v4 Mental Welfare cover - Mental Welfare Commission for Scotland

Annual Report MENTAL WELFARE COMMISSION2003-2004 FOR SCOTLAND

MENTAL WELFARE COMMISSIONFOR SCOTLANDAnnual Report2003-2004PUBLISHED: 27 OCTOBER 2004MENTAL WELFARE COMMISSION FOR SCOTLANDSE/2004/150K Floor, Argyle House3 Lady Lawson StreetEDINBURGHEH3 9SHTel: 0131-222 6111Fax: 0131-222 6112E-mail: enquiries@mwcscot.org.ukWeb: www.mwcscot.org.uk

THE MENTAL WELFARE COMMISSION FOR SCOTLANDCONTENTSPAGEWho We Are, Our Achievements 2003-04 & Contact InformationCommission Membership, 1 April 2003 – 31 March 2004Mental Welfare Commission for Scotland:What We Do & How We Can HelpivvviSection 1: INTRODUCTION1.1 Chairman’s Statement 11.2 Director’s Report 3Section 2: ABOUT OUR WORK2.1 Investigations and Inquiries 52.1.1 Report of the Inquiry into the Care and Treatment 5of Ms H & Mr E2.1.2 Report of the Inquiry into the Care and Treatment 7of Mr A2.1.3 Follow up to the Inquiry into the Care and 10Treatment of Mr C2.2 Visiting Programme 102.3 Communications Work 142.4 Suicides 152.5 Accidents and Incidents Reported to the Commission 172.6 Consent to Treatment 202.7 Requests for Discharge from Detention 222.8 Information and Advice 232.9 Implementation of the Mental Health (Care and Treatment) 24(Scotland) Act 20032.10 Implementation of Scottish Executive Relocation Policy 25ii

ANNUAL REPORT 2003-2004Section 3: MENTAL WELFARE IN SCOTLAND: OUR OVERVIEW3.1 Detentions Under Mental Health and Criminal 27Procedure Legislation3.1.1 Detention Statistics, 2003-2004 273.1.2 Trends in the Use of Detention 323.1.3 Use of Detention in the UK 333.1.4 Consent to Detention 353.1.5 Social Circumstances Reports 363.2 Guardianship and Intervention Orders 363.3 Mental Health Services for Children and Adolescents 413.4 Safe to Wander?: Good Practice Guidance 423.5 Use of Restraint 433.6 Unauthorised Removal of Adults Who Lack Capacity 44Section 4: MENTAL HEALTH LAW & POLICY4.1 Adults with Incapacity Act 464.1.1 Part 6 464.1.2 Part 5 484.1.3 Part 4 494.2 Developments in Mental Health Legislation across the UK 49Section 5: FINANCIAL STATEMENT 52Section 6: FURTHER INFORMATION 556.1 Bodies we meet with 556.2 Details of Our Publications 556.3 Bibliography 56Section 7: PRACTITIONERS’ FIVE-YEAR INDEX 1999-2004 58iii

THE MENTAL WELFARE COMMISSION FOR SCOTLANDWho We AreCommissioners, 2003-2004:Standing – left to right: Linda Graham (from 1 April 2004), Gina Netto,Alison McRae (Head of Corporate Services), Corinna Penrose, Malcolm Murray, Myra Maguire,Joe Morrow, Pramod Jauhar, Colin Welsh (from 1 April 2004), John Bain, Linda Pollock,Carol Dobson (from 1 March 2004), Shelagh Creegan,Tom Keenan, Gordon Shiach,Jamie Malcolm, Adrian LodgeSeated – left to right: Douglas White (from 1 April 2004), Juliet Cheetham, Donald Lyons (Director),Ian Miller (Chairman), Margaret Ross, Bill Gent, Lynne EdwardsThe following Commissioners are not in the photograph: Madeline Osborn,Archie Robb, Margaret WhoriskeyWe employ over 40 staff from a number of different practitioner, managementand administrative backgrounds.Our Achievements, 2003-2004During 2003-2004, we have:• Contributed to the development andimplementation of the new Mental HealthAct.• Visited 1122 service users in hospital and848 in care homes and in the community.• Changed our internal structure to allow usto visit more people more often in thefuture.• Visited 6 national and 15 localorganisations that help people fromminority ethnic backgrounds.• Reviewed 515 detentions, 211 accidentsand incidents, and 172 suicides.• Worked on 2 inquiries involving problemswith care and treatment and followed up acase from the previous year.• Continued to improve our telephoneadvice service and the recording of theinformation we provide.Contact UsIf you feel you have a matteryou would like to discuss withus you can contact us inconfidence in the followingways:• Phone: 0131 222 6111• Email:enquiries@mwcscot.org.uk• Website: www.mwcscot.org.ukUse it to ask for help.The site alsoprovides access to the full AnnualReport and other publications.• Write to: Mental WelfareCommission for Scotland,K Floor, Argyle House,3 Lady Lawson Street,Edinburgh EH3 9SHiv

THE MENTAL THE MENTAL WELFARE WELFARE COMMISSION COMMISSION FOR SCOTLAND FOR SCOTLANDMENTAL WELFARE COMMISSION FOR SCOTLAND:WHAT WE DO AND HOW WE CAN HELPOur duty to protectMental disorder, including learning disabilities and dementia, can sometimes make peoplevulnerable, leaving them open to exploitation or abuse or at risk of neglect.We are an independentorganisation set up by Parliament with the responsibility of protecting the welfare of people withmental disorder (including learning disabilities and dementia) in Scotland. We have a duty toanyone with a mental disorder whether they are in hospital, in local authority, voluntary run orprivate accommodation, or in their own homes.What do we do?Our duties come mainly from powers given to us by the Mental Health (Scotland) Act 1984 andthe Adults with Incapacity (Scotland) Act 2000. Specifically, we have to investigate any case whereit appears that any person with a mental disorder may be:• being ill treated;• not cared for or treated properly;• improperly detained (sectioned); or• at risk of losing their property or of it being damaged.In some cases relating to property, we pass our enquiries onto the Public Guardian.We must alsoregularly visit patients who are liable to be detained (sectioned) in hospital, or who are on welfareguardianship, intervention orders or community care orders.Our work includes the following:Hospital visitsWe visit every psychiatric or learning disability unit at least once a year to meet any patients,relatives or carers who may have asked to see one of our representatives.We also see patients whohave been detained (sectioned) for more than two years.Other visitsWe visit:• People on guardianship orders;• Patients who are on leave of absence from hospital or on community care orders;• People on intervention orders;• Patients or carers who raise concerns about treatment;• People with mental disorder, including learning disabilities, living in the community;• People who have asked to be released from detention (section);• People in prison.Discharge from being detained (sectioned)We have a duty to protect people against being detained (sectioned) if there is no genuine need.We consider requests for people to be released from detention (section) or from guardianship andcommunity care orders.We have the power to discharge from detention (other than for restrictedpatients), from guardianship and from community care orders.ReportsWe are told about anyone who is detained (sectioned) under the Mental Health (Scotland) Act1984 or who is placed under welfare guardianship, intervention orders and powers of attorneyunder the Adults With Incapacity (Scotland) Act 2000.We also receive a number of other reportsincluding reports on individual care, and reports on suicides and serious accidents and incidents.vi

ANNUAL REPORT 2003-2004SECTION 1 INTRODUCTIONMr Ian J Miller OBECHAIRMAN’S STATEMENTFor some time now, the Mental Welfare Commission has seen the need for change inthe way it operates to enable it to become more effective and efficient, both in itsinternal workings and in its links with external bodies.This has arisen partly from theQuinquennial Review carried out last year and partly from the series of consultationexercises which we carried out recently with users, carers and advocacy services.As aresult, 2003-04 has been a year of substantial change and challenge for the Commission.We welcomed our new Director, Dr Donald Lyons, who joined us in October 2003from Greater Glasgow Trust; he brings substantial experience in management and oldage psychiatry to the Commission. I would like to express the Commission’s thanksto Dr Maddy Osborn for taking on the responsibility of Acting Director, followingDr Dyer’s retirement in March 2003, until Dr Lyons took up his post, and also, onceagain, for editing this Annual Report.We have initiated several changes to our committee structure, by setting up three newgroups: Investigations and Enquiries; Suicides,Accidents and Incidents; and Visits andCasework.We believe these changes will streamline our internal operations.We thinkthat our three new visiting teams, covering the whole of Scotland, will enable us tocarry out more effectively our prime responsibilities of protecting the welfare ofpeople with mental disorder.A welcome increase in resources from the Executive hasallowed us to strengthen our administrative and practitioner structure, especially infinance and corporate services and in our visiting function.We are making a major investment in a new management information and recordssystem, which will be introduced to coincide with the implementation of the newMental Health (Care and Treatment) (Scotland) Act 2003, in April 2005. As detailedin Section 2.9 of the Report, we very much welcome the new Act; a great deal oftime has been spent this year on working, with the Executive and other bodies, toensure that this major and complex legislation is brought into effect, to provide betterrights for service users and their carers.1

