A Kiss is Just a Kiss: On the Risks Associated With Conveying Patients to Hospital

There is a whole chapter in the Mental Health Act Code of Practice on the conveyance of patients to hospital. Two of the particularly cogent paragraphs are as follows:

"11.2 Patients should always be conveyed in the manner which is most likely to preserve their dignity and privacy consistent with managing any risk to their health and safety or to other people.”

“11.21 AMHPs should not normally agree to a patient being conveyed by car unless satisfied that it would not put the patient or other people at risk of harm and that it is the most appropriate way of transporting the patient. In these circumstances there should be an escort for the patient other than the driver.”

The Masked AMHP has of course read these paragraphs, and has taken due notice of them. He does, however, consider that there are situations in which it is appropriate, or necessary, for the AMHP to take the patient to hospital themselves. Sometimes, there just does not seem to be any alternative at the time.

In both of the following cases, in which the Masked AMHP found himself in difficult osculatory situations, the patient was not formally detained under the MHA, but was being transported as an informal patient. I would submit that the Code does not specifically refer to informal admissions.

Leroy

I have mentioned Leroy before on this blog. He has a very long history of bipolar affective disorder, which is frequently exacerbated by his fondness for amphetamine.

Leroy had been an informal patient, but when allowed leave off the ward, he had not returned. I was asked to visit him at home to check him out, and see if he could either be persuaded to return to hospital, or whether he might need assessing under the MHA.

I went out with Pam, one of our nurses, and knocked on his door.

He came to the door and beamed at us.

“Thank God you’ve come!” he said. “It’s terrible – the TV’s talking to me, and I can’t stop it! I’m begging you, please take me back to hospital!”

We couldn’t really argue with that, and made the decision to take him back straight away.

However, during the journey back, in which I was driving, and Pam was sitting next to him in the back, we began to regret this decision.

Leroy was clearly very high, with marked pressure of speech. He was also patently psychotic.

“Masked AMHP,” he said, “You’re scaring me. You’re speaking with the voice of an alien from Alpha Centauri! Stop it please.”

“I’ll do my best, Leroy,” I said, and decided not to speak at all.

At last we reached the hospital. I took him down the corridor towards Bluebell Ward, keen to get him into a safe place.

Halfway there, he suddenly stopped.

“I’m not gay, or anything, Masked AMHP,” he said, “but I really want to kiss you. On the lips.”

With that, he put a hand round my throat and pushed me against the wall, his lips wide open and his tongue moving rapidly from side to side like a conga eel searching for prey.

I could suddenly see my whole life passing by. Could I survive a kiss from Leroy?

I managed to extricate myself just as he was about to launch himself on me, and hurried on down the corridor, with Leroy in close pursuit.

Once we were on the ward, I suggested that Leroy might need to be detained under Sec.5(2), so that we could arrange a formal assessment.

Florence

Florence was a lady in her early 60’s. She, too, had a long history of bipolar affective disorder. I had assessed, and detained her, on several occasions in the past. Her typical presentation was to become hypomanic, with grandiose ideas, and spending money on irrational things.

Her long suffering husband called us, to let us know that she had “gone off” again. I went out to conduct an initial assessment with Dave, her community nurse.

Her husband met us at the door. He was a lot older that Florence, and the strain was telling on him.

“She’s bought a one way ticket on Concorde to the USA,” he said in despair. (This was a few years ago, when Concorde was still in service.) “She wants to see the President to give him some advice.”

We found her in the sitting room, drinking a tumbler of sherry and watching a pornographic video on the TV.

We politely asked her to turn the TV off.

“It’s just getting to the good bit,” she said, taking a swig from her glass.

We eventually persuaded her to turn off the TV. She abruptly got up and wandered off into the kitchen. We followed her there.

She was quite plainly unwell, and her husband was unable to keep up with her.

We tried to talk to her to assess quite how unwell she was, but she kept jumping from one random topic to another.

I suddenly caught a glimpse of something  peering out from the side of their fridge. I pulled the fridge out to be confronted with a fairly large furry animal, which looked up at me with appealing eyes.

“What is this, Florence?” I asked her.

“That’s my new chinchilla,” she said. “I got it yesterday. I was wondering where it was. I’m planning to start a chinchilla farm.”

