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| Assignment Title | Unit C – The AMHP Role in Practice |
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| Submission Date | 06/02/24 |
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UNIT C- THE AMHP ROLE IN PRACTICE
The Approved Mental Health Professionals (AMHPs) are responsible for organising, co-ordinating and contributing to Mental Health Act assessments (MHAA). It is their duty/responsibility to decide whether to make an application to a named hospital for the detention of the assessed person following two medical recommendations or identify alternatives to compulsory detention under the Mental Health Act (MHA) (Mathew, O'Hare, and Hammington 2014).
I will critically analyse the AMHP's role while conducting a community MHAA for DM (confidentiality observed, GDPR 2018), a 29-year-old black male diagnosed with paranoid schizophrenia s1(2) MHA, 1983)). I will evaluate literature, case laws and legislation applied during the MHAA process. I had limitations as an AMHP trainee and was under the supervision of the warranted AMHP who made the final decision and completed the legal documents.
The AMHP team received a referral from the Early Intervention in Psychosis team (EIP) for DM. DM is well known to mental health and forensic services for previous MHA admissions due to psychotic episodes. The referral highlighted risks of disengagement, non-compliance with depot injection/medication, self-isolating, neglect, threatening behaviour, physically assaulting others, and expressing delusional thoughts of grandiosity that were linked to mental health but could not be managed in the community. DoH, 2009, states that a risk management plan is only as good as the time and effort put into communicating its findings to others.
AMHP's have responsibility to consider cases (MHA, 1983) on behalf of the local authority (s13 (1) MHA); Care Quality Commission, 2018). While triaging, I was aware that information received from the referrer is not a justification to coordinate an MHAA as evidenced in the case of St George's healthcare NHS trust v S, R V. Collins and other ex-partes (1998) for individual's have autonomy and the right of self-determination. Local AMHP policy 2017, advocates for least restrictive alternatives to be explored first like care review or check for any safeguarding concerns ((s.42(1); Care Act, (2014)) as an essential safeguard (Barcham, 2016).
I reviewed the referrer's information by scrutinising the stated risks on both the local authority and NHS systems while systematically mapping out risk assessment of the
referrer's request including making determination for the MHAA urgency (Barcham, 2016). I was mindful that decision due to presenting risks should not be influenced by public perception of risk which can be interpreted as stigmatisation (Wand, 2012) particularly for black males which I counter-balanced with referrer's amplification of presenting risks that can lead to disproportionate actions by the AMHP (Dwyer, 2012). According to Slovic et al, (2000), there is evidence that clinicians are more influenced to keep patients in hospital if risk has been communicated in a frequent format as opposed to probability. I, therefore requested the referrer for an updated risk assessment, current presentation, and treatment plan to inform my decision-making process whether MHAA was necessary (Hall, 2017). I gathered further information from the local and NHS information systems for they are linked (Carr and Goosey, 2019). The purpose of doing this was to eradicate any barriers that could create hinderances to information gathering and sharing (DoH, 2009), which can hinder the AMHP's role (CQC, 2018), and because professional curiosity enhances accurate information sharing that supports proper coordination of assessments to support people at risk (Thacker et al, 2019). The gathered information provided further evidence of risks to DM and others (para 14.9 & 14.10) and informed my decision-making.
The MHA COP, (2015) states that unless other local arrangements have been made, AMHP's have the responsibility to coordinate the MHAA process (para 14.41 DoH, 2015). DM's case was therefore considered on behalf of the local authority (s.13(1) MHA 1983)) because of the highlighted risks to self and others. In consultation with the AMHP, I initially considered the possibility of using s.115 MHA 1983 which empowers AMHP's to enter and inspect any premises in which a mentally disordered patient is living if there is reasonable cause to believe they are not under proper care and control without necessarily coordinating a MHAA. This would have been an ideal and a proportionate use of power to empower DM as well as employing the least restrictive option to safeguard DM's rights (Rooke, 2020) and in line with MHA COP Principle 1. However, s.115 MHA 1983, has limitations because it neither allows the AMHP to apply force of entry nor does it guarantee that its application will lead to MHAA without patient's consent (Rooke 2020). Furthermore, DM's presentation suggested that he was threatening and non-engaging and therefore using s.115
MHA 1983 without his consent to the MHAA could have presented a legal challenge for it doesn't have framework to remove patients to a place of safety (PoS).
