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So, hi, my name is Izzy. I'm the psych lead for Minor Bleep and I'm joined today by Doctor Anya Boris over who's going to take us through the Mental Health Act. So, thank you very much, Anya uh for offering to take uh to take this session for us. Brilliant. Thanks so much Izzy. Um, hi, everyone. So I'm Anya, I'm a psychiatry trainee in South London at the moment and I help co host podcast that you can see picture here and, and we're running this series on Psychiatry teaching with Izzy, which hopefully some of you have been two previous sessions and hopefully we'll see you at future ones as well. So the information that I'll be sharing today is specifically legally correct in England and Wales. So I'm gonna leave this up as I introduced the session. But if people want to share who, you know what, where they work or study, what if their medical nursing, any other health professions, just so I start to get an idea of who's in the room and can try and tailor some of the information that I shared to that. But in terms of the legal information as I say it will be around the Mental Health Act in England and Wales because that's what I use and have been trained in some of that may well be relevant in Scotland or other parts of the country. Some of the principles maybe relevant, sorry in other parts of the world, some of the principles maybe relevant in other parts of the world as well. But every country will have their own way of managing the legal side of mental health. So, if you work somewhere else, unfortunately, you won't be able to take this forward directly into your practice, but it may give you some pointers as to what kind of, of how to think about some of these issues. I'm not seeing anything in the chat, but if people are, um, I think that may just be me. So is he shot up if you are seeing things in the chat, if people are able to use the chat and, and are up to sharing who and where they are, please do. But not to worry. If not, I will try and keep things a little bit interactive. Um So again, feel free to pitch in with opinions or ideas. I may not be able to pick out everything that's posted, but I'll try and comment on things as we go and if people have questions, oh, I'm joining from London. I'm, I'm in, so I work in South London and, and live in London, uh in England. Um Very nice to meet you. See. Um The Yes, so let me make a start. So the way that I'm going to run this is just follow the journey of the case, which is not, it's actually not unusual for somebody to go through all the steps of the, the the main parts of the mental health act through their journey in psychiatric services. My hope is that you will understand the differences between the main parts of the Mental Health Act that you might encounter in routine clinical practice. There are other sections and other parts that are used commonly in, in uh specialist parts of psychiatry, but less commonly, I think just in general hospitals. So I'm trying to keep it fairly contained and reasonably straightforward. But obviously, if you're looking for more detailed information, I'll have some resources at the end where you can go to look that up and I'll talk briefly about some of the problems with the Mental Health Act as well because it has just recently undergone a review and it may, may well be changing in coming years. Um Some terminology just to introduce and if people feel up to share ing, if they know what these things are already feel free to post that in the chat, uh in particular, if anyone knows what an AMP is already, without me saying that's probably the key one to make sure that, you know, as I start the slides because actually all of the others I will be talking through as we go. Um So uh section 136 is uh a police used section. And so that's one that will be applied to people in the community. A section five to a section two and section three are all other sections of the Mental Health Act that relate to people who are in patient's in hospitals. And an AMP is an allied mental health professional. Calm. Very commonly, a social worker sometimes will be mental health nurse. But what they will definitely not be is a doctor and they are the person that is in practice, at least really the person that handles the mental health Act for patient's. So they are the ones who will make an application uh to use the Mental Health Act if a patient requires it, uh they are the person that will coordinate the Mental Health Act team. Uh They are the person who will liaise or who is most responsible for liaising with relatives in certain parts of the mental Health Act. They tend to be the person who explains the most to the patient. Although that's not just a role that is limited to them and certainly should be something that the entire team is involved with. But they are the people who, at least in my practice, I've often seen as being that person that the patient gets quite a lot from. Um So I will crack on with the case. And as I say, please do post questions or things that you want clarifying as we go. I if I cannot answer it, I will try and think of where the answer might be. Um because I'm I'm not a legal expert, but what I am is a clinician who has worked with the Mental Health Act for several years. So hopefully, I can give you an idea of how these things are relevant in clinical practice. So if we start with a case of a 24 year old lady brought in by police because of disturbed behavior on a section 136 to a and e obviously, this case is entirely fictional, but the principles are things that have existed in my clinical practice. The police handover, the receive is something like MS Jones was yelling in the street, she was crying, her friends couldn't seem to calm her down. She was saying that she wanted to die. So they called an ambulance. She was confused when we, as the police arrived. Could she be intoxicated a question from the police officers? They hand over to you. And so the questions too start with and that I will talk through is who can use the powers of a section 136. What is a section 136? How long does it last? And terminology that you're here refer to in context of a section 136 is place of safety. So again, to try and for us to will be clear and happy on what a place of safety is. Now before I switch to my next slide. Um Have people got any thoughts either from their previous clinical practice or just general knowledge of what any of these questions answers to these questions might be? I will continue with the answers, but I will continue to ask what ideas people already have as we go through the presentation. So feel free to pitch in at