The question “Who decides S17 leave?” may appear to be a silly one because ‘everybody’ knows that it is the RC’s responsibility to decide whether to grant leave (surely with MDT involvement and all that jazz). So what’s the issue now? I have my doubts based on recent evidence that the RC can actually make a decision not to grant leave.
[I own copyright to the image, just in case. Not a real patient.]
If a patient is about to kick off because they don’t have leave - it’s the patient that decides the leave for the RC. I can’t give a full list of cases where I’ve seen that happen. I’ll give recent scenarios that brought this home. See also Section 17 Leave under the Mental Health Act 1983
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Scenario 1:
- Alleged EUPD patient - and this is the latest craze for diagnoses from Northern Ireland down to England & Wales. [No proper documented diagnostics which is now the new normal for EUPD or any other kind of PD]
- Patient granted leave after robust 27.10 evaluation [Chapter 27 MHACOP] for once off leave on a particular day in custody of one nursing staff, to their parent’s home x 2 hours
- For whatever reasons patient did no go on leave that day.
- RC was prepared to grant leave for the next day to same destination, with same conditions as no change of risk profile or circumstances evident in previous 24 hours.
- On said next day their grandparent turned up at the hospital having just landed from America - and requests jointly with the patient, that leave be allowed, to a local food shop - no escort to be provided - and for 5 hours. [A handwritten note from P confirms this.]
- RC says no because was unable to devote time now for re-evaluating - as faced with a mountain of work. Note how the leave parameters changed.
- Grand parent demands to see RC.RC says unable to afford time now.
- P then kicks off by doing something to suffocate herself but staff intervened. No harm to P.
- P continues to be highly agitated and falls over causing what on good clinical examination by a PA was a suspected undisplaced Colle’s fracture and Scaphoid fracture of one arm/hand.
- Seconds later a pushed together 27.10 assessment by a senor noctor - not mentioning the above makes the case for leave. [27.10 is not a tickbox exercise. It’s something the RC must know and do for themselves. Staff may assist. RC may modify.]
- Two senior bods - one with ultimate Trust-power - descend on RC and press for P to go on leave. RC goes “So you both want me to send patient with a suspected Colle’s and scaphoid fracture on leave to a restaurant with supervision of their grand parent?” Both are clueless to what the RC is talking about. One of them was the noctor who constructed the 27.10.
- But when they get up to speed, they press on i.e. ‘if the X-ray shows no fracture - can P go on leave?’
- The main argument is: 1) fear of complaint by the relative and 2) Patient may kick off thus creating worse risk than if leave is granted.
- Total time consumed in the above 2.5 hours. Pile up of other work was now even worse.
So in effect any patient who would kick off and create more risk than if they were granted leave must be granted leave - it doesn’t matter the route or mechanism. Look this quite ‘mathematical’ in balancing risk to benefit at a moment in time. What this means is that the patient decides their own leave - and the RC is just an unnecessary obstructive figurehead. On these grounds - logically there is no need for RC oversight in law at all. How? Because on any given day if the risk of suicide or risk to staff is worse for not having leave then leave must be given. It’s not my logic - I’m just showing the logic of the ‘system’. Lesson to be learned: doing what is wrong in law but right for P and the system, is far more time efficient.
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Scenario 2
- P is an adolescent labelled with - you guessed - EUPD! Same thing - no proper diagnostics and consideration of exclusion criteria to be found anywhere.
- RC evaluates case carefully and decides that the symptomatology is very close to schizophrenia.
- P has some personality disturbance and is known to be pathologically manipulative (as against non-pathological manipulation which ‘everybody’ does)
- RC patient treated mainly along non-chemical lines by lifestyle adjustments in hospital and a small but increasing dose of depot.
- P was then incident free for over 5 days - the first in months where the average was about 7 self-harm or suicidal incidents per day.
- P granted leave in custody to a local retail park with 2 escorts, parent accompanying but no duty of care for P. On the day that was to happen P ‘inserted’ leave o a local restaurant into the minds of staff and her parent. So now it’s two destinations. But a 27.10 then first draft by nurse extends leave to all of the town! [Don’t ask - move on - it’s fact.]
- RC gets onto Google Maps and realises that the restaurant is only 3 min walk from hospital. Retail park is about 3 minutes drive.
- Parent was unaware how local restaurant came into the picture because they were aware of the leave plan RC had made in direct engagement.
- To avoid ‘wrestling’ match: RC gives in and grants leave with two staff to restaurant x 1 for 2 hrs and leave to retail park remained intact up to 3 times per week (no two on consecutive days) x 3 hours.
- So in this scenario - there wasn’t going to be a kick off if no leave to restaurant granted, but so as not to risk disturbing a run of 5 incident-free days, RC caved in.
The point in this scenario is that in balancing ‘risks’, the patient rules.
Questions for the erudite panel out here:
- How can systems ensure that the RC’s legal authority in leave decisions is respected in practice?
- What strategies can be used to balance short-term stability with long-term safety in leave decisions?
- How should RCs and systems respond to manipulative behaviour while maintaining boundaries and ensuring lawful patient care?
- What changes are needed to support RCs in making clinically sound decisions amidst systemic pressures?
- How can the MHA framework be strengthened to address the systemic pressures that undermine its integrity?
- How can RCs balance the principle of least restrictive practice with the need for risk-proportionate decision-making in complex cases?
Invitations to evaluate
Unfortunately I know there are zillions of ‘it depends’ to be asked or considered. No more information can be given. It is what it is.
- Scenario 1.
- Scenario 2.
The ‘if it was me’ sort of answer is personal opinion. I’m looking more for evaluation based on reported facts and knowledge of the law(s) to be applied and how they ought to be applied.
Supplemental: John Barrett: A Preventable Homicide - Lessons Learned