Page 1 of 2: OSCE-Buster: Mental Health Act

tezb · Credits: 6236 My Scrapbook

This is something that comes up in OSCE stations and you should be familiar with the UK Mental Health legislation.

For PLAB 2, you should be familiar with 4 parts of the Mental Health Act. These are important to understand regardless of what specialty you end up in.

I have outlined below the main sections you should understand and I will post some short scenarios later for people to answer.

Section 2
Why?
Assessment of mental illness
How Long?
Up to 28 days
If the patient requires further detention, a Section 3 should be applied for
What reason?
Patient must be suffering from a mental illness and
The patient presents a danger to themselves or others
Who?
2 Doctors (one approved).
Approved Social Worker.

Section 3
Why?
Treatment of a mental illness
How Long?
6 months
Further applications can be made at the end of this Section for a further six months, then for periods of 12 months thereafter.
What reason?
The patient must be suffering from a mental illness, psychopathic disorder or mental impairment which warrants treatment in hospital.
It is in the interest of the patients safety, or the safety of others to be detained in hospital.
In psychopathy, detention must be on the grounds of preventing deterioration of condition.
Who?
2 Doctors (one approved).
Approved Social Worker.

Section 4
Why?
Emergency admission for a mental illness.
It is for emergency situations only. In non emergency cases, a Section 2 would be appropriate.
How Long?
72 Hours.
After this period, a Section 2 or 3 should be applied for.
What reason?
The grounds are the same as Section 2, with the following additions:
-it is of urgent necessity for the patient to be admitted and detained under Section 2, and
-that compliance with the usual Section 2 requirements (that is, getting a second Medical Recommendation) would involve "undesirable delay"
Who?
The section need only be signed by one doctor.

Section 5
Section 5 orders are for patients who are already in hospital, for example a patient on a medical ward who becomes mentally ill during admission. A&E departments are not inpatient and therefore 5 cannot be applied.

Section 5(2)
Why?
Emergency detention of a patient who is already inpatient in hospital for a mental illness.
How Long?
The patient may be detained for 72 hours.
The Section cannot be extended. A Section 2 or 3 must be applied at the end of this period if the patient is to stay in hospital.
What Reason
The patient is deemed to be mentally ill.
Detention in hospital is necessary for the protection of the patient or others.
Who?
The Responsible Medical Officer (RMO) in charge of the patient (or nominated deputy) applies for a Section 5(2).

Section 5(4)
Why?
Emergency detention of a patient who is already inpatient in hospital for a mental illness by a nurse.
How Long?
The Section may not be extended. A Section 5(2) may be imposed, or a Section 2 or 3 applied.
What Reason
The patient is deemed to be mentally ill.
Detention in hospital is necessary for the protection of the patient or others.
Who?
This section is used by Nurses to detain patients already in hospital.

Common Law
Common Law may be used to detain a patient in hospital against their wishes, where a Section of the Mental Health Act cannot be applied. For instance, in an A&E department whilst waiting for a doctor to apply a Section 2 or 4. Generally, Common Law detention should only be used when the patient poses a danger to themselves, or another person and is not deemed in a suitable state to make an informed decision.

tezb · Credits: 6236 My Scrapbook

I have prepared the following scenarios for you to answer. I will give answers soon...

Scenario 1
A 42 year old man, who is being treated for his GP for depression. He has become worse lately and his wife thinks he should be admitted for psychiatric assessment. The GP is in agreement.

Which section should be applied in this case?

Scenario 2
A 21 year old lady has been admitted to the medical ward following a paracetamol overdose. She has a very low mood and is still clearly suicidal. The on-call psychiatrist has not seen the patient yet. She wants to leave hospital but says when she does she will jump from the roof.

What section would be applied?
Who would order the section?

Scenario 3
A 55 year old schizophrenic patient has been in the mental health unit. His section 2 is coming to an end. He requires further treatment.

Who would be required to sign the Section?
Which Section would be used?

Scenario 4
A GP visits a patient at home who has become psychotic and is threatening to kill his daughter. The emergency outreach team are currently on another call and will not be available for around 3 hours.

Which Section should be applied here?

Scenario 5
A 32 year old lady is inpatient on the psychiatric ward. She is psychotic and says she can fly. She is inpatient voluntarily and is demanding she should go home. It is 3am and the oncall doctor is not on site.

