Text size: a | a | a

Consent to treatment under part 16 of the Mental Health (Care & Treatment) (Scotland) Act 2003

 

Certificate of the designated medical practitioner 2009-10

 

AR-09-10-Table38

Our interest in this

The 2003 Act is designed to provide safeguards for patients in general. Part 16 makes provisions for additional safeguards in relation to medical treatment particularly, but not only, where this is given without the patient's consent. There are specific safeguards for certain forms of medical treatment including Electroconvulsive Therapy (ECT) and procedures classified as Neurosurgery for Mental Disorder (NMD). Under the 2003 Act certain treatments can only be authorised by an independent doctor, known as a Designated Medical Practitioner (DMP).

What we found

Neurosurgery for Mental Disorder (Sections 235 and 236)

The 2003 Act requires that all patients (including informal patients) who are to be considered for a procedure classified as neurosurgery should first be assessed by a Designated Medical Practitioner (DMP) and two other persons (not medical practitioners) arranged by the Commission. These three persons assess the individual's capacity to consent to neurosurgery and confirm this consent has been recorded in writing. In addition the DMP also assesses that the treatment is in the person's best interests. All three practitioners sign Form T1 if the treatment is approved. We ask for progress reports from the team providing ongoing care for all patients at 12 months and again at 24 months after the procedure. In some cases we seek reports on subsequent progress as well.

The Dundee Advanced Interventions Service (AIS) remains the only centre in Scotland providing neurosurgical treatment and receives referrals from Scotland, England and Eire and we continue to liaise with them as needed.

The practitioners we appointed met with two patients and two T1 forms were issued. Both had severe treatment resistant conditions, obsessive compulsive disorder in one case and depressive disorder in the other. The treatment was approved for one patient. The other assessment involved a person with complex problems and a second visit was required after further investigations were arranged. The procedure was approved after the second assessment. We received two further referrals in March 2010, whose visits were arranged in the following months and will be included in next year's report. We considered reports on a number of patients who had proceeded to neurosurgery previously.

Other safeguarded treatments (Sections 237 and 240)

Treatments covered by sections 237 and 240 include ECT, any medicine for the purpose of reducing sex drive, medicine given beyond two months and artificial nutrition.

Consent to treatment, given with a patient's agreement, is recorded on Form T2 usually by the responsible medical officer and with the patient's consent in writing. Treatment without consent is authorised by a DMP on Form T3. We received 591 T2 forms, substantially fewer than last year. Fifteen of the T2 forms were for ECT, the majority of the rest were for medication beyond two months. A number were either incomplete or incorrectly completed.We have recommended to the Scottish Government that it become a statutory requirement to send us these forms. In the meantime, we are grateful to those psychiatrists who send them to us and would like to remind all RMOs to use Version 6.1 of the form.

The number and types of treatments authorised by a Certificate of the DMP (Form T3) is shown in table 38 above. The majority of treatments authorised were medication longer than two months. 75 of the patients receiving ECT objected to it, or were resisting the treatment. One fifth of these required treatment to save life, the remainder to alleviate serious suffering and/or prevent serious deterioration.

We obtained data from the Scottish ECT Accreditation Network (SEAN) for a similar time period. SEAN data recorded a similar number of urgent treatments (42 in the SEAN data, 37 reported to the MWC). However, the number of people treated under the authority of a T3 form was, at most, 119 according to SEAN data. SEAN also recorded fewer people treated under the authority of the Adults with Incapacity Scotland Act 2000. It is likely that around 50 people for whom ECT was authorised by an independent opinion never received the treatment. This may have been because the patient improved without the need for ECT. Alternatively, there may have been other reasons to withhold ECT, e.g. physical illness.

The DMP does not always approve the treatment plan as it stands. For example the DMP may issue form T3, but recommend review after a few months. The DMP could ask for additional monitoring of physical health or a pharmacy review of medications. The treatment plan may be modified after discussion with the RMO or the DMP may occasionally disagree with the RMO.

Case example : Dr A was asked to approve a treatment plan which included clozapine. He reviewed the patient's history and previous doses of medication and did not feel there had been sufficient trial of other antipsychotics at high enough dose to justify this. After discussion with the RMO Dr B an alternative plan was agreed and the form T3 issued without clozapine.

Commission practitioners are undertaking unannounced visits to look at consent to treatment issues including an audit of T2 and T3 forms. We will be commenting on the findings in next year's report, but it appears there is a need for further guidance and training in the completion of T2 forms. Focused audits on specific topics are used to identify training needs for the annual seminar for DMPs. We note that hospital pharmacists continue to take an interest in monitoring this area of practice and have an important role in monitoring that the requirements of the act are being met.

Children and young people

We received 10 T2 forms for patients who were under 18 at the time of consenting to treatment all of which were for medication beyond two months. In one case the RMO was not a child specialist and the unit was contacted about this. Particular care is needed for patients under 18 who are in adult wards. The RMO assessing consent and completing the certificate must be a child specialist.

There were 19 T3 forms for patients under 18 receiving treatment without consent. One patient aged 16 received ECT and we requested further information from the RMO. Seven patients with a T3 received artificial nutrition and 12 medication beyond two months. In all cases, except one, the RMO or DMP was a child specialist. One patient seen in an adult IPCU was noted to be 17 when the initial DMP visit was undertaken, however the order was revoked before a second specialist DMP opinion could be arranged.

Designated Medical Practitioners (DMPs)

There were 78 DMPs on our register to provide second opinions on safeguarded treatments during the year. We held our annual DMP seminar in November 2009 which had expert speakers on eating disorders and artificial nutrition, and prescribing medication to reduce sex drive. We also reviewed good practice points for DMPs. Three induction seminars were held in spring 2010 which recruited 11 new DMPs and were also attended as refresher sessions by existing DMPs.

As in previous years, we are grateful to all those who undertake second opinions, often at short notice and sometimes out of normal working hours and at weekends to ensure people are seen as soon as possible. It remains difficult to find DMPs who are able to visit the Grampian and Highland regions.