THE MENTAL WELFARE COMMISSION FOR SCOTLANDDuring the year, we were advised that we would be included in the Scottish Executive’srelocation policy, since the lease of our offices in Argyle House is subject to review in2006.We were obliged to appoint consultants to carry out a detailed survey and thefirst phase of their report has been submitted to the Executive. Inevitably, the possibilityof relocation has had an unsettling effect on staff. Along with our external auditors,we have highlighted to the Executive our concerns that the timing of a possiblerelocation, to a different part of Scotland, would constitute a major risk to theCommission’s ability to play its part in the implementation of the new Act at thiscrucial time.We were particularly pleased this year that we have been able to recruit, for the firsttime, a Part-time Commissioner who has a learning disability. Douglas White’sappointment will strengthen the Commission’s work with people with a learningdisability and he has very quickly provided a new perspective for the Commission,which we very much welcome.Along with Douglas, we welcomed three other Parttimecommissioners, namely Carol Dobson, Linda Graham and Colin Welsh. At theend of the year, Archie Robb retired after eight years as a Part-time Commissionerand I would like to express my thanks to him for his contribution to the Commissionduring that time.As ever, there were staff changes.We welcomed three permanent new members of thepractitioner staff: Ian Cairns,Tony Jevon and Mike Warwick.We also welcomed newmembers of the administrative and corporate services staff: Rhian Hunter, Paul Nevin,Val Peden, Margaret Thomson, Ewan Walker and Alice Wallace.The Commission hasalready felt the benefit of their work, particularly in our enhanced casework andvisiting ability and in the management of our financial and information work.Finally, I would like to thank my fellow Commissioners, both full-time and part-time,and the professional, administrative and secretarial staff for the hard work and dedicationwhich they have given to the Commission during an extremely busy year.2

ANNUAL REPORT 2003-2004Dr D LyonsDIRECTOR’S REPORTThis is my first report as the new Director of the Commission. I took up the post at theend of October 2003, having previously worked in Glasgow as an Old Age Psychiatristand in management. I had close involvement with Alzheimer Scotland Action onDementia and with implementing the Adults with Incapacity (Scotland) Act 2000.I developed a close interest in mental health law and I am enthusiastic about changesin mental health legislation.I must pay tribute to my predecessor, Jim Dyer, a tough act to follow and to MadelineOsborn who guided the Commission for much of the year, including the time whenI was learning the ropes. I also want to thank everybody in the Commission for makingme so welcome and to everybody who has had contact with me during my first fewmonths for their help and encouragement.Listening and learning have been my major tasks so far. At the same time, theCommission as a whole has been listening and learning.This is a time of great changefor the Commission. While working hard to continue our duties under the presentMental Health Act and the Adults with Incapacity Act, we are preparing for theimplementation of the Mental Health (Care and Treatment) (Scotland) Act 2003 andfor our new responsibilities under this Act.The new Act will make fundamental changes to the work of the Commission.Section 2.9 of this report deals with this in more detail. Broadly, our “general protectivefunction” is replaced by a duty to monitor the operation of the Act and to promotegood practice, including the observance of the principles of the Act.We very muchlook forward to this latter responsibility. In particular, we strongly support theprinciples on which the Act is based and will seek to ensure that the care of peoplesubject to compulsory treatment is consistent with these principles.While looking forward, we also recognised the need to look at our existingresponsibilities. We have consulted widely over how we carry out our functions.We have listened carefully to what our stakeholders said to us, especially the views ofservice users and carers.The results are in section 2.3.This exercise gave us a muchgreater understanding of how we are seen by the people whose interests we are hereto serve. It confirmed our feeling that we needed to make some fundamental changesto the way we work.3

THE MENTAL WELFARE COMMISSION FOR SCOTLANDThe biggest change is our new visit programme.We now have three teams serving theWest, East and North of Scotland respectively. Our teams will get to know theservices in their areas well and can be more in touch with service users, carers andadvocates.This has been a major change for us.We all needed to learn new skills andlearn to work better within teams and with the people with whom we communicate.We are now carrying out visits that are smaller, more frequent and more focused onpeople who are not in hospital. However, we must continue to visit hospitals,sometimes without warning. Last year, this revealed some examples of people incontinuing hospital care whose quality of life could be much better.We published thisin our “Greater Expectations” report and we will continue our unannounced visits tosee what has changed.Everyone tells us how much they value our advice on the telephone.We listened tothat and are pleased to get good feedback. It made us more aware of the importanceof this service.We are looking at how we can expand it and make it more accessible.We now give greater priority to this work and hope that you continue to find ourhelp and advice useful.We often hear a view that we are too close to services and mental health professionals.From a personal point of view, it never felt like that when I was working in Glasgow.I found that the Commission asked pointed and appropriate questions about ourservices. Perhaps that does not come across strongly enough in our reports, but I thinkyou only need to read one of our inquiries to see that we are not slow to criticise andmake firm recommendations for improvement.This year, we have reported on two investigations into care and treatment. One ofthese involved a harrowing series of events in the life of a person with learningdisability.This is the third such report in the last six years that highlights services thathave failed to take appropriate action to protect vulnerable adults.We hope that policymakers and service providers will pay great attention to our report and that of theSocial Work Services Inspectorate (SWSI).This case highlighted to us the need for us to work more closely with inspection bodiessuch as SWSI, NHS Quality Improvement Scotland and the Care Commission. Wecan ensure that our visits to individual people inform the work of these bodies to setand monitor service standards.We are, however, a separate organisation, with our ownvery clear responsibilities, and we will remain independent.We continue to examine the impact of the Adults with Incapacity Act and havecommissioned Hilary Patrick, a leading authority in the field, to examine the use ofwelfare guardianship. Should guardianship be used whenever a major decision such asa move into a care home appears necessary, but the person lacks the capacity to makethe decision? Should it be used more selectively? There is no easy answer to this, butHilary has produced an excellent analysis of the issues and some practical ideas onhow to ensure that the principles of the Act can best be observed (see Section 4.1.1).As I said at the beginning, this is a time of great change.The Commission could not haveimplemented all the changes of the past year without the immense dedication and hardwork of all its staff and Commissioners and without the support, advice, encouragementand feedback from all our stakeholders.We now have to ensure that we are ready tomeet the challenge of our new responsibilities under the new Mental Health Act.Weare consulting widely over how we will meet our responsibilities under the new Actand we will continue to listen and learn.4

ANNUAL REPORT 2003-2004SECTION 2 ABOUT OUR WORK2.1 INVESTIGATIONS2.1.1 REPORT OF THE INQUIRY INTOTHE CARE AND TREATMENTOF MS H AND MR EIntroductionDuring 2003, the Commission carried out a majorinvestigation into the care and treatment of twopeople, Ms H and Mr E, who are both affected bylearning disability. They lived in the Borders, withothers who were also affected by learning disability.Ms H had suffered appalling abuse by one of thepersons with whom she lived and by other people.Mr E, who, in addition to his learning disability, hasa serious physical disorder, lived in conditions ofincreasingly severe neglect. Over many years, Ms Hand Mr E, and their companions, had numerouscontacts with a variety of staff, including socialworkers, general practitioners, district nurses, membersof the local learning disability team, general hospitalstaff, dieticians, speech therapists and police officers.Our investigation focused on the involvement ofhealth services in the case, including primary care,acute and learning disability services, and paidparticular attention to joint working between them.It was a major investigation, involving the scrutiny ofmany health and social work records and interviewswith 45 people. In parallel with our investigation, theScottish Executive’s Social Work Services Inspectorate(SWSI) carried out an inspection of Scottish BordersCouncil’s Department of Lifelong Care.In April 2004 a joint statement was made by theMental Welfare Commission and SWSI, whichhighlighted the findings of both investigations.This was a particularly harrowing case. In ourinvestigation our prime concern was, and still is, thewelfare of Ms H and Mr E.They want to move onwith their lives.We do not wish to make this moredifficult for them. For this reason we have beenparticularly careful not to identify the personsinvolved and have limited our discussion of the caseto the facts which were published in our jointstatement with SWSI.Background to the InquiryOn 1 March 2002 Ms H was admitted to BordersGeneral Hospital after she had gone to the house ofa friend, who found her to be badly injured andcalled an ambulance. She had multiple injuries fromphysical and sexual assault.Police investigation revealeda catalogue of abuse and assaults over the previousweeks, and possibly a much longer period. Later in2002, four men were convicted of the assaults.Ms H was considered to suffer from a learningdisability. A series of events had led to her beingcared for by one of the convicted offenders. Overmany years, the files held by social work, health andpolice services recorded events and statements thatraised serious concerns about his behaviour towardMs H. However, these records were not acted upon.Ms H and Mr E’s companions were receiving careunder the same circumstances. They had varyingdegrees of learning disabilities, physical disabilitiesand mental health needs. Health and social workrecords contained numerous statements of concernabout their care, including allegations of serious abuseand exploitation. However, these were not actedupon. From late 2000, the lives of these individualsbecame increasingly chaotic. They were neglected,lived in unsuitable and unsanitary conditions andwere financially and sexually exploited.Our findings and recommendationsThe main conclusions of our Inquiry can besummarised as follows:• Ms H was badly let down by services thatshould have intervened to protect her.We hopethat our recommendations about proceduresand communication will make such failuresless likely in future. We think that healthservices in the Borders should act on theserecommendations. We also think services inother parts of the country should use our reportas a basis for examining their procedures.5