any points. So a section or 36 is something that can be used by the police and the police can use these powers if they think somebody has a mental disorder, if somebody is in a public place and if they think that somebody needs immediate help. So the things that were relevant in this last case is that this lady was in a public place. So she was in the street. She kept saying that she wanted to die and her friends weren't able to make a difference to that and presumably, nor were police when they arrived and she seemed confused. So suggesting to them that there's a need for an immediate and an urgent Axion, you may also receive details from the police that you know, there are things like someone was actively demonstrating that they wanted to die or taking actions to harm themselves in some way. Again, that would be a frequent reason for somebody to uh to have a section 136 applied. You may hear examples like somebody was just acting in a very disturbed way. For instance, they were going into a shop and got into an argument and they couldn't seem to be calmed down. And what they were saying wasn't quite making sense. So there is an extreme disturbance of behavior. So it wouldn't be as simple as somebody seemed a bit upset and that would lead to someone going on a 136 know it, it tends to be quite an extreme change in someone's behavior or a very risky change in their behavior. And what a section 136 allows the police to do is to take a person to a place of safety where their mental health will be assessed. And the reason that this kind of legal framework is needed is because generally we are all protected and allowed to within the limits of the Law Act and do as we wish. Um So the police can't just take us from a place and take us to another place. But what this law allows to be done is for police to do just that because of a concern for somebody's safety and their need for immediate help. A section 136 lasts for 24 hours, but it can be extended by 12 hours. And the relevance of that to this cases, there's this question of intoxication. So if somebody is intoxicated and that is the reason for their change in behavior. And you might find that out at the place of safety, for instance, by doing, by measuring alcohol levels, by measuring if there's presence of drugs, by just taking the history from the person and people around them and finding out that yes, there was some kind of drug or alcohol or something like that being used, often a disturbance that is caused by, that will get better with a bit of time. And so you want to give that person that bit of time before you make a decision about what potentially quite significant treatment will be. So being able to extend the section means that you have more time for potentially things to just get better on their own so that you can let the person just go home with, with some kind of appropriate follow up rather than continuing into potentially other restrictive practices using further sections of the Mental Health Act. And finally, what is a place of safety? So in theory, lots of different places can be places of safety. So including someone's house, if the person who owns that residents agree, gives permission or agrees to that. Uh things like care homes again, technically can be classed as places of safety. But in practice, generally, what we mean by that is a hospital based place of safety. Any is one common destination and in certain parts of the country, you will have places of safety that are on a psychiatric site. So they are a unit that is set up very much like a psychiatric ward. It is not classed as an inpatient ward. Um but it has rooms, it's run by nurse. Is there is things like medication available to be used. There are ideally things that can provide extra comfort to people. So for instance, there may often be an occupational therapist there who can do activities with people for the hours that they're in the place of safety. Um Certainly there are a lot of those in London and in some other parts of England, again, if people are joining from other parts of the UK or other parts of the world, it would be interesting to hear if you have things like that or anything similar. Um because it would be great to learn how different places handle these kinds of things. In theory, a place of safety could also be a police station. Uh But increasingly, it's recognized that this is not an appropriate place for people to receive mental health treatment from for people under 18, it's called a never event. So somebody who is under 18 should not be taken to a police station on a section 136, they should always be taken to hospital. And that principle also does apply for people over 18. But it's not quite as strict, any questions on that point or any thoughts, that sort of reflections that people have any of any experiences that people want to share. And again, if anyone's joined a bit late and wants to share what part of the world they work in, what job or studying they do. It would be great to hear where people are out so I can try and tailor things. So let me move on to some potential clinical type situations that I've encountered any thoughts on what might happen if after being in the hospital for six hours. So it's in the place of safety for six hours. Everything seems back to normal with MS Jones, she's able to, you know, have a conversation with, you, tell you what it was that was going on. She says that she no longer wants to die. She feels she feels okay. She's perhaps not entirely sure what happened to, to lead to that change in behavior. But actually things seem all right. Now, can you just send her home and nothing else in terms of your legal powers? So, um, sorry. Um, it, the answer is that it depends. So if you are a clinicians, so a section 12 approved doctor who is seeing her and if Miss Jones has no prior history of any mental illness, then in theory, you could just discharge her without asking the AMP to come and see her if there is however, any prior history of mental illness, um, then you would be, uh, and often the recommendation is you have a discussion with the AMP anyway and if there is a prior history of mental illness, then the AMP would also need to come and see the patient and only they would be able to discharge her off the section. And what if Miss Jones speaks to you about? Hello? How upset she's been feeling and feels that she needs more help. And again, you're able to have a conversation with her about it, it becomes quite clear that it isn't the right option for her to go straight home. But actually she can talk to you about what it is that she needs any thoughts on what your legal pathway might be at that