GUIDELINES ON THE USE OF THE MENTAL HEALTH (NORTHERN IRELAND) ORDER 1986

The Role of the Psychiatrist

What is a Psychiatrist?A Psychiatrist is a qualified medical doctor who has specialised and taken further training in the care and treatment of people who have a mental disorder. Psychiatrists work in a range of community and hospital settings with children, young people and adults and, in most situations, as part of a multi-disciplinary team. mission and often plays a significant continuity role with both the service user/carer.

What specific duties and responsibilities does the Psychiatrist have under the Mental Health (Northern Ireland) Order 1986?

The Psychiatrist has a number of key duties and responsibilities under the Order. In relation to the assessment and treatment of a patient detained under Part II psychiatrist will be involved at the point of admission right through, if necessary, to the detention for assessment, treatment and discharge of the patient from detention.

The Order permits any doctor on the staff of a mental health, learning disability or general hospital to use a "holding power" (Form 5) under Article 7 (2) of the Order, to prevent a patient, not liable to be detained, from leaving hospital for up to 48 hours to allow an assessment in relation to an application for detention for assessment to take place.

If that application is made, a doctor on the staff of the hospital (this also applies when admission under the Order is sought in a General Hospital) can then carry out the initial medical examination of the person for whom admission for assessment is sought (Form 7).

However other duties and powers can only be exercised by a medical practitioner who has been appointed by RQIA for the purposes of Part II (Compulsory Admission to Hospital and Guardianship) of the Order and Part IV (Consent to Treatment) of the Order. These doctors are commonly known as Part II and Part IV doctors respectively.

A range of health and social care professionals are involved in the care and treatment of patients detained under the Order but it is the Responsible Medical Officer (RMO) who has overall and continuing responsibility for the patient's clinical management. Code 5.2

What is a Responsible Medical Officer?

A Responsible Medical Officer (RMO) is a Part II doctor in charge of the assessment or treatment of an individual detained patient. The RMO may also provide certain medical recommendations for guardianship which are required by the Order. In the absence of the RMO another Part II doctor may complete the duties of the RMO in relation to the Order.

The RMO has specific duties within each of the following parts of Order:

  • Compulsory admission to hospital for assessment and treatment
  • Consent to treatment (Part IV)
  • Reception into Guardianship
  • Patients concerned in criminal proceedings or under sentence (Part III)
  • Mental Health Review Tribunal (Part V)

Compulsory Admission to Hospital and Detention for Assessment and for Treatment Has the Psychiatrist any powers in relation to the person whose detention is sought prior to their arrival in hospital? Yes, in exceptional circumstances, it may not be possible for the applicant to ensure that the patient is conveyed to the hospital, to which admission is sought, within the 48 hours period permitted by the Order. In this situation a Part II doctor, but not specifically the RMO, on the staff of the admitting hospital may complete a Form 4 extending this period to up to 14 days.

What is the role of the Psychiatrist following an application for a person to be detained in hospital for assessment under Part II?

Once the patient has been conveyed to hospital, he must be immediately medically examined by a doctor on the staff of the hospital, the RMO or another Part II doctor. The outcome of the examination is recorded on Form 7.

Form 7 is usually completed by a doctor on the staff of the hospital, in which case it allows the patient to be detained for 48 hours (A decision to reject the application at this stage should not be taken lightly and should only be made by, or following discussion with, a Part II doctor). During this time the patient must be examined by the RMO or another Part II doctor and Form 8 completed.

If the Form 7 is completed by the RMO or another Part II doctor, then the patient may be detained for up to 7 days and Form 8 need not be completed.

The Part II doctor has a statutory responsibility to examine the patient again during the first 7 days of the admission, and again within the second 7 days for the assessment period to be extended to the maximum 14 days. If the period is to be extended Form 9 must be completed. What must the Psychiatrist do prior to the end of the assessment period? Following the 14 day assessment period the RMO, or another Part II doctor in the absence of the RMO, must decide if the patient will be detained for treatment of his mental disorder or discharged from detention.

If the decision is made that the patient should be detained for treatment a Form 10 must be completed by the RMO/Part II doctor before the expiry of the 14 day assessment period and will also be required to formally examine the patient again at 6 months, 1 year and annually thereafter.

At the end of the second 6 month period of detention the patient is examined by 2 Part II doctors, one of whom must not be on the staff of the hospital. This is an extra safeguard for the patient. One of these doctors will be usually be the RMO.

Consent to treatment (Part IV) What is the role and what are the responsibilities of the Psychiatrist in relation to consent to treatment? The Order acknowledges that modern psychiatric care is a team activity involving several disciplines. The team approach need not undermine the professional independence of the various team members. However, it is necessary to reconcile the need for team involvement in patient care with continuing responsibility for the patient's clinical management. The responsibility is recognised by The Order to rest with the RMO, as the doctor, who is in charge of the assessment or treatment of the patient.

In certain circumstances, patients are unable to provide consent for treatment of their mental illness, or are unwilling to do so, and the Mental Health (Northern Ireland) Order 1986 allows for treatment without consent in these cases. See Consent to Treatment Chapter in these Guidelines

  • The Administration of Medication (Article 64)

    A detained patient may be administered medication with or without his consent, for the purposes of ameliorating his mental disorder, for up to a period of three months. The Responsible Medical Officer should make an appropriate entry in the clinical notes.