I contemplated whether to request the police to apply s.17(1)(e) of the Police and Criminal Evidence Act (PACE)1984 that empower' s them to enter a person's premises without a warrant to save life or limb or prevent serious damage was applicable, but PACE has limitations and DM's case didn't meet PACE's threshold. According to GOV.UK, (2021), police attendance without a warrant frequently aggravates the situation and there is a trust deficit with the police among some black communities, especially black males who often feel discriminated by the police and mental health services (Mind.org.uk, 2018). This is due to societal stigma and stereotypes that often view them as larger, more likely to be dangerous, and threatening than white males. Nzira and Williams (2009) argue that the stereotyping of black males in mental health frequently leads to forms of power imbalance that lead to ethical dilemmas due to lack of racial diversity. It is thus necessary for AMHP's to recognise the importance of the Equality Act (2010) and the likelihood of excessive use of powers against blacks in MHAA. Although Overton et al, (2008) argue that some perceptions of risks can be subjective and preconceived, the AMHP's role faces a lot of risks and unpredictability. Having considered all the likely risks and protective factors in DM's case, I concluded that police attendance during the MHAA was necessary but could not be achieved under PACE, and the AMHP agreed. To avoid arbitrary use of police powers which may constitute a breach of Article 5 of the European Convention on Human Rights (EHCR), as evidenced in the case of R (Sessay) v South London and Maudsley NHS Foundation Trust [2011] 2717 (QB) where police were admonished for unlawfully relying on s.5 and s.6 of the MCA, 2005 to take Sessay to a PoS without the use of a warrant, I considered the need to apply to the magistrate's court for s135(1) MHA 1983 warrant because it offers protection and authority to remove and convey individuals to PoS for the purposes set out in s.135 and s.136 (MHA 1983) thus preventing infringement of articles 5 and 8 of EHCR, (1950) (Brown 2020, p148).
According to Andoh, (2009), warrant application must bear logical facts to be considered by the courts. I drafted the s.135(1) MHA 1983 Court Report and ensured that it detailed all the risks factors and attempts by EIP staff to engage and support
DM in the community without success. The warranted AMHP finalised the draft and applied to the court for s135(1) warrant by giving oral evidence (para 16.11) which I observed, and it was granted. I reflected on the warrant application process which was lengthy and can cause undue delay in the MHAA (Richards and Mughal, 2020), for it is time consuming to secure court dates including police availability (local AMHP policy, 2017) thereby impacting the MHAA urgency. Bartlett and Sandland, (2014, p.258) argue that delay in applying for a s135(1) warrant has the potential to lead to further deterioration of the individual's mental state. However, given the nature of the identified risks, police presence was extremely necessary for managing the risks to DM's health and safety, the public and for guiding the MHAA set-up process (Police and Crime Act, 2017).
On AMHP obtaining the warrant, I contacted police for their availability, booked a secure ambulance, informed bed managers prior to the planned MHAA (Local AMHP Policy, 2017) and locksmith because according to s47 Care Act (2014), it's the AMHP's responsibility to secure the patient's property (para 14.88). I am aware that the MHA (1983), places the responsibility of identifying a suitable bed for the patient on recommending doctor's (para 14.77). However, the local AMHP policy recommends assistance of the MHAA process by giving this responsibility to hospital bed managers. Two doctors are needed for the MHAA and ideally one must be section 12 approved and if practicable the other with a previous acquaintance with the patient (s12(2) MHA 1983) or has expertise of treating patient's mental health condition (TTM v LB Hackney (2010) EWHC)). The importance of ensuring that at least one of the doctors has 'previous acquaintance' is to prevent the case of TTM v LB Hackney where it was held that both doctors came to the case cold. 'Previous acquaintance', does not necessarily imply having a 'personal involvement' with the patient but to have some knowledge about them which might include doctor's familiarising themselves with patients records or a brief handover by the AMHP as in the case of AR v Bronglasis (2001) and (para 14.73, 14.74). DoH 2015 advocates for the preferability of a doctor who has treated the patient (para 14.40) therefore, I considered involving his GP, however there are difficulties of involving GP's in MHAA (Stevens et al, 2021) because of their unavailability that can hinder MHAA urgency and due to conflict of interest (s12A MHA 1983). According to Woodhead, (2019), there are shortages of s12 doctors for they prefer to complete MHAA outside of their
contracted hours therefore compounding difficulties of availability. With DM's racial background in mind and in consideration of factors such as age, gender and religion which might affect the MHAA outcome (para 14.41), I booked two s12 doctors ensuring racial diversity that one is from the Black and Minority Ethnic (BME); (Wickersham et. al, 2016), to promote anti-oppressive practice for statistics suggest that black people are more likely to be detained under the MHA than their white counterparts (Mind.org.uk, 2018).