point, if you're thinking that actually what she needs is more time in hospital. So she needs an admission. But how might you arrange that admission from a legal perspective? Would you can need to continue to use the Mental Health Act or could you do anything different? So this is something that will Yeah, lovely. Thank Suzy. Exactly. So this is something that will come in to discuss in more detail. But absolutely that, so you're potentially thinking about, could we arrange an informal admission for this lady and the principal that this highlights and a key principle of the mental health Act is to always be thinking about the least restrictive option. So what is the treatment pathway for this person that involves as few infringements upon their liberty as is possible? So if she can discuss, agree and has what we call capacity, which again will come to discuss. Then you may well be thinking about whether an informal admission is the appropriate way to go. Uh huh. What if you find that you're in a situation where MS Jones continues to be quite distressed? She can't seem to make sense of what's happening. She can't seem to really have a conversation with you that gets you to feeling like she understands what is going on. Like she can make a decision about what she would like. What might you be thinking at that point in terms of uh the legal powers that you might need to employ for an admission? Do people have any thoughts? So again, we'll come to discuss this more. But what I what this is getting at is that you will likely need to use more powers of the Mental Health Act in order to proceed with an admission at that point. So let's start with the first option. So let's say for instance that you've MS Jones needed some medical treatment. So as being admitted to the acute medical unit, initially, she has been seen by the psychiatry senior doctor. So the S P R and she's been seen by the Allied Mental Health Professional whilst in a and E she was discharged from the section 136 because she had a capacity and she agreed for an informal admission after her medical issues were resolved. So what we're going to discuss now is what an informal or voluntary admission means? And what does this capacity point mean? Again, if people already have thoughts about what they know about capacity, drop them in the chat or in your mind? If you don't quite feel comfortable for share in, just start to have a think of what can I remember about what capacity means? So an informal voluntary admission is something that means that the patient has capacity to understand that they're going to hospital and they have capacity to agree to treatment for that mental health problem. Some really common misconceptions that I was keen to clarify. And this is again on my base on the basis of work that I've done just in general, hospital's not psychiatric hospitals. There can be this idea that an informal admission means that somehow the person is less sick that the that we're just not that worried about them uh that we don't think they need to come into hospital as much as somebody who is under a section of the Mental Health Act or who's coming for a formal admission. Um Sometimes people say, oh, you know, if obviously the professionals aren't that bothered about me. If they were, then they would've sectioned me or other health professionals might say, you know, does she even need to come into hospital because it's, it's this voluntary or this, it's an informal admission, informal somehow sounds less important than formal. And it, and it isn't any of those things. It what it refers to is this least restrictive principal. So somebody may need to come into hospital just as much as somebody else. But if they can understand and way up communicate the reasons for why they think hospital treatment is the right option for them. And if they can be involved in that decision making, then we tried to go that way rather than using the powers of the Mental Health Act. Um It can obviously mean that somebody is less unwell in the sense that because that decision making ability is still there, sometimes it is the case that they are not as unwell as somebody who doesn't have that decision making ability, but it isn't a given and it doesn't strictly relate to that and it certainly doesn't relate to them being less in need of support or less in need of any kind of treatment. I appreciate that it's maybe a slightly nuanced point. So if anyone feels like that doesn't quite make sense or wants to ask questions, please do send them in the chat. But I think it is an important point to take away. Um When you leave here today for your clinical practice, it isn't, it isn't a question of worth or what somebody deserves. It's a really a question of the legal principles that we work of which is to follow the least restrictive option and it can be the case that somebody who is able to have the decision making abilities to follow that least restrictive option might not be as well as somebody who can't, but that isn't always true. And next, what is capacity? So capacity is something that comes under the Mental Capacity Act. So it's not part of the Mental Health Act directly. So I won't be talking about it in detail, but the principles are very important to the Mental Health Act. Uh and mental capacity often uh sorry, always is related to a specific decision. So if you are asked to assess somebody's capacity, make sure that you know what decision you're assessing that capacity for. And it might be something like the decision to have an admission to hospital, the decision to have a specific kind of treatment and somebody may have capacity to decide on treatment, say with medication, but they may not have capacity, decide on treatment, say with um uh something like electroconvulsive therapy, maybe uh somebody may have capacity to decide on being admitted to hospital, being treated at home, but they may not have capacity to make decisions on more complex things like how do they fund the payment for their home? Just for example. So it really depends and it's really important to, to know when you're going to speak to somebody to ascertain if they have capacity exactly what it is that you are discussing with them. For that reason, if you're assessing capacity for somebody to have a procedure like for instance, surgery, it's important that you know exactly what that procedure involves. Similarly, if you're assessing the capacity for a treatment like electroconvulsive therapy, psychiatric medication, that you've got a good working understanding of what those treatments mean. The reason that you need that is that you're going to be assessing somebody's