Hospital Managers’ Handbook
“It is the hospital managers who have the authority to detain patients under the
Act. They have the primary responsibility for seeing that the requirements of the
Act are followed. In particular, they must ensure that patients are detained only as
the Act allows, that their treatment and care accord fully with its provisions, and
that they are fully informed of, and are supported in exercising, their statutory
rights.”
Code of Practice (2008)
Contents
1. Introduction
1
2. Principles of Mental Health
2.1 The Guiding Principles
2.2 The Human Rights Act 1998
2
3
3. Mental Health Act 1983
3.1 Informal Patients
3.2 Sections
4
4
4. Hospital Managers’ Hearings
4.1 When to Hold a Review
4.2 Prior to the Hearing
4.3 The Hearing
4.4 Procedure for Reviewing Detention or SCT
4.5 Criteria for the Decision
4.6 After the Hearing
11
11
13
15
16
17
5. Mental Health Review Tribunal
18
Appendixes
Mental Health Act Team Contact Sheet
Glossary – Key Words and Phrases
Common Sections – Quick Reference
Flowchart of Detention
19
20
36
37
1. Introduction
The Mental Health Act 1983 (MHA) is the legislation that governs the formal
detention, treatment and care of mentally disordered people in hospitals.
The MHA has been amended by the Mental Health Act 2007.
Pennine Care NHS Foundation Trust, in accordance with the MHA and the
Code of Practice (Code) which offers guidance on how the Act should be
applied, has appointed a Committee to undertake the duties required of
‘Hospital Managers’ within the meaning of the Act.
The term ‘Hospital Managers’ refers to the Board of the NHS Trust with
responsibility for detained patients. Legislation allows the Trust to establish a
Committee comprising of Non-Executive Directors of the Trust and Associate
Managers. The day-to-day duties are delegated to specific officers of the
Trust, but only the Committee members are able to exercise the power of
discharge.
The terms Associate Managers or Managers throughout this handbook
relates only to this Committee and not to the management team who work
for Pennine Care.
The Hospital Managers retain a responsibility for the performance of their
delegated duties and as such must monitor and ensure these duties are
carried out in accordance with the Act and good practice standards.
Non-Executive Directors and Associate Managers are not personally liable
for decisions taken about the discharge of detained patients; liability will rest
with the Trust as a body.
Pennine Care NHS Foundation Trust must ensure that the Committee is fully
informed about the workings of the Act and the requirements placed on the
Committee members both generally and specifically in relation to reviews of
a patient’s detention. This handbook has been produced to assist Associate
Managers with performing their duties and to act as a reference when
carrying out review hearings with patients.
This handbook should be read in conjunction with the Code and any other
guidance that is provided. Training is available to the Hospital Managers and
the information gained from this should also be considered additionally to the
information contained within this handbook.
Throughout this handbook we have included references, tips and further
information in left hand margin which should assist and guide you.
As the law changes constantly all reasonable efforts will be made to provide
accurate and timely updates to this handbook.
Page 1
2. Principles of Mental Health
Section 118 of
the Act
While carrying out functions of the Act there are certain values and principles
that must be considered and applied as far as possible.
Chapter One of
the Code
2.1 The Guiding Principles
Before looking at the guiding principles in the Code it is useful to understand
where the MHA, Code and Principles fit together. This can be summarised
as follows;



The MHA tells us what to do;
The Code explains how to do it; and
The Guiding Principles guide us in how to apply the MHA
and Code in individual situations.
The Code states that everyone who is working with the MHA must have
regard to the guiding principles. As will become clear you may not be able to
apply the guiding principles all the time but you should consider them when
making decisions under the Act.
The list of guiding principles that follows has been taken directly from
Chapter 1 of the Code;
Purpose Principle
Decisions under the Act must be taken with a view to minimising the
undesirable effects of mental disorder, by maximising the safety and
wellbeing (mental and physical) of patients, promoting their recovery and
protecting other people from harm
Least Restriction Principle
People taking action without a patient’s consent must attempt to keep
to a minimum the restrictions they impose on the patient’s liberty,
having regard to the purpose for which the restrictions are imposed.
Respect Principle
People taking decisions under the Act must recognise and respect the
diverse needs, values and circumstances of each patient, including
their race, religion, culture, gender, age, sexual orientation and any
disability. They must consider the patient’s views, wishes and feelings
(whether expressed at the time or in advance), so far as they are
reasonably ascertainable, and follow those wishes wherever
practicable and consistent with the purpose of the decision. There
must be no unlawful discrimination
Participation Principle
Patients must be given the opportunity to be involved, as far as is
practicable in the circumstances, in planning, developing and
reviewing their own treatment and care to help ensure that it is
delivered in a way that is as appropriate and effective for them as
possible. The involvement of carers, family members and other
Page 2
Para 1.7 Code, All
decisions must, of
course, be lawful
and informed by
good professional
practice.
Lawfulness
necessarily
includes
compliance with
the Human Rights
Act 1998
people who have an interest in the patient’s welfare should be
encouraged (unless there are particular reasons to the contrary) and
their views taken seriously.
These principles should inform your decisions not determine them. Through
ongoing training and application Hospital Managers should be able to
develop an ability to apply the principles as a whole and balance them
dependent upon the decision to be made.
2.2 Human Rights Act 1998 (HRA)
The Human Rights Act 1998 has been discussed with regard to the impact
and duties it places on Hospitals and Hospital Managers. It should be noted
that as long as they are working within the Code guidelines the requirements
of the Human Rights Act are generally satisfied.
A recognition of basic human rights should be achieved through the
additional training but a brief explanation of the Articles most commonly
associated with Mental Health are listed below for information;
Article 2 - The Right to Life
A person has the right to have their life protected by law. There are
only certain very limited circumstances where it is acceptable for the
state to take away someone’s life e.g. if a police officer acts justifiably
in self defence.
Article 3 - Protection from Torture and Inhuman and Degrading
Treatment.
A person has the absolute right not to be tortured or subjected to
treatment or punishment, which is inhuman or degrading.
Article 5 – Right to Liberty and Security
A person has the right not to be deprived of their liberty – ‘arrested or
detained’ – except in limited cases specified in the article (e.g where
they are detained under the MHA) and provided there is a proper
legal basis in UK law. This right has been central to many human
rights based challenges brought by patients detained and treated
under the Mental Health Act 1983.
For further
information on the
HRA you may
visit the
Department of
Constitutional
Affairs website:
http://www.dca.go
v.uk/peoplesrights/humanrights/index.htm
Article 8 - Right to a Private Life
A person has the right to respect for their private and family life, their
home and their correspondence. This right can be restricted only in
specified circumstances.
Page 3
3. Mental Health Act 1983
Para’s 4.9 –
4.24 of the Code
3.1 Informal Patients
Hospital Managers do not conduct reviews of informal patients.
MCA and DOLS
are covered
later in this
handbook
An informal patient can be a patient who has the capacity to consent to
admission and does so or an incapacitated patient who lacks capacity to
consent to admission and may be admitted using the Mental Capacity Act
2005 (MCA) and following April 2009, the Deprivation of Liberty Safeguards
(DOLS).
3.2 Sections
As the Hospital Managers carry out a high number of reviews across the
Trust, the number and types of section they come across will vary. Although
it would be impractical to list all sections within this handbook a brief guide to
‘common’ sections follows.
Inpatient Sections
Section 2 - Admission for Assessment
This section lasts for up to 28 days and the criteria for detention is that the
patient suffers from a mental disorder which warrants detention in hospital
for assessment or assessment followed by treatment and that the patient
needs to be detained in the interests of his own health or safety or for the
protection of others. An Approved Mental Health Practitioner (AMHP) makes
an application and two doctors need to complete medical recommendations
(one must be section 12 approved)
Patients may appeal to the Hospital Managers once at any time during the
28 days but they must appeal within the first 14 days to the Mental Health
Review Tribunal.
S.12 means the
Doctor has
undergone
additional
training in
identifying
mental disorder
Section 3 – Admission for Treatment
This admission is for up to 6 months which is then renewable initially for a
further 6 months followed by periods of one year at a time for treatment of
patient suffering from mental disorder that makes it appropriate for him to
receive treatment in a hospital. It must also be necessary for the health and
safety of the patient or for the protection of other persons that he should
receive treatment and that appropriate treatment is available for him.
An Approved Mental Health Practitioner (AMHP) makes an application and
two doctors need to complete medical recommendations (one must be
section 12 approved)
Patients may appeal to the Hospital Managers at any time during the period
of detention but they can only appeal once in each period of detention to the
Mental Health Review Tribunal.
Where the patient has recently had a hearing (either MHRT or Managers)
the Associate Managers’ may refuse to consider his case if there hasn’t
Page 4
been a significant change in his circumstances or condition. This prevents
unnecessary hearings which may distress the patient and impact on those
involved in their care. The Trust requires a Non-Executive Director to make
the decision as to whether or not a hearing is held.
Section 37 – Hospital Order
Patient is sent to hospital by the courts following sentencing for a criminal
offence. The criteria and the resulting admission work in the same way as a
section 3 except for the appeal process. A s.37 patient cannot appeal to the
MHRT in the first six months of a detention but can still appeal to the
Hospital Managers.
Section 4 – Emergency Admission for Assessment
Admission for assessment in cases of emergency. This section lasts for a
maximum of 72 hours and application is by an AMHP with recommendation
by one doctor. The doctor must confirm that it is of urgent necessity for the
patient to be admitted and that waiting for a second doctor would cause
‘undesirable delay’.
There are no rights
of appeal on these
sections and their
treatment is not
covered by Part 4 of
the MHA. Patients
detained under
section 4 CAN
submit an appeal
that would be heard
upon conversion to
a longer term
detention
Section 5(2) – Emergency Inpatient Doctors Holding Power
Allows for patients already in hospital to be held for up to 72 hours by a
doctor.
Section 5(4) – Emergency Inpatient Nurses Holding Power
Allows patient to be detained for up to 6 hours (by a nurse) to allow for the
arrival of a doctor to carry out an assessment
Section 135 (1) – Warrant to Search and Remove
Allows that where there is reason to suspect that a person is suffering from a
mental disorder and is:
a. Being ill treated, neglected or not kept under proper control or
b. Is unable to care for her or himself and lives alone
an AMHP can apply to a magistrate for a warrant authorising a police officer
with a doctor and an AMHP to enter any premises and remove the person to
a place of safety. Once removed to a place of safety that person may be
detained there for a period of up to 72 hours
Section 135 (2) – Warrant to Retake an AWOL Patient
Allows for the retaking of a detained patient, who is absent without leave, by
forced entry if necessary to any premises where the patient is located and
entry has been refused.
Section 136 – Police Power to Detain
Under this section if a police officer believes that a person in a public place
is ‘suffering from mental disorder’ and is in ‘immediate need of care or
control’ the police officer can take that person to a ‘place of safety’ for a
maximum of 72 hours so that the person can be examined by a doctor and
interviewed by an AMHP and any necessary arrangements made for the
person’s treatment or care.
Page 5
Community Sections
s.17A was
introduced by the
Mental Health Act
2007 and
replaces
Supervised
Discharge
Section 17A – Supervised Community Treatment (SCT)
Patients who have been detained under an unrestricted treatment section
can be discharged into the community on a s.17A. This means a patient
suffering from a mental disorder can live in the community whilst still subject
to powers under the MHA.
Patients on SCT are subject to a Community Treatment Order (CTO) which
sets out conditions the patient is asked to keep to in order to ensure they
receive the treatment they need.
Applications are made by the patient’s Responsible Clinician and have to be
approved by an AMHP.
We will cover this Section in more detail later in the handbook (See Page 9).
Section 7 – Guardianship
For patients in the community guardianship allows their Responsible
Clinician and other professionals to specify their place of residence. Initially
for six months and then renewed for six months by the Responsible Clinician
and yearly after that. The Local Authority manages the detention rather than
Pennine Care.
Other Sections / Status
Part 4 - Treatment
Part 4 of the Act allows some detained patients to be compulsorily treated if
necessary. The emergency or short term sections are not subject to this.
Chapter 23 of
the Code
Only treatment for mental disorder can be given using this part of the Act.
Treatment may be given for the first three month period of detention and
following this may only be given with the patients consent or second opinion.
Part 4A – Treatment of a Community Patient (SCT)
Part 4A provides authority to treat a community patient without their consent.
S.64A – 64K authorise ‘relevant treatment’ to be given to a community
patient who has not been recalled. This treatment may only be given if;



