When To Use a Section 4 (and When Not To)

Detention under Section 4 of the Mental Health Act only requires one medical recommendation. It should be used “only in a genuine emergency, where the patient’s need for urgent assessment outweighs the desirability of waiting for a second doctor.” (5.4 Code of Practice). There should be evidence of “an immediate and significant risk of mental or physical harm to the patient or to others; danger of serious harm to property; or a need for physical restraint of the patient.” (5.6 CoP).

In 27 years of working within the Mental Health Act, I have used Sec.4 on only 17 occasions (and only once in the last 7 years). Most of those took place in the early years of the Act, when it was often impossible to get a second medical recommendation within a realistic time frame, especially in a rural area; when hospital bound consultants would still say: “Be a good chap and bring them in under a 4, and I’ll convert it to a 2 when you get here.”

I’ve written on this blog about the first time I used Sec.4 (Emma, posted on 11th July 2009) and the most recent time I’ve used it (Mavis, 24th April 2009). Here’s another example.

William was 40. He had learning difficulties and had been placed in a care home in our area for about a year. He had a history of impulsive and aggressive behaviour, and this had been getting worse over the last few weeks. He had assaulted two staff members and had been arrested, then bailed back to the home. Two days later, he assaulted three more staff members and was again arrested. He had again been bailed, but this time the home was no longer prepared to accommodate him. His Consultant Psychiatrist had arranged for a bed in a low secure private hospital and made a request for assessment for admission under Sec.2 Mental Health Act.

One might have imagined that this was a comparatively straightforward assessment of a man with learning difficulties (at least there was a bed – sometimes a bed for a patient with learning difficulties can take weeks to obtain, leaving the AMHP unable to complete an application because there is no hospital to put on the form, and sometimes having to obtain further medical recommendations because the first ones have run out of time).

But as I obtained more information, my heart sank. Firstly, the Consultant had not actually provided a medical recommendation, and was not currently available. Secondly, William was not at the police station, since he had been bailed and the staff had picked him up. And he was not at the care home, because they were refusing to take him back, and he was refusing to go back. At the time I received the request, he was being driven round the county in the home’s minibus, in the company of four of the staff. It was the only way to keep him happy and prevent him from beating them all up.

So somehow I had to arrange for the assessment of an aggressive and impulsive man with learning difficulties (and epilepsy and diabetes) who was only being managed by taking him wherever in the county he had a whim to go, otherwise he was going to assault even more staff. The Consultant, who had seen him and who could have furnished a recommendation, was unavailable. It did seem to be a matter of “urgent necessity” to admit him to hospital. It seemed logistically impossible to get two doctors in one place at the same time as the patient, and would involve unreasonable delay.

So I arranged for the assessment to take place at the GP’s surgery. I contacted the staff in the minibus on their mobile, liaised with the GP, and we all met up in the car park within an hour of receiving the call. The GP and I persuaded him to come into the surgery, where we interviewed him. Although he remained calm with us, this was probably more because of the novelty of the location, and the fact that he was supplied with a plate of biscuits. He did, however, become touchy when asked anything about the care home, and we felt we needed to finish our assessment at that point. With the GP’s lone recommendation I made an application under Sec.4 and rang the hospital to inform them that he was on his way.

But that was too easy, wasn’t it?

“We’re a low to medium secure unit,” the admitting nurse told me. “We only take patients who are detained under Sec.2 or Sec.3, or under Part III of the Act [relating to mentally disordered offenders].”

“What do you mean?” I asked. I explained the situation to the nurse as clearly as possible, aware that, now William was back in the minibus and expecting to go to hospital (which he said he preferred to the care home), he was again getting twitchy, because he liked to be in a moving vehicle, not in a car park. “If a patient has a lawful detention, I think it is immaterial what particular section they’re detained under.”

“We’ve never had anyone here on a Sec.4.”

“There’s always a first time for everything isn’t there? A Sec.4 was the only way I could see of getting him to a safe place. Once he’s admitted, we can get it converted to a Sec.2 within hours.”

This conversation continued for several more minutes. At one point the nurse transferred me to a social worker. I had a similar conversation with her, stressing that the longer the delay, the more agitated the patient was likely to become. In fact, I was myself beginning to get an inkling of the agitation William might be feeling. However, the social worker did seem to have a better grasp of the Mental Health Act, and of my predicament, and eventually she conceded that a section was, essentially, a section, and he could be admitted.

And within minutes of William’s arrival at the hospital, the Consultant miraculously made an appearance and supplied a second medical recommendation.