ability to weigh up that decision. So that weighing up means that they can talk through and think through the pros, the cons of what that decision involves and you need to be able to give them that information. So this isn't a memory test, it's not a knowledge test, but it is somebody's ability to understand the information that you give them and that you give them in a clear way to retain that information for long enough to make use of it and to use it in the decision making. Um and then to demonstrate that they can think through the pros and cons and then tell you that decision capacity is presumed. So we if you work in a general hospital, you may potentially not yet have encountered a situation where you're assessing someone's capacity. Um because it is, unless there is a mental disorder of some kind of that might be affecting capacity capacity is presumed. But if there is a mental disorder and that's a condition of assessing capacity, if there is a mental disorder that could be or a disorder of the brain that could be affecting someone's capacity, that's when you would go through those steps to, to make that assessment, feel free to send through any questions that you have in capacity whilst I we want to the next bit. So, uh sorry, I've made a slight error on this slide in that you are MS James nurse on the psychiatric ward and so you're not changing her fluids, but you are offering her food and drink. Um, so MS Jones has, has now arrived onto the psychiatric ward. She says that she's everything's fine, but actually your assessment is her psychiatric nurses that you're not that sure. She looks quite flat, she looks like she's been crying, you know that she's come in because she seemed things didn't seem good. Uh, and she came on a police section in the first place. So you're concerned not necessarily a question about what should you do just from a general psychiatric perspective, but what can you legally do to stop MS Jones from leaving any thoughts that anyone has? So yeah, use holding powers. Exactly. So colloquially known as the nurses holding power, a psychiatric nurse who for reasons of safety or or otherwise is unable to get a medical professional to come and see a patient in good time can use an applied section 54 of the Mental Health Act. So it isn't used very frequently because usually hospital provision are such that it is possible for nurses to get hold of a doctor to come and review the patient. But of course, there are situations where actually that isn't the case and a registered psychiatric nurse or so, a nurse for whom their scope of practice is within psychiatry or learning disabilities, you can use this section of the Mental Health Act. It enables that patient to be held on the ward for six hours. And again, this is we're talking about legal powers. So usually we are legally allowed to come and go from any environment as we wish. But if there is a significant concern about somebody's safety and there might be a mental disorder that is affecting their safety, we can employ this power to keep somebody, for instance, on the locked psychiatric ward. Um Adeola, you asked a very complicated question which when I was on my section 12 course sort of learning about all about the use of the Mental Health Act um was a big area of discussion. So I will come back to that at the end in part because there isn't a straightforward answer. Um But we can spend a little bit of time thinking and talking about it together. So with a section 54, the person has to be reviewed before the end of that six hours time, so that a decision and onward decision is made. Um So moving on to the next point and, and maybe actually until your question will fit into as we talk here. Um Okay, and I will explain this section will help explain why. What you ask is such a complicated question, which I imagine is what you've asked. So you're now the duty doctor in the psychiatric unit and you're called by her nurse and you very much agree with your colleague that she seems quite low. And to you, it, as the junior doctor, it looks like it is potentially a recurrence of her depressive illness. You can see from her notes that she's had a suicide attempt went on well in the last year and you establish that there's been a number of stressful things happening in her life over the last few days, two weeks, which is what's led to her being in hospital. Now, you don't think that she's fully considering the risks and you think that her depression is affecting her ability to do so. And I wonder on the back of what we've been talking about so far, what do people think is the relevance of that last section? So what does the fact that her depression might be affect? You know, that, that you think that she's got a recurrence of depressive illness and her depression is affecting her ability to do some thinking, what does that mean? And specifically in terms of capacity, so her capacity could be impaired. Yeah, exactly you NICUs. So she um there is a mental or brain disorder that is potentially impacting on her capacity and what and I wonder if your point is specifically also relates to the, you don't think she's fully considering the risks because which bit of capacity could you there say seems to be impaired? Yeah, exactly easy. Thank you. So, you're thinking that the weighing up is impaired. Maybe the understanding is impaired as well. So you could check that by, you know, seeing if she can say back to you what the concerns are that you have. Um, but it, but it may be that it's the sort of weighing up of the pros and cons that you just don't think she's able to do right now. We know that depression affects somebody's thinking from a concentration perspective, from a decision making perspective. So it's very reasonable to think that this could be happening for MS Jones. So what are your options? And the information that is important to know is that you are a doctor who is at fy two level or above and you are on a psychiatric ward. And so what you can do at this point is if she is actively trying to leave, then you can be thinking about using a section 52. And the reason that I made those points that you are a doctor who is at least at fy two level. And that she is an inpatient on a psychiatric ward is that you have to be an in patient in a hospital to, for the uh section five to, to be available to a doctor to use. And so this is what is difficult um in the situation that you described Ketola in that that person as an A and E A and E is not clusters award. So you cannot use a section 52 in A and E. Um and potentially as a junior doctor again, it depends what level of junior doctor you are in assessing the person, but