To identify the Nearest Relative (NR), I worked closely with the AMHP, and adhered to s26 (1) MHA 1983 hierarchy. According to information gathered, DM is single, lives alone, has no dependents and father is deceased. I identified the mother as the NR (s.26(4) MHA, 1983); (Re D (Mental patient: habeas corpus) (2000) 2 F.L.R. 848) and this was affirmed by the AMHP (para 14.57). Together with the AMHP, we contacted the NR and informed her of the planned MHAA including taking her views. It's AMHP's duty to inform NR (s11(3)), for assessment and treatment under s2 or s11(4) to consult if the aim of the MHAA is for admission for treatment under s.3 MHA (BB v Cygnet Health Care and London Borough of Lewisham [2008] EWHC 1259 (Admin). This being the procedure, I reasoned that it would be have been appropriate to first contact DM to explore any unknown difficult family dynamics (para 14.61) as stated in R (on the application of E) v Bristol City Council (2005) where the judge ruled that it was unlawful to contact E's NR without her consent but on hindsight the AMHP has got the prerogative of considering if it is 'reasonably practicable' to consult the NR and the decision should strike a balance to protect patient's articles 5 and 8 (EHCR, 1950) as evidenced by TW v Enfield Council (2014).
During the MHAA, I noted that the police and secured ambulance had parked on DM's driveway. Although their presence was required due to the highlighted risks, I was concerned about arousing the neighbour's curiosity because of the likely impact of stigma towards DM's wellbeing (Corrigan and Miller, 2004). I requested them to move further back. As well, NHS colleagues/professionals were eight thereby increasing the assessing team's numbers. According to Stone et al (2020), AMHP's must be proportionate when undertaking MHAA and dealing with issues of risks and ensure that patient's dignity is preserved. I worked with the AMHP to curtail the NHS
team to two representative, two s.12 doctors, the AMHP and myself to enter the property for I was mindful of what Dominelli, (2002) describes as 'power over them' which can be interpreted as oppressive and exploitative which is contrary to DM's human rights (HRA, 1998). Although we had the possession of the s135(1) warrant and the police, we agreed for the least restrictive option to first knock on DM's door. After several attempts, DM opened the door albeit with hesitation. He was informed of the s135(1) warrant, and he invited us in. Jones, (2018) states that possession of a warrant does not necessarily imply that it must be executed neither does it have to be issued based on the unreasonableness of assumptions without concrete grounds. However, according to Andoh, (2009) possession of the warrant offers protection, and empowers police officers to enter a property with an AMHP or doctor, if need be, by force if there is a belief that a person is suffering from a mental disorder to remove them to a PoS.
It's the AMHP's duty to interview patients in a suitable manner (s.13(2); DoH, 2015, para, 14.49)), therefore, I introduced the assessing team and explained the purpose of the assessment to DM (para 14.51). I considered DM's communication skills which was good (para, 14.42 MHA) and sought his consent for the MHAA to be conducted in his house (DoH, 2017). For the MHAA purpose the patient's property can be used as PoS (s135(7a) MHA 1983). According to Abbotts (2017), conducting MHAA in a patient's home reduces anxiety and promotes good communication. DM consented to MHAA in his home instead of being taken away to a PoS. According to DoH 2014, there is a critical shortage of PoS and conducting MHAA in a person's home helps to curtail the PoS national crisis (Home Office, 2016). I offered DM opportunity to speak to the AMHP alone (para 14.54) including having support from a familiar person/advocate (para 14.66; 14.70) which he declined. During the interview, DM presented with delusional thoughts of grandiosity and was thought disordered which was a clear manifestation of his psychotic symptoms. DM acknowledged not needing the medication for its not for the 'Royal family'.
During AMHP training, I have observed that the AMHP's role comes with power which can intimidate individuals to feel powerless and frightened during MHAA (Abbott, 2022); (Singh et al, 2013). Therefore, I was mindful that it's the AMHP's role to uphold DM's human rights article 5(1) right to liberty which should not be breached
by unlawful hospital detention (5(4)); and article 8 ECHR right to private life. Any decision to detain him under MHA had to be lawful (Article 5(1)(e) and guided by good practice (para 1.22). I ensured DM's wishes and views were listened to since according to M v South West London and St Georges Mental Health Trust 2008, the judge ruled that the interview purpose is achieved when AMHP's attempts to communicate with patient's who might have difficulties to respond appropriately.
