Guidance for the preparation of medical reports for mental health review tribunals

Guidance for the preparation of medical reports for mental health review tribunals

The following guidance has been approved by the Royal College of Psychiatrists, Home Office, Department of Health and The National Assembly for Wales.

This guidance, given in clarification of the requirements under Part B, Schedule 1 Mental Health Rules, 1983, is designed to help the authors of medical reports for tribunals know what the mental health review tribunal (MHRT) finds useful in reports.

Reports should include the following information:

1. • date of report

2. • patient's name

3. • Section of Mental Health Act under which detained and expiry date

4. • name of responsible medical officer (RMO) and name of doctor making report and job title (if not RMO)

5. • name of patient's keyworker

6. • copies of any earlier reports referred to in the current report

7. • in making this report doctors should specify, whenever appropriate, whether their statements derive from sources outside their personal experience. If this is the case, the source should be named.

Reasons for detention

1. (a) What were the circumstances that gave rise to the patient's detention?

2. (b) Considering the criteria in the Act, into which category does the patient's mental disorder fall? If there is an established diagnosis (diagnoses) please name it (them) with reference to the ICD-10. Please give the length of time the patient has been considered to suffer from it (them).

3. (c) Highlight the characteristics (including the nature and degree) of the disorder that warrant detention. Explain why it is not possible to provide care and/or treatment outside hospital or in a less restrictive setting.

4. (d) Is the patient being detained in the interests of his/her own health and/or in the interests of his/her own safety, or for the protection of others? If the patient has a long term or recurring disorder, explain the impact that it has or has had on the patient's life and the likely course of events if he/she were not cared for compulsorily.

5. (e) Other relevant and significant history.

6. (f) Details of progress since admission — current mental state and residual symptomatology:

   1. • insight

   2. • compliance (and detail unapproved absences, if any)

   3. • response to leave (if any granted).

7. • What current medication is the patient receiving, and are there any problems arising from it?

8. • Details of other forms of treatment tried or currently being delivered.

Care plan, compliance, risk and aftercare

1. (1) What future treatment is planned? Please provide details (or a copy, if available) of the care plan. What is the response to it of the patient, carers and relatives?

2. (2) What is the patient's attitude to treatment and his/her likely compliance to it in the future? Is this likely to vary if his/her insight changes?

3. (3) What is your assessment of outstanding risk factors regarding the patient's own health and safety and the protection of others? What do you consider may happen if the patient is discharged from compulsory detention? In particular, how will any outstanding risk factors be managed in any environment that you are considering or that you believe the tribunal will be asked to order or recommend?

4. (4) Please provide a brief note of the patient's unmet needs, what specific services are required to meet them and why the needs remain unmet.

5. (5) If you are considering aftercare (as opposed to current care in hospital) please set out what provision you would like for the patient and indicate whether problems in such provision would be caused by immediate discharge/release from detention.

For restricted patients

1. (6) If your report relates to a restricted patient, please deal with the issues set out on the attached Home Office list (if not already addressed).

2. (7) Where a conditional discharge is a possibility, please set out what would be the foreseeable consequences of failing to provide any of the elements of the proposed package of conditions.

NB Remember to send your report also to the Home Office mental health unit!

Note regarding confidential material not to be disclosed to the patient

If you wish to add a section to your report that you ask not to be disclosed to the patient, this is possible under Rule 12 of the MHRT rules if the information would adversely affect the health or welfare of the patient or others in the opinion of the tribunal.

The procedure is:

1. (1) You have the confidential material typed onto a separate page and clearly marked ‘not to be disclosed to the patient’.

2. (2) You write a covering letter explaining why you believe the material would adversely affect the health or welfare of the patient or others.

3. (3) The tribunal will then consider the application not to disclose the material to the patient as a preliminary issue before the tribunal hearing; you may have to answer questions on the non-disclosure request at this stage. The patient's legal representative will still receive a copy even if the material is withheld from the patient.