THE MENTAL WELFARE COMMISSION FOR SCOTLAND• Protection of vulnerable adults is essential to acaring society. We urge the Scottish Executiveto reconsider introducing legislation on thisissue. We believe that this would give thenecessary guidance to Health and SocialCare Services and provide an improved legalframework for decisions on when, and how,they should intervene in an individual’s life.• We found many caring professionals, who actedappropriately. However, some professionalsexpressed views which implied that theconditions in which Ms H and her companionslived were somehow acceptable.We think thatthis attitude is wrong. All of us have a duty toprotect those who are most vulnerable. In thiscase, despite all the information known toprofessionals, it was a neighbour who finallytook decisive action.• Health and social work services have to achievea balance between the protection of individualsand excessive intrusion into their lives. Inthis case, they failed to recognise the help thatMs H and Mr E required, and, when it wasrecognised, took insufficient action.The full recommendations of our reportWe made 14 recommendations as a result of ourinvestigations. We have also taken note of thefindings of the Social Work Services Inspectorate.Health and Social Work Services1. The role and function of the Borders learningdisability service should be reviewed, to ensurethat the service addresses the health needs ofpersons, including children, with a learningdisability. Special attention should be paid tocommunication, and to the clarity of roles andresponsibilities, within the learning disabilityteam.We are aware that NHS Borders and Scottish BordersCouncil has carried out such a review, which is nearingcompletion, with an agreed strategy having beenprepared. We support their proposal that, for adults,there should be a single community learning disabilityservice, formed from the existing NHS and social workservices, which should have a single manager. Ourrecommendations, in respect of communication androles, would apply to such a joint service.2. NHS Borders should provide guidance formembers of staff, within primary care, acute andlearning disability services, about their roles,responsibilities and communication.The guidanceshould address cases in which a variety ofprofessionals are involved in the assessment orcare of people with a learning disability.3. General practitioners and primary health careservices in the Borders should be made aware of,and have easy access to, information about theneeds of people who have a learning disability.They should receive services which are flexible,and delivered in a way that recognises and dealswith any special requirements they may have.General health services should have appropriateliaison and support from the specialist learningdisability services, as suggested by Promoting HealthSupporting Inclusion, NHS Quality ImprovementScotland (QIS) revised Learning Disability QualityIndicators and NHS Health Scotland LearningDisability Health Needs Assessment Report.4. NHS Borders, along with its partners in ScottishBorders Council and Lothian and Borders Police,should ensure that there is multidisciplinaryco-ordination of complex cases, involving peoplewith learning disability. The co-ordinationshould be at a sufficiently senior level to provideappropriate managerial supervision, effectivesharing of information and accountability ofpractice. Arrangements should include amechanism for the resolution of case-managementdisputes between staff.5. The implementation of the Vulnerable AdultsPolicy in the Borders should be monitored,reviewed and evaluated. It should ensure that theneeds of vulnerable persons with a learningdisability are recognised and responded to byhealth and social work services and theirpartners in Lothian and Borders Police. Theseservices should take account of recommendation23 of the The Same As You? report published inMay 2000, which states, “the appropriateagencies should develop policies and guidelineson protecting vulnerable adults. Social WorkDepartments should review their procedures onGuardianship, to include making a formalassessment of risk a normal part of decidingwhether an application should be made”.6

ANNUAL REPORT 2003-20046. The discharge policy and procedures of BordersGeneral Hospital should give guidance on theneeds of patients who have a learning disability.Liaison arrangements between learning disabilityservices and acute hospital services in theBorders should be in line with Promoting HealthSupporting Inclusion and the recent NHS HealthScotland Learning Disability Health NeedsAssessment Report and NHS QualityImprovement Scotland (QIS) revised LearningDisability Quality Indicators (both published on 23February 2004).7. NHS Borders and Scottish Borders Councilshould ensure that all appropriate staff are awareof the importance of informal carers and theirrights to a carer’s assessment. The ScottishExecutive has produced guidance for localauthorities, the NHS, voluntary services andother agencies, in relation to provision ofsupport to carers under the Community Careand Health (Scotland) Act 2002 (Circular NOCCD 2/2003).8. NHS Borders and Scottish Borders CouncilSocial Work Services should carry out a reviewof record-keeping for cases in which there ismulti-agency involvement.9. A dedicated dietetic service should form anintegral part of Borders learning disability services.10. NHS Borders should review existing policy onthe transfer of information when patients movebetween primary health care teams, and providemedical staff and community nursing staff withclear procedures and guidance for this.Scottish Executive11. The Scottish Executive should prioritise theintroduction of a Vulnerable Adults Bill.12. The Scottish Executive should give guidance toall Health Boards and local authorities, in linewith recommendation 23 of The Same As You?report, on the use of the Care ProgrammeApproach for people with learning disabilitieswho have complex needs, whether these needsare caused by disability or vulnerability.13. The Scottish Executive should produceguidance for health and social work services onhow to carry out critical incident reviews ofcases in which an individual with mental disorderhas been involved with multiple agencies.Other Bodies14. Regulatory bodies such as NHS QualityImprovement Scotland, Social Work ServicesInspectorate and the Care Commission shouldtake account of the findings of this report.Consideration should be given to a joint visit,with the Mental Welfare Commission, to theBorders learning disability services, within thenext 12 months.2.1.2 REPORT OF THE INQUIRY INTOTHE CARE AND TREATMENT OF MR AIntroductionMr A died as a result of injuries he received in a fallwhich occured while he was receiving treatment inhospital for a psychotic illness.The Procurator Fiscaldecided not to hold a Fatal Accident Inquiry.However, Mr A’s parents expressed concerns abouthis care in hospital and contacted the Commisson.Because there was little factual disagreement aboutthe events leading to Mr A’s death, we decided tocarry out an investigation based largely on theavailable records, rather than formally interviewingthe staff concerned.We met with Mr A’s parents andobtained additional written information from theNHS Trust which had been treating him.Summary of EventsMr A was admitted to hospital, suffering from apsychotic illness of acute onset. He had no history ofmental illness, although his sibling had a longstandingschizophrenic illness. The main features ofMr A’s illness were over-activity, elation and grandiosedelusional beliefs, which led him to act impulsivelyand put him at risk. Before admission to hospital, hehad attempted to walk on an ice covered pond andjumped through a glass window, apparently believingthat he could not be harmed. At times during theadmission, he expressed other delusions, including abelief that he could fly and that he was dead. Heattempted to leave the ward on at least three occasions.He was not detained under the Mental Health(Scotland) Act 1984 although he was described as“detainable” and was not allowed to leave the ward.7

THE MENTAL WELFARE COMMISSION FOR SCOTLANDHis admission lasted 16 days, during which time hismental state fluctuated considerably. Initially he waselated, unpredictable and irritable. He was reluctantto accept tablets and required injections of antipsychoticdrugs on two occasions. His mental stateimproved after these but deteriorated again shortlybefore his death.Throughout his admission, a senior house officerfrequently assessed his mental state. However, thisdoctor only had a few weeks’ experience in psychiatry.The consultant in charge of Mr A’s care interviewedhim on four occasions. However, she went on leaveeight days after his admission and, because ofproblems in consultant cover, he was not seen againby a consultant. The senior house officer twicephoned another consultant to discuss aspects of hiscare during the second half of his stay in hospital.During his admission, there were several unplannedchanges in his prescribed level of nursing observation.Initially he was placed on “constant” observation(the middle observation level).This level was reducedto the lowest level a few hours later by the seniorhouse officer. Later that day he attempted to leavethe ward, by breaking through the locked doors.Following this, his observation level was increased to“constant” again, and he remained on this level forfour days. It was then reduced again; this time by aduty doctor, at the nursing staff ’s request. Soonafterwards, he again attempted to leave the ward andwas once more placed on “constant” observation.He remained on this level for four days, after whichit was reduced again; it remained at the lowest level,until his death, eight days later.In his records, the prescribed level of nursingobservation was recorded in three places and theentries were not always in agreement. However, onthe day of his death, the nursing record indicatedthat he should only be allowed to leave the ward ifaccompanied by members of staff.The medical recordcontained a similar statement. In spite of this, he wasgiven permission to leave the ward in the companyof his parents. Shortly afterwards he ran away fromhis parents and fell from a considerable height. Hedied a few hours later from the injuries he suffered.No one witnessed the fall.Mr A’s consultant met with his parents soon after thedeath. They subsequently wrote to the Trust toexpress concerns about the availability of seniormedical staff and about the diagnosis.They believedthat the severity of his illness had been underestimated.The letter was acknowledged but nosubstantive reply was ever made.They were offered ameeting to feed their views into the local CriticalIncident Review. However, they did not attend asthey had no faith in the local managers and believedthat an independent inquiry was necessary.The Psychiatric ReportsA consultant psychiatrist, working at another Trusthospital, carried out a Confidential Enquiry, basinghis reports on records and interviews with membersof staff. Mr A’s parents were not invited to take part.Although it seems unlikely that his death was bysuicide, the report is entitled “Confidential Reporton the Suicide of Mr A”.The report concluded that“the care that the patient received was of a very highstandard and treatment was administered in line withgood psychiatric practice”. However, it noted that:there were problems with consultant cover; decisionswere taken by “a relatively junior member ofmedical staff ”; and there was a “lack of clarity indocumentation”. It made recommendations aboutthree aspects of care: the clarity of medical treatmentplans; the involvement of senior doctors in decisionsabout the level of observation; and the managementof sick and holiday leave among medical staff. Thereport was not completed until six months after MrA’s death.The Procurator Fiscal obtained an independentmedical report from a consultant psychiatristworking in another Health Board area. This reportconcluded that there was a breakdown incommunication, either among the nursing staff orbetween them and Mr A’s parents. It concluded thatthe records showed nursing staff should have beenaware that Mr A was only allowed to leave the wardin the company of staff, but that other aspects of careand treatment were “well within the bounds ofacceptable practice”.8