On this occasion, we managed to persuade her that it would be a good idea to go to hospital. This time, Dave drove, while I sat in the back with Florence.

Florence seemed to take a liking to me. She took off her shoes and put her stockinged legs on my lap. Then she began to sing.

“Somewhere, over the rainbow, skies are blue...”

She continued to sing a medley of songs from 30’s and 40’s movies.

I decided to humour her with a rendition of my own. This was a mistake.

“You must remember this, a kiss is just a kiss –“ I began.

Florence looked at me with sudden affection.

Very well, my dear,” she interrupted, licking her lips, and suddenly lunged forward and planted her moist lips firmly on mine, attempting to thrust her tongue down my throat at the same time.

“Need any help in the back there?” Dave enquired, seeing a commotion in his rear view mirror.

But I was not at that moment able to reply.

AMHP’s in Court: Some Recent Case Law

Case Law relating specifically to the discharge of AMHP’s powers under the MHA is fairly rare. I don’t know whether this is because AMHP’s rarely make mistakes, or whether it is because most people who are detained under the MHA don’t know enough about the legal process to know whether or not an error in law has been made.

Whatever the reason, court cases of relevance to AMHP practice seem to be like buses – you don’t get any for ages, then two come along at once. In fact, the two particular cases I’m writing about were heard within a month of each other – in March and April 2012.

The first is DD v.Durham County Council & Middlesbrough City Council ([2012] EWHC 1053 (QB)). Although the events with which the Claimant took issue occurred at the end of 2009 and the beginning of 2010, the Claimant did not actually issue proceedings until nearly the end of 2011.

DD had been serving a prison sentence. When the sentence ended, but during a period in which DD continued to reside in the prison, he was assessed under the MHA by two AMHP’s, and the decision was made to detain him under Sec.2 for assessment. He was admitted to a medium secure psychiatric unit. Before this expired, he was assessed by two more AMHP’s, who decided that he should be detained for treatment under Sec.3. Because the location of the assessment was not in the Durham area, and because of the adverse weather conditions pertaining at the time, a Middlesbrough AMHP subsequently assessed and applied for his detention under Sec.3.

DD wanted to instigate proceedings under Sec.139 MHA. This relates to liability for acts “done in bad faith or without reasonable care”. In effect, he wanted to sue one or more of the AMHP’s who had been involved for detaining him illegally.

DD argued that both the AMHP’s who had completed the Sec.2 application and the subsequent Sec.3 had breached their duties under Sec.13(2) MHA.

Sec.13(2) states:

“Before making an application for the admission of a patient to hospital an approved mental health professional shall interview the patient in a suitable manner and satisfy himself that detention in a hospital is in all the circumstances of the case the most appropriate way of providing the care and medical treatment of which the patient stands in need.”

He argued that the AMHP in question had “a duty to investigate the proposed place of detention, the location where the patient will be kept while there and the regime to which he will be subject. This is said to arise because of the need to make a recommendation in the light of ‘all the circumstances’”. This was because he was objecting to the secure unit he was sent to, instead preferring to go to Rampton.

The Judge in the case dismissed this argument in one paragraph:

“It is obvious than an AMHP is not directly responsible for the medical or other regimes to which a detained person is subjected… An AMHP has certain responsibilities under the Mental Health Act which include recommending a person for detention under s.2 or under s.3. Their responsibilities have to be discharged in the light of all the relevant circumstances of the case, which would include taking into account the assessments of qualified doctors. Their functions do not extend, however, to choosing an institution in which the person concerned is to be detained – still less to researching the available facilities or carrying out a reconnaissance to assess their quality.”

This is reassuring confirmation of what I am sure is a universal view held by AMHP’s, which is that they only need to decide whether or not a patient needs to be detained, and not the suitability or otherwise of the hospital they will be admitted to.

DD described himself as having “a paranoid, narcissistic and antisocial personality disorder”. This observation would be entirely consistent with the nature of his complaint.

While in this case, the AMHP’s involved were all exonerated, this was not the outcome in GP v. Derby City Council ([2012] EWHC 1451 (Admin)).