Appendix - Checklist of points considered by the Home Office in examining the cases of restricted patients

The role of the Home Office in the management of restricted patients is to protect the public from serious harm. To carry this out effectively, the Home Office needs to know:

1. (a) why a patient has been dangerous in the past

2. (b) whether he or she is still dangerous (if so, why; if not, why not and in what circumstances he or she might be dangerous again)

3. (c) what the treatment plan is.

The following list is not exhaustive, but is intended to cover some of the points that may need to be addressed when reporting to the Home Office. Not all points will apply to all patients; but all sections (not just those covering the main diagnosis) that apply to a particular patient should be completed. Attaching relevant reports is always encouraged.

Reports to the Home Office should reflect the views of the multi-disciplinary team. Please indicate whether the team has been consulted.

For all patients

1. (1) Should the patient still be detained and for what reasons?

2. (2) If yes, which level of security does the patient need?

3. (3) What is the team's current understanding of the factors underpinning the index offence and previous dangerous behaviour?

4. (4) What change has taken place in respect of those factors (i.e. to affect the perceived level of dangerousness)?

5. (5) What are the potential risk factors in the future (e.g. compliance with medication, substance misuse, potential future circumstances, etc.)

6. (6) What are the patients' current attitudes to the index offence, other dangerous behaviour and any previous victims?

7. (7) What is the outward evidence of change (i.e. behaviour in hospital or on leave, attitudes towards staff and patients and potential victim groups?) How has the patient responded to stressful situations? Describe any physical violence or verbal aggression?

8. (8) Have alcohol or illicit drugs affected the patient in the past and did either contribute to the offending behaviour? If so, is this still a problem in hospital and what are the patient's current attitudes to drugs and alcohol? What specific therapeutic approaches have there been towards substance misuse?

9. (9) Which issues still need to be addressed, and what are the short-and long-term treatment plans?

10. (10) What is known about circumstances of the victim, or victim's family?

Patients with mental illness

1. (11) How is the patient's dangerous behaviour related to his/her mental illness?

2. (12) Which symptoms of mental illness remain?

3. (13) Has stability been maintained under differing circumstances? Under what circumstances might stability be threatened?

4. (14) Has medication helped and how important is it in maintaining the patient's stability?

5. (15) To what extend does the patient have insight into his/her illness and the need for medication?

6. (16) Does the patient comply with medication in hospital? Is there any reluctance? Would he/she be likely to comply outside?

Patients with psychopathy

1. (17) What are the individual characteristics of the personality disorder?

2. (18) What have been the treatment approaches to specific problem areas?

3. (19) Is the patient now more mature, predictable and concerned about others? Please give evidence.

4. (20) Is he/she more tolerant of frustration and stress? Please give evidence.

5. (21) Does the patient now take into account the consequences of his or her actions and learn from experience? Please give evidence.

Patients with mental impairment

1. (22) How has the patient benefited from treatment/training?

2. (23) Is his/her behaviour more acceptable? Please give evidence.

3. (24) Is the patient's behaviour explosive or impulsive? Please give evidence.

4. (25) Does the patient now learn from experience and take into account the consequences of his/her actions? Please give evidence.

Patients with dangerous sexual behaviour (all forms of mental disorder)

1. (26) Does the patients still show undesirable interest in the victim type?

2. (27) Describe any access to the victim type and the patient's attitude towards this group

3. (28) What form has sexual activity in hospital taken?

4. (29) What do psychological tests or other evaluation indicate?

5. (30) What is the current content of fantasy material?

Patients who set fires (all forms of mental disorder)

1. (31) What interest does the patient still have in fires?

2. (32) Has he/she set fires in hospital?

3. (33) What access does he/she have to a lighter or matches?

4. (34) In what way do fires appear in current fantasy material?

5. (35) Does the patient have insight into previous fire setting behaviour?

And, finally

1. (36) Please give any other relevant information that would be useful to the Home Office.