Medication imposed in community after discharge

Law and practice Mental Health Act
1

Hi all,

A patient was discharged from section 3 in 2018. The responsible clinician signed off on the section 23 discharge form ticking ‘The patient will be discharged from hospital/CTO on (date) //2018.’

The patient was then forced into the care of their family, GP and the community and had to sign a ‘Care Plan - Crisis Resolution Home Treatment Team offer’.

They were also allocated a care coordinator for those years monitoring anything they did on a weekly / monthly basis.

The patient did not want to sign this document (care plan) as they stated from the beginning they were not suffering from any evidential condition. It was illegitimately done.

Now, what I am struggling to understand here. The patient according to this document (s23 discharge form); it appears they were completely discharged from any section and community order. The patient afterwards was made to believe they had to comply to whatever they wanted and take serious medication that damaged their body for a year or so. And it left them physically having to rehabilitate the damage done to their movements for years after.

If the patient was not under a CTO - then why was the patient made to take this medication without their consent? The patient during that period shared they did not consent to treatment multiple times - but it was ignored.

With a CTO they are given the right to an advocate and a tribunal - none of this was offered to the patient during this community treatment plan which lasted between 2019 and 2021 - two years. Two years of their life without any choice from them to leave that plan.

If someone can explain here in a clear and simple way what has happened here and what can be done now - I would appreciate it.

Thanks.

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2

Sounds like a potential GMC referral to me. But… but… I’m usually wrong on social media forums by crowd sentiment.

3

Even under a CTO it would be unlawful to impose medication in the community without consent. I suppose that is often the effect, though. There’s an exception for patients lacking capacity if force isn’t required.

You could get the patient’s records to see whether there is any evidence there of what you are saying.

4

"CAPACITY AND CONSENT
The patient has capacity to engage in the agreed care plan because they are: Able to understand, retain, repeat, weigh up on balance, use the information given The patient gives informed consent to treatment without coercion. Yes"

This was written by one worker after discharge. I assume the patient isn’t lacking capacity as they have apparently got the patient’s ‘informed consent’ to treat them?

There is one comment from the RC at the time where they write ‘Capacity and consent They were not sure why they were taking the depot though was willing to continue to take this and was aware that this was being prescribed for mental illness.

The RC is saying the patient has no idea why they have been prescribed this drug, but are agreeing to it and they are aware what the medication is for - still here, that does not sound to me that the patient has been informed about what this is medication is about in relation to them considering they are not sure of it. That again contradicts what informed consent is. Because the patient has not been informed otherwise there would be no lack of certainty from them? Surely you can not prescribe medication if the person you are prescribing to has not been informed properly of what they are made to take?

The quote is from a review months after discharge - but these reviews about the patient’s capacity and consent has not been followed through with those legal steps required in the files e.g. ability to retain info etc. They just write they ‘agree’.

In the patient’s records there are comments made by them - that the patient does not agree to therapy or any other psychological treatment - the patient denies any disorder - it’s been recorded even throughout their sectioned detention on both 2 and 3 and after discharge from each nurse or professional that they do not exhibit any symptoms of a disorder - towards the end where the patient is trying to get them off the medication - they fabricate some comments saying the patient was requesting for a ‘reduction’ (rather than ‘stopping’) this reduction was mentioned repeatedly in the notes - instead, even this request of a reduction was delayed and ignored by the RC - the patient recalls that in the end the RC over the phone still ignored what the patient said to come off the medication and decided to tell the patient to hand the phone call to a relative for their decision. Then steps were made to stop.

To add - there are comments written down by them saying the patient 'continues to say the reasons they take medication is because it was prescribed by the doctor. They do wish to stop the medication at some point. No other concerns expressed.’ or ’ Informed they would need to attend the centre for their depot which they was reluctant to do but eventually agreed’ and ‘P was happy that this was the last injection as they stated they were stopping following this one.’ With the last comment - it was several months before they got their last injection.