ANNUAL REPORT 2003-2004Mr A’s Parents’ ConcernsMr A’s parents had a number of concerns about hiscare in hospital.The first was that the seriousness ofhis illness was underestimated. They believed, basedon their experience with his brother, that he was sounwell that he should have been treated in anintensive psychiatric care unit. In view of theseriousness of his illness, they thought that aconsultant psychiatrist should have been directlyinvolved in his care, throughout the admission.They considered the senior house officer to beinsufficiently experienced. They also reported thatthey had expressed concerns about their son’s mentalstate to members of staff on a number of occasionsand they did not believe that these had beenrecorded or passed on to medical staff. (The recordssupport their view.) They also believed that, in viewof his worsening mental state, he should not havebeen allowed to leave the ward with them on theday of his death.They had assumed that the outingwas safe because hospital staff had approved it.Theywere also concerned that they had never received asubstantive reply to their letter to the Trust, writtenshortly after their son’s death.FindingsAfter considering the available information, wemade the following findings:1. There were clear grounds for detaining Mr Aunder the Mental Health Act.These included hissafety, the need for restraint and his doubtfulconsent to treatment. However, he was notdetained and there is no record of the reasons forthis. If he had been detained, a senior psychiatristwould have been required to approve any periodof leave from the hospital.2. Because of an unexpected combination ofconsultant sickness and annual leave, aninexperienced junior doctor was left to managea complex case. There was no direct consultantinvolvement in Mr A’s care in the second half ofhis admission, during which his mental statedeteriorated significantly.3. Junior doctors made mistaken decisions toreduce nursing observation levels, withoutconsulting senior doctors. There was a lack offorward planning in deciding observation levelsin relation to the risks of harm to Mr A.4. There was no detailed multidisciplinary care plan.5. Mr A’s parents noticed a deterioration in theirson’s mental state but their views were ignored.Nursing staff failed to record them.6. The records were inconsistent. There wasinaccurate duplication and ambiguity in places.However, Mr A’s death could have been avoidedif the records had been read with care.7. The Trust failed to respond to Mr and Mrs A’sletter of complaint. They were not asked tocontribute to the Trust’s Confidential Enquiry,which failed to address many of their concerns.RecommendationsBy the time that our investigation was completed,the Trust had taken a number of actions to addressthe findings of its Confidential Enquiry, including theintroduction of a new system of recording care plansand improved arrangements for medical cover. Wemade a number of recommendations, which aresummarised below.1. The Trust should review the effectiveness of itsnew care plan documentation after one year. Itmust ensure that decisions about observationlevels are recorded clearly in the nursing andmedical notes.2. The Trust should review its nursing observationpolicy to ensure that decisions to reduceobservation levels are taken by sufficiently seniormembers of staff, and that they have access to allrelevant clinical information (includinginformation from relatives).3. The Trust should review its arrangements forescorting patients who are subject to raised levelsof observation.4. The Trust should review the need to train staff inrisk assessment.5. The Trust’s clinical governance committeeshould consider whether guidance on the use ofthe Mental Health Act requires review.6. NHS Quality Improvement Scotland (QIS)should be made aware of the problem ofconsultant cover in the Trust, so that it maymonitor this.9

THE MENTAL WELFARE COMMISSION FOR SCOTLAND7. The Trust should consider its communicationwith relatives and carers. Relatives and carersshould be involved in Critical Incident Reviewsand related enquiries, in accordance with theMental Health Reference Group’s RiskManagement report.8. The Trust should reply to Mr and Mrs A’s letterand consider whether an apology would beappropriate.The Commission will meet the Health Board andTrust, to follow up these recommendations and discusswhat further action is needed.2.1.3 FOLLOW UP TO THE MR CINQUIRYLast year we reported on the Commission’s inquiryinto the care and treatment of Mr C who hasdementia. Mr C had remained in hospital for nearlythree years because of delays in obtaining a place ina care home, and the funding for it. He became seenas a “bed blocker”. During this time he had noregular occupational therapy or activities and hespent his days walking up and down the ward’scorridors. No outings were arranged and he hadvery few visits from his family. In our inquiry, wefocused on the inadequate arrangements for dealingwith delayed discharges from hospital and on thepoor quality of life for patients in long stay wards.We followed up the recommendations from ourinquiry, with the Trust and Local Authority, both inwriting and face to face. Their initial response waspositive and we were satisfied that appropriatearrangements had been made to improve planningfor patients whose discharge might be delayed. TheScottish Executive’s figures on delayed dischargepatients confirmed that the new arrangements hadbeen effective.However, we were disappointed with the services’lack of progress in improving long stay patients’quality of life.We had recommended a full review ofpossible ways of doing this, but our recommendationswere initially dealt with in a piecemeal fashion and hadlimited outcomes.We recently made an unannouncedvisit to the Trust’s long stay wards, which showedthat, while the physical care of patients continued tobe good, there was little improvement in theirquality of life. Nurses were acutely aware of thesedeficiencies but said they had few resources and littlesupport from managers to bring about changes.In December 2003, we wrote to the Chair of theHealth Board about our continuing dissatisfaction.Following a prompt internal enquiry, the Board’ssenior managers met us and agreed a satisfactoryaction plan. Through training and increasedresources, the Trust is now giving more attention tothe ways in which long stay patients’ quality of lifecan be improved. We aim to continue to monitorthis through our visits to continuing care wards.2.2 VISIT PROGRAMME 2003-2004Our visit programme continues to be one of themain ways that we make contact with people whoare receiving care and treatment in hospitals andother care settings.We visit both patients who havebeen detained for longer than two years, and thosewho ask to see us at the time of our visit.We carryout monthly visits to the State Hospital. Weincreasingly carry out our visits without notifyingthe staff beforehand.What do we do with the information and issues thatarise from these visits? We raise individual cases withclinicians and with service providers and we alertNHS bodies and local authorities to any generalproblems that we have found in mental health andlearning disability services.We report on deficienciesin individuals’ care, loss or damage to their propertyand any ill treatment or improper detention theymay suffer.In addition to visiting hospitals and care homes, wevisit individuals who are on welfare guardianship orcommunity care orders or leave of absence fromdetention.We also visit those who have asked us toconsider their discharge from detention or recall oftheir welfare guardianship orders. (More informationabout this work is given in Section 2.7 of thisReport.)At the end of every year we meet with seniormanagers from NHS bodies and local authoritysocial work departments, to discuss general issuesarising from all of our visits.Visit Programme Activity: Key Points in2003-04• We visited 65 hospitals and care facilities• We carried out 6 unannounced visits (includingone to the State Hospital)10

ANNUAL REPORT 2003-2004• We held 1905 individual interviews withpatients or residents: 58% of the interviewswere initiated by us• We met with 48 relativesDetails of people seen during our hospital visits aregiven in Tables 1 and 2. During 2003-04, the numberof individuals seen in hospitals continued to rise,increasing by 6%, compared with last year, and 13%,compared with 2001-02. We also interviewed over50% more relatives, compared with 2002-03.Table 1: Individuals Seen on the VisitProgramme, 2003-04Statutory 144Requested interviews 676First language is not English 16Incapax 31Other MWC initiated 75Total individual interviews 942Service users seen in groups 17Relatives 48Total contacts 1007Table 2: Individuals Seen on Monthly Visitsto the State Hospital, 2003-04Requests for discharge 38Other requests 26Statutory and routine visits to restricted patients 51Total 115Table 3 shows details of all the individuals we saw athome or in care homes. Compared with the previousyear, we saw 46% more people (848, compared with582). Most of this increase was due to a large rise inthe number of visits to people on guardianship orders(392, compared to 205). This reflects the increasinguse of guardianship, as discussed in Section 3.2 ofthis Annual Report.Visits to individuals on Leave ofAbsence from hospital also rose significantly (321,compared with 243).This probably reflects the sharpincrease in use of Leave of Absence by mental healthservices, as discussed in Section 3.1.1.Table 3:Visits to Individuals in Care Homesand the Community, 2003-04Leave of Absence 321Leave of Absence/Statutory 5Guardianship – initial 392Guardianship – return 99Intervention Orders 26Community Care Orders 5Total 848The Main Issues Arising from our VisitsOur visits are always focused on individuals, whetherthey are cared for in adult acute admission wards,old age psychiatry wards, continuing care facilities,intensive psychiatric care units or the State Hospital.We have found that common themes emerge fromthese visits, regardless of the type of facility. Many ofthese themes relate to the challenges of trying tomeet individual needs in institutional settings.Thereis an ever-present tension between attempts to focuson the personal needs of an individual in a ward orcare home, and the many institutional pressures thatwork against these being recognised and met.We have continued to see a wide range in thestandards of individual care across the country. Someservices provide good and creative care and are alwayslooking at how to improve; their common feature istheir focus on the individual patient or resident, andhis or her relatives or carers. We have also seenservices with dull and mediocre environments andattitudes, where service-users and their relatives tellus, rightly, that they do not feel they are being givenan adequate service.The following are the outstanding issues that havearisen during our visits in 2003-04:• Admission of young people to adult acute admissionwardsOn visits to adult acute admission wards andintensive psychiatric care units, we have had contactwith patients as young as 13, who had been admittedthere because a child or adolescent bed was notavailable. Staff, rightly, have grave concerns abouttreating children and young people in settings thatare entirely unsuitable, despite efforts to provideappropriate care. Child protection issues are raised by11