At the time of the court hearing, GP had been detained under Sec.3 in a low secure unit since July 2011. He was challenging the legality of this detention on the grounds that the AMHP had failed to consult with the patient’s Nearest Relative as required under Sec.11(4)(a).

The AMHP who made the application maintained that he had attempted to contact the NR on her mobile phone, but had not been able to speak to them. He therefore stated that it was not reasonably practicable, or would involve unreasonable delay to do so, and completed the application. In the space provided on Form A6, he had written: "I have tried to contact several times but the mobile went to answer machine. As GP Section 2 is due to lapse later today and given his current state I felt it would involve unreasonable delay to consult with Ms P."

This assessment was concluded at around 1600 hrs on the day that the existing Sec.2 detention was due to expire at midnight. The AMHP had been under pressure of time, and was also being pressured by the ward staff to complete the application on the basis that the patient needed to be transferred to a Psychiatric Intensive Care Unit (PICU).

The Judge noted that the AMHP had been ringing the wrong number, but that the correct number was available on medical records. He also noted that the AMHP himself had stated in evidence that it was his usual practice to visit the NR at their home in order to consult with them under Sec.3. The Judge concluded that there had been enough time to visit the NR, and that the AMHP should have done this. He therefore concluded that the AMHP had indeed failed in his duty to consult with the NR, and as a consequence, this rendered the Sec.3 unlawful.

The Judge said:

“On the evidence that is available, the question has to be asked as to whether it was plainly wrong to proceed with an immediate certification in the circumstances as they were. I conclude that it was because, as I have attempted to explain, section 11 provides constitutional protection for those that are faced with detention under the Mental Health Act. Compliance with the requirements of section 11(4) is therefore the price which is paid for the ability of those charged with the treatment of those with mental illnesses and disabilities to detain people without immediate recourse to a court and in a way which is compliant with Article 5. Thus there is a heavy duty on those who carry out these tasks to ensure that those statutory provisions are complied with.”

This case has considerable implications for AMHP practice. The Judge makes it clear that, in order not to breach Article 5 of the Human Rights Act (The right to liberty and security), an AMHP must go to considerable and quite possibly arduous lengths to fulfill their legal obligations. It is not enough to ring the NR a couple of times and then fill in the form saying that it is impracticable to consult with them. The AMHP must show far more evidence of their efforts.

The consequence of this particular lapse was that the patient was deemed to have been unlawfully detained for up to 9 months.

Maintaining identity as a social worker in a multidisciplinary team

How do social workers recognise and maintain the core social work tasks in a multidisciplinary team? The Masked AMHP shares the advice he gave to one social work student.

You can read the Masked AMHP's recently published piece on the Guardian Social Care Network here.

The Masked AMHP Reaches 100!

I even made my own cake!

This is the Masked AMHP’s 100^th post!

When I created this blog back in March 2009, I had no idea whether or not I would be able to sustain writing it beyond a few months. Would I run out of things to write about? Would I simply get bored?  Would I be able to keep to my initial remit, which was to inform and entertain? Would anyone actually read the blog?

Well, I’ve now managed to keep thinking of things to write about for over 3 years. And people do seem to read, and even sometimes enjoy, the blog. When Blogger started to provide me with statistics, back in July 2009, I was gratified to discover that around 1400 people were accessing the blog every month. That was nearly 50 people every day! I am now getting around 10,000 page views a month, and the readership seems to be continuing to grow month on month. 

One of the things I love about blogging is the feedback you receive from readers. I’ve had many interesting, thought provoking and encouraging comments, from professionals, other bloggers and, importantly, from many service users. These comments have helped me to think that writing the blog has been worthwhile, and even useful to others. I’d particularly like to mention CB here, who used to write the awesome FightingMonsters blog. Not only was she my first Follower, but her early comments encouraged me to continue. 

By the way, I find the negative and argumentative comments on the blog just as stimulating in their own way. I have even used some as a springboard for discussing significant issues. (Hello, Monica!) 

(And I’ve even had a comment from someone who could only be Richard Jones himself, the author of the Mental Health Act Manual, the Bible of AMHP’s everywhere. It’s like suddenly discovering that God himself is actually listening to you as you say your prayers at bedtime. And has something to say about it.) 