The treatment is immediately necessary and the patient is
capable and consents
The treatment is immediately necessary and there is
consent from someone authorized under the MCA to make
decisions on the patients behalf
The patient lacks capacity and force is not necessary to
secure compliance
Page 6

Emergency treatment needs to be given using force if
necessary, to a patient who lacks capacity
This treatment can only be provided where a Second Opinion Appointed
Doctor (SOAD) has issued a certificate authorising the treatment.
Section 17 – Leave of Absence
Under section 17 of the Act, the Responsible Clinician may grant leave to
the patient, subject to any conditions, which the Responsible Clinician
considers necessary in the interests of the patient or the protection of other
persons. Only the Responsible Clinician may grant leave.
Section 20 – Renewal
Sections 3, 37, 17A and 47 require the Responsible Clinician to complete a
renewal form before the expiry of the section. This allows for the section to
continue for a further period of either six or twelve months, dependent upon
the length of time they have already been detained.
Once a form has been completed the Hospital Managers are then obliged to
review the continued detention. It is good practice for the review hearing to
take place before the section expires but it may also take place following the
expiry date.
Section 18 – Absent Without Leave (AWOL)
If a patient takes leave of absence from the hospital without a section 17
authorising this then the patient is classed as AWOL.
If a SCT patient is recalled to hospital and does not return they are also
classed as AWOL.
Section 23 – Discharge
Sections can be ended in a number of ways including




Responsible Clinician discharges the patient before the end of the
section
Mental Health Review Tribunal discharges patient following review
Hospital Managers discharge patient following review
Nearest Relative discharges the patient
Section 117- Aftercare
It is the duty of the health authority & local social services to provide, in cooperation with relevant voluntary organisations and aftercare services. It is
important that all patients who are subject to S117 are identified & records
kept of them. Those subject to S117 are patients on (or have been on) S3,
S37, S17A, S41, S47 & S48.
Page 7
We will now expand on particular elements of the MHA which require further
explanation and consideration.
Chapter 3 of the
Code
Mental Disorder
There is one broad definition of Mental Disorder within the meaning of the
MHA which is ‘any disorder or disability of mind’. This applies to all sections.
Where a patient has a learning disability, this must also be associated with
abnormally aggressive or seriously irresponsible conduct to meet the criteria.
Dependence upon alcohol or drugs is excluded and can not be considered a
disorder or disability of mind.
Chapter 6 of the
Code
Appropriate Treatment Test
When a patient has been detained under a treatment section of the MHA
there must be appropriate medical treatment available for their mental
disorder. This is to ensure no-one is detained unless they are actually to be
offered treatment for their mental disorder.
Medical treatment for mental disorder means medical treatment for the
purpose of alleviating, or preventing a worsening of, a mental disorder or
one or more of its symptoms or manifestations
Medical
treatment also
includes
nursing,
psychological
intervention and
specialist mental
health
habilitation,
rehabilitation
and care.
‘The appropriate medical treatment test requires a judgement about whether
an appropriate package of treatment for mental disorder is available for the
individual in question. Where the appropriate medical treatment test forms
part of the criteria for detention, the medical treatment in question is
treatment for mental disorder in the hospital in which the patient is to be
detained. Where it is part of the criteria for SCT it refers to the treatment for
mental disorder that the person will be offered while on SCT.’ (Para 6.9
Code)
Supervised Community Treatment (SCT)
As stated earlier this allows a patient to receive the care and treatment they
need for their mental disorder in the community rather than in hospital. To be
eligible for SCT the patient must have been detained on one of the treatment
sections when the application for the CTO was made.
Each time a period of Section 17 leave is granted to a detained patient for
more than seven consecutive days, their Responsible Clinician must
consider whether it would be appropriate for the patient to be on SCT rather
than an inpatient.
The patients Responsible Clinician may specify conditions to be applied by
the CTO. The only limitation on these conditions is that they are ‘necessary
or appropriate’ for;
Page 8



Ensuring the patient receives medical treatment
Preventing the risk of harm to the patient’s health or safety
Protecting other persons
Once on a SCT the patient may be recalled to the hospital for up to 72 hours
or the CTO can be revoked and the patient would revert to the section he
was on immediately prior to discharge. The Responsible Clinician can recall
the patient if he is of the opinion;


Chapter 8 of the
Code
The patient requires medical treatment in hospital for his
mental disorder; and
There would be a risk of harm to the health and safety of
the patient or to other persons if the patient were not
recalled to hospital for that purpose.
Nearest Relative
Unlike a persons next of kin, which is chosen by the patient, the Nearest
Relative (NR) is defined by the MHA. Identifying a person’s NR can be a
complex task and is generally carried out by an AMHP upon a patients
admission to hospital.
In s.26 of the MHA there is a hierarchy as follows;
Husband, wife or civil partner
Son or Daughter
Father or Mother
Brother or Sister
Grandparent
Grandchild
Uncle or Aunt
Nephew or Niece
If there is no-one in the first category then you move to the next but if there
is more than one person in a category then you would use the eldest. The
NR must also be living in the United Kingdom.
The first
category
includes people
living with a
patient as
though they are
a couple for over
6 months
If anyone on the list is living with the patient or is a carer, they are the NR. If
anyone is not on the list but they have lived with them for five years or more,
they are the NR. If no one qualifies as a NR, the Court can appoint someone
to act as NR.
The MHA confers various rights and powers on a patient’s nearest relative in
connection with detention, Supervised Community Treatment and
Guardianship under the MHA. These include the right to:


