Conflicting information

Law and practice Mental Capacity Act
1

A relative has been on section 2 for 2weeks and quite unwell. The issues are the usual osychotic break symptoms .
Background -stopped taking meds -section 2 October 2024. Dr suggested section 3 and I agreed, 2nd opinion dr disagreed and she was discharged. 2weeks after discharge sectioned again under section 3 for 8 weeks. Discharged despite others telling DR she was still showing signs of psychosis.
From discharge at beginning of March 2025 she has been taken to hospital by police, been reported missing , left temp accommodation with police being called by public to report concerns for welfare. Section 2 again July 25.
I received a call to say my she is being discharged as she displayed no signs of psychosis and staff have not reported psychosis.
My question is, if a patient has been admitted for psychosis and being treated (she is refusing medication so has not been given antipsychotics which she has been in for 5 years) why would the staff need to write that she has psychosis? She has been a difficult patient and the staff have told me not to take anything personally because she is unwell so they do know this. I have stated all the things that happened on my visit the previous day with her psychosis which resulted in me having to leave but the nurse that called just said well, the doctor hasn’t seen this and staff haven’t reported anything. To anybody that knows her she is quite clearly unwell How would I prove this? From experience if she is discharged she will be back very soon

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Could you at least ask that she’s put onto a CTO so they can readmit her easily if she’s refusing medication?

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The community team don’t really bother with her when she is out of hospital and she will be street homeless so it would be hard to enforce anyway

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If you believe discharge poses a serious risk, you can raise this with the local authority under adult safeguarding procedures.

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The situation is terrible! My analysis (unfortunately) will make only carefully qualified assumptions based on the text presented. I do not know what you mean other than my interpretation of words on a page. I will appear to be an AI because my logic is too sharp (I’m told by several), and my style of writing is very different. This post is created in Typora, unfortunately (which is not AI)

I understood that your relative has a history of psychosis, has been sectioned multiple times, and has a pattern of relapse shortly after discharge. Key points include:

  1. It was unclear that you are the Nearest Relative under S26 MHA 1983, but I cautiously assume this.
  2. Section 2 (October 2024) : up to 28-day detention for assessment (but possible to give some treatment)
  3. Section 3 (disagreement over) : Initially suggested by one doctor, opposed by a second opinion doctor which led to discharge.
    • Second Opinion Doctor normally has a special meaning arising from S58 MHA 1983. I did not assume that was the context.
  4. Re-sectioned under Section 3 (after discharge) : up to 6-month detention for treatment
  5. Post-discharge (March 2025) : Multiple incidents — hospital via police, missing, welfare concerns, and police involvement.
  6. Section 2 again (July 2025) : Now being discharged again.
  7. Concerns : She is not taking medication , denied symptoms , and staff are not documenting psychosis , despite family observations.

Inferences made

The key issues arise from Section 2 in July 2025. It is at this point there is some difference of opinion between two doctors. It appears that there was a MHA assessment with an AMHP. One of the two doctors who would be part of that assessment was unable to recommend detention. Hence there was no go for Section 3 being implemented. Naturally Section 2 came to an end and your relative was discharged but I am not 100% clear on that.

Your key question

Staff do not need to “write that she has psychosis”. The Approved Clinician (who is normally the Responsible Clinician[RC]) has to form an opinion as to the existence of psychosis based on evidence (and other legal criteria). That’s where one of the other medical recommendations for a MHA Assessment comes in.

But the law is clear. The Responsible Clinician can shout 'Psychosis - here is the evidence’ till they’re blue in the face - if one of the other two persons (one a doctor) at the MHA assessment says ‘NO’ that’s the end of it i.e. no go for Section 3.

The problem for the second doctor making a recommendation is that they won’t be expected to know the patient as well as the RC. The patient could easily say (as I heard before): “Psychosis - what psychosis? Do I sound crazy to you? There is no evidence that I’m psychotic on the records! Why would you just take the word of the consultant [The RC]?”

She being difficult and staff saying she is unwell means little among the legalities. There needs to be evidence. I’ll say more on that in a bit.

Precisely! If staff haven’t been reporting or recording anything then there is no evidence for a second doctor to see. The staff who saw and heard may not have been there on the day of assessment to give rich oral (spoken) evidence (I don’t know - I’ll take your word for it.)

The issue is evidence available at the material time of the MHA assessment. It sounds like she is still on the last few days of the Section 2, when you said “if she is discharged.” [Opinion is not evidence, unless given by someone who is a recognised expert approved to appear at a Court or Tribunal]

On that assumption - if you’re me you can raise merry hell because I never back down. But you’re not me so do no such thing, please.

For people in your situation, I normally say “Cut through all the red tape and write straight to the Chief Executive of the relevant Trust or other detaining authority - a detailed and clearly worded letter or email.” (if it’s not too late of course). And copy to CEO of the relevant social services body. Because I use Google regularly I have no problem in finding these folk.