THE MENTAL WELFARE COMMISSION FOR SCOTLANDplacing children in acute adult mental health wards.We believe this situation to be entirely unacceptable.We discuss this situation in more detail in our sectionon mental health services for children and youngpeople (Section 3.3).• Boredom and drabnessIn around a third of the 65 facilities we visited thisyear, we were told by patients and relatives that therewere not enough activities or stimulation. We haveseen patients who sit around watching televisionthroughout the day and have very limited contactwith staff.Although lack of staff resources may partlybe a reason for this, simply providing additional staffis not the whole answer. Clear strategy, leadershipand training is required. Managers and all clinicalstaff have to take responsibility for ensuring thatpeople in care settings have appropriate stimulationin their lives. Involvement in activity needs to betailored to individual needs and be integrated withindividual care plans.Across Scotland, there are excellent examples ofcreative work between care services and outsideagencies, to achieve a range of activities that arevaried enough to meet the individual needs ofpatients. New models of care are being tried out inadmission wards in Glasgow; patients on these wardstold us that their experience of being in hospital hadimproved, compared with previous admissions. Westrongly believe that this is an area of care that hasnot been given enough attention by many servicesand we will continue to press for improvements.There has been a general improvement in theenvironment of many of the in-patient facilities thatwe visit. However, there remain some that are drab,poorly maintained and untherapeutic. In-patient careremains an important component of a comprehensivecommunity-based service.Where an inpatient unit’sbeds are under pressure and it is poorly maintained,it does not provide an attractive proposition forsomeone who requires admission, and can lead to anunderstandable reluctance to come into hospital.This issue is very apparent in services for older people.We have been struck by the very wide variation instandards across the country. In one unit it is possibleto find an attractive environment with tranquilgarden areas, places to sit with visitors and a soothingatmosphere. In another unit of similar design andwith a similar client group, we have found anenvironment that was clinical, lacking in characterand presenting a cold, impersonal feel. We suspectthat poor local leadership is probably the mostimportant reason for such unpleasant environments.• Learning disability – hospital closures andreprovisioningWe meet people with learning disability, bothbefore and after they move out of hospital. We areparticularly concerned about the group of individualswho remain in learning disability hospitals scheduledfor closure.Their future care can be uncertain for avariety of reasons, including: difficulties in funding;problems in identifying sites for new buildings; alack of appropriate housing stock; and delays inidentifying suitable staff. As well as reducing theiruncertainty, it is vitally important that hospitalmanagers try to give these individuals a decentquality of life and do not subject them to multiplemoves through a progression of closing wards, withincreasingly limited facilities.We have also visited people who have left hospitaland now have detailed care planning, homelyenvironments and integration into their localcommunities. However, we have been concernedabout some individuals who have moved fromhospital and find themselves living in situationswhere their only personal contacts are with paidcarers. In some respects, this could be regarded asbeing worse than living in hospital.• Pressures on acute inpatient services and access tointensive careThere have been many developments in bedmanagement throughout the country that,we are told,have improved the availability of beds. However, weare aware patients needing hospital care too oftencannot get a bed locally and find themselves beingadmitted to units some distance away from theirhome.This brings them many difficulties, including:discontinuity of care, new staff, impaired contactwith relatives and uncertainty over the timing of areturn to the local facility. Each of these can have anadverse effect on their progress. As we reported inthe 2000-01 Annual Report, access to care inIntensive Psychiatric Care Units can be particularlytroublesome. On one visit to Inverness, we met apatient from Glasgow, who was moved there becausehe required intensive care and the Inverness unit hadthe nearest available bed at the time. NHS Glasgowagreed with us that this was not acceptable.12

ANNUAL REPORT 2003-2004The Special Visiting Theme for 2003-04:Race and CultureRacial and cultural issues among people with mentaldisorder were the Commission’s special focus duringthe 2003-04 visiting programme. We visited sixnational and 15 local organisations aimed at helpingindividuals from minority ethnic backgrounds. Mostof these were in Edinburgh and Glasgow, but we alsocontacted organisations in Fife, Aberdeen andFalkirk. The full report of this work will bepublished separately. What follows is a summary ofthe main findings.We identified some factors which we thoughtsignificantly affected people from minority ethnicbackgrounds, who also had a mental disorder. Theyincluded:• Experience of racial discrimination andharassment• Social isolation and loneliness• Limited support from services, and poor accessto them.• Limited informal support from families• Difficulties getting housing and employment• The stigma of mental illness in somecommunities, which led to under-reportingof mental health problems.Vulnerable groupsService providers, particularly in Glasgow, describedthe circumstances of asylum seekers as being a majorconcern. We had the impression of services inGlasgow struggling to meet the mental health needsof individuals from diverse ethnic groups who havea variety of serious social, economic and politicaldifficulties, in addition to their, often serious,mental disorder.In addition, other vulnerable groups were identified.They included: young women; people who misuseddrugs and alcohol; older people who were unable tospeak English; women with dual heritage children;and individuals from specific ethnic groups, such asBangladeshi and Polish communities.Barriers to careWe identified some examples of good practice, inparticular two services for asylum-seekers inGlasgow and another for carers of older people inEdinburgh. However, we also discovered a numberof barriers to care.These included:• Difficulties in communication due to languagedifficulties and lack of adequate interpretingservices.• Lack of culturally appropriate care settings,particularly single-sex accommodation.• Lack of culturally sensitive assessment procedures,to help in planning appropriate care.• Uncertainty in planning culturally appropriatefollow-up, when patients are discharged fromhospital.• Lack of appropriate advocacy services• Problems in the community placement ofhomeless people with mental disorder, whosefear of racial harassment could have significanteffect on their well-being.Further action• For service providersWe think that service providers should make theirservices more sensitive to the cultural and languageneeds of users from minority ethnic backgrounds.This includes the development of appropriateassessment and discharge procedures. They shouldreview the quality and availability of interpretingservices and the availability of culturally appropriateadvocacy services. This will be especially importantwhen the Mental Health (Care and Treatment)(Scotland) Act 2003 is implemented next year:respect for diversity is an important principle of theAct. Staff training is necessary to ensure that peoplefrom these backgrounds have their mental healthneeds met and ethnic monitoring should beproperly established to check on this.We think that NHS Quality Improvement Scotland,the Care Commission and the Social Work ServicesInspectorate have an important role in ensuring thatservices change in the necessary ways.13

THE MENTAL WELFARE COMMISSION FOR SCOTLAND• For the CommissionWe are continuing to review the appropriateness of,and ease of access to, our information and services.In our role of monitoring the new Act, we will bepublishing information on how it is being usedamong people of different ethnic backgrounds. Wealso hope to develop further the links we have madewith some of the organisations we have visited.The full report will be available later this year andwill also be available on the Commission’s web site,www.mwcscot.org.ukOur New Visit Programme for 2004-05At the end of 2003-04, we undertook a majorreorganisation of our visit programme.We hope thiswill make it better suited to visiting people inhospital, care homes and community settings, help uscarry out our new monitoring functions under theMental Health (Care and Treatment) (Scotland) Act2003 and improve our reporting back to serviceusers and providers. Further details are given inSection 2.3 of this Annual Report and in theDirector’s Report. We will report on our newprogramme in next year’s Annual Report.2.3 COMMUNICATIONS WORKFollowing consultations with users and carers during2002-03 we have made significant improvements inhow we communicate with others, particularly withservice-users. Some of the things we have doneinclude:• Creating a part-time Commissioner post forsomeone with a learning disability.We are verypleased that Douglas White has been appointedto the post.This is the first public appointmentin Scotland of a person with learning disabilitiesand is further recognition in the Commissionof a need to involve service users in our work.Of our 17 part-time Commissioners, he is oneof the four from a service user or carerbackground.• Changing our visiting programme from ourhistoric pattern of having single large-scaleannual visits to hospitals to having smaller-scale,but more frequent, visits.We hope that this willmake us more accessible to service-users andcarers, and give us greater flexibility to meetindividuals who want to talk to us. We thinkthat it will enable us to visit parts of servicesthat we have not previously visited. This willinclude visits to community-based services suchas clubhouses and resource centres. We havealso started to inform patient councils and localadvocacy services of the dates of our visits,rather than depend on service staff doing thisfor us. The new visit programme started on1 June 2004.• Producing two executive summaries of ourAnnual Report – one in plain English and theother in an easy to read format, designedspecifically for people with learning disabilities.• Holding three roadshows, in different parts ofScotland, to explain our role and the work thatwe do.• Holding a further consultation event withservice users, this time in the Forth Valley area.This was requested by the local associations formental health, who facilitated it with the helpof the Scottish Development Centre forMental Health.In an effort to ensure a coherent approach to ourcommunications work, we are in the process ofdeveloping a new communications strategy. Thestrategy aims to:• Identify ways of communicating with allstakeholders;• Consider mechanisms for communicating withhard-to-reach people;• Review our corporate image and makesuggestions for change; and• Help to identify a clear and concise messagewhich will communicate our role.To help with this, we asked a consultancy to contactpeople who have used mental health or learningdisability services, and practitioners working in theseservices, to obtain their views of how effective ourcommunications were.We were pleased to hear thatsome people thought we had made improvementsover the past few years. However, we were also told,and recognise, that there is a lot of work still to do.14