we'll come back to that question in, in time as well. A section 52 is again colloquially known as a doctor's holding power. So it means that you can legally keep that person on the ward for 72 hours. Uh Within that time, the ideas that that person is being reviewed by a senior clinician who is thinking about what the next steps in that put in that person's treatment journey should be if she is not actively trying to leave. So she's just saying I don't want to be here. Um But okay, you know, I'll stay, you don't necessarily need to be using the section five to because it does apply in those situations where somebody is trying to leave and you are and you therefore need legal powers to be able to keep the person in the place where they are. Um So if they are not actively trying to leave and you're not actively restricting them from leaving, you may be able to, you may just have more time to be able to think with them about what the right treatment steps would be, um, and, and have more of a discussion again that starts to get quite nuanced, particularly if they're saying I don't want to be here and I want to leave, but perhaps because they're so depressed and so, and well, they can't actually get up to try and leave. Have those discussions with your senior. If, if those are the types of situation that your situations that you're facing, um, any questions on the 52, feel free to send them along as they come even if out of order, but I will carry on for now. So as I say, the, the next step after a section 52 should be that somebody is somebody seniors then coming to review that patient. So that might be the S P R that might be the consultant in some parts of the country. You might have uh sort of nurse practitioner G P type people who are working and have training within, who have section 12 training. So have approvals within the Mental Health Act. Um most commonly my practice it, it would be the, the S P R. So the registrar dr you join in with them when they review and you see that they also establish that MS Jones has some delusions of guilt. So she feels worthless and guilty and responsible for bad things or bad events that have happened. They get some feedback from the nurses that she's really not been eating or drinking in the time that she's been here, she continues to not agree for admission. Um And she, the judgment is that she doesn't have capacity to make that decision. So the question is that I will address at this point is when can a section to be used? And, and what indeed, what is the section too? I will share a quote. Um and this has come from the Mental Health Act review from a philosopher. Um So he, he was quoted within the mental half fact review. And I guess this tries to instill upon what a difficult decision it can be to use the Mental Health Act and what a difficult decision it should be and why the principles of least restrictive factors are most important. So I will just read it out. So sometimes compulsory admission to a place of safety for a short period of respite care, even where conditions are far from ideal together with the short term, even in voluntary administration of some sedative medication can be a way of returning an individual in such a state of extreme distress to a condition where they can make thoughtful decisions about their own lives. So this is just a brief quote to explain that we know that in some situations, it feels like we're caught between a rock and a hard place when we're trying to make a decision for a person. Sometimes it's very clear that the only option for somebody is admission to hospital but sometimes it's less clear. Um And what the things that you're trying to weigh up as the clinician. And at this point, I'm talking potentially about being a fairly senior clinician. Um But it is, is the person just in such a state of distress that we have to do these things that we know aren't ideal. Um But to try and get them back to a place where that distresses less and where they can be involved in the decision making around their health. So a section to is compulsory section um or a type of section that enables some compulsory treatment of a person. It is called uh an assessment section. But can that assessment can also involve a trial of treatment? It's a section that lasts up to 28 days and something that patient's often asked me as gosh, I'm going to be in hospital for, for a whole month, the answer to which is no, not necessarily, maybe yes, but maybe no, it isn't up to and that can be helpful to explain to someone. So again, it's something that would want people to take away from this session uh as a in terms of when it can be used. So generally, at least in London, the practice would be that it is a senior doctor who would use uh who would use the section two on and in a situation where somebody has a mental disorder of a nature or degree that warrants detention. And by nature, what we're talking about is that they have a specific psychiatric condition. That's what the nature bit and degree is that there is severity. So it isn't generally, you are not just saying that everyone who has some kind of past diagnosis of psychiatric illness can have a section used. Your the idea of degree is also important so that they are experiencing a relapse or that there is some severity of that illness that warrants the detention. Um The principal that you're working off that, that they need to be detained for a short time for assessment and possibly medical treatment. And there's a question of risk. So it's necessary for their own health or safety and for the all for the protection of other people. And in this case, the way that you were able to make that assessment as the senior doctor is, you've got feedback from the nursing team that she's not really eating. You've got feedback from your junior doctor that she's that there's been that she's expressed thoughts of not wanting to be alive. And that there has been a past history of when she's been unwell, that there have been suicide attempts. So you've got some idea that there, there is a risk to her as a person the way that a have um now come to those. So the way that a section 12 is used is you will have a doctor who makes the, what's called the first recommendation for that section. Again, as I say, generally, that will be a senior level doctor often who's gone through the section 12 approval process that isn't always necessary. But uh again, nuanced area and it can depend on where you work in terms of what just local policies are. So the for for reasons of simplicity will say that it is a senior doctor who has been through the section 12 approval process. Once that first