But always keep in mind:

  1. What I would do is not for everybody.
  2. My opinions are not advice (a very fine line between the concepts)
  3. And because I am not afraid of using AI, I seek assistance all the time with drafting letters.

Suggested lessons for all relatives (at your own risk - no liabilities accepted)

  1. Always write a report on your visit to your loved ones. Pen and plain old paper are lovely things.
  2. Photograph it if possible or ask for a photocopy. [If you’re not allowed to use a mobile phone in the premises, step outside, photograph and get back in. Never be tricked by the ‘rules’.]
  3. Hand it to a nurse in charge - record their full name and time of handing them it.
  4. Refuse to leave until they sign for receipt of the letter on piece of paper you will keep. Let them call the police, if they want. [Prepare for anything these days]
  5. Expect chaos in UK mental health services.
  6. Expect that evidence will not be recorded as most staff are running around like headless chickens.
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Thank you for your reply. It’s very informative.
I spoke to a social worker from adult safeguarding on the day she was taken to hospital who said she has been very let down by the service so far.
I do have another question as I am going to raise this on Monday.
There is a recent history (and only when not taking nedication) of her walking the streets of the city centre at night with no shoes or coat. As she shouts and behaves in a certain way this has resulted in a few assaults against her.
During her 2 weeks in the hospital she has been assaulted by other patients six times. She can be very angry and shouty and the staff has told her they lash out at her because she is antagonistic(only when she is unwell she is like this).
She has a 7x7 inch bruise/bursted vessel on her inner thigh from a kick.
So the question is, even if the doctor hasn’t seen any signs of psychosis, are they making a presumption that this is her personality?
It’s a concern for her being discharged as a further assault against her might end up being serious.
Would they take this risk into consideration?

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There are two issues in there that could be related but may not be related.

The first is evidential issues which if not previously considered, could be submitted.

The next issue is about personality. Everybody is entitled to have a personality. [Caution: Appreciate that I take the words as they appear on the page. I do not interpret ‘what others might know what you mean’.]

Personality is not a mental disorder. For the benefit of those who may not know, none of the following are mental disorders in any recognised diagnostic system (such as ICD10, ICD 11 or DSM-V-TR): anxiety, hallucinations, roaming the streets aimlessly (partially clothed), antagonistic behaviour, disruptive behaviour, criminal behaviour, behaviours that may have made a person prone to assaults on themselves. They are not mental disorders for the purposes of the MHA 1983 (amended 2007). This basket is either signs or symptoms, or absolutely nothing relevant to mental disorder. [Note: I have used ‘mental disorder’ because the words ‘mental illness’ do not appear in the MHA 1983 with any relevance to detention.] But unbeknownst to most there are some psychiatrists who use ‘personality’ (in England & Wales) as a reason not to admit people to hospital. How would I know? I’ve met them and seen them in action.

All the above needs to be considered along with contexts of other features to determine if there is a mental disorder or not. The lay public are free to say ‘"Obviously the woman is mentally disordered - what’s the matter with you! Are you a psychiatrist?’ (heard it said before). The matter with me, is that I am obliged to obey standards of medical practice related to diagnostics, arising from the General Medical Council when coming to diagnoses. Joe and Jane Public are not so regulated. And not all psychiatrists care about standards related to diagnostics.

Some people - even qualified psychiatrists and psychologists I have known - use ‘personality’ whimsically to mean ‘personality disorder’. This is malpractice that goes unnoticed by any professional regulatory body, or quality assurance body like the CQC - so it continues like ‘nobody’s business’. Unfortunately my privileges to post links have recently been restricted due to my misbehaviour on the site, it would appear. So I am unable to send you further in-depth information relevant to personality and personality disorder.

Nonetheless, in England & Wales and Scotland it is possible to detain someone under a Mental Health Act for a personality disorder meeting various criteria in respective jurisdictions. However, in Northern Ireland (that forgotten part of the Kingdom) a person cannot be admitted for treatment of a personality disorder unless there is a co-existent other mental disorder that permits detention [Supplemental: and the ‘appropriate treatment’ and ‘availability’ requirements do not exist for NI].

Keeping your question in focus: The absence of documentation of psychosis leading to an absence of tangible evidence of psychosis, does not mean that psychosis does not exist. It could easily be the result of slackness in a health service somewhere. [Caution: this is a statement of speculation - not an allegation about any service where your relative is cared for. And I say so because I have seen too much slackness going on in the last 5 years across countless health care organisations - that the CQC apparently cannot see.]

The absence of documentary evidence of psychosis does not translate to ‘personality’ or ‘personality disorder’ for reasons that I hope are obvious. I cannot comment obviously, on what ‘presumption’ they may be making because I do not know the details of what’s in their minds.

I do not know what they would take into consideration. All I can say is that every assessment of a patient should consider all relevant risks. [Risk means estimated probability of adverse outcome relative to impacts - Royal Society definiton 1992] Risks are one basket (among others) of issues when considering detention of a patient under the MHA 1983 (Amended 2007).