The Mental Health Commission has published its biennial report 'Risks, Rights and Recovery'. The publication is a result of a series of visits to patients detained under the Mental Health Act 1983 over a two year period. Service users took an active part in the report with many personal quotes from service users highlighting good and bad practice being included. The document is lengthly but makes over forty recommendations which are detailed below:
Hospitals should review their bed-management practice and seek
to ensure that it does not unnecessarily compromise patients’ treatment or well-being.
Particular attention should be paid to fostering a culture of patient involvement in decisions
over bed-management that affect their care and treatment.
i) Services should adopt the CSIP/NIMHE discharges toolkit.
ii) Discussions with patients (and, where appropriate, carers and relatives) over bedmanagement
arrangements, especially as this relates to leave of absence from hospital,
should be recorded by staff in patients’ notes.
Services should ensure that risk assessment of detained patients
takes account of ‘positive risk management’ and is undertaken in collaboration with
patients and, where appropriate, carers and relatives.
• All hospital wards caring for detained patients should instigate “patient protected time”
schemes, where patients are guaranteed time with nursing staff apart from all other
• Ward managers should audit the performance of protected time schemes, keeping
records of problems in observing protected time and taking account of patient
Psychiatric nursing skill mix and staffing levels should be
reviewed using the principles outlined in the Royal College of Nursing’s 2007 report
All acute inpatient mental health service managers should be
familiar with the Star Wards initiative and the Sainsbury Centre report The Search for
Acute Solutions95, and should consider their proposals for improving patients’
experience in hospital.
Hospitals should consult with staff and service users over the
redesign or reprovision of mental health services to accommodate detained patients.
Mental health services should obtain a copy of the Parents in
Hospital report and implement its recommendations.
Mental health services should only authorise relatives or carers
to ‘escort’ patients on leave under the terms of s.17(3) after careful consideration that this
is an appropriate legal responsibility to devolve from nursing staff.
Detaining authorities’ compliance with gender equality duties
should be monitored by their own Boards and by commissioning agencies funding the
detention of patients. Particular attention should be paid to the avoidance of mixed-sex
accommodation and the safety and security of women patients.
The admission of elderly patients with functional mental
disorder to acute units should be avoided wherever possible, and such admissions should
trigger particular vigilance over the safety and security of the patient involved, and the
training and engagement levels of staff involved in their care.
Hospital managers should audit and review educational and
other activities available to the patients detained in their care, seeking to improve
opportunity of access for such patients
NHS and independent hospital managers should consider as
a matter of priority patients’ access to outdoor space with appropriate safety and
The Department of Health should consider specific funding of
smoking cessation services within psychiatric services to counter any unintended
consequences of public health targets. Smoking cessation services must remain voluntary
for detained patients.
Hospital menus should be reviewed to ensure that healthier
options are made available, with the involvement of dietitians in both overall reviews of
food quality and choice and in the care of individual patient’s needs.
Any patient who has been detained for assessment or treatment
under the Act, or under any of the powers in part III of the Act should be subject to CPA at
Mandatory training should be developed for all mental health
and learning disability staff expected to engage in physical restraint interventions to
complement the current mandatory training in non-physical interventions
Government should bring forward its consultation on the mental
health criteria for jury service to ensure that exclusions are for functional rather than
Government should revise the school governor regulations as
suggested above, to ensure that exclusions are for functional rather than discriminatory
National guidance should instil a presumption that s.136
incidents are not to be recorded as a police ‘criminal’ record.
Good practice in implementing the requirements of s.131A(3)
in the revised Act should involve a doctor with specific child and adolescent mental
Ethnic monitoring of patients subject to community treatment
orders under the amended Mental Health Act should be an explicit mandatory requirement.
Social services, police and ambulance authorities should agree
protocols over attendance for Mental Health Act assessments
General hospitals should have service level agreements with
neighbouring mental health services for the delivery of Mental Health Act Administration
and training. Advice from the mental health service should be sought upon any use, or
planned use, of the MHA within the general hospital. The service level agreement should
i) arrangements for regular scrutiny of all detention papers and the files of detained
patients to ensure compliance with the requirements of the Mental Health Act and Code
ii) The submission of six monthly reports on the extent of compliance to the chief executive
of the general hospital
iii) An annual report to the general hospital’s Board on its use of detention under the Act.
Exercise of nurses’ holding powers under the 1983 Act should
remain the preserve of suitably qualified and/or trained nursing staff, even under a system
of generic nursing qualifications.