recommendation is then sent to the AMP, so that's your allied Health Professional, that the AMP then coordinates a Mental Health Act assessment. So they bring along a section 12 approved doctor and together they will assess that person. So they will they are independent. So they are not somebody who is working with the team that has made the first recommendation. Um quite often they'll be completely external to the hospital trust, but that isn't always know that isn't necessarily necessary. They will read through the notes, they will speak to the person, they might speak to their relatives and they will then make a decision on if that first recommendation is sort of an indeed an appropriate first recommendation. And if the best treatment option is for that person to have a period of admission under the Mental Health Act. Um If you ever work on awards where you hear about somebody having a first recommendation made and you're able to join the Mental Health Act Assessment when it comes uh it's really good, really, really good to do so because then you get a very good understanding of how it is that Sampson, the section 12 doctor work together, how they do the assessment. It's um it's often a very good way of seeing a psychiatric assessment. Um So I would definitely recommend speaking to the AMP when they come into the ward and seeing if they're happy for, for that to happen. They will always obviously ask the patient if they're happy for an observer to join as well. Um, a couple of situations that you might hear about or that you might come across and that will lead us into talking about the final section of the Mental Health Act that we'll talk about today. So that's a bit of a hint for anyone who's encountered the mental health Act. But what might you be thinking about? And this is potentially a few steps up from where people are working. But if you're the senior doctor, what might you be thinking if this is MS Jones third admission this year with an established diagnosis of treatment resistant depression or what might you have to do if she's still really quite unwell, three weeks down the line. And again, we're talking legally rather than any particular clinical decisions that you have to make and I've run out of water. So if my voice goes funny, I do apologize. So what I'm getting out here is we might be thinking about using section three of the Mental Health Act. And this formally is so formally, probably not formally more like colloquially, again known as a treatment section. Um but the reasons for why it's used is treatment. So it is a section that lasts for much longer than a section too. The situations in which it can be used is that the patient has a mental disorder that they need to be detained for their own health or safety or for the protection of other people. There again will be a question of what is the nature of that mental disorder and what is degree, the degree of it and keep pot is that treatment can't be given unless that person is detained in hospital and there is appropriate treatment available. So you if you, you have to demonstrate that there is some kind of treatment available and you have to demonstrate which hospitality is that that treatment is available at the things that make a section three different from a section to as I say, first of all that it is longer. So it is again for a maximum of six months. That doesn't mean that it is a minimum or will always be six months. It may well be shorter. It may just be that you need an extra few weeks or you think you predict that you need an extra few weeks from when the section two will end, you still need legal powers to keep the person in hospital because you were not well enough to be able to be involved in or to be able to make that decision themselves. Um But so as I said, it does not have to be 64 months that the person stays in. The other key difference from a section two is the involvement of the nearest relative. So they have to be consulted for a section three. So that means the person who is the legally defined nearest relative has to be spoken to. They can actually be the person who applies for a section three. Um But also importantly, what they can do is object if they think that the application is inappropriate. Now, the nearest relative is not the same as the next of kin. So again, something that is really important to take away from today, there is a legally defined list of the nearest relative if you're interested, you know, give it a Google. So you can see how it goes. Um But it is not the same as a nominated next of kin that the patient has chosen. It is actually a legal list of who that person is. And if the person at the top of the list isn't something that exists, you know, for instance, like a marital partner, then it goes down to the next person on the list. Any questions on section three, the in terms of the application process for it is again, very similar to a section too. Um Yes, very good point. And it'll and I will come to you so very similar to a section too. And that again, the first recommendation is made by uh one doctor and then the AMP and the section 12 doctor will come to review and assess the patient and the ample then make a decision as to whether they will apply for us for section three to be used. Um When contacting the nearest relative, are we also going to consider patient's confidentiality and consent? Yeah, absolutely. Um So it is a, it can be very tricky when somebody does not consent to information being shared with the relative with the nearest relative. The question that you you as the team, both the treating team but also with the AMP will be considering is what are the reasons that they're not consenting is a reason of safety. You know that it's not uncommon for it to be that the legally defined nearest relative as somebody who against whom there might be safeguarding concerns. Um Is it related to the person's disorder mental disorder? So do they have, we would hope so in order to use this as part of your decision, you would want to know that it is established diagnosis of say delusions against that relative. Um So you will absolutely be considering it in terms of how you will use that to make the decision is soak a specific that I won't say one way or another. But it's a conversation to be having with the team and most importantly with the AMP because they are doing this every single day and they have heaps of experience of how to make that decision. You may get to a point where you are seeking some kind of legal advice from within the trust in order with how you're going to proceed. Because these are really, really important issues around confidentiality