The use of emergency detention certificates
Our interest in these figures
Under the Mental Health (Care & Treatment) (Scotland) Act 2003, an emergency detention certificate (EDC) can be issued by an approved medical practitioner (AMP) in order to secure a psychiatric assessment, where there is grounds to believe that someone has a mental disorder. Mental Health Officers (specially trained social workers) should also give their consent to an emergency detention, if this is possible within the time available.
We collect information on the age and gender of people detained as an emergency, how the use of emergency detention varies depending on the area in which people live. We also look at what happens to people after a period of emergency detention. We look, for example at whether people go on to a short-term detention, or whether the person goes on to receive care and treatment on a voluntary basis.
What we found
The age distribution of people detained under EDCs is similar to previous years. We have however picked up an emerging difference in the gender of people detained as an emergency. The proportion of women detained under EDCs has risen steadily over the last three years. We have looked into the reason for this. Comparing
2008-09 with 2006-07, we found that:
- The total number of EDCs fell by 8%
- EDCs for men fell by 13%
- EDCs for women fell by only 3%
The difference is most evident in the 18-64 population. Compared with 2006-07, 20 (2%) fewer women in this age group were detained compared with 156 (18%) fewer men.
There is no increase in the number of men being detained under short-term detention, so the general fall in the use of the 2003 Act is evident for men but not for women. General adult mental health services need to look at why this is the case. One possible explanation is that rates of deliberate self harm are higher in women. If so, there is a need to examine services for people who self-harm to make sure that there are services in place that will lessen the need for detention.
We shall look more closely at the characteristics of women detained under EDCs next year.
Figure 1: Episodes initiated between 1 April 2008 and 31 March 2009 displayed by gender
Our interest in this
Because of our findings in relation to gender and the use of EDCs, we wanted to look more closely at whether men and women were treated differently under emergency and short-term detention.
What we found
The striking finding is the number of women who are admitted for short periods under emergency detention but not detained further. The use of emergency detention certificates therefore appear to be responses to relatively brief mental health crises. The explanation for this is not clear - we have speculated about deliberate self harm, but we think this figure suggests mental health services need to look at how well they respond to women at times of crisis.
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Our interest in these figures
Emergency detention should only be used where granting a short-term detention certificate would involve too much of a delay for the individual. We look at the extent to which emergency detention is used to detain people who are already in hospital, or to admit individuals who have been admitted from the community.
We hear of anxiety from some people that, although they agree to be in hospital, they may be detained if they want to leave. We are concerned that this may constitute 'de facto' detention i.e. detention without the safeguards of law. Looking at the rates of admission from hospital helps us to identify where this might be happening. In previous years, around half of EDCs were granted for people who were already in hospital.
We place great importance in the role of the mental health officer (MHO) in the decision to detain a person. The MHO provides the important safeguard of looking critically at the proposal to detain the person and can help to look at alternative ways to support the person without needing to use compulsory admission. Where the person needs to be admitted, the MHO can help to explain the process and make arrangements to make admission easier and to safeguard the person's property and possessions. The 2003 Act requires either consent from an MHO, or an explanation of why this was not possible. We would like to see consent in as many cases as possible. We look to see whether there is more likely to be MHO consent in some NHS Board areas than others.
What we found
As in previous years, around half of EDCs were granted for people already in hospital. We found MHO consent for 66% of EDCs. This is the same proportion as last year and down from 72% in 2006-07. NHS Boards with proportions of MHO consent that are significantly lower than this should discuss the reasons with their local authority partners.
NHS Ayrshire and Arran has had low rates of consent in the past and is low again this year. This may reflect the rural nature of this area and the fact that out-of-hours MHO services cover a large area of the West of Scotland and might have difficulty attending in time (although the same argument might apply to NHS Highland where the rate of consent in much higher). NHS Lanarkshire has a low rate of consent but is a relatively low user of emergency detention.
NHS Greater Glasgow and Clyde should examine this data closely. They have a low rate of consent, a high use of emergency detention and a high rate of detaining people already in hospital (we know MHO consent is less likely in this group - see table below). We can help by providing the Board with data on which hospitals seem to use this power most.
Our interest in these figures
We usually find that detention of a person already in hospital is less likely to involve MHO consent. This is probably because the person is expressing an immediate wish to leave and the medical practitioner has conducted an examination, decided that the person should be detained but cannot wait for the MHO.
We have concerns that people can be detained for up to 72 hours without MHO consent.
What we found
As in previous years, a person who was already in hospital is less likely to have MHO consent for emergency detention. We have recommended possible changes to the 2003 Act to shorten the period for emergency detention under these circumstances, or to allow nurses the power to detain until both the medical practitioner and MHO are able to attend and assess the person.
Our interest in these figures
While short-term detention should be the usual route into compulsory treatment, emergency detention is still used, mostly outside office hours. We think it is important that there is consent from an MHO wherever possible. The table above looks at the extent of MHO consent outside office hours.
What we found
We are pleased that it is still the case that most EDCs granted outside office hours have MHO consent. The exceptions appear to be NHS Lanarkshire and NHS Ayrshire and Arran. These areas were both served by the West of Scotland out-of-hours MHO service. It appears to us that this service is not providing the level of MHO cover necessary for these areas. We understand that North and South Lanarkshire councils have withdrawn from this service from April this year and we will study the coming year's data with interest. North and South Ayrshire local authorities should consider our data and examine other ways to provide a round-the-clock MHO service.
Our interest in these figures
Short-term detention should be the usual route for admission to hospital under the Act. This involves mental health specialists - an AMP and an MHO. EDCs can be granted for up to 72 hours. An AMP or MHO is not necessarily involved and there is no right of appeal.
The 2003 Act says that hospital managers should arrange for an AMP to examine the person as soon as possible after admission. We think this should happen within 24 hours. Usually, this should result in a decision to revoke the certificate or to detain the person under a short-term detention certificate. We do not think that the certificate should run for the full 72 hours and then expire.
We look at all EDCs and measure the time until they are either superseded or revoked to make sure that there is evidence of early expert assessment. If the person is admitted over a weekend, it might be acceptable for the AMP to assess, but not make a decision and wait for the team that knows the person best to assess the person on the Monday. This should only happen occasionally.
What we found
The table above shows that only 38% of people detained on an EDC had the order either revoked or superseded within the first 24 hours. We don't think this is what the 2003 Act intended and would like this figure to be much higher. Also, around a quarter of all certificates appear to run for the full 72 hours without being either revoked or superseded. We have found this consistently since the 2003 Act was implemented.
We think this is a problem. People should not be deprived of their liberty, for that length of time, on the basis of a certificate granted by one doctor who does not need to be a specialist and without the consent of an MHO. Of all EDCs that continued beyond 24 hours, 36% had no consent from an MHO.
We have recommended changes in the law to restrict the duration of emergency detention under those circumstances. Meanwhile, we remind hospital managers of their responsibilities and would like clear evidence of early assessment by specialists to make sure that detention is necessary.
Annual reports
- directors introduction
- overview of the Mental Health (Care & Treatment) (Scotland) Act 2003 introduction
- new orders granted in 2008-09
- total numbers of 2003 Act orders in existence
- monitoring our priority areas
- additional findings from our monitoring of mental health law
- our overview of the use of the Adults with Incapacity (Scotland) Act 2000