A recent discussion of seclusion practices in relation to our in-patients prompted us to consider the formalities of ‘ordering seclusion’. There are two fundamental aspects to this: the statutory forms which are filled out on the wards and the Mental Health Commission (MHC) rules (Mental Health Commission, 2009). It does not appear that these fully comport with each other.
A widespread interpretation of the statutory seclusion forms has led to a practice whereby registrars (‘registered medical practitioners’, per the Act) reviewing a patient who has been put in seclusion ‘backdate’ their order to include the period between the commencement of seclusion by nursing staff, and the medical review. This is a similar problem to that acknowledged in the MHC review of its own rules in 2008, discussed below (Mental Health Commission, 2008).
The MHC rules regarding seclusion and restraint require a medical review ‘as soon as practicable’ after the commencement of seclusion, and within 4 hours. The reviewing doctor must then ‘discontinue the use of seclusion unless he or she orders its continued use following discussion with the nursing staff’ (MHC, 2009). There is no mention of a requirement for the medical practitioner to have ordered seclusion prior to his/her review.
However, there is also no specific power given to nursing staff to ‘order’ a period of seclusion, even though they may ‘initiate’ seclusion.
In 2008, a recommendation was contained in the MHC’s own review of its regulations that nursing staff be in a position to authorise seclusion. The reviewing team highlighted this recommendation for immediate attention (MHC, 2008), acknowledging ‘The issue of retrospective authorisation poses significant difficulties for staff working in Approved Centres. This places both those initiating and those required to authorise an episode of seclusion and/or restraint in an uncertain position at times.’ They recommended: ‘Experienced nursing staff should have the necessary authority to authorise all episodes of seclusion, mechanical means of bodily restraint and physical restraint.’ The subsequent updated version of the Rules (MHC, 2009) permitted nursing staff to initiate, but, inexplicably, not to order nor authorise.
We suggest that the practice of medical staff retrospectively authorising an episode of seclusion which they did not order or witness is undesirable. Nursing staff are empowered by the regulations to commence seclusion, and it would make more sense if nursing staff were also to make the order for seclusion covering that period prior to assessment by medical staff.
Clarification from the MHC of the documentation requirements – and amendment of the regulations and forms relating to seclusion, if needed – would be most helpful.
Yours etc,
Dr Norella Broderick
Dr Elizabeth Cummings
Conflicts of Interest
The authors have no conflict of interest to declare.