Within the records they have falsely put down the patient agrees to medication. However, as written above - the notes have this contradiction of comments from them e.g. No evidential disorder observed, refusing alternative forms of therapy, denying themselves they need the medication or have any disorder; RC wants them to take anti-depressants based on assumption - it is noted down the patient declines anti-depressants as they feel they do not have depression etc. Also after medication is stopped - the RC mentions a few times that they want the patient to recommence medication - but the patient does not want to. Which in itself is bizarre - when there is no reason to recommence.

Yet, considering the records noting down all of this - why would then this person agree to taking medication? Then, agree to taking high strength medication? Lastly, be given high strength medication from the RC?

Towards the end of their care plan - it is noted by one new care coordinator of what the patient thought about the whole process. They write along the lines that the patient ‘felt they had no choice in the matter and had to comply in taking medication even though they did not’.

I understand if the patient signed off on a care plan - that the community teams can administer legally some support services for a specific time frame. But even then with medication - that is a completely different area. If the patient declines at any stage - they should have stopped. It was always under the impression they had to take it or they risk detention. They were completely dismissed. It’s also a very long time to continually to make someone see them without any choice - two years. In those two years they felt they could not do anything because of their visits and monitoring - when in reality the patient always had the right to say ‘no’ to them and continue with their life.

It doesn’t make any sense that this can only come a care plan - the document signed says the patient is discharged fully from any restrictions - so what on earth has happened here? Was the law different back in 2018/2019 over Crisis resolution home treatment team care plans?

Apologise if my comment is not clear - kept finding parts within the records that were unclear that I kept adding on - which is why it might not be cohesive to read. Again anyone who can make sense of all of this or try to make sense of it - would be better than nothing. Thanks.

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5

This sort of thing has always been a grey area. We all do some things semi-voluntarily because the alternative might be worse. It’s not uncommon for patients to go along with medication for a quiet life and to avoid the risk of being detained again. The team probably just thought that is what was happening here, and also thought it better than re-detention. I don’t know about the discrepancies (e.g. stopping vs reducing) – it could be lying or misunderstanding on one side or the other, or a combination of these.

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6

Thanks for the reply.

Is there a court that would listen to anything like this? Or it is too late to submit any legal application as it was in 2019-2021?

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7

The issue is the transition. P was discharged and then immediately taken over by the CMHT - they were then made to sign an agreement without being given a choice to not to or even have time to think about it. There was no indication from them whether this was bound by law to comply. P was pressured throughout this to comply as they assumed it was bound by law. There was no separation clearly communicated by the CMHT from what they do and what the MHA teams etc do. It was branded all apart of the same process - that was the problem - if P was informed clearly from the start that this was not legally something they had to do and not apart of the MHA. It feels as if the CMHT took advantage of the situation, by not allowing P time to settle in after discharge - I can’t put it into words. But I will give it a go:

Say someone has committed a crime - they are arrested - go through the legal court process - serve jail time. Parole board release prisoner - they are now transitioned into the probation phase. It is all done as one. No confusion here. Here it is the same thing. You have someone detained by law with officers and ambulance - they are by law sectioned for a while - towards the end they are discharged - then suddenly CMHT take over riding on the coattails of your detention under section - then, using that fresh legal background to enforce what they do upon you. So, this transition from hospital to home is essentially intercepted - not giving the patient any chance to think and understand what is happening - they are left always with the impression it is all apart of the same thing. What would have happened if P was given a few weeks to settle in with the family home? What would have happened if P was told within the document they signed all of the information about the care plan and what can happen? P had capacity. They can read. Why the rush?

Having known P for a while - P would have said “No - thank you - please now leave!”. P never wanted a quiet life - P always wanted their life - not what others wanted of them. What they wanted.

8

Thanks for the reply.

P is going to report the RC and the care coordinator i.e. the nurse to the relevant bodies that they are registered to as soon as they can.

It’s highly unlikely any positive outcome will be met for P in their submissions. But P will be looking into the legal courts about all of this.

