out an assessment of the woman’s mental state
or, perhaps more than one assessment over the course of several days.
He/she may certify that the patient is acutely suicidal, that there is a real and substantial risk
to her life and that this risk can only be averted by a termination of pregnancy. A general
practitioner is likely to have considerable experience of assessing suicide risk and of making
medical recommendations for detention of persons under the Mental Health Act 2001 and
so is well placed to carry out a similar type of certification process under the proposed
legislation. If the general practitioner is certifying that the woman satisfies the appropriate
criteria under the act, he/she will inform the executive which will confirm or arrange an
assessment by a consultant psychiatrist
The second medical opinion should be by a consultant psychiatrist. This doctor should be
drawn from a panel of consultant psychiatrists who are agreeable to operate the enacted
legislation. This process is again similar to the pathway for hospital admission under the
Mental Health Act where a consultant psychiatrist must assess a person brought to an
approved centre following appropriate application and medical recommendation by the
general practitioner. A consultant psychiatrist has a particular expertise in assessing suicide
risk so it is appropriate that he/she would carry out this assessment.
This process of consultation with a general practitioner and referral to a consultant
psychiatrist for further assessment reflects the ideal care pathway for all suicidal patients
and also the pathway for admission to an approved centre under the Mental Health Act. It
is likely to be the least distressing process for the pregnant woman, the most appropriate
way of accessing the assessment and care that the woman needs and is a process that is
practical, as evidenced by the current operation of the Mental Health Act.
A further medical opinion is not necessary and indeed the explanatory notes for Head 2(3)
refers to the Mental Health Act 2001 to support the need for only two medical opinions
where there is a risk of loss of life from physical illness. The assessment of suicidal intent is
one of the core skills of consultant psychiatrists who are carrying out such assessments on a
daily basis.
The relative rarity of completed suicide and the inability to determine the number of people
saved from death by suicide following appropriate suicide risk assessment and intervention
means that an exact calculation of the accuracy of assessing suicidal intent is not possible.
This does not mean that suicide risk assessments carried out by a woman’s general
practitioner and a consultant psychiatrist are inaccurate.
The involvement of an obstetrician/gynaecologist in the assessment of risk of death by
suicide is not appropriate as it is outside their area of expertise.
It should not be necessary for the consultant psychiatrist to be “attached to an institution
where such a procedure is carried out” as this would unnecessarily restrict access to an
appropriate and timely assessment which could be done by a consultant psychiatrist not
attached to the maternity hospital.
Head 6:
(5) and (6): the timescale proposed of up to seven days to convene a committee and up to a
further seven days to form an opinion could lead to a potential delay of two weeks following
a woman’s appeal to a decision being made. This is likely to cause considerable distress
which could be alleviated by shorter timeframes of 72 hours to the convening and 72 hours
to a decision being made.
Head 8:
The requirement that one of the consultant psychiatrists “shall be employed at an
appropriate location” is unnecessary. Most women at risk of suicide in the early stages of
pregnancy would be most likely to be seen by a general adult community psychiatrist or a
liaison psychiatrist, following self harm rather than a perinatal psychiatrist “employed at an
appropriate location”.
The proposed timeframe is too long and a delay of up to seven days should be shortened to
72 hours.
The decision of the review committee should be by majority decision. This is the case for
decisions made by the mental health review tribunal under the Mental Health Act where
three persons on the tribunal decide on whether to revoke or affirm the detention of a
person under the act. A simple majority is sufficient and this should also apply under this
legislation.
The certification procedure proposed here ensures that the most appropriate and relevant
medical opinions are obtained and that the usual care pathway and referral processes are
followed in order to minimise any unnecessary, additional distress to the pregnant
woman. This process is similar to current procedures under the Mental Health Act 2001
and so the practical application of the legislation can be assured.
Dr Eamonn Moloney MB,FRCPsych
Executive Clinical Director/Consultant Psychiatrist
South Lee Mental Health Unit
Cork University Hospital
Cork
15th May 2013