A case in Leeds has been highlighted in the local press after a man complained of “negligence” following his step-daughter turning up at home, barefoot and in pyjamas despite having been “sectioned” under the Mental Health Act a couple of days before. He has called for staff to be disciplined, because of this. After providing the standard response about an investigation being underway and that the trust had offered to contact the patient’s step-father, the spokesperson said,
“It is important to note that The Becklin Centre is not a locked unit as we have service users who are admitted voluntarily or detained under the Mental Health Act.”
Continuing my concerns about lessons learned versus not learned, this statement bothered me —
Regardless of whether a patient is detained or admitted voluntarily, there is human rights case law about both categories which points out the duty of care owed to patients by trust. It is, for example, not the case that a patient’s being a voluntary patient means they can always just be allowed to walk out and that they cannot be prevented from leaving. Melanie Rabone was a voluntary patient in Greater Manchester who left admits concerns she was a suicide risk and the police were informed of her being a high-risk missing person. She was tragically found deceased by officers a short distance away and her family brought an Article 2 ECHR case in the civil courts, and won.
Now: this does *not* mean that all voluntary patients can be stopped from leaving – it would turn on the specifics of a particular patient. Some patients are admitted on a voluntary basis because they have capacity to make their own decision about hospital admission and are willing to go in. If they chose to leave and there was no immediate or serious concern about their health & safety or that of others, it could be the case they are not prevent from discharging themselves. That said, had any patient with capacity declined to agree to admission OR changed their mind about voluntary admission after arrival, some may have been ‘sectioned’ under the MHA and admitted on a compulsory basis. The Mental Health Act 1983, is not “capacity specific” legislation, so alluding to a a clean distinction between voluntary and compulsory admission as being the basis of whether doors are locked, is a touch misleading.
Some voluntary patients may need to be prevented from leaving by use of the MHA, for both legal and safety reasons.
SECTIONED
As the Rabone case shows, a duty of care to prevent absconding can exist, subject to those specifics. The Leeds case is anonymised, as the patient’s step-father does not want details being known so we cannot say from this coverage what the precise concerns and risks were, but his step-daughter was not a voluntary patient. Having been admitted under the MHA, it (should!) either mean she lacked capacity to consent to admission or she did not consent to admission and was admitted anyway, because the MHA criteria were met. The criteria mean there is some degree of risk that needs mitigation, whether to the patient or others.
Running in parallel to the Rabone case, we have the Carol Savage case, from Essex – this was a case where an MHA, detained patient was known to be suicidal and left hospital, later dying by suicide. Mrs Savage’s family also brought an Article 2 challenge against the Essex trust and won their civil claim that her right to life had been violated by not ensuring she was appropriately detained for her own safety. So the lesson from those two cases and other besides are that hospitals owe duties of care to both sectioned and voluntary patients, and that this can extend to ensure they do not abscond, where the risk from that is high enough.
Thankfully, the coverage of this particular case in Leeds does not indicate suicidality, but the patient obviously wished to return home to her family. I have to infer from her step-father’s concerns that he was troubled by what may have happened to her whilst travelling unaccompanied. Of course, this could have included a traffic collision, to name just one potential adverse outcome and if that or any other kind of adverse outcome had proved fatal, we might wonder what view a Coroner would have taken and what any civil claim may have concluded.
FOLLOWING PATIENTS
One final thought occurred to me, because of explicit mention of staff being unable to keep up with the patient after she left. In my own experience, NHS staff rarely follow absconding patients beyond the hospital grounds. I have known a few instances of where individuals nurses felt it was morally right to keep following because of their concern about risk, but those examples did include one where a nurse asked the police not to let NHS managers know they had done so, because they would be in difficulty. Of course, absconding patients raise a number of practical, as well as legal issues for the NHS staff who are following.
In the case of a detained patient, those staff would have legal powers under s18 MHA to stop and return the patient, using reasonable force if necessary. I have rarely known this happen, views being taken that it’s not appropriate for NHS staff to be getting physical with patients when it may not be obvious to the public who they are – it could look like an attack or an assault. Secondly, there is the issue of training and competence to actually achieve the task: are the nurses or staff who escort patients on leave or under transfer appropriately trained to know how to conduct an intervention safely? We often find they are not, because not all staff who work on mental health wards are trained in that way.
This local case, mercifully absent a serious adverse outcome, concerned me because of the reaction of the spokesperson for the NHS trust, a doctor. The public remarks either betray a confusion about the value of distinguishing between voluntary and compulsory patients or a something else is going on about the potential for various types of legal responsibility to be discharged. Either way, it means some situations where we might imagine NHS staff choosing to follow vulnerable people only so far, unable or unwilling to intervene to ensure safety, dignity and rights, only for some to the ring 999 in the hope the police can further guess which way the patient went, after that disengagement.
Whether the door is or is not locked, is not the determining variable we need to care about but it is worth noting that some trusts who presumably took a similar view about locks now have locks on doors which were not previously locked, precisely because things can go badly and somewhat predictably awry, even with voluntary patients.
NB: after publication of this post, I’ve been told the Becklin Centre is locked. Make of that what you will.
Winner of the President’s Medal, the Royal College of Psychiatrists.
Winner of the Mind Digital Media Award
All opinions expressed are my own – they do not represent the views of any organisation. (c) Michael Brown, 2022
I try to keep this blog up to date, but inevitably over time, amendments to the law as well as court rulings and other findings from inquests and complaints processes mean it is difficult to ensure all the articles and pages remain current. Please ensure you check all legal issues in particular and take appropriate professional advice where necessary.
Government legislation website – www.legislation.gov.uk
Mental Health Cop 