I have had encouragement from other estimable blogs, including the sadly defunct Mental Nurse, as well as The World in Mentalists and The Not So Big Society. It’s always much appreciated when a post is recommended by others. 

I was very flattered when Guardian Select took an interest in the blog and included it in their directory, and in the last year I have had a number of pieces published in the Guardian’s Social Care Network. 

About a year ago I set up the Masked AMHP’s Facebook group. I had no idea what, if anything would come from it. Over that time, the group has evolved into an open forum for discussion about a wide range of issues relating to mental health. The membership is gratifyingly cosmopolitan and eclectic, ranging from AMHP’s and trainee AMHP’s through to bloggers, academics and importantly, service users. We even have a police officer and a chaplain!

The group has developed into a unique opportunity for people from all sides to come together and discuss how mental health, and the Mental Health Act, impacts on their personal and professional lives. At the last count, there were 325 members. So why not join? (Shameless Plug.) 

So what is next for the Masked AMHP? Should I write a book, and if so, what about? (I’ve been thinking hard about this.) Do readers have any preferences for the types of posts I write, or have suggestions for future posts? Should I start Tweeting? I’d be delighted to hear from you. 

In the meantime, I’ll have to see whether I have the inspiration, or the energy, to write another hundred posts. After all, I’m getting pretty ancient by now.

Thank you all for reading.

Should an AMHP Assess Someone They Know under the Mental Health Act?

Approved Mental Health Professionals can work in a wide variety of settings, ranging from community mental health teams, through to older people’s or learning disability social work teams, and some (although not many) even work  in children and family teams. Many social workers in Emergency Duty Teams, which provide emergency social work services out of normal working hours, are also AMHP’s.

Generally speaking, AMHP’s have to be on a duty rota as a requirement of approval. This can mean either setting aside a day a week when you are available in your work place to take calls for Mental Health Act assessments, or sitting in an AMHP office with a group of other duty AMHP’s, ready to take whatever chance throws at you.

Some AMHP’s take the view that they should only deal with MHA assessments when they are on the duty rota. If that is the case, it is fairly rare for anyone with whom they have been professionally involved to need to be assessed on the specific day that they are on the rota.

Some AMHP’s take the view that it is a matter of best professional practice to “consume their own smoke”, especially if they are based in a mental health team. In this case, they would expect to provide an AMHP service to the team’s service users. I tend to take this view.

There is a lot to be said for sitting in an AMHP office, mingling with your colleagues. You can enlist their advice or support when dealing with a call. If you don’t get a call, you can drink coffee and swap anecdotes. You can gain a great sense of camaraderie from being in the AMHP office.

But if you work in a community mental health team, in a way, you are always on call. You always have your AMHP hat on, or at least, you can whip it on and off at the drop of a hat, so to speak.

There are advantages to this. You can act as a consultant, giving a professional opinion in team meetings and case discussions. In a multidisciplinary team, you can be made aware of a situation which could potentially lead to a formal assessment and suggest ways to avert it. If your advice is taken, and it still ends up with you having to initiate a formal MHA assessment, then you can feel confident that all other avenues have been explored, and that there is no alternative.

If you have care coordination responsibility for the service user, you can make judgments as to whether at any particular moment in time that service user might need a formal assessment, and then act accordingly. If you have a rapport with the service user, then you can discuss your concerns with them, and may be able to persuade them to take action to avoid a potential admission, or at the very least to persuade them to accept admission informally.

But there are also disadvantages to this approach. A service user may be suspicious of you if they think that at any time you might whip out some pink forms and section them. You may also take the professional judgment that it may damage your ability to work with them afterwards if you are the AMHP who detains them.

In my experience, I have found that some service users have never forgiven me for sectioning them, and it has been difficult, if not impossible, to work with them afterwards.

However, I have also found that some service users have been very thankful that I took the action I did, and have continued to work with me afterwards. It can even work to our mutual advantage. If I am very familiar with someone’s relapse signature, then I can be frank with them and share with them the concerns I have if I see their early warning signs. They are more likely to take heed if they know that I know.

I have been in some situations where I am able to make judgments about someone’s mental state based on my extensive past knowledge of when they are well or unwell, being able to detect dangerous signs that an AMHP or other professional who does not know the patient might misinterpret.