Which Section could be used here?
Who would apply the Section?

Scenario 6
A 30 year old chronic alcoholic has attended the A&E department. He is showing signs of chronic liver disease and is very sick. The A&E registrar think that if he leaves the hospital he will die.

Which Section (if any) would be appropriate in this case?

Answers to follow soon. Feel free to discuss the issues for each case...

tezb · Credits: 6236 My Scrapbook

Examples of what I have seen and had in OSCEs.

In a Psychiatry station, you may be asked to assess a patient for a mental health condition. For example, mania, depression, psychosis etc.

At the end, the examiner may ask questions about the patient. It is plausible, that if the patient could be Sectioned under the Mental Health Act, that you would be asked which Section would be appropriate to use.

In some UK Medical Schools, "static" OSCE stations are used, with scenarios similar to those above.

In my own experience, we were show videos of psychiatric patients and asked for the diagnosis and which section would be appropriate, who would need to sign it and how long it would last.

In addition to all this... If you work in the UK you should be aware of these Sections as you may well need to use them/call on them at some stage in your career. Patients on medical and surgical wards can become rapidly unstable with mental illnesses and the imposisition of Section 5(2) necessary... If you don't know which Section is which, you haven't a hope in hell of applying one!

tezb · Credits: 6236 My Scrapbook

Any body want to have a go at the questions before I give the answers?

Deano · Credits: 291 My Scrapbook

blue_mars · Credits: 32163 My Scrapbook My Reading List 3 Books

Fantastic info Tezb. It is very useful. However, I want to make a suggestion.
Under common law you cannot detain the patient but you can treat them against their wish. If they try to leave the ward (ex: A&E) you cannot stop them but inform the police who can restrain the patient on section 136.
I hope you don’t mind me posting this.

tezb · Credits: 6236 My Scrapbook

Yes this is true in some circumstances. There have been some high profile legal cases recently that have it against a patients human rights to be detained under common law in some cases of mental incapacity etc.

Under common law patients can be made to wait on the premises until a doctor with authority to detain arrives.

The Mental Health Act states:

-Common Law powers may be used to detain and control patients in emergency situations whilst awaiting the presence of either a doctor or specialist nurse who has the power under the Mental Health Act 1983 to detain under either Section 5 (2) or Section 5 (4) however

-Such powers should only be used as a safety net to cover situations where it is not possible to immediately invoke statutory powers

-In order to be consistent with the Human Rights Act 1998, Common Law powers should NOT be used as an alternative to powers contained the Mental Health Act 1983.

Appropriate Use of Common Law
-Where a patient requires restraint but is not showing any inclination to leave the hospital nurses and doctors have to rely on common law powers to detain and control patients

-Common Law powers may be appropriate when it is confined to a short period of time to enable an informal patient to be detained or secluded but for a limited period of time only

-As patients detained under Section 5 (4) are not subject to Consent Treatment provisions of Part IV of MHA 1983, treatment of such patients can ONLY be given under common law powers therefore -

-Emergency medical treatment to a patient whose mental disorder precludes a valid consent to treatment is justified under the common law doctrine of necessity if such action is in their best interests

Its a mine field.......

This means common law may be used to hold a patient for a short period of time until an authorised clinicain can invoke a Section of the Mental Health Act.

In the case of our gentleman in A&E: he may be detained under common law for treatment until a psychiatrist is able to invoke a Section 4 or Section 2.

tezb · Credits: 6236 My Scrapbook

Answers:

Scenario 1
Section 2

Scenario 2
Section 5(2)
One doctor must sign it

Scenario 3
Section 3
Signed by two doctors
Applied for any Approved Social Worker

Scenario 4
Section 4

Scenario 5
Section 5(4)
Applied by the nurse looking after the patient

Scenario 6
Common law may be used to hold and treat this gentleman until a psychiatrist can apply a Section 4 emergency admission order. This should only be for a very short period of time!

blue_mars · Credits: 32163 My Scrapbook My Reading List 3 Books

nice examples, keep posting more

tezb · Credits: 6236 My Scrapbook

Thanks blue_mars... I'm just posting the basics that all medics should know about the Mental Health Act for PLAB2 or equivalent as its important and helpful...

Details of any other sections not mentioned above are even beyond my knowledge without having to look it up!

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