ANNUAL REPORT 2003-2004The consultants made the following recommendations:• We should develop key messages about our role,which can be communicated simply and easily.• We should introduce a free-phone numberwithin a region of Scotland, to test the nationaldemand for this service and make decisionsabout the best way of meeting that demand.• We should produce a set of posters and leaflets,written in Plain English and using symbols andpictures, with translated text.• We should call on the advice of user groups(for both people with mental health problemsand people with learning disabilities), to help usdevelop appropriate communications materialand effective distribution systems.• We should develop a systematic way of ensuringeffective distribution of our information.• We should produce a range of information onaudio and video tapes, similar to information inour printed leaflets.• We should review our systems for feeding backwhat we have done in relation to complaintsand enquiries.• We should develop educational material, aboutour role, which can be incorporated into trainingcourses for practitioner staff (nursing, socialwork, medical, and voluntary sector training).We intend to take forward all of theserecommendations. The introduction of the newMental Health Act in April 2005 gives us an idealopportunity to update all of our current publications.2.4 SUICIDES REPORTED TO THECOMMISSIONUnexpected death always comes as a shock and isdistressing for friends and relatives alike.The impactof suicide is all the greater because, more often thannot, it is associated with feelings of guilt and failure.When someone is receiving psychiatric help, thesefeelings will affect all those involved, including staffand fellow service users. Though not all deaths bysuicide can be prevented, we can try to reduce thechance of an individual committing suicide, byensuring he or she receives comprehensive andcoordinated assessment and care.The Commission’s role is to examine the individualcircumstances surrounding such deaths and theclinical care being provided. Table 1 shows thenumbers reported to us in 2003-04. As shown inTable 2, roughly three-quarters of the people weconsidered in 2003-04 were considered to havedefinitely committed suicide. More often than not,after investigation,we concluded that no further actionwas warranted. We considered that further enquiryshould be made in only one third of the cases weexamined. We believe that there should be robustlocal procedures to investigate untoward incidentsand deaths, so that lessons can be learned and practiceimproved.While we are pleased to note a progressiveincrease in the use of local Critical Incident Reviewsand audit, we remain concerned that not all suicidesoccurring in hospital are examined in this way (seeTable 3).Table 1: Annual Total of Suicides Consideredby the Commission, 1994-04Total Total Total Total TotalIP OP IP & OP Male Female Totals* **1994-95 24 52 76 48 28 761995-96 15 46 61 37 24 611996-97 32 55 87 59 28 871997-98 26 66 92 64 28 921998-99 22 59 81 54 27 811999-00 20 75 95 63 32 952000-01 20 64 84 57 27 842001-02 26 75 101 63 38 1012002-03 15 108 123 88 35 1232003-04 25 147 172 101 71 172* IP = In-patient ** OP = Out-patientTable 2: Estimate of the Likelihood that Casewas Suicide, 2003-04IP OP Totals (%)Identified as suicide 20 106 126 (73)Probably suicide 4 20 24 (14)Possibly suicide 1 21 22 (13)Totals 25 147 172 (100)15

THE MENTAL WELFARE COMMISSION FOR SCOTLANDTable 3: Suicide Reviews and Audit, 2003-04IP OP Totals (%)Review or audit held 23 128 151 (88)No review or audit held 2 18 20 (12)Unknown 0 1 1Totals 25 147 172 (100)Great care should be taken when trying tointerpret the information in our tables. Theinformation we receive is not comprehensive,though we do believe that most suicides ofinpatients are now reported to the Commission.More accurate information is available from theNational Confidential Inquiry into Suicide andHomicide by People with Mental Illness. Ourfigures are also affected by changes in ourarrangements for dealing with these notifications.They only appear in the tables once all the reportson a death have been obtained and presented tothe Commission.There may be significant delays,therefore, between the notification of a death by ahospital or local authority and its formalconsideration. We are currently reviewing thisprocess and we hope that cases will be dealt withmore quickly in future.What the tables do show is a progressive increase inthe number of cases being considered by theCommission; up by almost a third on the previousyear, as shown in Table 1.Table 4 shows that, as in theprevious year, deaths amongst younger peoplebetween 25 and 44 years were most prevalent,though older people remained at significant risk.Hanging continued to be the commonest method ofcommitting suicide; this is important for thoseassessing the risks for patients in hospital (see Table 5).As shown in Table 6, a significant number of reportscontinued to indicate that the patient appeared to feelbetter prior to committing suicide; this highlightsthe need for continuing vigilance and risk assessment.Table 7 confirms the well-established link betweensuicide and previous self-harm.Table 4: Age and Sex Distribution of CasesConsidered by the Commission, 2003-04Male Female Both Total (%)Age IP OP IP OP IP OP15-24 0 7 3 0 3 7 10 (6)25-34 3 33 0 14 3 47 50 (29)35-44 5 16 4 16 9 32 41 (24)45-54 1 17 0 11 1 28 29 (17)55-64 3 8 3 9 6 17 23 (13)65-74 2 3 1 8 3 11 14 (8)75-84 0 2 0 2 0 4 4 (2)85+0 0 1 0 0 0 1 1 (1)Totals 14 87 11 60 25 147 172 (100)Table 5: Mode of Death, 2003-04Male Female Both TotalIP OP IP OP IP OP (%)Hangingor otherasphyxiation 6 33 3 18 9 51 60 (35)Overdose 2 24 4 22 6 46 52 (30)Drowning 3 4 1 8 4 12 16 (9)Jumping 1 10 1 5 2 15 17 (10)fromheightCar exhaust 5 2 7 7 (4)Railway 4 4 4 (2)Road 1 1 1 (1)Cutting 3 1 1 1 4 5 (3)Fire 1 2 1 2 3 (2)Other 1 1 1 1 2 (1)Not Known 3 2 5 5 (3)Totals 14 87 11 60 25 147 172 (100)What the tables cannot show, though, are theexpressions of personal concern by the staff directlyinvolved in the individual’s care; these are increasinglymentioned in the reports that we receive.16

ANNUAL REPORT 2003-2004Table 6: Mental state at last contact beforedeath, 2003-04IP OP Totals Male Female TotalsIP&OP (%)Better 3 24 27 13 14 27(16)Worse 3 13 16 7 9 16(9)No 4 23 27 14 13 27different (16)Unknown 15 87 102 67 35 102(59)Totals 25 147 172 101 71 172(100)The role of the CommissionOur authority for investigating suicides comesfrom Section 3(2)(a) of the Mental Health(Scotland) Act 1984. We are interested not onlywhen such a death occurs where the patient isdetained or an in-patient but also when it occurswhile an outpatient, day-patient or following arecent discharge from care.We expect deaths whileunder psychiatric care to be notified to us by theconsultant in charge or responsible medical officer.We welcome, though, the small but increasingnumber that are being notified by procuratorsfiscal, social workers or care home managers. Wewould like to see more notifications from localauthorities, particularly where they have taken thelead in providing care.Table 7: Past History of Self-Harm orThreats of Self-Harm, 2003-04Male Female Totals (%)Actual self-harm 48 38 86 (50)Threats only 25 14 39 (23)None 20 9 29 (17)Not known 8 10 18 (10)Totals 101 71 172 (100)Advice on reporting a possible suicide tothe CommissionNotify the Commission of the death very soonafter the event. A full report should then beprepared which can wait until after the suicidereview.This report should include:• A brief background emphasising risk factors• A brief psychiatric history and diagnosis• Any past history of threats of self-harm oractual self-harm• Significant life events prior to death• Treatment and care plan at time of death andany recent changes• If an in-patient, observation status at the timeof death• The circumstances and method of suicide• Actions taken by the Procurator Fiscal,Trustor Local Authority• The outcome of the suicide review or auditor other enquiry.This advice can be found on our website atwww.mwcscot.org.uk2.5 ACCIDENTS AND INCIDENTSREPORTED TO THECOMMISSIONWhen a significant accident or incident is reportedto us, one of our practitioner staff looks at the reportand decides if further information is required or not.When we have sufficient information, the incident isconsidered by one of our standing committees, theSuicides,Accidents and Incidents Group.This groupconsists of Commissioners and practitioner stafffrom a variety of professional, service user and carerbackgrounds. It identifies any lessons that can belearnt and communicated to services, to reducethe risk of harm to other individuals in similarcircumstances. Further action may include:• Specific recommendations to services, andindividual practitioners or care managers aboutcare, treatment and service organisation• Follow up of recommendations to ensure thataction has been taken• Arrangements for our visit teams to check andmonitor outcomesSome recent outcomes of cases have included:• Services have reviewed care planningarrangements and updated risk managementplans17

