This assignment is in two parts the first part, or essay, will critically discuss how mental health law might be applied in the care and management of Simon, the client in the scenario (appendix A). The essay will also look at how Simon's past care pathway, especially the previous use of forced admission treatment, may have adversely affected his future care pathway. It will include how the health professionals would gain access, assess and decide, using the law, how best to help Simon.
Simon has a diagnosis of Paranoid Schizophrenia and this is the most common manifestation of Schizophrenia (NICE 2009, NHS 2009). These symptoms are referred to as "positive" and "negative". The positive symptoms include hallucinations and delusions (NICE 2009, NHS 2009). In Simon's case these delusions are of a paranoid nature where Simon believes that he is being spied on and that the all the health professionals are colluding against him. The negative symptoms are more evident in the prodromal stage, the early onset of the acute stage of the illness. These negative symptoms include concentration problems, apathy and social withdrawal, all of which Simon experienced especially the social withdrawal (Townsend 1999, NICE 2009).
As a matter of course Simon's psychiatrist should be contacted and informed of the situation. This being done with a view to them attending with Simons General Practitioner and an Approved Mental Health Professional (W.A.G 2008, M.H.A 1983). This would then constitute the makeup of a full emergency mental health assessment team (W.A.G 2008, M.H.A 1983). When this has been done the appropriate authorities, namely the police, can be informed and asked to attend also. Their role as a peace keeper and to gain access is imperative to enable the mental health professionals to talk to Simon, and if necessary perform a mental health assessment (W.A.G 2008). The nurse should risk assess the situation to gauge the amount of potential danger, if any, that Simon and others could be in, due to Simons actions (Wetherell 2001). If the risk to Simon is assessed as high, due to him once again dismantling the electrics, then because of "best interest" and "necessity" in collaboration with the attending team, the police can be asked to assess the need to gain emergency access (P.A.C.E 1984, M.C.A 2005). The police could use the powers of the Police and Criminal Evidence Act (1984) sec 17(1) (e), after notifying Simon of the reason, to forcibly enter Simons home as in the case of Baker v Crown Prosecution Service (2009). The police though have to be sure that something serious had happened or was about to happen as in Syed v Director of Public Prosecutions (2010).This section states that it would be appropriate for the police to enter as it is imperative in "saving life or limb or preventing serious damage to property" (P.A.C.E 1984). Being that Simon has stopped dismantling the flats electrics a more considered approach could possibly be used.
It is recommended though that any intervention be the least restrictive (M.H.A 1983). Due to this and in the interest of a collaborative approach it could be an idea if the psychiatrist or approved mental professional could attempt to engage with Simon and seek his cooperation (N.I.C.E 2009, Barker 2007). This would make gaining access easier, as it would then be consenting access, and it would reduce any "anxiety" and "fright" that Simon may endure. Thomas, Cutting and Hardy (2004) stress that if the patient distrusts their nurse they are less likely to accept help. Mc Cabe and Timmins (2006) point out that the focus of communication ought to be patient centred. This is important in developing and maintaining the therapeutic relationship between Simon and his carers (Peplau 1997, Rogers 1957, Barker 2007). While Nichols (1993) found that developing a therapeutic relationship with a patient can aid the treatment of patients, and help patients deal with a variety of illnesses and disorders.
Even though a less restrictive treatment path is recommended it is argued that the therapeutic relationship would be hindered whilst Simon's paranoia is in the ascendancy (Johnstone et al, 1986, N.I.C.E 2009 M.H.A 1983). To help Simon with this positive symptom it would benefit Simon, and aid engagement with the nursing team, to restart Simon's antipsychotic medication (N.I.C.E 2009, Perkins et al 2005). The use of coercion could be the reason behind Simon's distrust of nurses and his non concordance (Kaltiala-Heino et al 1997, Bracken and Thomas 2001). This fear could also be a symptom of post traumatic stress disorder, brought on by previous forced admissions (Meyer et al 1999). The health systems use of the law to coerce could therefore be viewed as traumatising, negative and damaging to Simons future treatment concordance (Monahan et al 2001, Bracken and Thomas2001).
With relationship in mind the nurse could take a low profile approach due to Simon's paranoia driving his distrust (N.I.C.E 2009). If one of the team did manage to gain Simons trust, and Simon did agree to the least restrictive course of action, that being, one of an informal admission to an acute psychiatric hospital. It could be argued that due to the nature of Simon's illness this would be short lived and Simon would not stay or accept treatment from the nursing team (N.I.C.E 2009). Therefore the mental health capacity of Simon should be taken into account as well at this stage so that his admission does not become unlawful, as in the case of Bournewood NHS Trust (ECHR 2004, M.C.A 2005). This is because under common law informal patients have two basic rights. The first is that they may leave hospital whenever they like and secondly that they may refuse to accept any form of treatment that they do not want (Hogget 1996).
