Eleanor Roosevelt, 1958

'Where, after all, do universal human rights begin? In small places, close to home -- so close and so small that they cannot be seen on any map of the world. Yet they are the world of the individual person... Unless these rights have meaning there, they have little meaning anywhere. Without concerted citizen action to uphold them close to home, we shall look in vain for progress in the larger world.' Eleanor Roosevelt, 1958

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Tuesday, 11 February 2014

Discharges from detention by the Tribunal under the Mental Health Act 1983

The Care Quality Commission's annual report on the Mental Health Act 1983 (MHA) contains data on applications to, and discharges by, the First Tier Tribunal (Mental Health).  The Tribunal has powers under the MHA to confer an absolute discharge, delayed discharge or (in some cases) conditional discharges on detained patients.

I was looking at these data and wondering if the rates of discharge by the Tribunal vary for different types of applicant.  It turned out that they do - restricted patients are most likely to be discharged, followed by patients detained under s2 MHA whilst unrestricted patients detained under other parts of the MHA were the least likely to be discharged.

I have recently been learning to use two new (open source) software packages: R for statistics and Inkscape (a vector based graphics program).  I am learning these because I want more flexibility in presenting data than Excel or SPSS can give me.  I was practising with these packages on the MHA Tribunal data and made this chart, based on a 'recipe' from a book called Visualise This.  I'm not sure if it's helpful to anyone, but I thought I'd share it anyway, and I've put it on a power point slide here in case you want to use it.  Pie charts should be avoided when you have a large number of variables.  but I wanted to use them here because I can convey the number of people the Tribunal made discharge or no-discharge decisions for using the area, and the proportion of people discharged by the Tribunal by the angle of the slice of pie.

As an aside, the data from CQC on Tribunals don't quite add up to 100%.  The number of hearings is greater than the total number of 'discharge' and 'no discharge', presumably because some hearings did not result in a decision either way.  I also haven't included the number of people who applied for a Tribunal hearing but either withdrew their application or were discharged prior to the hearing.


  1. I wonder why anyone would bother applying to the Tribunal - particularly under s2 as the (even cumulative) discharge rate is so very low. Basically if the clinical team object then you are unlikely to be discharged.

    You cannot underestimate the trauma and distress caused to those applying. to Tribunal. It destroys absolutely all trust in clinicians, AMHP's and community teams vested with writing a report. as you simply will not be heard and MH professionals are always considered the 'experts'. You end up being more traumatised than when you were admitted and the triggering effects cannot be underestimated which means that the admission will be longer unless you manage to abscond or commit suicide ,

    Sometimes the clinical team know they are going to take you off section but choose to wait sometimes until the same day in order to try and coerce 'engagement'. What they don't realise is that the patient then has so little trust and faith in them and the system that it is impossible for any realistic assessment and treatment to take place.

    Patients are told to 'play the game' in order to be discharged - by nurses, by clinicians, by solicitors. So if you are able you learn what to say which must mean you are 'better' as you are now compliant.

    It is a cruel and very sick system that simply goes through the motions without any real purpose of justice or humanity. I wouldn't ever bother appealing again..Other options become much more attractive when lose your liberty simply because you are unwell

    1. Yes, sadly that reflects my experience of compulsory detention too.

    2. Yes, it is incredibly hard to report bad practice - or even make a perfectly reasonable request - in such a controlled and coercive environment. I've been on the receiving end of this sort of bullying culture too. And the CQC gave my hospital green ticks in every category just 6 months before my stay. I do wonder how bad practice will be unearthed in this system where patients are so very vulnerable to being mistreated and disbelieved.

  2. Hi anonymous, thanks for taking the time to comment and sharing your experiences. It sounds like it was a bad experience for you. There has been some research on experiences of the tribunal, carried out by CQC and AJTC. Some patients had bad experiences like yours, some others were more positive, it's here if you'd like to read it:

    Your experiences highlight the risks of a coercive system - that people can lose their trust and faith in those who are supposed to help them. I hope you can find support from someone you trust.

  3. Is it possible for someone to go to a Tribunal and get a complete discharge for wrongly being diagnosed with a Mental Health Diagnoses?

    Left parked on Medication for 8 years with no supervision. Then when ask for help to come away from psychiatric drugs end up being Psychiatrically abused and left with a possible Chronic Brain impairment?

    That to me is a grave injustice......

    1. Hi anonymous, I'm afraid I'm not a good person to ask about the criteria for detention under the MHA, as my work is more focussed on the MCA. The MHA code of practice discusses the principles of the MHA, and if you haven't already seen it it might help to answer your question?

    2. Thank you I understand.

      3 years of Psychiatric Abuse in the name of Mental Health under the MCA 2005........

    3. Oh dear... I'm sure you've got plenty on your plate, but if you were interested there is a lot of discussion about rights to liberty and to refuse treatment, as well as rights to support, for users and survivors of of psychiatry. It's connected with a new UN Convention on the Rights of Persons with Disabilities. There's quite a lot written about it that's freely available online. I'd suggest googling the work of Gerard Quinn, Tina Minkowitz, Amita Dhanda and Gabor Gombos for work on the right to refuse treatment. The World Network of Users and Survivors of Psychiatry, and the Mental Disability Advocacy Centre, are also doing lots of work in this area. It's not binding on the UK Courts, but I suspect it may increasingly influence their decisions in the decades to come.