Some of the people I have worked with exhibit signs that include extreme rudeness when they are unwell. One example that springs to mind is attending a ward review in which the patient refused to leave their room. We therefore took the ward review to him. He lay in bed looking at us for a few moments, then pointed to the alarm button on the wall and said, “If I want to see a doctor, I press that.”

However, when this person is well, he is warm, amiable and polite. But if you were not intimately aware of his relapse signs, you might simply regard him as being sullen and uncooperative.

(I expect there are some service users reading this who right now are fulminating and shouting at their computer screen: “Of course he’s rude! He didn’t want to be sectioned did he? And the only reason he’s polite later is that he wants to avoid being sectioned again!” To those people, I can only say that after a lot of experience you can learn to tell the difference. I do not automatically think that someone being rude to me is a sign of mental illness. If that were the case, a lot of Department of Work and Pensions officials would be languishing in hospital.)

Another area where acting under the MHA can be an integral part of your ongoing role as care coordinator/AMHP is with Community Treatment Orders. Increasingly often, I am finding that a potential eventual discharge on a CTO is being considered almost as soon as a patient has been detained under Sec.3. It can become part of the long term discharge planning process. It would therefore seem to me to be appropriate for me as their care coordinator to undertake the AMHP role in the CTO process, rather than someone coming in cold to make that decision.

I am currently managing several patients who are on CTO’s, where I was the AMHP that endorsed the application. It means that when the time comes to review the CTO, with a view to either discharging or extending it, I am fully aware of the past risk history, the progress and effectiveness of the CTO during the previous months, and am in a better position to assess the usefulness or otherwise of extending it. I can also better “own” the inevitable report for either a managers’ hearing or a Tribunal. Curiously, some of these patients see being on a CTO as a wholly positive experience; they seem to see it as insurance against returning to hospital.

Overall, then, I regard the AMHP role in connection with service users with whom I am professionally involved as a positive thing. It can, perhaps strangely, make the professional relationship stronger, and even lead to an increase in trust. I’ve written quite a lot in this blog about people I have assessed and/or detained on more than one occasion. The evidence I have is, that as long as you act with honesty and integrity, the service user will respect you for it.



Mental Health Act or Mental Capacity Act? The Case of E

Inserting a nasogastric tube, while potentially live saving, is a lot less pleasant than this posed model would have you believe

Since my lost post (What’s the Point of Mental Hospitals? Suicide and Suicide Prevention), there has coincidentally been a court judgment relating very closely to the arguments being put forward in that post, as well as the extensive and at times contentious comments on the post.

On 15^th June 2012 the Honourable Mr Justice Peter Jackson issued a judgment in the Court of Protection relating to a 32 year old woman known only as E, who was suffering from Anorexia Nervosa, Emotionally Unstable Personality Disorder, and chronic alcohol dependence. This judgment could have far reaching implications.

E had a Body Mass Index of less than 12. She was in a palliative care setting and was refusing to eat. She had a very long history of anorexia, and had had been subject to many treatment regimes over that time, with little or no success. She was at the point of death. The essential decision the Judge had to make was whether or not further life saving treatment against her will was in her best interests.

It was presented to the Judge that, although past treatment had failed, there was a prospect that long term treatment for her eating disorder and other underlying conditions had some prospect of success. In a remarkably humane and clearly written judgment, the Judge concluded:

“The competing factors are, in my judgment, almost exactly in equilibrium, but having considered them as carefully as I am able, I find that the balance tips slowly but unmistakably in the direction of life-preserving treatment. In the end, the presumption in favour of the preservation of life is not displaced.

 I declare that E lacks capacity to make decisions about life-sustaining treatment, and that it is lawful and in her best interests for her to be fed, forcibly if necessary. I find that the resulting interference with E’s rights under Articles 8 and 3 is proportionate and necessary in order to protect her right to life under Article 2.”

This Judgment relates primarily to the Mental Capacity Act. The outcome of the Judgment appears to mean that E can be detained in a hospital and compelled to receive treatment for her mental disorders for 1-2 years or more. She can be deprived of her liberty on the basis that it is in her best interests. And all this will take place under the aegis of the Mental Capacity Act.