Apply for detention or Guardianship;
Object to Approved Mental Health Professionals making
applications for admission to hospital for treatment or for
Guardianship;
Page 9


Ask that their relative be assessed under the MHA, and
receive written information if the decision is taken not to
admit that person; and
Discharge the patient (with various exceptions) or (in
certain cases) to apply to the Mental Health Review
Tribunal (MHRT) instead.
Nearest relatives are also entitled to be given information in respect of
patients in a variety of circumstances. They therefore provide a significant
protection for people who experience mental distress – both in terms of
helping them to get help when they need it and in being able to question and
prevent the use of compulsion if it is not truly necessary.
Due to the prescriptive nature of the hierarchy list there will be occasions
where the NR identified is not suitable to act as such. In this event they can
be displaced by a court.
There are a number of people who can apply to court to displace a nearest
relative:




The patient
Any relative of the patient
Anyone who lives with the patient
An AMHP
If a patient or someone else wishes to make an application to the County
Court for an order to displace their nearest relative, they may do so on a
number of grounds:
1. That there is no nearest relative;
2. That the nearest relative is too ill to take on the role;
3. That the nearest relative has objected unreasonably to
admission;
4. That the nearest relative has discharged the patient without
regard to that person
(or other people’s) safety;
5. That the nearest relative is ‘otherwise unsuitable’.
The court will
decide what
constitutes
‘suitability’ but
factors may
include where
the patient is
known to have
suffered abuse,
is scared or is
unknown to the
person
identified.
Page 10
4 Hospital Managers Hearings
4.1 When to Hold a Review
Section 132 of
the MHA
Chapter 2 of the
Code
Chapter 31 of
the Code
The reviews of a patient’s detention, carried out by a panel of three Hospital
Managers can be described as a `review’, a `panel’ or a `hearing’.
Hospital Managers have a duty to ensure that all patients are aware that
they may seek discharge by the Hospital Managers and of the distinction
between this and their right to a Mental Health Review Tribunal hearing (See
4.2). The delegated officers such as the Mental Health Act Administrators or
nursing staff usually carry out this duty on behalf of the Hospital Manager’s.
Hospital managers:




May undertake a review of whether or not a patient should
be discharged at any time at their discretion;
Must undertake a review if the patient’s responsible
clinician submits to them a report under section 20 of the
Act renewing detention or under section 20A extending
SCT;
Should consider holding a review when they receive a
request from (or on behalf of) a patient; and
Should consider holding a review when the responsible
clinician makes a report to them under section 25 barring
an order by the nearest relative to discharge a patient.
In the last two cases, when deciding whether to consider the case,
managers’ panels are entitled to take into account whether the Tribunal has
recently considered the patient’s case or is due to do so in the near future.
In the Trust all contested renewals take place through the full hearings
process.
In the event of an uncontested renewal under section 20, patients should be
interviewed by at least one member of the managers’ panel considering their
case, if they request it, or if the panel thinks it desirable after reading the
renewal or extension report.
4.2 Prior to the hearing:
With the assistance of the Mental Health Act Office, the Hospital Managers
should ensure

that they have reports from the patient's Responsible
Clinician and other relevant disciplines;
Page 11
Para 2.31 of the
Code

Written reports should be accompanied by documentation
compiled under the Care Programme Approach (or its
equivalent).

that, if the patient consents, his or her nearest relative (as
defined by the Act) and/or most concerned relatives are
informed of the review and asked to comment or to be in
attendance.

that, if the patient withholds consent to attendance of
his/her nearest relative at the hearing, the appropriate
professional concerned with the patient's care obtains the
views of the patient's nearest relative and/or most
concerned relatives and includes these in his or her report.
This is also dependent upon the consent of the patient.
The Mental Health Act Office will also:
Para 31.26 of
the Code

identify panel members and select a chairperson from the
approved list, paying due attention to the gender and
ethnicity and other needs of the patient, and set a time for
the hearing with the panel;

organise legal representation on behalf of the patient, if so
requested;

Where the patient is on SCT consider the most appropriate
location for the hearing, as the hospital may not be
convenient or acceptable to the patient

explain the procedure to the patient and his or her legal
representative;

ascertain whether the patient wishes a relative or friend to
attend the hearing;

inform the patient and (where appropriate) his or her
friend/relative/legal representative of the date, time and
venue of the hearing;

inform relevant professional staff of the date, time and
venue of the hearing;

ensure that all reports are circulated to the patient and his
or her friend/relative/legal adviser as appropriate (other
than in exceptional circumstances where elements of the
report may be withheld)

In circumstances where reports are unavailable in the days
prior to the hearing, ensure that reports are made available
Page 12
to all parties at least one hour prior to the scheduled time of
hearing. In most cases, the panel members attend 30
minutes prior to a hearing commencing and therefore the
reports will be ready for their arrival.
4.3 The Hearing
4.3.1 The Review Panel
Before the start of a meeting, each Manager should receive papers to be
discussed.
The review will be conducted by a Review Panel of three Hospital Managers,
and where possible selected to provide a balance of experience, gender and
ethnicity with regard to the patient concerned.
The MHA Administrator will select the Chairperson (normally a NonExecutive Director) in advance of the hearing and will communicate the
identity of the Chair to the other panel members.
On the day of the hearing, another Panel member may be selected to be
Chair if the Panel judges this to be in the best interest of the patient.
4.3.2 The Role of the Chair
During the hearing, the Chair's role is to encourage comprehensive
questioning and to ensure that each panel member has fully participated in
discussion and the decision-making process. The Chair is also responsible
for ensuring the decision is fully documented and given to the Mental Health
Act Office.
4.3.3 Professional attendance and postponement of hearings
It is desirable for the Responsible Clinician to be present but, if absence is
unavoidable, a representative doctor will be asked to attend in place of the
Responsible Clinician.
Where appropriate staff are not present and/or up-to-date reports are
missing, the Managers must consider whether or not they have sufficient
available information in order to make an informed decision. In such
circumstances, it may be necessary, in consultation with the patient and/or
their legal representative and/or advocate, to postpone the hearing due to
insufficient information being available.
The Managers are able to receive verbal evidence in the absence of a
written report or to provide an update if the report was written some time
before the hearing.
4.3.4 Mental Health Act Administrator Attendance
Page 13
It has been agreed that the Mental Health Act Administrator will not be
present during the hearing unless requested by the panel or the patient.
They will however be available during the hearing if required. Legal advice
should be obtained in the first instance through the Mental Health Act Office
who are able to escalate the issue to the Mental Health Law Coordinator
4.3.5 Opportunity for Private Consultation with the Panel
The Chairperson should check whether the patient wishes to speak privately
with the panel either at the beginning or at the end of the hearing. The
patient and other parties to the review will normally be able to hear each
other's statements to the Panel and to put questions to each other. However,
the patient should always be offered the opportunity of speaking alone with
the Panel.
4.3.6 Order of proceedings
At the start of the hearing, the Chairperson should state clearly the order of
proceedings, which should normally be as follows:









introduce all those in attendance;
state clearly the purpose of the hearing and the order of
proceedings (to help focus the discussion and set the
agenda);
ask the Responsible Clinician and other professionals to
give their views on whether the patient's continued
detention or SCT is justified and the factors on which those
views are based;
give the patient the opportunity and any necessary help to
comment on the views expressed, either personally, or
through his/her advocate or solicitor if appointed;
after each presentation, seek clarification or any further
information.
Provide the patient and/or his or her advocate or relative
the opportunity to ask questions;
if the patient agrees, the patient's representative or relative
should be asked if they wish to make a statement and the
Panel may seek clarification or any further information;
the advocate or solicitor should be given the opportunity to
ask the patient any questions and the patient the
opportunity to respond;
the patient and/or his or her advocate should have the
opportunity of summarising the case for discharge in the
light of the evidence presented.
The Panel should bear in mind that:

the hearing is likely to be stressful for the patient. The Panel
should therefore balance the formality necessary to carry
out their tasks with informality in the interest of supporting
the patient;
Page 14



they should assist, in so far as possible, the patient in
making his or her case for discharge effectively where they
do not have a representative;
there is no set time for the length of a hearing. However,
the Panel should consider the effect of a lengthy review on
the patient's wellbeing;
if the patient becomes distressed, a short break may be
directed by the Chairperson;
If the patient chooses to absent himself or herself from the hearing, the
Panel should decide whether to continue with the hearing.
The procedures for the hearing should be informal. For example, hearsay
evidence may be accepted but should where possible be substantiated.
Although all parties should be actively and positively questioned, formal
cross-examination should be avoided.
The questions should be asked of all parties in a manner which is thorough,
fair and courteous.
Care should be given not to undermine the patient's relationship with his or
her family and with professional staff;
Subject to the patient's right to object to the presence of relatives, all parties
should normally be present throughout the hearing except:


during any time when the patient wishes to speak to the
Panel alone (usually at the beginning or end of the
hearing);
when the patient does not wish to be present.
4.4 Procedure for Reviewing Detention or SCT
In exercising the powers of discharge, the Hospital Managers must act in a
way that is fair, reasonable and lawful, giving due consideration to the
various reports and recommendations made, but not being bound by such
reports and recommendations.
Managers' power to discharge a detained patient can be exercised only
when all three members of the panel are in favour of discharge otherwise the
decision will be unlawful.
In cases where Managers uphold a patient's continued detention they must
ensure that the patient and the patients’ nearest relative (where the patient
consents to them being told) are fully informed of the reasons for this
decision in line with guidance given in the Code and Article 5(2) of the
Human Rights Act 1998.
Managers have a responsibility to always ensure that full and
comprehensive reasons for decisions are clearly recorded on the Managers’
Hearing Decision form.
Page 15
Reasons for and decisions reached should not be irrational or appear that no
other managers panel properly directing itself as to the law and on the
available information, could have made.
In the event that a legal challenge to a decision to continue detention arises,
the information will facilitate a response. In this situation, the following
actions should be taken:


In collaboration with the Managers, the Administrator would
write to the patient's solicitor (if appointed) giving a clear
account of the reasons for the continued detention;
Copies of relevant supporting documentation should
accompany the letter in the event that the patient's solicitor
continues to challenge the decision. Further advice must be
obtained from the Trust's solicitors through the normal legal
process of the Trust.
4.5 Criteria for the decision
The MHA does not provide specific discharge criteria for the Hospital
Managers to apply. Although the Code does offer guidance on this matter as
follows;
Hospital Managers should consider whether the grounds for continued
detention or continued SCT under the Act are satisfied. To ensure that this is
done in a systematic and consistent way, managers’ panels should consider
the questions set out below, in the order stated.
For patients detained for assessment under section 2 of the Act:



Is the patient still suffering from mental disorder?
If so, is the disorder of a nature or degree which warrants
the continued detention of the patient in hospital?
Ought the detention to continue in the interests of the
patient’s health or safety or for the protection of other
people?
For other detained inpatients:




Is the patient still suffering from mental disorder?
If so, is the disorder of a nature or degree which makes
treatment in a hospital appropriate?
Is continued detention for medical treatment necessary for
the patient’s health or safety or for the protection of other
people?
Is appropriate medical treatment available for the patient?
For patients on SCT:

Is the patient still suffering from mental disorder?
Page 16


Dangerous is
equal to the
probability of
dangerous acts,
such as causing
serious physical
injury or lasting
psychological
harm, not
merely on the
patient’s general
need for safety
and others’
general need for
protection


If so, is the disorder of a nature or degree which makes it
appropriate for the patient to receive medical treatment?
If so, is it necessary in the interests of the patient’s health or
safety or the protection of other people that the patient
should receive such treatment?
Is it still necessary for the responsible clinician to be able to
exercise the power to recall the patient to hospital, if that is
needed?
Is appropriate medical treatment available for the patient?
Where the answer to all the relevant questions above is “yes”, but the
responsible clinician has made a report under section 25 barring a nearest
relative’s attempt to discharge the patient, the managers should also
consider the following question:

Would the patient, if discharged, be likely to act in a manner
that is dangerous to other people or to themselves?
If the panel is satisfied from the evidence presented to them that the answer
to any of these questions (except the Section 25 question) is "no", the
patient should be discharged, providing there is evidence that adequate care
would be in place. If it is not in place and its absence makes it likely that the
patient's health or safety will be compromised, the panel have the powers to
either adjourn the hearing or to defer discharge for a reasonable specified
period to allow for care arrangements to be in place.
The hospital managers do retain a residual discretion not to discharge in
these cases, so panels should always consider whether there are
exceptional reasons why the patient should not be discharged. Hospital
Managers involved in these cases should ensure the reasons are well
documented, guiding principles are applied and the MHA Office must be
immediately informed.
In all cases, hospital managers have discretion to discharge patients even if
the criteria for continued detention or SCT are met. Managers’ panels must
therefore always consider whether there are other reasons why the patient
should be discharged despite the answers to the questions set out above.
This must be well documented and the MHA Office must be immediately
informed.
4.6 After the Hearing
4.6.1 Informing the patient of the Hospital Managers' Decision
In communicating their decision, the Panel should ensure that:

Their decision and the reasons for it are communicated
immediately to the patient, to any relative who has been
involved and to the relevant professionals;
Page 17

Wherever possible, at least one member of the Panel
explains to the patient in person the reason for the decision.
But if the patient is unavailable or unwilling to meet with a
panel member, the reason for the decision should be
communicated by their advocate or a member of the
professional staff;
5 Mental Health Review Tribunal
The MHRT is the statutory, independent body responsible for hearing
appeals against detention. It operates like a mobile court and sits in the
hospital where the patient is detained.
An MHRT will consist of a lawyer, a doctor and a lay member. The patient,
their hospital doctor and social worker will also be at the hearing together
with the patient's nearest relative, unless the patient objects. The legal
member will chair the proceedings.
Patients detained under section 2 of the MHA who wish to appeal to an
MHRT must do so within 14 days of the start of their detention. If between
making the appeal and the hearing the patient is transferred to a section 3,
the MHRT will still hear the original appeal and it will not affect the patient's
right to appeal under section 3. Patients detained under section 3 of the
Mental Health Act may appeal to an MHRT once in a 6 month period.
Patients under section 37 can only apply to an MHRT after the first 6
months. Thereafter, their rights of appeal are the same as for section 3
patients.
Some patients have to have their cases referred by the Hospital Managers
to an MHRT even though they have not asked for an appeal. These include
patients detained under section 3 or SCT who have not been to an MHRT
within the last 6 months and in the case of SCT did not appeal during their
detention under section 3. Patients who have had their detention or SCT
renewed and have not appealed to an MHRT in the last 3 years (if aged 18
years or over) or the last 1 year (if aged less than 18 years) will also be
automatically referred.
For patients detained under section 2 the hearing must take place within 7
days of the MHRT office receiving the application. For patients detained
under section 3 the hearing will normally take place within 8 weeks. For
restricted patients (sections with restrictions include s.37/41 or 48/49) the
hearing will normally take place within 20 weeks.
The MHRT's principal powers are:




to discharge a detained patient from hospital immediately or
after a short further period of detention.
to recommend leave of absence
to recommend SCT
to recommend transfer to another hospital
Page 18
Mental Health Act Team
1.
Trust:
Kim Shepherd
Mental Health Law Manager
Trust Headquarters
St Petersfield
225 Old Street
Ashton Under Lyne
OL6 7SR
Tel: 0161 604 3008
2.
Bury:
Lisa West / Carolyn Davis
Roch House
Fairfield General Hospital
Rochdale Old Road
Bury
BL9 7TD
Tel: 0161 778 3681
3.
Oldham:
Pam Smith / Gemma Scholes
Parklands House
Royal Oldham Hospital
Rochdale Road
Oldham
OL1 2JH
Tel: 0161 778 5753
4.
Rochdale:
Diane Birchall / Gemma Scholes
Borough Mental Health Offices
Birch Hill Hospital
Littleborough
Rochdale
OL12 9QB
Tel: 01706 754621
5.
Stockport:
Debbie Arrell
Psychiatry Administration Department
Stepping Hill Hospital
Poplar Grove
Stockport
SK2 7JE
Tel: 0161 419 5349
6.
Tameside:
Mia Majid / Jean Milhench
Mental Health Unit
Tameside General Hospital
Fountain Street
Ashton-under-Lyne
OL6 9RW
Tel: 0161 604 3777
6.
Rehab:
Luci Lewis / Jan Broomhead
Mental Health Unit
Tameside General Hospital
Fountain Street
Ashton-under-Lyne
OL6 9RW
Tel: 0161 604 3789
Page 19
Email addresses are firstname.surname@nhs.net
Page 20
Glossary
Key words and phrases
Taken from the Code & MIND
A
Absent Without Leave (AWOL) When a detained patient leaves hospital without
getting permission first or does not return to hospital when required to do so. Also
applies to guardianship patients who leave the place their guardian says they
should live and to SCT patients and conditionally discharged restricted patients who
don’t return to hospital when recalled, or who leave the hospital without permission
after they have been recalled.
The Act Unless otherwise stated, the Mental Health Act 1983 (as amended by the
Mental Health Act 2007).
Advance Decision to Refuse Treatment A decision, under the Mental Capacity
Act, to refuse specified treatment made in advance by a person who has capacity to
do so. This decision will then apply at a future time when that person lacks capacity
to consent to, or refuse the specified treatment.
Advocacy Independent help and support with understanding issues and assistance
in putting forward one’s own views, feelings and ideas.
See also Independent mental health advocate.
After-care Community care services following discharge from hospital; especially
the duty of health and social services to provide after-care under section 117 of the
Act, following the discharge of a patient from detention for treatment under the Act.
The duty applies to SCT patients and conditionally discharged restricted patients,
as well as those who have been fully discharged.
Application An application made by an approved mental health professional, for
detention or a nearest relative, under Part 2 of the Act for a patient to be detained in
a hospital either for assessment or for medical treatment. Applications may be
made under section 2 (application for admission for assessment), section 3
(application for admission for medical treatment) or section 4 (emergency
application for admission for assessment).
Appropriate Medical Treatment Medical treatment for mental disorder which is
appropriate taking into account the nature and degree of the person’s mental
disorder and all the other circumstances of their case.
Appropriate Medical Treatment Test The requirement in some of the criteria for
detention, and in the criteria for SCT, that appropriate medical treatment must be
available for the patient.
Approved Clinician A mental health professional approved by the Secretary of
State (or the Welsh Ministers) to act as an approved clinician for the purposes of
the Act. Some decisions under the Act can only be taken by people who are
approved clinicians. All responsible clinicians must be approved clinicians.
Approved Mental Health Practitioner A social worker or other professional
approved by a local social services authority (LSSA) to carry out a variety of
functions under the Act.
Page 21
Assessment Examining a patient to establish whether the patient has a mental
disorder and, if they do, what treatment and care they need.
It is also used to be mean examining or interviewing a patient to decide whether an
application for detention or a guardianship application should be made.
Attorney Someone appointed under the Mental Capacity Act who has the legal
right to make decisions (eg decisions about treatment) within the scope of their
authority on behalf of the person (the donor) who made the power of attorney. Also
known as a “donee of lasting power of attorney”.
Acute Confusional state: A sudden & rapid onset of confusion, of an alarmingly
high level, usually a symptom of an acute physical illness. The duration can be
short & the cause treated.
Affect: A subjective interpretation of the feelings accompanying an idea or image.
Similar in meaning to ‘mood’, it can be defined as a state of emotional tone or
feeling which can fluctuate through a range of depression & elation.
Affective disorder: Disorder of mood including the commoner disturbances in
emotional equilibrium that may form part of an overall clinical picture in mental
disorder; depression, anxiety, incongruity and blunting of affect, la belle
indifference, lability, hostility, depersonalisation. There may be difficulty in
differentiating the symptoms of major affective disorder from an environmental
causation or organic illness, therefore careful assessment &
history taking is particularly important.
Akathisia: A motor restlessness ranging from a feeling of inner disquiet, often
localised in the muscles, to an inability to sit still or lie quietly; a side effect of some
antipsychotic drugs.
Antecedent: The stimulus or cue that occurs before behaviour that leads to
occurrence.
Antisocial personality disorder: A disorder occurring in adult patients with a
history of
conduct disorder; behaviour which is often characterised by poor work record,
disregard
for social norms, aggressiveness, financial irresponsibility, impulsiveness, lying,
recklessness,
inability to maintain close relationships or to meet responsibilities for significant
others & a lack of remorse for harmful behaviour.
Anxiety: A diffuse apprehension vague in nature & associated with feelings of
uncertainty &
helplessness. It is an emotion without a specific object, is subjectively experienced
by the individual & is communicated interpersonally. It occurs as a result of a threat
to the person’s being, self-esteem or identity.
Apathy: Lack of feelings, emotions, interests or concern.
Automatic thoughts: These are contained in a stream of thoughts which are
usually going on in a individual’s head. They effect the person’s feelings and inform
their behaviour, but often occur without the person being aware of them. It is only
when individuals are asked to focus in on their unreported thoughts that they
become aware of them
Page 22
B
Bipolar affective disorder: A sub-group of the affective disorders charcterised by
at least an episode of manic behaviour, with or without a history of episodes of
depression. Also known as manic depression
Borderline personality disorder: A specific personality disorder with the essential
features of unstable mood, interpersonal relationships & self image; characteristic
behaviours may include unstable relationships, exploitation of others, impulsive
behaviour, labile effect, problems expressing anger appropriately, self-destructive
behaviour & identity disturbances.
C
Capacity The ability to take a decision about a particular matter at the time the
decision needs to be made. Some people may lack capacity to take a particular
decision (eg to consent to treatment) because they cannot understand, retain, use
or weigh the information relevant to the decision. A legal definition of lack of
capacity for people aged 16 or over is set out in section 2 of the Mental Capacity
Act 2005.
See also competence to consent.
Care Programme Approach (CPA) A system of care and support for individuals
with complex needs which includes an assessment, a care plan and a care coordinator. It is used mainly for adults in England who receive specialist mental
healthcare and in some CAMHS services. There are similar systems for supporting
other groups of individuals, including children and young people (Children’s
Assessment Framework), older adults (Single Assessment Process) and people
with learning disabilities (Person Centred Planning).
Carer Someone who provides voluntary care by looking after and assisting a family
member, friend or neighbour who requires support because of their mental health
needs.
Child (and children) A person under the age of 16.
Child and adolescent mental health services (CAMHS)
Specialist mental health services for children and adolescents. Over all types of
provision and intervention – from mental health promotion and primary prevention
and specialist community-based services through to very specialist care, as
provided by in-patient units for children and young people with mental illness. They
are mainly composed of a multi-disciplinary workforce with specialist training in
child and adolescent mental health.
Children Act 1989 A law relating to children and young people and those with
parental responsibility for them.
Commission The independent body which is responsible for monitoring the
operation of the Act. At the time of publication, this is the Mental Health Act
Commission (MHAC). However, legislation is currently before Parliament which will
abolish the MHAC and transfer its functions to a new body, the Care Quality
Commission, which is to establish a new integrated health and adult social care
regulator, bringing together existing health and social care regulators into one
regulatory body. Subject to Parliament, it is expected that the new Commission will
be established in April 2009.
Page 23
Community treatment order (CTO) Written authorisation on a statutory form for
the discharge of a patient from detention in hospital onto supervised community
treatment.
Competence Similar to capacity to consent, but specifically about children. As well
to consent as covering a child’s inability to make particular decisions because of
their mental condition, it also covers children who do not have the maturity to take
the particular decision in question.
Compulsory Things that can be done to people under the Act without their
measures agreement. This includes detention in hospital, supervised ommunity
treatment and guardianship.
Compulsory Medical Treatment: Treatment for mental disorder given under the
Act against the wishes of the patient.
Conditional discharge: from hospital by the Secretary of State for Justice or the
Tribunal of a restricted patient subject to conditions. The patient remains subject
to recall to hospital by the Secretary of State.
Conditionally Discharged Restricted Patient: A restricted patient who has been
given a conditional discharge.
Consent Agreeing to allow someone else to do something to or for you. Particularly
consent to treatment. Valid consent requires that the person has the capacity to
make the decision (or the competence to consent, if a child), and they are given the