THE MENTAL WELFARE COMMISSION FOR SCOTLAND• Services have reviewed other policies andprocedures e.g. manual handling and protectionof vulnerable adults, and also initiated stafftraining sessions• We have informed the Committee for theSafety of Medicines about possible druginteractions• We have told the Chief Medical Officer aboutpotential problems associated with the physicalmonitoring of patients receiving particulardrug treatmentsAccidents and Incidents reported by LocalAuthorities, Independent Providers andVoluntary Organisations, 2003-04During 2003-04 we received seventy-one reports ofsignificant accidents and incidents.This is an increaseof 14%, compared with 2002-03. The majority ofreports were from the voluntary sector (35) and localauthorities (31).Table 1 shows the types of incidentsreported.Table 1: Accidents and Incidents reportedto the Commission by Local Authorities,Voluntary Organisations and the IndependentSector, 2003-04.Nature of IncidentAlleged AssaultBy staff 3By staff (sexual) 2By other service user 5By other service user (sexual) 1By other individual 2By other individual (sexual) 5Assault on staff 1Assault on individual 1Assault on other service user (sexual) 2Sub total 22DeathNatural causes 23Drug related 3Death following incident 3Sub total 29(continued)Possible financial exploitation 10Physical injuries 7Medication wrongly administered 1Set fire to room 1Absconded from care establishment 1Sub total 20Total 71Forty-six of these incidents related to people withlearning disabilities, twelve to people with dementia,eight to people with other mental illness and five topeople with drug and alcohol dependency.In four of the five incidents involving assaults bystaff, the staff members were dismissed; police foundno evidence in the fifth. Of the other seventeenreported assaults: in four cases the police found nosubstantiating evidence; in four the individualsbecame subject to welfare guardianship; in threethe individuals were moved to alternativeaccommodation; and in four risk management planswere updated. In two cases, the alleged perpetratorshave been charged.Protecting Vulnerable PeopleThe Scottish Executive has proposed theintroduction of a list of people unsuitable to workwith vulnerable adults. We are concerned that thiscould be counter-productive, because it couldinduce an unwarranted sense of complacency andwould not address the needs of people who areabused or exploited by non-professionals. In ourview this list would not be a substitute for aVulnerable Adults Act and we would have seriousconcerns if it were the only protection being offeredto vulnerable adults.A National Audit of DeathsThe NHS Health Scotland Needs Assessment Reporton People with Learning Disabilities in Scotlandconcluded that failure to recognise and meetcomplex and multiple health needs may contributeto premature deaths.The report recommended thatwe and the Care Commission audit all deaths ofpeople with learning disabilities, in any non-familycare setting.We have considered this and are awaitingguidance from the Scottish Executive on theimplementation of the report’s recommendations.18

ANNUAL REPORT 2003-2004Accidents and Incidents Reported to theCommission by Health Services 2003-04The type of accidents and incidents reported to theCommission by health services are shown in Table 2.Table 2: Accidents and Incidents Reported tothe Commission by Health Services, 2003-04Nature of IncidentAlleged AssaultBy other patient 1By other patient (sexual) 3By staff 6By staff (sexual) 5By other 2By other (sexual) 2On another patient 8On another patient (sexual) 2On staff 7On other 1Sub total 37Self-Harm (non fatal)Overdose 3By ligature 2Burning 2Cutting 5Fall 10Other 5Sub total 27DeathFollowing accident/incident 7Sudden/Unexpected 18Death Unascertained 5Sub total 30Absconsion (detained patients) 15Restraint 6Murder/Manslaughter of Other 1Other 24Total 140Observation of People with Acute MentalHealth DisturbanceIn 2003-04, we continued to receive reports ofserious self-harm among patients in hospital whowere being observed by “15 minute timed awarenesschecks”. In 2002, NHS Scotland’s Clinical Resourceand Audit Group (CRAG) published a Good Practicestatement, Engaging People. This document replacedthe 1995 CRAG/SCOTMEG guidance NursingObservation of Acutely Ill Psychiatric Patients in Hospital.The updated 2002 Guidelines clearly state thattimed observations of patients do not contribute tothe safety of the observation process, although beingaware of a patient’s whereabouts contributes to goodgeneral nursing practice. This view is supported bySafety First, the 2001 report of the NationalConfidential Inquiry into Suicide and Homicide byPeople with Mental Illness.We will continue to raisethis issue with any service which uses timed checks forobservation of acutely unwell people.Reporting of Accidents and Incidents byGeneral PractitionersWe are aware that we do not always receive reportsof the most serious accidents and incidents involvingpeople with mental disorder. Quite often, the onlyperson involved in the patient’s ongoing care andtreatment is the General Practitioner, who may notbe aware of the need to report to the Commission.We would urge General Practitioners to let us knowof any serious accidents/incidents which may laterlead to further enquiry, e.g. investigation byProcurator Fiscal, Fatal Accident Inquiry, CriticalIncident Review, Suicide Review, etc.Advice on reporting an accident/incident to theCommission is shown in the box and is available onour website (www.mwcscot.org.uk). If you areunsure about making a report, please do not hesitateto contact us for advice.*In addition to the above, 52 cases of death by natural causeswere reported.19

THE MENTAL WELFARE COMMISSION FOR SCOTLANDAdvice on Reporting an Incident to theCommissionReports should contain the following information• A brief account of the circumstances of theincident.• Information on diagnosis, treatment (if relevant)and the mental state of the person at the timeof the incident.• Information regarding any other person(s)involved in the incident, indicating whetherthey are patients, staff or public.• A note of any changes being considered inprocedure, management, or materialenvironment as a result of the incident.• An indication of any further investigation orenquiry which is being carried out.2.6 CONSENT TO TREATMENTNeurosurgery for Mental DisorderWhen neurosurgery is proposed as a treatment forthe mental disorder of a patient subject to the 1984Mental Health Act, Part X of the Act requires theCommission to arrange the assessment of both theindividual’s ability to consent to it and itsappropriateness for him or her. Commissionersnormally do these assessments. They also carry outequivalent assessments of informal patients; this is bya voluntary agreement with the University ofDundee, which is the centre for this treatmentin Scotland.During the past year, only one new patient wasreferred for assessment. The patient was detainedunder the English Mental Health Act 1983, with along standing treatment-resistant depression, and hadbeen referred to the Dundee Service.The operationproposed was a bilateral anterior cingulotomy.The Commissioners who carried out theassessments confirmed that the patient was capableof understanding the nature of the proposedoperation and had given informed consent to it, andthat the treatment was appropriate.A second patient, who had been assessed for ananterior capsulotomy operation in the previous year,was re-referred. This was because new evidencesuggested that this operation could have a higherrate of adverse effects than the alternative procedureof bilateral anterior cingulotomy. We consideredwhether the proposed change of operation made areassessment necessary. After correspondence withthe patient, we decided that formal reassessment wasnot necessary and that the criteria for going aheadwith the treatment were met.These individuals have now had their operations.Wewill be seeking follow up reports on their progressduring the next year.Mental Health (Care and Treatment)(Scotland) Act 2003Regulations are currently being drafted to providesafeguards for treatments which will be given underthe new mental health legislation. Some new surgicalprocedures, which have been developed for thetreatment of mental disorder, would not be covered bythe sections of the new Act relating to neurosurgery;these are deep brain stimulation and vagus nervestimulation. Because they are recent treatments andinvolve invasive procedures, we think they needspecific safeguards.We have, therefore, recommendedto the Scottish Executive that they should be specifiedas regulated treatments under the Act.Second Opinion WorkSecond Opinions under Sections 48 and 50 of theAdults with Incapacity (Scotland) Act 2000Under Section 48 of the Adults with Incapacity(Scotland) Act 2000, four treatments require theapproval of a second opinion doctor appointed bythe Mental Welfare Commission.The treatments are:drug treatment to reduce sex drive; ECT; abortion;and any medical treatment which is likely to lead tosterilization as an unavoidable result.The number ofsecond opinions carried out in respect of thesetreatments during 2003-2004 is shown in Table 1.Table 1: Second Opinions under Sections 48and 50, 2003-04Section 48 Section 50Medication 17 0ECT 26 0Total 43 020