While I have no dispute that the judgment was made in the best interests of E, as an AMHP, I am confused, to say the least, at the implications of this judgment for the Mental Health Act.

Far more eminent authorities than the Masked AMHP have commentated on this judgment (Lucy Series, for one, in her excellent The Small Places blog, has raised some cogent issues, and it has had widespread coverage in the national press), so I do not propose to dissect it paragraph by paragraph. I also do not know enough about the case and the extensive treatments E has had over the years to comment on why those involved in her care took the decisions they did that led to E being an informal patient in a palliative care setting.

I am, nevertheless, greatly concerned about the implications for my, and all AMHP’s, practice under the MHA.

The case of GJ (GJ v The FT and The PCT and the Secretary of State for Health (2009) EWHC 2972 (Fam), 20th November 2009) is one that has informed AMHP practice for some time in that it clarified some aspects of the interface between the Mental Health Act and the Mental Capacity Act. This case concluded essentially that, if the Mental Health Act could be used, then it should be used; the MHA trumped the MCA. So, for example, if a person who lacked capacity needed treatment in a hospital for mental disorder and they were not in agreement with this, then treatment should be given under Sec.3 MHA rather than under the Deprivation of Liberty Safeguards under the MCA.

But the case of E seems to throw a spanner in the works.

I have written about the use of the MHA with people with anorexia nervosa before on my blog (Anorexia, the MentalHealth Act – and Kayleigh). To me, it seems clear that anorexia nervosa is a mental disorder within the meaning of the MHA, and if a patient needs treatment for the physical effects of starvation, then it is entirely appropriate to detain them under Sec.3 MHA for treatment. In addition, despite some of the opinions expressed in response to my last post, I regard it as an AMHP’s duty to save life and prevent suicide.

But, as a consequence of bringing E’s case to the Court of Protection and inviting a judgment relating to deprivation of liberty and best interests, E can now receive extremely invasive treatment against her will for an indefinite, but undoubtedly very long period of time, without being detained under the MHA at all.

Not only did it appear unnecessary to bring this case to the Court of Protection, but it appears to have a consequence of reducing E’s recourse to legal challenge of her detention. Had E been detained under Sec.3 MHA for this treatment, then she could have appealed against the decision, and her case could then have been considered by a Tribunal. Even if she had not appealed against detention under the MHA, there would have been periodic automatic referral whenever her detention was extended.

While treatment might be in E’s best interests, I am not sure if the judgment itself was, in the long term, in the best interests of either E or other mentally disordered patients lacking capacity and requiring inpatient treatment against their will.

Why bother with the Mental Health Act at all, if all such treatment can be given under the Deprivation of Liberty Safeguards?

What’s the Point of Mental Hospitals? Suicide and Suicide Prevention

Modern psychiatric wards are light and airy

Monica is one of my blog readers. She often comments on posts. Her comments can be quite challenging. She has a very individual perspective, often making statements which force me to look more closely at my basic assumptions when it comes to mental disorder.

Monica’s most recent comments were in response to my last post, about Paul, a service user who killed himself while a hospital inpatient. Here, my implicit assumption was that it’s not a good idea to allow people to kill themselves if they suffer from a mental disorder and that as an AMHP I should make every effort to try to prevent suicide, including admitting people to psychiatric hospital, either informally or under the Mental Health Act.

As is often the case on my blog, Monica questioned this. She wrote:

“One good way to solve this problem would be to just not hospitalize patients for mental illness. If any deaths are due to conditions at the hospital, such as violence or accidents, they just won't happen if the patients are not in the hospital. Maybe suicides will still happen, in fact more of them since some hospitalized patients are there precisely because they are suicidal. So what? Some people would kill themselves, but suicide is the ultimate act of self-determination. If people are not smart enough to stay alive or have good reasons to prefer death, why should anybody prevent their suicide, and why should taxpayers pay for that?”

I could just dismiss this comment, but it does actually raise important issues – why do we try to prevent suicide? Are there times when mental health professionals, and indeed Society as a whole, should allow people to take their own lives? And what is the point in having psychiatric hospitals?