information they need to make the decision, and that they are not under any duress
or inappropriate pressure.
Convey (and Conveyance) Transporting a patient under the Act to hospital (or
anywhere else), compulsorily if necessary.
Court of Protection The specialist court set up under the Mental Capacity Act to
deal with all issues relating to people who lack capacity to take decisions for
themselves.
Criteria for detention: A set of criteria that must be met before a person can be
detained, or remain detained, under the Act. The criteria are different in different
sections of the Act.
Criteria for SCT Patient A set of criteria that must be met before a person can
become an SCT or remain an SCT patient.
Criminal Records An Executive Agency of the Home Office, which provides
access to criminal record information through its disclosure service.
Capacity: In order to have ‘capacity’ a person must understand what the medical
treatment is & why it is proposed in his/her instance.
Catatonia: A syndrome of motor abnormalities occurring in schizophrenia and (less
commonly) in organic cerebral disease, characterised by stupor and the adoption of
strange postures or outbursts of excitement & hyperactivity. Rarely reported
nowadays.
Page 24
Chronic confusional state: A slow & insidious onset of confusion, which is likely to
go unnoticed. It is a symptom of chronic physical illness such as thyroid gland
underactivity. May occur over a period of years but can be reversed with treatment.
Cognitive disorder: Disorder associated with the way in which the individual
interprets the world. The underlying thought processes are seen as instrumental in
determining how a person behaves & their emotional reactions.
Cognitive disturbance: A self defeating attitude or responses which may become
habitual
particularly directed towards lowered self esteem.
Compulsion: A recurring irresistible impulse to perform some act.
Concreteness: Use of specific terminology rather than abstraction by the patient in
describing feelings, experiences & behaviour.
Confabulation: Asked what they had for breakfast that morning or for details of
past psychiatric history, patients will tell amore or less plausible story that is
completely invented.
Congruent communication: A communication pattern in which the sender is
communicating the same message on both verbal & non-verbal levels.
D
Deprivation of liberty A term used in Article 5 of the European Convention on
Human Rights (ECHR) to mean the circumstances in which a person’s freedom is
taken away. Its meaning in practice has been developed through case law.
Deprivation of liberty Safeguards (DOLS) The framework of safeguards under
the Mental Capacity Act (as amended by the Mental Health Act 2007) for people
who need to be deprived of their liberty in their best interests for care or treatment
to which they lack the capacity to consent themselves.
Deputy (or Court appointed deputy) A person appointed by the Court of
Protection under section 16 - of the Mental Capacity Act to take specified decisions
on behalf of someone who lacks capacity to take those decisions themselves. This
is not the same thing as the nominated deputy sometimes appointed by the doctor
or approved clinician in charge of a patient’s treatment.
Detained Patient: Unless otherwise stated, a patient who is detained in hospital
under the Act, or who is liable to be detained in hospital but who is (for any reason)
currently out of hospital.
Detention (and detained) Unless otherwise stated, being held compulsorily in
hospital under the Act for a period of assessment or medical treatment. Sometimes
referred to colloquially as “sectioning”.
Detention For Assessment The detention of a person in order to carry out an
Can normally only last for a maximum of 28 days. Also known as “section 2
detention”.
Detention for Medical Treatment The detention of a person in order to give them
the medical treatment for mental disorder they need. There are various types of
detention for medical treatment in the Act. It most often means detention as a (and
Page 25
result of an application for detention under section 3 of the Act. But it also includes
several types of detention under Part 3 of the Act, including hospital directions,
hospital orders and interim hospital orders.
Diagnostic Over-Shadowing A risk for everyone with a mental disorder, but a
particular danger for people with learning disabilities, that behavioural problems
may be misinterpreted as symptomatic of mental disorder when they are in fact a
sign of an underlying physical health problem.
Discharge Unless otherwise stated, a decision that a patient should no longer be
subject to detention, supervised community treatment, guardianship or conditional
discharge. Discharge from detention is not the same as being discharged from
hospital. The patient might already have left hospital on leave of absence, or might
agree to remain in hospital as an informal patient.
Displacement (Of Nearest Relative) The provision under section 29 of the Act,
under which the county court can order that the functions of the nearest relative be
carried out by another person or by a local social services authority.
Doctor A registered medical practitioner.
Doctor Approved Under Section 12 A doctor who has been approved by the
Secretary of State (or the Welsh Ministers) under the Act as having special
experience in the diagnosis or treatment of mental disorder. In practice, strategic
health authorities take these decisions on behalf of the Secretary of State in
England. Some medical recommendations and medical evidence to courts under
the Act can only be made by a doctor who is approved under section 12. (Doctors
who are approved clinicians are automatically treated as though they have been
approved under section 12.)
Dangerousness: The probability that an individual will commit an act of violence on
another person, in the near or distant future, if afforded the opportunity to do so.
Delirium tremens: Associated with alcohol dependency & occurs about 24 hours
after withdrawal. Characterised by tremor, restlessness, disorientation, visual
hallucinations, autonomic arousal & occasionally fits.
Delusions: A false belief that is firmly held even though it is not shared by others &
is contradicted by social reality.
Dementia: A progressive organic mental disorder resulting in a lowering of the
usual level of mental ability. Alzheimer’s disease is most common (80% cases) but
is also caused by Huntington’s disease, Pick’s disease, Creutzfeld-Jakob disease
(CJD), long term alcohol/drug abuse, stroke, Parkinson’s disease, meningitis,
syphilis, HIV/AIDS, hydrocephalus.
Denial: Avoidance of disagreeable realities by ignoring or refusing to recognise
them.
Depersonalisation: A characteristic of depression when a person is aware of a
change in self & may feel that they have become so different as to have become
detached from their personality. The person may describe the feeling as ‘if in a
dream’ or ‘like automatum’. Mild depersonalisation can occur in states of physical &
mental fatigue.
Depression: An abnormal extension or overelaboration of sadness or grief.
Page 26
Disassocation: The separation of any group of mental or behavioural processes
from the rest of a person’s consciousness or identity.
Double bind: Simultaneous communication of conflicting messages in the context
of a situation that does not allow escape.
Dysphasia: A disturbance of either the comprehension or expression of speech.
Dystonia: Acute tonic muscle spasms, often of the tongue, jaw, eye & neck but
sometime the whole body. Usually occurs as a result of medication.
E
Electro-Convulsive Therapy (ECT) A form of medical treatment for mental
disorder in which seizures are induced by passing electricity through the brain of an
anaesthetised patient; generally used as treatment for severe depression.
Emergency Application An application for detention for assessment made only
one supporting medical recommendation in cases of urgent necessity. The patient
can only be detained for a maximum of 72 hours unless a second medical
recommendation is received. Also known as a “section 4 application”.
European Convention on Human Rights (ECHR) The European Convention for
the Protection of Human Rights and Fundamental Freedoms. The substantive rights
it guarantees are largely incorporated into UK law by the Human Rights Act 1998.
Echolia: Heard speech is repeated, usually only a word or phrase.
Ertomania: Typical account is of a woman who falls in love with an unobtainable
man of higher status. All acts by the man are interpreted to be consent with his love
being returned to her, including blunt rejection.
F
Flight of ideas: Over productive speech characterised by rapid shifting from one
topic to
another & fragmented ideas.
Free association: The verbalisation of thoughts as they occur, without any
conscious screening or censorship
G
GP A patient’s general practitioner (or “family doctor”)
Guardian See guardianship.
Guardianship The appointment of a guardian to help and supervise patients in the
community for their own welfare or to protect other people. The guardian may be
either a local social services authority (LSSA) or someone else approved by an
LSSA (a private guardian).
Guardianship Application An application to a local social services authority by an
approved mental health professional or a nearest relative for a patient to
Page 27
become subject to guardianship.
Guardianship Order An order by the court, under Part 3 of the Act that a mentally
disordered offender should become subject to guardianship.
Guiding Principles The principles set out in chapter 1 that have to be considered
when decisions are made under the Act.
Grandiose delusions: A belief that a person has a special skill, role or mission in
the world; especially when there are elaborate beliefs about why the patient was
chosen.
H
Habilitation Equipping someone with skills and abilities they have never had.
As opposed to rehabilitation, which means helping them recover skills and abilities
they have lost.
Health Action Plan A plan which details the actions needed to maintain and
improve the health of an individual with a learning disability and any help needed
to achieve them. It links the individual with the range of services and supports they
need in order to have better health. It is part of their broader person-centred plan.
Holding Powers The powers in section 5 of the Act which allow hospital in-patients
to be detained temporarily so that a decision can be made about whether an
application for detention should be made. There are two holding powers: under
section 5(2), doctors and approved clinicians can detain patients for up to 72 hours;
and under section 5(4), certain nurses can detain patients for up to 6 hours.
Hospital Direction An order by the court under Part 3 of the Act for the detention
for medical treatment in hospital of a mentally disordered offender. It is
given alongside a prison sentence. Hospital directions are given under
section 45A of the Act.
Hospital Managers The organisation (or individual) responsible for the operation of
the Act in a particular hospital (eg an NHS trust, an NHS foundation trust or
