The Psychiatrist: In the court of medical appeal

A unique aspect of general psychiatry is its interface with the law. That’s because so many people with severe mental illness lack insight when unwell, especially when psychotic, and thus by definition not “in touch with reality”. They have a right to treatment, and the law (as embodied in the Mental Health Act) says they can be hospitalised and treated against their will.

Their rights are read to them on admission (or once they have the capacity to take such notions on board) and they then have a right of appeal. The case is heard within about 10 days if it’s a 28-day assessment order (Section 2), or within a couple of months if it’s a six-month treatment order (Section 3). About two-thirds of patients choose to appeal.

The psychiatrist in charge of your care (or “responsible clinician” – RC) should prepare a report and attend the tribunal hearing, whenever it happens. Ward rounds, outpatient appointments and even holidays can readily be disrupted. Likewise an “approved mental health practitioner”, usually a social worker, has to provide a social circumstances report, and the ward nurse a nursing report.

Time and date are fixed and quite an entourage can gather if the patient wants family members there, and specialists or students are attending. We file into whatever room has been set aside by the hospital, and into our prescribed places, across the table from the tribunal members.

The tribunal consists of three people, a lawyer, who is the chair, a consultant psychiatrist (who will have examined the patient before the hearing), and a lay person. They have read all the reports, and the hearing should begin. Quite often there are delays since reports have not arrived, or haven’t been read, or a previous tribunal has gone on too long, and the members have had to trek from elsewhere, getting lost in signless wastelands of hospital car parks. Legal debate or clarification may also delay things.

Proceedings are quite informal, and start with the tribunal’s doctor asking the RC about the diagnosis and the reasons for detention. The lawyer and layperson add their questions, and then the patient’s lawyer joins in. This is when spats can occur. The social worker and the nurse are questioned, the patient is given his/her say, and if all has gone well (an hour or two, say) the tribunal is left to its decision-making.

The criteria for detention are simple. Do you have a mental disorder, as defined in the Act, such that you are liable to detention on the grounds of risk to your own health or safety, or to protect others? About 90 per cent of hearings maintain the Section.

A patient, whom I’d known for years, appealed and did quite well for the first half-hour of the tribunal. He kept his mouth shut and stayed with the programme. But gradually he started to comment, and on being questioned by his lawyer, gave his side of the argument. This was a glorious technicolour description of speeding thoughts, the happiness of running half-naked in the streets and the joyful innocence of his bipolar affective disorder manic state. He was a bit difficult to interrupt, but the tribunal were very polite, and smiled (he was quite infectious in his enthusiasm). We then left the room while they made their decision. As we waited outside he turned to me, saying with a smile, “I blew that, doc, didn’t I?”

He had done, and his detention was upheld, but he was better in several weeks, on antipsychotics and his reinstated lithium, and there were no hard feelings, as (it’s comforting to report) there rarely are.

Trevor Turner is a consultant psychiatrist working in east London. Some details have been changed to protect identity

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