Nicholas Salvador – not guilty by reason of insanity

Today’s news has been filled with the face of Nicholas Salvador, a 25 year old gentleman who, last year, killed two cats before going on to behead an 82 year old grandmother in her own back garden.

Nicholas Salvador is a paranoid schizophrenic. He has today been found not guilty by reason of insanity and will spend an indefinite amount of time in a secure psychiatric hospital. What is not discussed in the news is how such a verdict works in practice. Well, officially, Nicholas Salvador will be detained under section 37/41 Mental Health Act 1983.

Section 37 is a hospital order and it operates as an alternative to a prison sentence. Section 41 is a restriction order and this is something added by the Crown Court if there are concerns regarding public safety and the patient’s own risk. Prior to someone being admitted to hospital in such circumstances, two medical practitioners must carry out assessments of the person. For a judge to give a restriction order, one of these medical practitioners must speak in court.

It is possible that Mr Salvador will have to spend some time in prison whilst waiting for a bed to become available for him – the procedure is that the Hospital Managers should find a patient a bed within 28 days.

The reason that the newspapers are stating that Mr Salvador will be detained indefinitely is because, since 2007, a section 37/41 does not have a time limit, meaning that it can run for as long as necessary with no need for it to be renewed.

Although unlikely to happen, it would be possible for Mr Salvador to appeal against today’s order of the court to the Court of Appeal, but this would need to be done within the next 28 days.

A section 37/41 is naturally strict – a patient detained on this section cannot leave hospital without the agreement of the Secretary of State for Justice. When the person’s Responsible Clinician (the doctor in charge of their care) thinks that the patient is well enough to be discharged from hospital, he will ask for the Secretary of State’s agreement. The reasons for such strict rules are clear – the person, had they not been suffering from a mental disorder, would have been sent to prison. It is section 41 that places these extra restrictions on the detention. Even if the patient wants leave from hospital, and a request for leave is made by the responsible clinician, the Ministry of Justice must agree to grant that leave, and it may simply be leave to go to the local shop.

Once the hospital order has been in place for six months, the person detained may apply for a Tribunal. With a Tribunal, a successful appeal of a section would mean that the patient can be discharged. Such discharge can be either absolute or conditional. With absolute discharge, the person will be released from detention. It is unlikely that someone who has been subject to a forensic section i.e. a section 37/41, will be granted absolute discharge. Conditional discharge is much more likely as it allows the person to remain subject to the Mental Health Act whilst living within the community. Should any of the conditions specified be broken, the patient can be recalled to hospital by the Secretary of State. As soon as a patient on a section 37/41 is recalled to hospital, there is an automatic tribunal within the first month of discharge. Following this, the section must last for six months before the patient is able to apply to the Tribunal himself.

Alternatively, if the conditional discharge goes well and all conditions are complied with, the patient may wish to apply for absolute discharge, although they do have to wait at least one year. If the application for absolute discharge following one year of conditional discharge is not successful, the person is only able to apply two yearly.

Ta-dah! Hopefully this explains what all of the newspapers are talking about and the process involved when detaining Nicholas Salvador.

Community Treatment Orders – What are they and are they effective?

It is possible for someone who has been detained under the Mental Health Act 1983 (MHA) to be discharged from hospital and placed on a Community Treatment Order. CTOs were introduced in late 2008. Effectively, a CTO is the least restrictive option for providing treatment, as it allows people to be monitored whilst remaining in the community, as opposed to being detained in hospital further.

A CTO can be placed on a patient detained under section 3 or section 37 MHA 1983. These are the only sections under which someone may be placed on a community treatment order. To be clear, section 3 lasts for an initial period of six months. This can be renewed for a further six months and then yearly following that. Someone will be placed on section 3 if they are well known to mental health services or have been in hospital before, or if they have previously been detained under section 2 for assessment. Section 3 is for treatment. Section 37, on the other hand, is a hospital order imposed by a court, with the recommendation of two doctors, instead of a prison sentence. Section 37 lasts for an initial period of six months, renewable for a further six months, and subsequently yearly.

The Responsible Clinician (the person responsible for the person’s treatment) can discharge a patient from hospital and provide supervised treatment whilst the person is in the community. Prior to granting a CTO, the Responsible Clinician must ensure that certain conditions are met: the person has a mental condition that requires medical treatment; treatment is required for the person’s health or safety, or for the protection of others; the person is able to continue their treatment in the community; the person can access the right treatment in the community; and, it is justified that the person can be recalled to hospital if necessary. The Responsible Clinician ought also to consider the risk of a deterioration in the person’s condition were they not detained in a hospital.

If necessary, the Responsible Clinician can recall the person back to hospital. Recall could occur if the conditions set out prior to discharge are not complied with or if the person becomes unwell again. One condition may be that the person must continue taking their medication, or must reside at a certain place.