the owners of an independent hospital). Hospital managers have various functions
under the Act, which include the power to discharge a patient. In practice, most of
the hospital managers’ decisions are taken on their behalf by individuals (or groups
of individuals) authorised by the hospital managers to do so. This can include
clinical staff. Hospital managers’ decisions about discharge are normally delegated
to a “managers’ panel” of three or more people.
Hospital Order An order by a court under Part 3 of the Act for the detention for
medical treatment in hospital of a mentally disordered offender, given instead of a
prison sentence or other form of punishment. Hospital orders are normally made
under section 37 of the Act.
Human Rights Act 1998 A law largely incorporating into UK law the substantive
rights set out in the European Convention on Human Rights.
Hallucinations: Perceptual distortion arising from any of the five senses (ie seeing,
hearing, feeling,tasting, smelling something that is not present).
Hysteria: 1) When anxiety created by emotional conflict is converted into physical
symptoms (eg paralysis, tics, mutism) ) A state of tension or excitement where
there is a temporary loss of control over the emotions.
Page 28
I
Ideas of reference: Incorrect interpretation of casual incidents & external events as
having direct personal references.
Illusions: False perceptions or false responses to a sensory stimulus.
Independent Hospital A hospital which is not managed by the NHS.
Independent (IMHA) Advocate Mental Health An advocate available to offer help
to patients under arrangements which are specifically required to be made under
the Act.2
Independent Mental Health Advocate (IMHA) The services which make
independent mental health advocates available to patients. The Act calls patients
who are eligible for these services “qualifying patients”.
Informal Patient Someone who is being treated for a mental disorder and who is
not detained under the Act. Also sometimes known as a “voluntary patient”.
Institutionalisation: The habituation of an individual to the patterns of behaviour &
routines associated with, & expected in, an institution.This requirement to conform
is associated with restriction in personal freesom & choice, creating loss of
individuality.
Interim Hospital Order An order by a court under Part 3 of the Act for the
detention for medical treatment in hospital of a mentally disordered offender on an
interim basis, to enable the court to decide whether to make a hospital
order or deal with the offender’s case in some other way. Interim hospital orders are
made under section 38 of the Act.
Introjection: An intense type of identification in which one incorporates qualities or
values of another person or group into one’s own ego structure.
L
Learning Disability In the Act, a learning disability means a state of arrested or
incomplete development of the mind which includes significant impairment of
intelligence and social functioning. It is a form of mental disorder.
Learning Disability The rule which says that certain parts of the Act only apply to a
learning disability if the learning disability is associated with qualification abnormally
aggressive or seriously irresponsible behaviour on the part of the person
concerned.
Leave of Absence Permission for a patient who is detained in hospital to be absent
from the hospital for short periods, eg to go to the shops or spend a weekend at
home, or for much longer periods. Patients remain under the powers of the Act
when they are on leave and can be recalled to hospital if necessary in the interest
of the patient’s health or safety or for the protection of other people.
Local Social Services Authority (LSSA) The local authority (or council)
responsible for social services in a particular area of the country.
Page 29
La belle indifference: A term sometimes applied to an apparent lack of concern
commonly
associated with symptoms of hysteria.
Lability: A rapid change in mood, which can occur especially in elderly people with
a mental disorder
.
Loose association: Lack of a logical relationship between thoughts & ideas that
renders speech & thought inexact, vague, diffuse & unfocussed.
Low stimulus environment: An area away from general ward areas where the
patient is less aroused by the environment & where nursing is more intense.
Related to Psychiatric intensive care unit (PICU).
M
Managers See hospital managers.
Managers’ Panel A panel of three or more people appointed to take decisions on
behalf of hospital managers about the discharge of patients from detention
or supervised community treatment.
Medical Recommendation Normally means a recommendation provided by a
doctor in support of an application for detention or a guardianship application.
Medical Treatment In the Act, this covers a wide range of services. As well as the
kind of care and treatment given by doctors, it also includes nursing,
psychological therapies, and specialist mental health habilitation, rehabilitation and
care.
Medical Treatment for Mental Disorder Medical treatment which is for the
purpose of alleviating, or treatment preventing a worsening of, the mental disorder,
or one or more of its for mental symptoms or manifestations.
Mental Capacity Act The Mental Capacity Act 2005. An Act of Parliament that
governs decision-making on behalf of people who lack capacity, both where
they lose capacity at some point in their lives, eg as a result of dementia or brain
injury, and where the incapacitating condition has been present since birth.
Mental Disorder Any disorder or disability of the mind. As well as mental illnesses,
it includes conditions like personality disorders, autistic spectrum disorders and
learning disabilities.
Mental Health Act Commission See Commission.
Mental Illness An illness of the mind. It includes common conditions like
depression and anxiety and less common conditions like schizophrenia, bipolar
disorder, anorexia nervosa and dementia.
Mentally Disordered Offender A person who has a mental disorder and who has
committed a criminal offence.
Mania: A condition characterised by a mood that is elated, expansive or irritable.
Manic depression: Outdated term for bipolar affective disorder.
Page 30
Mental disorder: means mental illness, arrested or incomplete development of
mind, psychopathic disorder and any other disorder or disability of mind.
Mental handicap: A dated term for learning difficulties and/or disabilities.
Morbid jealousy: Conviction that a partner is having an affair, checks partner’s
clothes and
movements. Denial is interpreted as proof. Patients are potentially dangerous as
they may resort to violence. Morbid jealousy is often associated with alcoholism and
is more common in men. It can arise in organic states.
Mood: A general overview of predominant feelings: includes past & current
affective experiences.
N
Nearest Relative A person defined by section 26 of the Act who has certain rights
and powers under the Act in respect of a patient for whom they are the nearest
relative.
NHS The National Health Service.
NHS Commissioners Primary care trusts (PCTs) and other bodies responsible for
commissioning NHS services.
NHS Trust and NHS Foundation Trust Types of NHS body responsible for
providing NHS services in a local area.
Nominated Deputy A doctor or approved clinician who may make a report
detaining a patient under the holding powers in section 5 in the absence of the
doctor or approved clinician who is in charge of the patient’s treatment.
Neurosis: disorder, which does not affect the whole personality; characterised by
anxiety & tension.
P
Part 2 The part of the Act which deals with detention, guardianship and
supervised community treatment for civil (ie non-offender) patients.
Some aspects of Part 2 also apply to some patients who have been
detained or made subject to guardianship by the courts or who have
been transferred from prison to detenton in hospital by the Secretary
of State for Justice under Part 3 of the Act.
Part 2 Patient A civil patient – ie a patient who became subject to compulsory
measures under the Act as a result of an application for detention or
a guardianship application by a nearest relative or an approved
mental health professional under Part 2 of the Act.
Part 3 The part of the Act which deals with mentally disordered offenders
and defendants in criminal proceedings. Among other things, it allows
courts to detain people in hospital for treatment instead of punishing
them, where particular criteria are met. It also allows the Secretary of
State for Justice to transfer people from prison to detention in hospital
for treatment.
Page 31
Part 3 Patient A patient made subject to compulsory measures under the Act by
the courts or by being transferred to detention in hospital from prison under Part 3
of the Act. Part 3 patients can be either “restricted” (ie subject to special restrictions
on when they can be discharged, given leave of absence, and various other
matters) or “unrestricted” (ie treated for the most part like a Part 2 patient).
Part 4 The part of the Act which deals mainly with the medical treatment for mental
disorder of detained patients (including SCT patients who have been recalled to
hospital). In particular, it sets out when they can and cannot be treated for their
mental disorder without their consent.
Part 4A The Part of the Act which deals with the medical treatment for mental
disorder of SCT patients when they have not been recalled to hospital.
Part 4A Certificate A SOAD certificate approving particular forms of medical
treatment for mental disorder for an SCT patient.
Part 4A Patient means an SCT patient who has not been patient recalled to
hospital.
Patient People who are, or appear to be, suffering from a mental disorder. This use
of the term is not a recommendation that the term “patient” should be used in
practice in preference to other terms such as “service users”, “clients” or similar
terms. It is simply a reflection of the terminology used in the Act itself.
Person Centred Plan An individual plan for each person with a learning
disability, tailored to their needs and aspirations, which aims to help them to be a
part of their community and to help the community to welcome them.
Place of Safety A place in which people may be temporarily detained under the
Act. In particular, a place to which the police may remove a person for the
purpose of assessment under section 135 or 136 of the Act. (A place
of safety may be a hospital, a residential care home, a police station,
or any other suitable place.)
Primary Care Trust (PCT) The NHS body responsible, in particular, for
commissioning (arranging) NHS services for a particular part of England. PCTs may
also provide NHS services themselves.
Private Guardian An individual person (rather than a local social services
authority) who is a patient’s guardian under the Act.
Perception: The organisation & interpretation of stimuli into meaningful knowledge.
Polypharmacy: Use of combinations of psychoactive drugs in a patient at the
same time; more than one drug may not be more effective than a single agent, can