  4. (From first anonymous poster)

    The thing is the entire system is based on coercion and threat and abuses by ward staff go un-noticed and unreported as these people have huge influence over every aspect of your life when detained. So if you complain you may pay a high price.

    I have never been aggressive or physically resistant or abusive - I close down. Yet simply for asking a nurse not to shout at me through the office door I was told that the 30 mins leave a day I was granted would not happen as -'you have complained about us so we don't have to' (sic). This was on my very first s2 detention.

    Interestingly I was on the ward when a CQC inspection happened and was interviewed. The ward manager and the charge nurse after trying to deter the inspector from talking to me then tried to insist that they remained present. However - as there was no safety or risk issue- and after much protest from me the CQC spoke to me without the nurses there.

    This was before the additional powers now granted and the same ward and Trust has failed a recent inspection as it was unannounced.

    You will be well aware of how any form of co-ercion and intimidation can and does skew patients accounts- it is VERY risky to complain or report anything to an inspectorate whether detained or afterwards. There is no parity of choice in NHS care in MH and even with the right to Personal Health Budgets CCG's are going to struggle with getting their heads around providing real choice ( and it doesnt cover emergency care anyway).

    So at the moment if you express any form of dissatisfaction there is real risk that your care will be compromised by the MH Trust who have a monopoly over care.
    The CQC don't seem to have a role in monitoring this and have no real authority to act and MH Trusts know this. So no MH Trust has to co-operate - and that includes encouraging patients to be open about their care and Tribunal experiences

  5. Thanks again anonymous, your experiences really highlight the difficulties in uncovering these issues. They also highlight the importance of the CQC using their powers to interview in private, but even then I suspect patients are fearful about the consequences of speaking out. I hope you don't mind, but I'd like to flag your comment up via Twitter, and so CQC and others can reflect on it?

  6. From Anonymous 1

    Please do. Unless the CQC actually use the powers they have now been given and protect patients then they will never get true account. There is much talk about protecting whistleblowing employees but there is nothing in place that protects patients/service users if they report on abuses in the system.

    The CQC actually have current cases in London where they are investigating a Trust that has been alleged to have covered up safeguarding reports of the most serious nature by recording them as complaints instead. Indeed the CQC used to encourage this approach if individuals alerted them - hopefully this is changing as their role becomes clearer.

    The thing is that even with full detailed accounts and even where staff have been prosecuted the CQC, the LA and the CCG do not have any powers to enforce change in policy and practice. One glaring example is the access all staff have to electronic notes - including therapy notes thereby not allowing a safe secure disclosure space which in terms of disclosing abuse within a Trust means the alleged perpetrator has access to the pt disclosure.There is nothing to stop this and it is only picked up on a post event audit if the Trust agreed to do an audit.

    What I and others would like to see is that the moment a sfaeguarding concern is raised this automatically generates sealed notes for the duration of the investigation that only safeguarding managers have access to. One pt who alleges a very serious incident requested sealed notes so she could disclose and the response of the Trust (Medical Director) was to take an entire year to consider this and then refuse. The pt then attempted suicide.

    So even very practical steps - endorsed by the police in the above case- dont have to be taken. The police often cannot proceed with a case as the MH Trust ( if that is where the alleged abuse takes place) then effectively blocks all support to the victim who cannot get their MH needs met in other ways.. This undermines any potentia; for criminal conviction. This is what the CQC in particular seem to have great difficulty in understanding and apparently have absolutely no powers to create safe disclosure and reporting systems.

    So please flag this up any way you think may help as there are current cases the CQC are aware of and could actually look at the patient journey and experience and see where changes are needed. Allowing safeguarding reports to be recorded as complaints is a very serious practice and culture issue that the CQC need to ensure they do not endorse

  7. I don't know anything about safeguarding procedures, so your comment has got me wondering whether the complaint I raised (when the ward had become so unsafe that I felt I had no choice but to complain) should have been picked up as a safeguarding report instead. Does that make a difference to the CQC?

    My complaint related to assaults on me by staff and patients, as well as inadequate responses of staff to protect me from patient assaults when I asked for help. Nothing came of the internal investigation, where I was either blamed or told the assaults had not taken place (because, you know, mental patient).

    There was one safeguarding report (made due to a staff assault) which resulted in the staff member of staff being reassigned to another ward for the duration of my detention. But nothing came of that safeguarding report - I understand I should have been notified and the case resolved somehow, but I never did hear anything further. I think safeguarding is something to do with the council, but I've never heard anything from them.

    I wonder if these are issues that the CQC should be involved in too. And I wonder where I could find guidance about these issues. Post-traumatic stress disorder caused by what was done to me during my detention has prevented me from being able to address these issues since discharge without support - and there doesn't seem to be any.