There is a very long standing and deep seated belief that suicide is a bad thing. Indeed, it was a criminal offence in the UK to commit, or attempt to commit suicide until as recently as 1961, when the Suicide Act was passed. The Christian Church regarded suicide as a sin, to the extent that people who committed suicide could not be buried in consecrated ground.

The Suicide Act, while decriminalising suicide, also created the offence of aiding, abetting, encouraging or procuring the suicide of another. Additionally, the Human Rights Act 1998 states “Everyone's right to life shall be protected by law. No one shall be deprived of his life intentionally save in the execution of a sentence of a court following his conviction of a crime for which the penalty is provided by law” (Article 2).

Taken together, these create a powerful imperative for a mental health professional, or indeed any individual, to actively work to prevent suicide, and negligence on the part of a mental health professional could lead to disciplinary action or even prosecution.

There are also National policies aimed at reducing the incidence of suicide. Saving Lives: Our Healthier Nation, published in 1999, aimed to reduce the death rate by suicide by 20% by 2010. A further document, National Suicide Prevention Strategy for England, published in 2002, made it clear that suicide was seen as a “major public health issue.” It stated: “Around 5000 people take their own lives in England every year. In the last 20 years or so, suicide rates have fallen in older men and women, but risen in young men.” It went on to say that in men under 35, suicide was the most common cause of death.

Monica talks about people who are “not smart enough to stay alive”. I’m not sure who she means here – is she talking about people with severe learning difficulties, who might endanger themselves by inadvertently running into traffic? Or perhaps young children, who don’t realise that fire can burn them? In either case, I would not want to live in a society that did not seek to protect such vulnerable people from the consequences of their actions.

Or perhaps she’s referring to adults of normal intelligence who act in ways that others might consider to be reckless or who take apparently needless risks, such as free diving, potholing, bungee jumping, or driving too fast.

The above examples all relate to mental capacity. If someone has the capacity to act in unwise ways, then of course they should be permitted to do so, as long as their actions do not adversely affect others. But if they lack capacity, such as through severe mental disorder, then I do believe, and the law supports this, that they should be protected and prevented from taking certain actions.

Monica is right to draw attention to the risks of being a hospital inpatient. Medical hospitals are often very dangerous places to be if you are ill – they can be repositories of nasty and potentially fatal diseases, and being in hospital can expose you to these if your immune system is compromised.

Similarly, Monica is right, in a way, to say that psychiatric wards can be dangerous places – there have certainly been a number of celebrated cases where restraint has led to the death of a patient, and there have also been instances where patients have been attacked and even killed by other inpatients.

So what would happen if there were no mental hospitals? Well, this has been tried. In 1978, in Italy, a law was passed that made actually made it illegal to admit people to mental hospitals. This experiment centred on Trieste. An interesting analysis of this can be found here.

Ultimately, what this meant was the closure of traditional style asylums and their replacement with community mental health teams. In practice, this did not actually mean that there were no inpatient beds, it simply meant that CMHT’s had small units with 6-12 beds attached to them which could be used for crisis intervention within the locality in which the patient lived. Their use of the powers of compulsory detention under their Mental Health legislation was very rarely used. I would have no problem were this model to be consistently adopted as a means of mental health provision in the UK.

Monica states that “suicide is the ultimate act of self-determination”. If I knew that I had a terminal illness, and the quality of my life became worthless as the result of this illness, then I would certainly want to be allowed to end my life without undue interference.

Many people feel the same; those that can afford to, go to Switzerland for an assisted suicide. Others have challenged the right in the Courts to end their lives and to have someone to assist them – so far, with little success. I don’t think such people should generally be considered to come within the remit of the Mental Health Act.

But there are many occasions when otherwise physically healthy people express the desire and intent to end their life as a direct consequence of mental illness or mental disorder. People with serious depression or psychosis may hear voices that tell them to kill themselves. They may develop the delusional conviction that their loved ones would be better off if they were dead.

The point is that when they are in that state, such people lack the capacity to make an informed decision. Suicide in these cases ceases to be an “act of self-determination”. I believe that it should then be the job of a humane society to protect them, and to try to bring them back to a state of mental wellness such that they no longer believe that they should be dead.

There are times when admission to hospital is the only means of ensuring people’s safety. Ignoring their need is not an option.