Given then this extremely complex and potentially volatile set of circumstances the Approved Mental Health Professional could, after assessing Simon's behaviour, apply to the Magistrates Court for a section 135, to gain entry(M.H.A 1983, W.A.G 2008).
The magistrate has to be satisfied that Simon is suffering from a mental disorder as defined in the Mental Health Act 1983.The Magistrate also has to be satisfied that there is a reasonable cause to suspect that Simon has been, or is being, ill-treated, neglected or kept otherwise than under proper control, in any place within the jurisdiction of the justice or is living alone and unable to care for himself (M.H.A 1983). This would, if the warrant was granted, allow the police to force entry if necessary, so that a full and formal mental health assessment could be carried out (M.H.A 1983, W.A.G 2008).
It is not strictly a necessity though to have to carry out an assessment immediately on the utilisation of a section 135 warrant (M.H.A 1983). The police then have the power to transport and hold Simon for seventy two hours in a "place of safety", which could be an acute psychiatric hospital (M.H.A 1983, W.A.G 2008). Once things have settled down and are less stressful for Simon, a full mental health assessment with the aforementioned team, Psychiatrist, General Practitioner and an Approved Mental Health Professional could be undertaken (Peplau 1997, Rogers 1957, Barker 2007, Nichols 1993, W.A.G 2008, M.H.A 1983).
On completing the mental health assessment, the assessing team need to decide the best course of action to suite Simon's currant needs. This decision would ultimately be made by the Approved Mental Health Professional who has evaluate the social and medical evidence presented (W.A.G 2008). They would have to decide whether to admit Simon under a section of the mental health act 1983 and which section would best enable the nurses to treat Simon's symptoms and build a therapeutic relationship, section2 or the more restrictive section 3 (W.A.G 2008).
If the two doctors agree that Simon is suffering from a mental disorder, and that this is of a nature or to a degree that, despite his refusal to go to hospital, he ought to be detained in hospital in the interest of his own health, his safety, or for the protection of others, they can complete a medical recommendation form and give this to the Approved Mental Health Professional (W.A.G 2008, M.H.A 1983). If the Approved Mental Health Professional agrees that there is no other alternative but to detain Simon in hospital, an application form requesting that the hospital managers detain the person could be completed (W.A.G 2008, M.H.A 1983). Simon's period of assessment in hospital could then legally begin. Consensual treatment whilst under this Section, such as medication, is permitted but can also be given against Simon's wishes under Section 2 assessment orders, as observation of response to treatment is considered part of the assessment process (W.A.G 2008, M.H.A 1983). This section would compulsorily admit Simon for a period of twenty eight days upon which it expires and cannot be renewed (W.A.G 2008, M.H.A 1983). Simon will have the right to appeal against this section and can apply to a Tribunal during the first fourteen days; the Tribunal should then take place within seven days of the application (W.A.G 2008, M.H.A 1983).
The main decision would be how to facilitate treatment given that Simon is unwilling to engage with the nursing team. With this in mind, the other possibility open to the Approved Mental Health Professional is compulsory admittance of Simon utilizing Section 3 of the Mental Health Act 1983 (W.A.G 2008, M.H.A 1983). This Section is a treatment order, and can initially last up to six months (W.A.G 2008, M.H.A 1983). It can then, if needed, be renewed after six months, the next order lasts up to six months and each subsequent order lasts up to one year (W.A.G 2008, M.H.A 1983). If Simon is admitted under Section 3 he may appeal to a Tribunal once in a six month period (W.A.G 2008, M.H.A 1983). The hearing usually takes place within six to eight weeks of the application.
One major difference is that for Section 3 treatment orders, the doctors must be clear about Simon's diagnosis and proposed treatment plan, and be confident that "appropriate medical treatment" is available for him (W.A.G 2008, M.H.A 1983). Most treatments for mental disorder can be given under Section 3 treatment orders, including injections of psychotropic medication such as antipsychotics. However, after three months of detention, either the Simon has to consent to their treatment or an independent doctor has to give a second opinion to confirm that the treatment being given remains in the person's best interests (W.A.G 2008, M.H.A 1983).
In conclusion, given these extreme circumstances the mental health professionals need to continually risk assess his behaviour to safeguard Simon. If Simon's behaviour changes and, through dismantling the electrics, putting himself in danger, then the police could use their powers of entry. Being that Simon is reasonably settled though utilising a Section 135 is the route directed by the Mental Health Act.
The Mental Health Team already know Simon from previous successful treatment paths, hence he is currently living in the community. So the need for assessment and diagnosis does not imminently exist. Even though the use of coercion may be exacerbating Simon's paranoia it is necessary to admit Simon using Section 3 of the Mental Health Act. This would enable the team to immediately restart Simon on his previously identified treatment path. Once this has been achieved and Simon's symptoms have become more manageable for Simon the therapeutic relationship can be rebuilt and strengthened. The nursing team can collaboratively work with Simon to identify what led to this relapse and with Simon build a future plan to identify relapse signatures and discuss any problems Simon has, if any, with his medication regime.