To have a number of their years stolen from them like this when they never did nothing evidently anything wrong is not acceptable, should not be acceptable or viewed as acceptable by anyone.

If P leaves what happened to them just as it is quietly. Then what happened to them will happen or continue to happen with others.

I apologise Jonathan. This part makes no sense. You are saying it is common for patients to submit to being heavily drugged out of fear of being detained again - so, this is what the team saw and did nothing? Then you are saying - by medicating them long term without any evidence to medicate was better than the patient possibly in the future being re-admitted?

It’s the second part that I feel sets a dangerous precedent. You are writing that it’s better to breach someone’s bodily autonomy and basic human rights over something that has not happened or will never happen yet?

9

I’m not saying any of those things. I was just trying to answer your question about what happened.

Your best bet would be to find a medical negligence solicitor willing to discuss it with you in detail. Maybe a firm like Bindmans. I think the limitation period is 3 years (with exceptions, e.g. later date of knowledge, or gaining mental capacity).

10

Medics aka doctors tend to band together to defend their own. Everybody knows that.

Hence one often hears about misunderstandings and a range of other possible reasons.

It matters not what is common practice. What matters is the law and people’s rights.

Nobody should be treated against their will without protections of the law (which includes common law where applicable).

I’ve seen the sort of standard or common practice referred to several times in the last 5 years. It is illegal. Those who are wronged need to sue.

To put my money where my mouth is, I’m prepared to donate £100 to each such cause where on balance of probability the evidence points to wrong doing.

To learn less avoid this What is consent? - Investigative Psychiatry

Oooo… I probably just upset a whole bunch of doctors.

11

It is fine if you are saying it - you have every right to have an opinion. You’ve done nothing wrong.

But how I know what you mean is you are suggesting this as a possible explanation without any approval of it. It is expressed as an ‘acceptable’ explanation.

Normally someone that describes what you are describing would say along the lines; ‘Sadly, I think this is what may have happened etc’ or ‘It’s possible this has happened - if it has - then P has every right to feel upset etc’. However, you do not - you offer your impression without condoning what you think has occurred. Your tone is accepting this as perfectly fine and a commonality amongst patients. It’s seen as a ‘grey area’ rather than a ‘red flag’.

Like I said - it is fine to have your views. It’s better people are aware where you actually stand on this subject. For example, this response after I highlight what you have said - now, you are providing me with legal firms that would look into this - whereas why not do that sooner when the question was asked or when you offered that reply?

It terms of exceptions - how would one qualify this as an exception to the limitation period? Do they explain their reasons over the phone for the delay and then they would make up their own judgment to take it on or not? Is there anything the patient can write or say to them to make them look past the limitation period?

I prefer someone replying than no one - so, I appreciate your responses. Thanks Jonathan - because without that response P would not have discovered the scale and context of what has actually happened.

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12

Apologies for butting in.

Limitation periods generally stand as floodgates in law. My broad knowledge and experience is that limitation periods can be circumvented. It depends so much on factual circumstances and quality of submissions. That means cost for the right sort of legal representation.

If funds are unlimited then applicants can dispense with cost vs compensation. But most discover that cost is prohibitive in legal battles.

But there are options for raising merry hell:

  1. Pro bono unit or finding good lawyer who would work pro bono.
  2. Using Ai: caution I’m not saying that AI is good legal representation! I’m saying that using AI can help clarify, formulate and plan.
  3. There maybe non-legal approaches that achieve results. AI can help point to those. AI is not a qualified adviser on anything (saying it before someone else jumps on me to tell me so).

Phone? I’ve written before on the dangers and uselessness of using phone and emails for things like this.

My bottom line which is not for everybody is: Never back down!

13

Thanks.

Ai is a bit like the magic mirror in Snow White - feed it questions - get the answers you want.

Just have to wait and see what happens.

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14

The GIGO principle operates: Garbage In Garbage Out. Of relevance - is that ‘some people’ expect AI to be perfect when they don’t expect humans to be perfect!