    Beyond the 3 month period the administration of medication becomes a more complex issue:

    For detained patients capable of giving consent to treatment, consent must be validated by the Responsible Medical Officer or a Part IV doctor, the outcome documented on Form 22 and the Treatment Plan specified.

    For detained patients unwilling or unable to give consent to treatment the matter is referred to another Part II doctor (or a Part IV) doctor for a second opinion.

    The Part II doctor may be a doctor on the staff of the hospital in which the patient is detained

    The Part II doctor will examine the patient, discuss his case with relevant staff and consider the likelihood of the treatment alleviating or preventing a deterioration of the patient's condition.

    If he is satisfied that it will, then Form 23 must be completed authorizing the Treatment Plan specified.

  • The Administration of ECT (Article 64)
    In the case of ECT, for voluntary patients consent to treatment must be obtained in the usual way.

    For detained patients capable of giving consent to ECT, this must be validated by the Responsible Medical Officer and Form 22 completed.

    For detained patients unable or unwilling to give consent to ECT, a second opinion is sought from a Part IV doctor through RQIA and Form 23 completed.
  • Withdrawal of consent for treatment by a patient
    A patient may withdraw consent for treatment at any time and where he does so the common law applies, except where statute overrides it. In such circumstances treatment should cease immediately unless the RMO considers that its discontinuance would cause serious suffering to the patient. A second medical opinion must then be obtained from another Part II doctor or a Part IV doctor as described above.

  • Review of Treatment
    Where a patient is given treatment under the Mental Health (Northern Ireland) Order 1986, the RMO must report to RQIA each time the patient's detention is renewed, on the treatment and the patient's condition. RQIA may revoke the treatment order if legislation has been used inappropriately.

Reception into GuardianshipWhat Responsibilities does the Psychiatrist have in relation to Reception into Guardianship? The psychiatrist also has duties in relation to persons received into Guardianship.

The recommendation of a Part II doctor is required as one of the two medical recommendations required for the reception of a patient into guardianship. The other recommendation should (if at all possible) be made by the patient's own GP or by a

What additional responsibilities does the Psychiatrist have in relation to Guardianship? The RMO/Part II doctor has statutory responsibilities in relation to both the renewal of guardianship, if required, and in the transfer of a patient from detention in hospital to guardianship.

Patients concerned in criminal proceedings or under sentence (Part III)What role does the Psychiatrist have in relation to patients concerned in criminal proceedings or under sentence (Part III)? Psychiatrists may be involved in a number of processes in relation to patients concerned in criminal proceedings or under sentence.

  • Remand to Hospital
    The Court may remand to hospital a person who has been accused of an offence, for a report of his mental condition or for treatment. Before doing this, the Court must be satisfied that there is reason to suspect mental illness or severe mental impairment and it will seek oral evidence by a Part II doctor.
  • Hospital Order and Restriction Order
    The Court may order the hospital admission under the Order, of a person convicted of an imprisonable offence, or make a Hospital Order for an accused person without conviction, if it is satisfied that he committed the act of which he is accused. The Court may also make an order restricting discharge from hospital. The Court must be satisfied that the person is suffering from mental illness or severe mental impairment and will require oral evidence from a Part II doctor and written or oral evidence from another medical practitioner.
  • Interim Hospital Order
    The court may order the hospital admission of a person convicted of an imprisonable offence, if it has reason to suppose, but is not certain at the time, that a hospital order is justified. The court must firstly be satisfied that the convicted person is suffering from mental illness or severe mental impairment. Oral evidence by a Part II doctor in addition to oral or written evidence by another medical practitioner is required.

  • Admissions directed by the Department of Justice (previously the Secretary of State)
    Transfer directions
    The Department of Justice may direct the hospital admission of a person serving a sentence of imprisonment or of certain other persons who are in custody, most commonly those on remand. Written reports by a Part II doctor and one other medical practitioner are required. These must specify that the person to be transferred is suffering from mental illness or severe mental impairment and that the nature or degree of the disorder is such to warrant his detention in hospital for medical treatment. In practice these reports are commonly made by a consultant psychiatrist in attendance at the prison and a prison medical officer. Guardianship ordered by a court. Courts are empowered to make Guardianship Orders where the criteria, which are similar to those applying to a hospital order, are met and the court considers reception into guardianship of the Board, or any other person appropriate. The courts decision will be based on the oral evidence supplied by a Part II doctor, written or oral evidence from another medical practitioner and written or oral evidence from an Approved Social Worker.

The Mental Health Review Tribunal (Part V)

What is the role of the Psychiatrist in relation to the Mental Health Review Tribunal? The Psychiatrist has a number of tasks in relation to the Tribunal. The Mental Health Review Tribunal Rules require that, following a request for a review of a patient's detention or reception into guardianship, a medical report and social circumstances report must be prepared and submitted to the Tribunal.

The medical report is normally prepared by the RMO with responsibility for the patient's care and treatment. The RMO is acting in a professional capacity but also as a representative of the Health and Social Care Trust, as the detaining authority or authority who has received the patient into guardianship.

The RMO is also required to attend the Tribunal hearing to formally adopt the medical report and to give evidence in relation to the needs for the patient's continued detention or reception in guardianship.

In a separate capacity, the Psychiatrist has a professional role as a member of the panel in a Mental Health Review Tribunal. Under Article 70 and Schedule 3 of the Order each MHRT Panel is required to include a medical member (usually a Consultant Psychiatrist who is not employed by the detaining authority and has no personal connection with the patient and has not recently treated the patient in a professional capacity).