cause drug interactions & may increase the incidence of adverse reactions.
Projection: Attributing one’s own thoughts or impulses to another person. Through
this process the person can attribute intolerable wishes, emotional feelings or
motivations to another person.
Psychopath: A person with an antisocial personality (also known as sociopath).
Not connected to pyschosis.
Page 32
Psychosis: A category of health problems that are distinguished by regressive
behaviour, personality disintegration, reduced level of awareness, great difficulty in
functioning adequately & gross impairment in reality testing.
Q
Qualifying Patients Patients who are eligible for support from independent mental
health advocacy services.
R
Recall (and Recalled) A requirement that a patient who is subject to the Act return
to hospital. It can apply to patients who are on leave of absence, who are on
supervised community treatment, or who have been given a conditional discharge
from hospital.
Regulations Secondary legislation made under the Act. In most cases, it means
the Mental Health (Hospital, Guardianship and Treatment) (England) Regulations
2008.
Rehabilitation See habilitation.
Remand to Hospital (and Remanded to Hospital) An order by a court under Part
3 of the Act for the detention in hospital of a defendant in criminal proceedings.
Remand under section 35 is for a report on the person’s mental condition. Remand
under section 36 is for medical treatment for mental disorder.
Responsible Clinician The approved clinician with overall responsibility for a
patient’s case. Certain decisions (such as renewing a patient’s detention or placing
a patient on supervised community treatment) can only be taken by the
responsible clinician.
Responsible Hospital The hospital whose managers are responsible for an SCT
patient. To begin with, at least, this is the hospital in which the patient was detained
before being discharged onto supervised community treatment.
Responsible Local Social Services Authority (LSSA) The local social services
authority (LSSA) responsible for a patient who is subject to guardianship under the
Act. The responsible LSSA is normally the LSSA for the area where the patient
lives. But if the patient has a private guardian, it is the LSSA for the area where
the guardian lives.
Restricted Patient A Part 3 patient who, following criminal proceedings, is made
subject to a restriction order under section 41 of the Act, to a limitation direction
under section 45A or to a restriction direction under section 49. The order or
direction will be imposed on an offender where it appears that it is necessary to
protect the public from serious harm. One of the effects of the restrictions imposed
by these sections is that restricted patients cannot be given leave of absence or be
transferred to another hospital without the consent of the Secretary of State for
Justice, and only the Tribunal can discharge them without the Secretary of State’s
agreement. See also Unrestricted Part 3 patient.
Revocation (and Revoke) Term used in the Act to describe the rescinding of a
community treatment order (CTO) when an SCT patient needs further treatment in
hospital under the Act. If a patient’s CTO is revoked, the patient is detained under
the powers of the Act in the same way as before the CTO was made.
Page 33
Reality orientation: Formal process of keeping a person alert to events in the here
& now.
Relapse: Return of symptoms.
S
SCT patient A patient who is on supervised community treatment.
Second Opinion Appointed Doctor (SOAD) An independent doctor appointed by
the Commission who gives a second opinion on whether certain types of medical
treatment for mental disorder should be given without the patient’s consent.
Secretary of State Cabinet ministers in the Government. In the Act, either the
Secretary of State for Health or the Secretary of State for Justice, depending on
the context.
Secretary of State for Health Secretary of State for Justice The Secretary of
State who is responsible, among other things, for the NHS and social services for
adults. The Secretary of State for Health is supported by the Department of Health.
The Secretary of State who is responsible, among other things, for courts, prisons,
probation, criminal law and sentencing. The Secretary of State for Justice is
supported by the Ministry of Justice.
Section 4 Application See emergency application.
Section 57 Treatment A form of medical treatment for mental disorder to which the
special treatment rules in section 57 of the Act apply, especially neurosurgery for
mental disorder (sometimes called “psychosurgery”). It is possible that other forms
of treatment may be added to section 57, section 58 or section 58A by regulations.
Section 58 Treatment A form of medical treatment for mental disorder to which the
special rules in section 58 of the Act apply, which means medication for
mental disorder for detained patients after an initial three-month period.
Section 58A Treatment A form of medical treatment for mental disorder to which
the special rules in section 58 of the Act apply, especially electro-convulsive
therapy.
Section 117 See after-care.
SOAD Certificate A certificate issued by a second opinion appointed doctor
(SOAD) approving particular forms of medical treatment for a patient.
Strategic Health Authority (SHA) NHS body responsible for overseeing all NHS
services in a particular region of England.
Supervised Community Treatment Arrangements under which patients can be
discharged from detention in hospital under the Act, but remain subject to the Act in
the community rather than in hospital. Patients on SCT are expected to comply with
conditions set out in the community treatment order and can be recalled to hospital
if treatment in hospital is necessary again.
Schizoaffective disorder: Diagnosis given to patients who meets the diagnostic
criteria
Page 34
for schizophrenia as well as one or both of the major mood disorders of bipolar
disorder & major depression.
Schizophrenia: Umbrella term for a range of symptoms. A person can’t distinguish
their own intense thoughts, ideas, perceptions and imaginings from reality (the
shared perceptions, sets of ideas and values that other people in that culture hold
to be real). Among other symptoms, a person might be hearing voices, or may
believe that other people can read their mind and control their thoughts.
Schizophrenia does not mean ‘a split personality’.
Seclusion: Separating the patient from others in a safe, contained environment.
Self-esteem: The person’s judgement of personal worth obtained by analysing how
well his or her behaviour conforms to self ideal.
Splitting: Viewing people & situations as either all good or bad. Failure to integrate
the positive & negative qualities of oneself & of objects.
T
Tribunal A judicial body which has the power to discharge patients from detention,
supervised community treatment, guardianship and conditional discharge. At the
time of publication, this means the Mental Health Review Tribunal (MHRT).
However, subject to Parliament, the MHRT is intended to be replaced in England by
a new First Tier Tribunal established under the Tribunals, Courts and Enforcement
Act 2007.
Tardive dyskinesia: Literally ‘late appearing abnormal movements’, a variable
complex of
choreiform or athetoid movements developing in patients exposed to antipsychotic
drugs. Typical movements include tongue withering or protrusion, chewing, lip
puckering, chorieform finger movements, toe & ankle movements, leg jiggling &
movements of neck, trunk & pelvis.
Thought blocking: Sudden stopping in the train of thoughts or in the midst of a
sentence.
Thought broadcasting: A person believes that everybody can hear their thoughts.
Thought withdrawal: A belief that thoughts are being taken away from an
individual.
Thought insertion: A belief that thoughts are being inserted into an individual’s
head.
U
Unrestricted Part 3 Patient A patient subject to a hospital order or guardianship
order under Part 3 of the Act, or who has been transferred from prison to detention
in hospital under that Part, who is not also subject to a restriction order or direction.
For the most part, unrestricted patients are treated in the same way as Part 2
patients, although they cannot be discharged by their nearest relative. See also
Restricted patient.
Page 35
V
Voluntary Patient See informal patient.
W
Word salad: Series of words that seem totally unrelated.
Welsh Ministers Ministers in the Welsh Assembly Government.
Y
Young Person A person aged 16 or 17.
Page 36
Common Sections
SECTION
5(2)
IN PATIENT
EMERGENCY
2 ASSESSMENT
3 TREATMENT
4 EMERGENCY
ADMISSION
17A SUPERVISED
COMMUNITY
TREATMENT
DURATION
IMPLEMENTATION
PROCESS
APPEAL
DISCHARGE
PROCESS
FOLLOWED BY
SPECIAL
INSTRUCTIONS
NO
EXPIRES/S23 BY
RC/ ASSESSED &
NOT DETAINABLE
EXPIRES BECOMES
INFORMAL OR
CONVERTED TO A 2
OR 3
72 HOURS BEGINS
WHEN RECEIVED BY
MANAGERS (FORM 14)
28 DAYS
2 MEDICAL
RECOMMENDATIONS
1 ASW OR NEAREST
RELATIVE
APPLICATION
WITHIN FIRST 14
DAYS TO MHRT OR
ANY TIME TO
MANAGERS
EXPIRES OR RC S23
OR
MHRT/MANAGERS
EXPIRES BECOMES
INFORMAL OR SEC
3
ASSESSMENT ONLY
MUST BE CONVERTED
TO S3 IF DIAGNOSIS
MADE
6 MONTHS
2 MEDICAL
RECOMMENDATIONS
1 ASW OR NEAREST
RELATIVE
APPLICATION
ONCE IN 1ST 6-MTH
THEN EVERY
PERIOD OF
DETENTION OR
ANY TIME TO
MANAGERS
EXPIRES OR RC S23
OR
MHRT/MANAGERS
RENEWABLE AFTER
6 MTH THEN
YEARLY
72 HOURS
1 MEDICAL
RECOMMENDATION 1
ASW APPLICATION
NO
EXPIRES/S23 OR
ASSESSED & NOT
DETAINABLE
CONVERT TO 2 OR
APPLICATION FOR 3
6 MONTHS
RESPONSIBLE
CLINICIAN WITH
AGREEMENT OF
AMHP
ONCE IN 1ST 6-MTH
THEN EVERY
PERIOD OF
DETENTION OR
ANY TIME TO
MANAGERS
EXPIRES OR RC S23
OR REVOCATION
OR
MHRT/MANAGERS
RENEWABLE AFTER
6 MTH THEN
YEARLY
72 HOURS
RC/SHO IN
PSYCHIATRY
NO
RC/12(2) AFTER
FULL ASSESSMENT
ASW MUST ASSESS
SHO CANNOT
DISCHARGE
INFORMAL
ADMISSION S2 / S3
OR DISCHARGE
RC/COVERING RC
NOT SPR
NO
NOT APPLICABLE
FURTHER SEC 17
NOT APPLICABLE
NOT APPLICABLE
RC OR
MHRT/MANAGERS
117 FOR SEC 3
136
POLICE – PLACE OF
SAFETY
72 HOURS
POLICE
17
LEAVE
AS SPECIFIED
23 DISCHARGE
NOT APPLICABLE
THE THREE MONTH
RULE FOR TREATMENT
APPLIES
SUBJECT TO S117 ON
DISCHARGE
BEGINS WHEN PATIENT
ARRIVES IN HOSPITAL 2
MED REC CONVERTS S4
TO S2 (WITHIN 72
HOURS)
PART 4A FOR
TREATMENT APPLIES.
SUBJECT TO S117. MAY
BE RECALLED FOR
UPTO 72 HOURS
PLACE OF SAFETY MAY
ALSO BE POLICE
STATION IF
INTOXICATED/VIOLENT.
A&E EN ROUTE IF REQ’S
MEDICAL ATTENTION
POLICE TO STAY UNTIL
MANAGERS ACCEPT
RESPONSIBILITY
TIMES, ESCORTS AND
DESTINATION TO BE
SPECIFIED
S23 TO BE SIGNED BY
RC
Page 37
FLOWCHART OF
DETENTION
MHA Assessment by AMHP
Emergency – s.4 or s.135
Non-Emergency – s.2, 3
Patient in Community
Police Officer - S.136
Court
Before Sentencing
Assessment – s.35
Treatment – s.36
Interim – s.38
After Sentencing
Hospital Order – s37
Guardianship Order – s37
(return to community)
Hospital Order with Restrictions
– 37/41
Hospital
Recall / Revocation
Community
Supervised Community Treatment – s.17A
Conditionally Discharged – s.41
Community
Informal
Aftercare – s.117
Guardianship – s.7
Conditionally Discharged – s.41
38
Remand Centre
Transfer – s48
Transfer with
Restrictions – s.48/49
Prison
Transfer – s47
Transfer with
Restrictions – s.47/49