‘Some’ believe that AI replaces human judgement. Well I have news for them - that flying in aeroplane does not grow anyone wings! And travelling in an automobile does not grow anyone ‘wheels’. :blush::cowboy_hat_face:

‘Some’ still believe in working with quill and ink pots, which is fine as everybody has individual choice!

15

Just re-reading this more carefully. This situation has been happening across the land for donkeys years. Nobody except me cares. To the annoyance of many, I invoke S62(2)

It surely contradicts what ‘informed consent’ means. But…but… there are two kinds of capacities as I have shown. Understanding Capacity under MHA 1983 vs MCA 2005 in the UK [Obviously, not everyone will be convinced!]

MHA 1983 : The MHA does not explicitly define “capacity” in its statutory text. Instead, its framework for consent to treatment (e.g., in Form T2 ) relies on the phrase: “capable of understanding the nature, purpose and likely effects of the treatment” The same phrase applies on Form 22 under the Northern Ireland Mental Health Order 1986.

Note the other aspects of capacity: being informed of alternatives, and communicating free-willing agreement are not required. Perhaps it is assumed that medical RCs (or RMOs in NI) will be ‘good’ and provide all relevant information.

Also of interest is that there is no requirement in Statute law (referred to) to address materiality (post-Montgomery 2015), in the so-called ‘informed consent’. Caution: this does not mean I like any of this. This means that RCs and RMOs can be minimalist according to Statute. Caution: I am not saying that all RCs and RMOs are minimalist.

So shockingly the above can meet the Statutory requirements (which I find ridiculous). But…but… Statute and statutory processes can be as ridiculous as they like - and they still stand as ‘the law’ which everyone has to obey (or use in their defence).

I doubt the GMC will be able to ‘arraign’ any medical doctor for following the minimalist statutory requirements whilst neglecting their own GMC standards or the Mental Capacity Act (2005) requirements.

16

Hi all,

I’m unclear on what normally happens afterwards.

If the RC elects to treat you with medication under section does that continue after section ceases?

Does the RC’s legal authority still stand afterwards and you have to take medication?

Do you have choice in the matter during the handover phase to HTT or CMHT whilst you are in the ward just about to be discharged?

17

There is no straightforward answer.

In the first three months of detention under S3, the RC can do what they like. It’s not uncommon from my observations for patients to be drugged up to the eyeballs with all sort of cocktails. Oh yes - these are easily justifiable but not subject to any statutory oversight:

  1. A bit psychotic - have an antipsychotic or two.
  2. A bit mood unstable - have a mood stabiliser or two.
  3. Low mood - have an antidepressant or two.
  4. Suffering with anxiety - have pregabalin or benzos or even promethazine which is not licensed as an anxiolytic.

After 3 months, for non-consenting patients under a T3 certificate for treatment with medications:

  1. A SOAD will usually approve whatever the patient was established on, and
  2. There is unlikely to be menton of any unlicensed use of medication under para 102 to 108 of the GMC’s updated 2024 standards on prescribing.

After 3 months, for consenting patients on a T2 certificate:

  1. Whatever the RC says - does the patient dare to disagree?
  2. More junk can be added to any pre-existing cocktail.
  3. There is unlikely to be menton of any unlicensed use of medication under para 102 to 108 of the GMC’s 2022, or updated 2024 standards on prescribing - and he required documentation.

On sudden discharge - like Tribunal discharge - or rushed discharges which have beome the norm:

  1. ‘Nobody’ cares about T2 and T3 consent or capacity issue if no CTO. How? The CQC doesn’t have the time, manpower or nous to regularly check documentation. The GMC is not an inspectorate. Trust don’t have the time, manpower or nous to check either. So long as some tickbox is done on an EPR that’s it! Look, if seen this for myself repeatedly over the last 5 years especially.
  2. So I’ve seen patients like those in the community and nobody knows or cares about consent. Most patients and relatives won’t now what’s what - and if they did know what’s what, they’ll stay quiet (I hope it’s obvious ‘why’).