    It's ironic that my physical and emotional injuries from hospital treatment probably won't be recorded in the system because I was too adversely affected to do anything about it afterwards.

    1. Hi there, sorry about your problems posting, I don't know what happened there. Thanks for persisting. I meant safeguarding in a hand-wavy sense, but thinking about it, it is the kind of thing a council should look into. Generally speaking CQC don't hear complaints, but if you were treated under the Mental Health Act they do have a power to investigate:

      It sounds absolutely awful, I'm really sorry that happened to you. You raise a very serious problem that people who have been assaulted or mistreated in hospital are expected to prompt a complaint when they are very often not in a place to do that at the time. I also wanted to say that I really appreciate your tweets, they are really interesting and thought provoking.

  8. The Local Authority which covers the Trust that treats you is responsible for overseeing all safeguarding investigations in their area. Sometimes there will be say 2 local authorities covered by one Trust- as in London. So for eg in Camden and Islington Foundation Trust if an alleged assault took place at the site for Camden pts then Camden Council should oversee any investigation.

    And here is where it becomes a complete mess. Yes what you describe is a safeguarding issue. Yes the Trust should have followed it's safeguarding policy which you can request on a Freedom of Information Request if it is not available through the website .

    The CQC has had very severe criticism for not responding appropriately when an individual reports abuse. It has certainly in cases I am aware of told the complainant to use the NHS complaints procedure.HOWEVER...and it is a big however they produce a document in Feb 2013 - Safeguarding Protocol (on the website). This categorically states what they are meant to do when someone reports to them either directly or the report the complainant has made has not been followed through.

    Their powers are limited but they are there. Check the CQC inspection report and find out the name of the local inspector for the council concerned. The council will have an Adult Safeguarding Board and team and the CQC inspector sits on this. The Council also have their own ( often national ) policy on Adult Safeguarding so you can obtain this and see what action should have been taken.

    The CCG who fund the service are also required to be informed of safeguarding reports but god knows why as they dont appear to have a specific role.

    All historical reports can be investigated. You can ask for your notes (lol) in relation to the specific incidents. MH Trusts always withold these when they know there is an issue.

    There is a very active case at present where the local authority and CQC are now looking at why a safeguarding investigation was not run and very serious assault that was then part of a criminal investigation was only dealt with as a complaint - indeed as a vexatious complainant. However this only arose as the individual lost faith and all trust in the MH Trust and was legally advised to make a formal complaint to the CQC and to the local authority on how they supervised the safeguarding investigation the MH Trust should have run.It is assumed that there is a pre determined outcome as the local authority lays itself wide open if it admits any shortcomings.

    And of course if you follow through then the MH Trust will do whatever it takes to not accept any liability and in the above case cut off all services including crisis services because the victim ( they now accept she is a victim after criminal investigation) will not withdraw the claim. Despite 8 detentions under various forms of the MHA in the last 3 years.

    The other document of interest is produced by the SCIE and is titled :Safeguarding adults at risk of harm:A legal guide for practitioners. Long but gives guidance to MH workers.

    Tread carefully. It may be that if you confirm that the Trust did not deal with each and every safeguarding issue you raised as safeguarding but parked it in complaints then you may decide to strategically move on in the way described above. The victim was asked to submit evidence on the failings of the NHS complaints procedure to the recent inquiry regarding this case. You are not required to go through the Ombudsman if you don't want to. And it will be impossible without the MH Trust being candid So in my experience - dont bother but just personal opinion.


  9. (From the second anonymous poster)

    The London Borough above did not take my complaint seriously and wrote back without addressing the serious complaint that I raised concerns about. With hindsight had I raised safe guarding concerns then am I right in understanding my concerns would have been dealt with more SERIOUSLY......

  10. Or not....
    The CQC can still take a complaint as can the local authority.
    Things you may want to consider in a complaint would be if each report was considered as a safeguarding issue- if it wasnt then the MH Trust has to record why not. If there was any reason to believe there MAY have been a criminal act then the Trust is obliged to report to the police. In any case they are required to act within 24 hrs , hold a strategy meeting wthin 3 days and interview you approriately and supportively in order to investigate.The MH Trust is required to report to the CQC and the local authority if there is a safeeguarding concern whether you are sectioned o not. However if you were sectioned at the time the cqc has a much clearer duty

    If you were reporting for eg in LB Camden then you would e mail say the head of the CQC and the compliance inspector at the CQC for the MH Trust that covers that area. This info is available on the website - the head of the cqc is david.behan@ and the compliance inspector for that area is uk.
    You would also probably inform the local authority. So again hypothetically if this is Camden you would e mail the Director of Adult Social Care whose name and contact details are on the website -

    If I knew that there was another case currently under investigation within the same MH Trust and this was a historical case as well I may refer to it .

    I may also consider contacting an interested journalist who had already done a joint investigation with the BBC in to the same Trust on the different matter of crisis care - Andy McNicholl at Community Care for eg (

    I would also consider telling any advocate I had in the event that they already knew of other cases. Sharing is power