Sunday, 1 November 2015

Sec 13(4): The Right of the Nearest Relative to Request a Mental Health Act Assessment

Relatives are frequently unaware of their right under Sec.13(4) MHA to request an assessment of their relative under the Mental Health Act.
Those who are aware of this, are often under the misapprehension that this will inevitably trigger a visit to their relative by an Approved Mental Health Professional and two doctors.
Sec.13(4) states:
(4) It shall be the duty of a local social services authority, if so required by the nearest relative of a patient residing in their area, to make arrangements … for an approved mental health professional to consider the patient’s case with a view to making an application for his admission to hospital; and if in any such case that professional decides not to make an application he shall inform the nearest relative of his reasons in writing.
The new extended 2015 Reference Guide has very little to say to enlarge upon this, other than referring the reader to the new 2015 Code of Practice, and stating that “the nearest relative can require the local authority (verbally or in writing)…to arrange for an approved mental health professional (AMHP) to ‘consider the patient’s case’ including whether there is a need for compulsory admission to hospital.” (p.21).
The Code of Practice only refers to this section in two paragraphs, at para14.36, and para14.102. The only thing that para13.36 adds is to state that the local authority must respond not only to a direct request from the Nr, but also to a request “on behalf of” the NR.
So what does all this mean to the nearest relative and to the AMHP receiving a request under Sec.13(4) from the nearest relative?
The NR does not need to put the request in writing, but can make a request by phone. They can also ask someone else to make a request, such as another relative, or their GP, and this must be considered as if  it were a direct request from the NR.
The local authority AMHP service has to respond to this request. But this does not necessarily mean that they will conduct a formal assessment. An AMHP only has to “consider the patient’s case”. If, having done this, they do not think that an assessment is merited, there is no requirement to assess.
From the AMHP point of view, there may be many reasons why it is not appropriate to assess the patient under the MHA. A typical reason may be that other arrangements are being, or have been made. This might include a GP referring the patient to the local crisis team for assessment. It would therefore be wrong to pre-empt this assessment, under the principle of the least restrictive option.
Another reason might be that the patient is already involved with a community mental health team, who are managing the patient’s condition and would not welcome and AMHP’s intervention, or do not consider that a MHA assessment is necessary.
It may be that, while the relative is concerned about the patient, the patient has not actually seen a doctor recently. In which case, I would always advise the relative that they should arrange for the patient to see a doctor first.
In some cases, the request may be “mischievous”; in other words, the relative may have made frequent or recent requests for their relative to be assessed, and unless there has been any significant changes in the patient’s condition, it would be oppressive to keep formally assessing the patient.
I recall one such case, where the mother of the patient, a pregnant single parent with a young child, reported that she was expressing a range of alarming paranoid delusions, especially around her unborn baby. The ex-partner of the patient also corroborated this.
I went out with the GP and a psychiatrist, to find her preparing tea for her daughter and a school friend. Everything appeared completely normal, and she spoke politely and rationally to us for about an hour. We were unable to elicit any symptoms of mental illness, but based on the reports of the relatives, we rather heavy-heartedly decided to detain her, and she was detained under Sec.2 for 28 days.
During that time she was not given any medication, and did not provide any evidence to ward staff of any mental illness.
On another occasion, I received a request from the husband of a woman. They were recently separated. His concerns seemed to boil down to the view that since his wife did not want to talk to him, and would not agree to what he wanted to happen to the property and children, then she must be mentally ill. I did not respond to this request.
Once an AMHP has considered the case, and has either decided not to undertake a formal assessment, or has assessed and has decided not to detain, they have a legal requirement to write to the referring relative. These letters have to be very carefully written. The Code of Practice states: “Such a letter should contain, as far as possible, sufficient details to enable the nearest relative to understand the decision while at the same time preserving the patient’s right to confidentiality.”(para14.102)
Sec.13(4) requests from nearest relatives always used to be a fairly rare occurrence. Recently, however, our local AMHP service has received a mysterious increase in these requests. Could it be that relatives are becoming better informed about their rights under the Mental Health Act?
I don’t actually think so. We have discovered that relatives have been contacting the patient’s community mental health team because of concerns about their mental health, who have then advised them to make a referral to the AMHP service.
This appears to be due to service cuts or staff shortages. It appears that increasing numbers of patients are active to community teams, but have not got an allocated care co-ordinator, and the over worked duty worker has the idea that, if their team cannot make a timely response, then the AMHP service can always conduct an assessment under the MHA.
We have been working hard to disabuse community mental health services of this notion.