Disputing a diagnosis given during the sectioning process?

If a person wants to clear their medical records of a diagnosis written about them when they were sectioned. What is the correct process of disputing this?

It appears that at local GP level they can not do anything about it as it wasn’t them who made the diagnosis; it was the lead psychiatrist.

Address a complaint to your local ICB. Without medical evidence to support your case you are not likely to be successful in getting a former diagnosis deleted or changed, but you can request that a note be attached to your file explaining the reasons for your objection.

Thanks Barry.

What type of medical evidence would the person need to provide to convince the ICB to rectify the records?

Could a solicitor help formulate and produce the person’s case to present to the ICB?

Not sure if this helps but a diagnosis is personal sensitive data under the General Data Protection Regs for UK. The Information Commissioners Office will be able to give you advice on how to approach this and, if necessary, how to make a subject access request which could result in an invitation to have a record amended or expunged.

This is a matter I am trying to deal with now. The first attempt was to relate the section 2 hand written report to the requirements of the MHA and CoP, in this case there was written evidence by the panel that a mental disorder had not been clearly determined by their own statement with none of the signs and symptoms that indicate the presence or appearance of a mental disorder being documented. The section 2 seemed to be based solely on the incorrect and declared incorrect by the subject of risk to the subject. The follow up AMHP interview was not correctly carried out and they did not note the lack of documented evidence for the determination of a mental disorder and executed detention. The RC did not note the absence of information for a mental disorder and detained for 20 days during which they determined no depression or psychosis and did not record any substantiated signs and symptoms of a mental disorder and later documented the subject would not be at risk if released, but still did not release as required by the CoP if no disorder and risk arising from it is found during detention. Release was carried out by a stand in RC when the other RC went on holiday for the second time, and within hours of taking up that stand in duty.
A pretty strong case for deleting the reference to section 2 in the medical records.
But of course as in this case the Trust declines to agree, and the CQC won’t look at the contents of reports and the GMC does not think it is serious enough, the ombudsman PHSO is a possible solution. Presumably a supportive response from PHSO would provide the ICB with some leverage.

Sorry I don’t have relevant expertise nor experience to give you an authoritative answer.

I suggest first writing on your own - or with the assistance of CAB or PASS - making a clear concise request with your reasons. Include whatever medical evidence you have already - eg tribunal decision rejecting the diagnosis, or statement of another psychiatrist that the diagnosis was wholly unjustified. Make the least demand which will satisfy you. If the ICB does not make acceptable offer/suggestion then you can consider getting legal advice/assistance if the matter is that important to you.

Just to clear up it is not for me; it is for a patient that I am trying to support.

The patient backed out of their tribunal therefore no positive outcome was reached.

But there is medical evidence supporting that the patient was not mentally unwell and proving that the original diagnosis was incorrect.

As this happened a few years ago in the past. It appears to be not possible to get another psychiatrist to assess the patient unless in the present context.

Sounds very complicated. I’m hoping medical evidence would stand strong here, but this area in mental health doesn’t operate on evidence. Only opinion.

Really great stuff Barry - thanks!

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Thanks Andrew for taking the time to write all of this. It is interesting.

Are you a lawyer dealing with this when you say you are ’ trying to dealing with now’?

What is ‘CoP’?

The patient has medical records of their time that show no evidence of this particular diagnosis.

AMHP within their documents have not noted any substantial risk of harm in their report.

Who is the RC?

What do you mean by the trust - the NHS ICB?

PHSO?

Are you saying that despite all of the documents and evidences showing the patient to be not mentally unwell they still declined the proposal for change?

Thanks for the reply Jo.

What do you mean by ‘subject access request’? Do you request it from the ICO?

And how and why would they invite you as a result of this request?

No you can make a subject access request to any organisation that has handled your data (and you can make it on behalf of someone) Right of access | ICO

To answer your questions.
I am not a mental health professional or in the legal profession.
I represent a person of interest.
CoP is the Mental Health Act (MHA) Code of Practice a statutory document defining requirements in more detail.
RC is the responsible clinician attending during detention.
The Trust is the NHS Trust in which the detention took place.
PHSO is the Parliamentary and health service Ombudsman.
From what you say the sectioning documents gave a mental disorder diagnosis that you think was incorrect, is this because there was a later different diagnosis?. In my understanding if the recommendation for detention document, hand written in my case, gave a correct list of signs and symptoms that can reasonably indicate the presence of a mental disorder the first criterion for the recommendation has been met even though the actual nature of the disorder is disputed by yourselves. The second criterion is risk to the subject or others and you indicate the AMHP did not note any substantial risk of harm in their reports, but if the recommendation for detention described how a risk arose from the perceived disorder, then the recommendation for detention meets the criteria. If the following steps executing detention were carried out correctly then the detention was compliant with the MHA and CoP. As far as my reading of the legal position goes if during detention no mental disorder is confirmed and/or a risk arising from a mental disorder that has been identified correctly is not present then the RC should release the subject.
My strategy is to show lack of compliance with the MHA and CoP and therefore the reference to section 2 in the medical records should be deleted. If that lack of compliance is agreed then the GP may amend the record, but if they don’t feel comfortable with that then I will apply to ICB.

The diagnosis - ie the classification of mental disorder - is not as important as the effect that it has on the patient. The disorder must be of a “nature and degree” which makes detention in hospital and treatment “appropriate,” and symptoms must be such that detention and treatment is “necessary” for the health or safety of the patient or of some other person. So a patient who has a (possibly historical) diagnosis but is not currently displaying any harmful symptoms is not liable to be detained and treated.

The diagnosis might change as the responsible clinician gets to know the patient’s symptoms better; the important point is that the symptoms are attributable to SOME mental disorder rather than eg to alcohol or narcotics or to a bacterial infection (eg UTI - urinary tract infection) or a vitamin deficiency (B12 is common). Also that the symptoms involve harm.

IMO disputing a diagnosis is not worthwhile, unless you think the symptoms have a physical cause.

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IMO disputing a diagnosis is not worthwhile, unless you think the symptoms have a physical cause.

The person was diagnosed based on the opinion that there condition was psychological rather than physical. E.g. like a disease etc.

They have clear evidence that it was a physical condition and not a form of delusional disorder.

If this is the case. Do you think it is then worth disputing this diagnosis even though a number of years have passed?

It is worth disputing at a tribunal hearing or clinical review meeting, if the issue is “live” - but probably not just to get a historical medical record changed.

You write “they have clear evidence.” You will need to produce this evidence. If you don’t have a copy you can ask the clinician/hospital to disclose it, or ask the tribunal to direct the clinician/hospital to produce it under Rule 5(3)(d) - provided you know what document(s) you are asking to see.

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