RC’s have no authority where there is no inpatient section or absent a CTO. RC’s change like the ‘weather’ in their numbers ‘all the time’. [Caution: I did not say across all of psychiatry or across the land as constant. But watch the locum psychiatrist thing. Trusts are allowed by law to appoint whoever they like as a consultant psychiatrist due to some rather weak laws or regulations (GIYF)]

The short answer is NO. The long answer if you are a Trust official is something like, “We always aim to give our patients choice by engaging them fully in the discharge process”.

Declarations: My responses though apparently cynical are based on real observations. I have not been resourced to carry out an audit or inspect Trusts. I have worked in all the wrong places e.g. two of several ended up on Panorama and Dispatches, others eventually ending up in bother after major messups. This means that my observations are biased by the sort of Trusts I have worked for - dozens over the last 20 years. My observations ought not to be generalised.

18

So, if the patient said ‘I do not want medication after my discharge’ in that ward meeting discussing the transition with everyone - would that legally stand? Or in the moment in time whilst they are still within the ward and I guess under S3 but just about to be released - they still have to comply?

Also I’m not too clear on what ‘T2 and T3’ forms are?

Thanks.

19

The follwing is rough and ready - which means there may be errors - which will then lead to questions or accusations about AI. Wait for it

Patient detained under Section 3
↓
First 3 months of detention
↓
Treatment for mental disorder can be given without consent
↓
After 3 months:
↓
Is treatment to continue?
→ No: End
↳ Yes: Continue below

Does the patient consent to ongoing treatment?
→ Yes:
↓
Issue T2 Certificate
↓
Continue treatment with consent
↳ No:
↓
Refer case to SOAD under Section 58 MHA
↓
SOAD assesses:
↓
SOAD approves?
→ Yes:
↓
Issue T3 Certificate
↓
Administer treatment without consent
↳ No:
↓
Cannot proceed without patient consent and SOAD approval.

I understand the words not the question. Many patients don’t want medication after discharge. In practice to get discharged it’s a good idea for the patient to be consenting to treatment with medicaiton in the community - else obviously the patient has a higher probability of relapse. Some patients say they will consent to treatment if discharged and then chuck the pills down the toilet or wherever.

But what would be the point of discharging patient who meets the criteria for detention and who will refuse treatment in the community? Do you see what I mean?

20

Thanks.

I’ve been helping the patient (friend) put everything together, but to be honest all of this is very complex. It’s complex because normally when you have rules in place - the people at the top uphold the rules as per by definition. But with this area of law and the lack of monitoring surrounding how everyone does their role. It has left this situation where the rules are bent and distorted into whatever framework that suits any RC or MH worker’s narrative. That is why it is complex. The rules are far too easy to manipulate because there is no one making sure the rules are enforced correctly. Anyone in a position of authority can do as they please without fearing the ramifications for it - and, concerning patients seen as suffering with a ‘severe mental disorder’ - who is actually going to take them seriously if they do highlight credible flaws and violations done to them within the process? Everything remains stagnant, polluted and, sadly at a cost to the very persons they are all meant to be protecting - the patient.

Just feels like the people who claim to be caring and doing it for the right selfless altruistic reasons initially - have just lost sight of what they really wanted to do. Which is a shame.

The patient has nearly understood most of everything that has occurred to them. Which has not been easy at all - especially this last revelation. As it meant the patient had to suffer all those years for nothing - when in reality it could have been prevented.

But that’s life - I guess. Patient is better and stronger for it than worse - just now about finding someone to look into their findings with a non-judgemental eye and see if anything of it is of any use for them to use in a potential legal case (s).

Patient just needs different perspectives to view everything because right now albeit myself and them can see clear breaches - but with a neutral expert who has experience in these processes they may see that some parts are not substantial enough and there maybe some parts that are - and some that are not at all - then some areas that were not known before that could be monumental.

The case is certainly not closed - very much open.

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