If recalled back to hospital, a person can be held for up to 72 hours whilst what should happen next is deliberated. It may be that the CTO is revoked and the person can be placed back on the section that they were on prior to discharge into the community. Alternatively, if all conditions are complied with and the person is deemed fit to be fully discharged by the Responsible Clinician, then the person can be discharged from the CTO and the conditions of that will no longer operate.

The purpose of the CTO when introduced was to end the ‘detrimental cycle’ of patients being discharged from hospital, stopping taking their medication and ending up back in hospital. In effect, the CTO could be viewed as a practice run for discharge where the risk of relapse and re-detention is (hopefully) reduced. According to the Minister of State when discussing supervised community treatment, “the power of recall provides the means to tackle relapse, and to avoid its potentially adverse consequences for the patient or someone else. Recall to hospital allows patients to be treated quickly and to return to the community straightaway if it is clinically safe to do so”.

It is possible for the Responsible Clinician to grant the patient a section 17 long-term leave of absence, rather than a CTO, and the Responsible Clinician must ‘consider’ whether the patient should be dealt with using long term leave. Research (T Burns et al) has actually shown that, when compared with patients who are on section 17 leave, the imposition of CTOs does not reduce the rate of readmission to hospital, with around one third of each group being readmitted within a year. The findings of this study backed up two previous studies that had also found no benefit from CTOs in reducing readmission. This conclusion has, however, been disputed by a number of people.

The study came at a time when most mental health services were reorganised thus the care of those participating in the study was passed to psychiatrists who were not necessarily familiar with the trial. It also did not assess to what extent people took their prescribed medication – something which, of course, is incredibly important when looking at re-admission.

CTOs are established in over 70 jursidictions and have existed since the 1980’s/90’s in most parts of North America and Australasia. The law on CTOs does not explicitly state what standards should be used to assess their effectiveness, though frequency of contact with out-patient services, victimisation, arrest, mortality and quality of life tend to be used in studies testing their effectiveness.

In 2008, when CTOs were first introduced, Lawson-Smith et al stated that “Community Treatment Orders should arguably be used on a restricted group of patients who suffer from severe and relapsing mental illness, who quickly disengage and are repeatedly re-admitted’. It has become clear that CTOs are not used on a limited basis at all – according to statistics from The Health and Social Care Information Centre, between 2008 and March 2014, the number of people subject to CTOs has seen an increase of 206%. In that same period, the number of people detained under section 3 MHA 1983 has decreased. The link between this reduction and the increase in CTOs appears more than coincidental, given that patients subject to a CTO can be recalled to hospital, rather than re-assessed under the MHA.

In 2009, The Guardian published an article entitled ‘Hazards of a Health Safeguard’. The article included a lady who was subject to a CTO, one of the conditions of which was that she had to have blood tests every two months to prove that she had been taking her medication. She stated that doing so made her feel like “a laboratory rat”. Whilst it is understandable that those subject to CTOs will feel some frustration, the conditions are there for a reason – for the health or safety of the person or for the protection of others. If someone is discharged entirely from hospital and does not take their medication, they will simply end up being re-admitted. These CTOs operate to try to curtail that trend and, whilst CTOs have received stark criticism, the one major study on them (mentioned above) is in fact fraught with criticism. And, with regard to how those subject to CTOs actually feel about them, there appears to be no research at all on this in the UK.

Research on the effectiveness of CTOs in improving the quality of life of those subjected to them has been conducted in other countries – it looked at 752 people and concluded that “results from the trials showed overall that compulsory community treatment was no more likely to result in better service use, social functioning, mental state or quality of life compared with standard ‘voluntary’ care”. The research did, positively, find that “people receiving compulsory community treatment were less likely to be victims of violent or non-violent crime”. We should perhaps not place too much weight on this research, given that the quality of evidence for the main outcomes of the trials were recorded as ‘low to medium grade’.

At this stage, the only conclusion that can be drawn regarding the effectiveness of CTOs is that further research is needed. There is strong opposition towards CTOs, yet many professionals view them as necessary – placing a patient on a CTO means that they cannot deteriorate to the point where it is necessary for them to spend a long period in hospital. If the patient does not meet their conditions then they can be recalled to hospital, stopping them from going for X amount of months without their medication and, in most cases, exacerbating their mental health issues.

Those who are placed on a CTO, like the woman mentioned in The Guardian article above, may view the conditions placed on them as unnecessarily restrictive. It is understandable that it may seem this way, given that the patient is not returning to ‘normality’ per se. However, being able to live in the community rather than a hospital has to be viewed as much less restrictive. In effect, it is giving patients a chance and I don’t see how that could be a bad thing.