Following the interview, the assessing team held discussion to explore the possibility of informal admission (s131 (MHA 1983)) that will require DM to consent (s131(3) (MHA 1983). DM was presented with the relevant admission information (CC v KK & STCC (2012) including restrictions and expectations to comply with treatment on the ward if he agrees to informal admission. According to Heart of England NHS Foundation v JB (2014), individuals are not expected to understand all the information but sufficient information for informed decision-making therefore, DM was required to demonstrate that he has capacity by understanding, retaining, weighing, and communicating the salient information provided (A Primary Care Trust v LDV (2013). Griffith and Tengah, (2013) are of the view that a person's behaviour and presentation should be considered during the decision-making process. DM lacked capacity to decide on treatment for his mental health and therefore, could not consent to informal admission. Previously, when someone was deemed to lack capacity the GJ v The Foundation Trust & Anor (2009) had set the principle that MHA should take precedence over MCA but later trumped in AM v SLAM (2013). Admission under DoLs (para 13.40; 14.19, Doh 2015) could have been considered but DM did not meet criteria for he was objecting.
Following discussion, the assessing team agreed that DM met the criteria for detention under section 2 MHA 1983. I queried why s.3 MHA 1983, was not considered since DM has an established diagnosis and was initially discharged under s.3 MHA 1983 in the community. The assessing team informed me that given DM mental health had further deteriorated, his presentation was new and needed a fresh assessment for a proper diagnosis for he was suffering from a mental disorder (s1 MHA 1983) of a nature or degree which warrants admission to hospital for a period for assessment and or treatment for a treatment plan to be formulated (Brown, 2020); para 14.27)). Although, I understood that this was a collective
decision by the assessing team the case of R v Wilson ex parte Williamson (1996) cautions that s.2 should not be used as a temporary provision to circumvent fulfilling obligation under s.3 for example, failure to consult with the NR (s 11(4) MHA)). With the AMHP's supervision, I contacted the NR and informed her of the MHAA outcome (s11(3) MHA including discharge rights (s.23(2) MHA)) after giving 72 hours' notice to the hospital managers. In contrast for s.3 MHA 1983, the NR must be consulted and can object to an application being made. The NR's role is to act as an additional safeguard for patient subject to MHA (Articles 5 & 8, ECHR 1951); (TW v Enfield 2014). Given that this was a planned community MHAA, the bed management team confirmed bed availability (Local AMHP Policy, 2017).
With the AMHP's supervision, I informed DM of the MHAA outcome (para 14.100) and his rights to appeal the decision (s132 (MHA 1983). DM vehemently objected the outcome, shouted obscenities, and threatened violence towards the assessing team. Due to previous forensic history, the assessing team stepped back and the police took charge. In my observation, police presence agitated him more and could have exacerbated his challenging behaviour (Morgan and Paterson (2019)). I offered DM assistance to pack his personal belongings which he declined.
DM refused to enter the ambulance voluntarily, police used reasonable force to handcuff and place him in the fitted cage of the secure ambulance while still in handcuffs. I questioned if it is because black men suffering from mental disorders are viewed as dangerous (John, 2020). The duly completed forms (s6 MHA 1983) gave sufficient authority to transport DM to hospital by secure ambulance (para 17.3 DoH 2015). These powers, authority, protection, and privileges which a constable has (s137(2) MHA) to convey was delegated to the ambulance driver (s137 MHA 1983) while the AMHP and I followed behind. On arrival to the ward/hospital the duly completed forms by the two s.12 doctors and the AMHP application for s.2 MHA were given to the ward charge nurse. I provided a handover to the charge nurse and with the AMHP's supervision I drafted the outline AMHP report (para 14.93). The AMHP completed the application and final paperwork to the Mental Health office (para 14.95).
In conclusion, my learning as an AMHP trainee is that AMHP's should endeavour to always adhere to good practice (s.139 MHA) to protect patients' rights and an effective MHAA should provide least restrictive alternatives to detention (para 14.34 DoH) and advocate for community mechanisms to manage risks (Rooke, 2020). Unfortunately, the AMHP's role is frequently hampered by lack of community resources and the need to respond quickly to contain risks leads to admission as the alternative.
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