A record should be made of patient’s views and concerns
regarding every significant period of leave from hospital.
Police authorities should seek to ensure that arrangements for
the medical assessment of s.136 detainees in police custody meet the expectations of the
Code of Practice through being undertaken by a s.12 approved doctor wherever
practicable, and that exceptions to this are recorded with reasons.
The MHRT secretariat should collate and publish data on MHRT
applications and outcomes including patients’ gender, ethnicity and the section of the Act to
which they are subject.
Government should commission an independent review of the
effects of the fixed-fee scheme for mental health, with particular focus on patients’ access to
appropriate legal representation at MHRTs.
Standards of places of safety should be considered as an area
for focus and development at a national level in Wales.
Detaining authorities should ensure that patients due to receive
Second Opinion visits are given advance notice of the visit and information about the
Detaining authorities should ensure that their responsible
medical officers comply with the requirements of the Code of Practice in assessing the
patient’s mental capacity and consent status.
The Secretary of State should keep under active consideration
the reduction of the three-month period under s.58(3) of the Act, and use his power to
reduce this period as resources allow.
Selected recommendations of the RCPsych Consensus Statement on High-Dose
• Each service should establish the audit of antipsychotic doses as a matter of routine
practice. Careful watch should be kept on the dosage in terms of total percentage
arising from drug combinations, and the use of PRN (as required) medication. Local
systems should be developed to alert the responsible psychiatrist/clinical team to
patients currently being administered or at risk of receiving high doses.
• Before resorting to a high dose of antipsychotic medication, evidence-based strategies
for treatment resistance should be exhausted, including use of clozapine.
• The decision to prescribe high dose should be taken explicitly and should involve an
individual risk–benefit assessment by a fully trained psychiatrist. This should be
undertaken in consultation with the wider clinical team and the patient and a patient
advocate, if available, and if the patient wishes their presence.
• The decision to prescribe high dose should be documented in the case notes, including
the risks and benefits of the strategy, the aims, and when and how the outcome will be
• Before prescribing high-dose antipsychotics, carry out an ECG to establish a baseline,
and exclude cardiac contraindications, including long QT syndromes.An ECG should
be repeated after a few days and then every 1–3 months in the early stages of high-dose
treatment. The ECG should be repeated as clinically indicated.
• If high-dose antipsychotic treatment has been used in response to aggression with
psychosis, it is particularly important that the routine monitoring of a sedated patient
is carried out, with particular attention to regular checks of pulse, blood pressure,
respiration, temperature and hydration. ECGs should be carried out frequently during
dose escalation, if and when possible.
Detaining authorities should ensure that their clinical teams are
familiar and comply with the RCPsych consensus statement through having local policies,
with both the policy implementation and the use of high-dose medication audited and
considered at Board level.
Covert administration of any part of a treatment plan authorised
on an extant Form 39 should have been explicitly considered by the SOAD. Where a
decision is made to covertly administer medication, a new Second Opinion should be
requested even if the medication otherwise remains within the parameters of the extant
When administering benzodiazepines:
• nursing staff should be particularly careful that the medication is authorised, and that the patient has not
already received the authorised dose for that day;
• the reason for each administration must be clearly recorded by medical or nursing staff administering;
• the precise dosage administered must be similarly recorded for each administration; and
• all prescriptions should be reviewed at a minimum of four-weekly intervals
Clinicians responsible for detained patients’ care should be aware that they are required to
submit a s.61 report to the MHAC at the times specified under that section even when a
patient has consented to treatment subsequent to the last Second Opinion visit.
The Care Quality Commission should keep under close review
the effect of the change in criteria for imposing ECT without consent to adult patients under
the revised Mental Health Act 1983.
Government should consider specific funding for ECTAS
compliance in ECT facilities, to preserve local amenities and avoid patients having to travel
long distances for treatment.
The Secretary of State should consider the regulation of
deep-brain stimulation for mental disorder, bringing the technique within the scope of s.57
of the 1983 Act.
A copy of Mental Health Unit authorisation of leave should be
kept alongside local leave documentation for restricted patients. RMOs should be careful
to define the parameters of leave for such patients where elements of that leave are at
The Department of Health should ensure that the new regulator
for health and adult social care complies with the requirements of the Optional Protocol to
the Convention against Torture, as part of the UK government’s National Preventive
Mental Health Act Commission 2008, published by The Stationary Office, Crown Copyright 2008.
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