and consent. So, yes, absolutely considering it, absolutely not just going, you know, don't worry about it. Just call up the first phone number that you see on the list that applies to the legally defined nearest relative and just give them all the information without thinking about it so very well raised. Um I'm gonna come to talk about what are the issues with the Mental health Act. But if people please do feel free to send in questions as we go. So I've lifted quotes directly from the independent review and I've linked it here in case people want to read Simond Wesley was the chair and he writes really, really eloquently really in a way that's very readable. Uh It feels like almost like he's speaking to you, like it's quite emotional writing. So it's, it's interesting to read. Um and he describes some of the problems with the current mental health factors. It is. So they believe that it's necessary to improve patients' and service users ability to make decisions about their own care and treatment and that this is essential in upholding dignity. And so one of the recommendations from the review is to have something called advanced choice documents where people can say what treatment they would like to have if they became unwell and got to a point where they no longer had capacity. The recommendation that they've made from that review is that even if that treatment is not the ideal treatment or necessarily the sort of best evidence based treatment, but it is available. Uh clinicians will have to think really quite long and hard about going against the choices that are raised in an advanced choice document. Um All of these things are recommendations. They haven't yet come into law, they haven't come into updates. Um But this is just to give you an idea of the sorts of conversations that are happening um when it comes to the Mental Health Act, one of the most troubling in difficult areas that they have considered. But that also we as clinicians are very aware of is the fact that people from ethnic minority communities are far more likely to be subject to the compulsory powers over under the Act, whether that's in hospital or in the community. Um And again, this, so this is a reason for why the Mental Health Act was being reviewed and they have some recommendations around the kinds of work that should be done to try and improve this. But also again, just the thinking that clinicians should have this point of the nearest relative is something that is quite contentious and the feeling is that people should be able to choose their own nominated person rather than it being just a relative that is nominated legally rather than necessarily that, that the person feels is the person that knows them best or the person that should be involved in legal decisions about them. They highlight that too often. It is a crisis rather than a need that opens the door to psychiatric services. I there wasn't sort of a very specific recommendation that I picked out to highlight what they thought should be done about this. But I thought it was important that they noticed it because I think this is something that patient's very often say to us. You know, they say no one seems interested in my deteriorating mental health. It's only when I get to the point of crisis that everyone suddenly comes running, starts to use the Mental Health Act. And again, the review notes that uh the aspiration that voluntary admission has the norm should be what we are aiming for. And that it right now the situation is that it's actually it is probably fairly unlikely in lots of parts of the country that somebody will go into a psychiatric hospital unless it's under a section of the Mental Health Act because services are so strained and resources seem to be so low that it's, it seems to be that, that that's what's required. Um And, and they highlight in, in this review that they think that maybe there's something there to be looked at and changed one point that the review considered was around people with learning disabilities, autism or both. And that they considered this quite carefully and they said that removing um this from the act right now is not the right thing to do, but they, there's a lot of review to be done so that the Mental Health Act, they recognize that the mental health actors used inappropriate in people who are autistic or have learning disabilities to keep them in uh inappropriate care as opposed to providing potentially appropriate care. The reason why they say that there aren't changes that they're actively recommending is that there are um there are some reason there are some situations in which it is necessary and the nuances such that they, that they aren't able to make change at this point. And again, I think a really important point to note is that they called on the government to invest in modernizing the mental health estate. And this links to the quote that I showed before which recognizes that often the environment in which we are um legally enforcing and compulsory detaining people in is not somewhere that we would ourselves want to be admitted to. Um There are some very good awards in terms of their physical environment. But I think it's realistic. And they note in this review that they're awesome wards where the environment is not good and it should be better, particularly because we are using legal powers to keep people there. There isn't an answer that I can offer to what the solution is, but it is something that again, you should have in your mind when, if, if and when you are using the powers of the Mental Health Act uh and thinking about the least restrictive option. So, is there any way that I can get this person home with their consent and safely, rather than bringing them into hospital? Because I know that the environment isn't always perfect. Um I will end with some resources. So the one point actually that I haven't put on here is that charities like mind and rethink mental illness also have some very good and very legible information on the Mental Health Act and obviously mind the bleep, I'm sure is he can weigh in on this, but we'll have resources as well. The, if you came to my last session, I talked about this podcast is Psychiatry working a BBC radio. For again, they talk um it follows the journey of a person with psychosis through the psychiatric services system and they talk about the Mental Health Act within that it's, it's not podcast specifically about the Mental Health Act, but it still gives you a really, really nuanced and balanced understanding of the good things and the difficulties within psychiatric practice. Um And obviously, I'd be remiss if I didn't mention the podcast that has brought me here to speak to you guys. And that's the Thinking mind podcast, lots of ranges of topics, um conversations with experts. And again, trying to bring nuance discussion's around psychological, philosophical psychiatric ideas. Um in the absence of other questions, let me come back to add it to the, to your question and explain the kinds of thinking, the kinds of advice that you might get. So this is an issue of a patient who in whom you think that there is a risk because they've just, they've come in with attempted suicide. Um They've been told that medically they're well, so there aren't any physical concerns to keep them in hospital, they're in a any so they're not admitted onto a ward. So you cannot use 52 powers. Um but they are insisting on going home the way to think about this case and involving senior people in the decision making is what do you already know about this person with fingers crossed? You know that you've got some kind of past psychiatric history on them in some situations you won't. Um But what do you know about them? Do they have any known mental disorders, any psychiatric conditions? What can you get from them by talking to them? And I guess really that's step one is just go and talk to them, try and figure out what it is that's going on. Uh that is making them want to leave. Sometimes you can establish something really straightforward, you know, that A and E is just a really unpleasant environment. They feel really distressed, they feel really upset, they feel really unwell. Sometimes people just need that to be heard and to be understood and for someone to say like, yes, I know this is not the place where you want to be. Um What can we do to make it even a little bit better? You know, can we, can we find a slightly quieter space? Can we get you something that will help you feel comfortable like a phone charger? Is there anyone who can come to be here with you? Um Can we get you even, you know, some earplugs or B B as creativelive as it might be necessary to be? Um Sometimes it is something as simple and environmental as that. Often it isn't, but often actually, it's a combination of things that is making somebody not want to stay in the hospital. Um So addressing each little thing in turn might get you closer to be able to engage them in staying there because the bottom line is there isn't a straightforward legal power that will enable you to stay, that will enable you to keep them in hospital if there is a clear concern around risk. Um then some people will talk about things like being able to use common law, the issue with common law is that it's meant to be used in sort of quite short emergent situations. Um And I have neither the, I think expertise nor the time to talk about it in detail. But, but that's something that, that can be sometimes uh called upon. But as we were, as we discussed in our section 12 training, it's, it's tricky territory. So involve a senior person. Um You potentially could use the cup it Mental Capacity Act if you feel like they don't have capacity. Um but in a situation where they potentially do have capacity, it becomes tricky. So this is so the simplest answer is going to speak to the patient, see if you can establish a relationship and a report with them and see if you can bring them on board with the need to stay for a review and an assessment. Um As part of that conversation, you will inevitably get some information about, you know, just how dangerous it is for them to be going, just how unwell they are and be able to use that information um to then make a decision about about what the best way to go is. But it's, it's tricky and it's really very dependent on what the cases I appreciate that will not have completely answered your question, but feel free to follow up if you've got further questions. And if there's any other questions that people have as well, I think there is a feedback link that is being sent. Um Please do fill it in because constructive criticism is really helpful. We've got more of these sessions coming up and I've tried to implement some of the feedback from the previous sessions. Um It's sorry from my previous session into this one. So it definitely makes a difference if there's anything that you liked or you think that more should be done of as well, that's really useful. Um But I will pause and let easy talk and obviously, there's more questions than I can come back in. Uh Yeah, I just wanted to say that the the feedback forms on the chats. Um We've got coming up in this Psychiatry series uh leadership and team dynamic session, which will be on the third, that will be generally applicable to just I think life in any training sphere um within the within the hospital setting for kind of multiple members of the M D T. So everyone is welcome for that session and it should be more of a looking at maintaining your own well being and processing like the inevitabilities of the job, whether that be like colleague to colleague or patient um colleagues situations. And then we've also got on the 17th of July. So these are both Monday days, the third and the 17th, the 17th will be um with Rebecca who's also from the podcast and that will be on psychotropic medications. So, again, a very useful topic. Um, and all of the recordings are on med all at the moment. This one will be available shortly after. Um, so feel free to watch, watch them back or on demand later date. Um Also in the pro also in the kind of psychiatry page process. Um, there's going to be another, um, co lead, um, who will probably announce, announce soon, but they will also help with bringing in some of the kind of pediatric topics. So Cam's um pediatric presentations of mental health um disorders. So I think that would be a really good way of us to kind of expand um what we're already offering. So we'll definitely do some collaboration with the Pete's team. So if there's anything else you want in terms of future sessions and webinars, we'll definitely be looking into that as well. So just pop that all on the feedback. Yeah. Um But otherwise I hope everyone's had a really good time and thank you so much, Anya as always, uh this has been a really good session. Uh The Mental Health Act is definitely something that I need constant refreshing of. Um And I'll definitely need it my A and E job as well coming up. So, thank you very much. Thank you and thanks everyone so much for coming um and for pitching in with questions and comments. It's, yeah, it's been a pleasure and thanks easy for organizing because it's really great and amazing to have this series. So nice one. Cool. Have a good evening. Bye everyone. Thank you.