ANNUAL REPORT 2003-2004The number of second opinions for the use ofmedication is the same as 2002-03, but the number ofsecond opinions for ECT increased from 11 to 26. Itis likely that this increase is because treatments, whichwould previously have been given under the MentalHealth Act, are now being given under the Adultswith Incapacity Act. Compared with the previousyear,fewer second opinions were given for ECT underthe Mental Health Act in 2003-04 (38 comparedwith 48), which may support this view.Under Section 50, a second opinion is used toresolve disputes between the doctor responsible fortreatment and any person authorised to taketreatment decisions on the adult’s behalf. No secondopinions under Section 50 have yet been requested.Second opinions under Section 98 of theMental Health (Scotland) Act 1984Compared with the previous year, in 2003-04 therewas an increase of more than 10% in the number ofrequests for second opinions for the use ofmedication without the patient’s consent. However,the frequency with which second opinions weregiven for ECT continued to reduce, as noted above.The total number of courses of ECT given underthe Act, to both consenting and non-consentingpatients, also fell; it reduced from 223 to 189, adecrease of 15%.Table 2 shows the number of second opinioncertificates (Form 10) given by doctors appointedunder Section 98 of the Act. It also shows thecertificates of consent to treatment (Form 9) givenby the Responsible Medical Officers.Table 2: Mental Health (Scotland) Act 1984:Forms 9 and 10, 2003-04*Form 9 Form 10Medication 1153 (52) 658 (30)ECT 38 (0) 151 (7)Total 1191 (52) 809 (37)* Figures in brackets indicate coexisting Form 9 and 10. Part ofthe treatment is covered by Form 9 and part by Form 10.Second Opinion Doctor SeminarsTwo seminars were held during the year: the first fornew second opinion doctors, appointed underSection 98 of the Mental Health (Scotland) Act1984, and the second for existing second opiniondoctors. A number of practice issues were discussedat the seminars, including National Institute forClinical Excellence (NICE) Guidance on ECT.Other issues discussed included:• the first year of the Adults with Incapacity Act;• the Review of the Code of Practice for Part 5of the Act;• the effects of the Mental Health (Care andTreatment) (Scotland) Act 2003.Under the new Act, it will be necessary for secondopinion doctors to take more account of the viewsand wishes of patients and named persons whencarrying out a second opinion assessment. It seemslikely that there will also be an increase in the needfor second opinions under the new Act.The Commission is grateful to the following doctors,who have provided second opinions under Section98 of the Mental Health Act and Section 48 of theAdults with Incapacity Act, during the past year.Dr Ali Dr Emslie Dr MorrisonDr Al-Mousawi Dr Flanigan Dr MurphyDr Aryiku Dr Flowerdew Dr MurrayDr B Martin Dr Gibb Dr NeilsonDr Backett Dr Götz Dr OlleyDr Baird Dr Groves Dr PatienceDr Bell Dr Humphries Dr PowellDr Berry Dr J Martin Dr ReidDr Burley Dr J Taylor Dr RiddleDr Clark Dr K Brown Dr RitsonDr Collins Dr Kerr Dr RobertsonDr Cooper Dr Leighton Dr RobinsonDr Crawford Dr Lock Dr RogersDr Creaney Dr Logie Dr RollDr D Brown Dr M Taylor Dr SlatfordDr D Taylor Dr MacDonald Dr SmithDr Dalkin Dr MacFlynn Dr StewartDr Dickson Dr MacLeod Dr SykesDr Dingwall Dr Mani Dr TaitDr Drayson Dr Matson Dr ThomsonDr Duncan Dr McClure Dr WalkerDr Dyer Dr McKnight Dr White21

THE MENTAL WELFARE COMMISSION FOR SCOTLAND2.7 REQUESTS FOR DISCHARGEFROM DETENTIONRequests for Reviews of DetentionAs shown in Table 1, in 2003-04, the Commissionconsidered 515 requests from patients to be dischargedfrom compulsory orders under mental health andcriminal procedure legislation. The majority ofrequests came from people subject to Sections 26and 18 of the Mental Health (Scotland) Act 1984.Review ProceduresWe need to be asked within the first two weeks of ashort-term order, under Section 26 of the Act, inorder to see the person during the 28-day period.For people detained under longer-term orders, suchas Section 18, we ask for reports from medical andnursing or social work staff and discuss these reportswith the detained person. We hope that this helpshim or her understand the grounds for detentionand gives him or her an opportunity to challenge thedetention. We have received many careful andthoughtful challenges from detained people. Theseare often made with the help of advocacy workersand we are keen to encourage this. In most cases, thedetained person has seen the medical and nursingor social work reports. However a significantproportion have not been given a copy.A weekly meeting of the Commission considers allrequests for review of detention. The meetingconsists of Commissioners from a wide variety ofbackgrounds. In coming to a decision, they considerthe statements made by all parties and a report fromone of our Medical Commissioners or Officers.Wehave the authority to discharge, if we are satisfiedthat the grounds for continued detention are notmet.We cannot discharge a person from a restrictionorder, but can make recommendations to ScottishMinisters. We often raise other issues with theperson’s Responsible Medical Officer or with healthand social work service managers, if we feel theperson’s care could be improved or we discover anyapparent irregularities in the detention procedures.We have tried to give detained people more personalfeedback on the reasons for our decisions.We makea point of doing this when the person has given us adetailed argument to support his or her request to bedischarged. Under the Data Protection Act 1998, heor she may ask us for a copy of the report preparedby the Commission doctor who has seen him or her.We are happy to give this, but we may need thepermission of certain other people if their views areincluded in the report.Outcome of Reviews of DetentionTable 1: Reviews of Detention, 2001-04Basis for Detention 2001- 2002- 2003-02 03 04Section 18 MH(S)A* 195 217 223Section 26 MH(S)A 193 189 219Section 71/72 MH(S)A 7 10 4Section 74 MH(S)A 1 5 3CP(S)A ** 57 84 63Community Care Orders 1 0 1Conditional Discharge 2 0 2Total 456 505 515* Mental Health (Scotland) Act 1984** Criminal Procedure (Scotland) Act 1975 and 1995In 2003-04, we considered 515 requests fordischarge, an increase on previous years.There was aparticular increase in requests for review of shorttermdetention. We discharged eight people duringthe year, three from Section 18, two from Section 26and three from Criminal Procedure Detentions.Thisis similar to 2002-03. Of the 16 people who asked usto review their restriction orders, we maderecommendations to Scottish Ministers in one case.Audit of Reviews of DetentionIn 2003-04, we carried out an audit of our reviewof detention procedures. This involved examining153 consecutive cases. Our findings included thefollowing:• We received a report from the ResponsibleMedical Officer in 90% of cases• We received a report from the nurse or socialworker in 78% of cases• We raised issues about the detained person’swelfare in 19% of cases• We found irregularities in detention proceduresin 6% of cases• We found problems in consent to treatmentprocedures in 22% of cases.The response rate to our requests for reports isencouraging, but could be better.The findings showthat, although we do not use our powers of dischargeoften, we raise significant welfare concerns in abouta fifth of cases. The frequency of apparent errors inconsent to treatment procedures is a cause for22

ANNUAL REPORT 2003-2004concern. We will examine this issue in more detailand report further on it.We will continue to accept requests for review ofdetention until the implementation of the MentalHealth (Care and Treatment) (Scotland) Act 2003 inApril 2005. After that, the Mental Health Tribunalfor Scotland has this responsibility.We will have thepower to refer people to the tribunal if, in the courseof our duty to visit or to make enquiries, we thinkthat the criteria for compulsion are not satisfied.2.8 INFORMATION AND ADVICEThis section reports on use of the Commission’stelephone advice line and email enquiry service, andoutlines developments in our publications programme.Telephone Advice ServiceOur telephone advice service was described inSection 5.5 of the Annual Report for 2000-01,which is available on our web site.We have analysed calls over a three-month period,January – March 2004. As shown in Table 1, duringthis period we received 740 calls. Compared withthe same period in 2003, this is a decrease of 20%. Itis equivalent to an annual figure of 2960, comparedwith 3608 in the previous year. We do not believethat the number of calls did, in fact, decrease; ratherthat problems with our call logging led to an underreportingof calls. We have received more enquiriesby email than in the previous year.Table 1: Identity of Callers in a Three-MonthPeriod, 2004Callers Calls (%)Patient/Service User 200 (27)Relative/Carer/Friend 118 (16)Social Worker 102 (14)Psychiatrist 84 (11)Nurse 61 (8)Advocacy Worker 37 (5)Medical Records Staff 27 (4)Solicitor 8 (1)GP 4 (1)Other 99 (13)Total 740 (100)The identify of the callers is also shown in Table 1.For the third successive year, patients or service usersformed the greater proportion of callers (43%).Table 2: Nature of Calls Received in a Three-Month Period, 2004Nature of Call Number (%)Mental Health (Scotland) Act 1984Detention 112 (48)Request for review of detention 62 (27)Part X (Consent to Treatment) 19 (8)LOA/AWOL Issues 6 (3)Cross-Border Issues 16 (7)Incidents/Deaths 2 (1)Other 14 (6)Sub Total 231 (100)Other Legal IssuesFinancial Issues 7 (10)Adults With Incapacity (Scotland) 53 (75)Act 2000Criminal Procedure (Scotland) 6 (8)Act 1995Other 5 (7)Sub Total 71 (100)Practice IssuesConsent 17 (32)Ethics 7 (13)MWC Guidance Papers 1 (2)Other 28 (53)Sub Total 53 (100)Other IssuesConcerns and complaints 109 (49)Misc. information & advice 115 (51)Sub Total 224 (100)Unknown 161Total 740The nature of the calls is shown in Table 2. As in2002-03, the largest category of calls concernedaspects of the Mental Health (Scotland) Act 1984.We continued to receive a large proportion of callson subjects related to the Adults with Incapacity(Scotland) Act 2000. Calls about the Mental Health(Care & Treatment) (Scotland) Act 2003 are included inthe miscellaneous information and advice category.23

THE MENTAL WELFARE COMMISSION FOR SCOTLANDE-mail EnquiriesA large number of people have been asking forinformation by e-mail, since we introduced thisfacility in June 2001. During the three-month period,January – March 2004, we received 86 e-mails to ourEnquiries address (enquiries@mwcscot.org.uk). It isequivalent to an annual figure of 344. Most wererequests for the Commission’s printed publicationsand guidance, or for help and advice.We also receivedrequests for information on the new Mental HealthAct and requests for statistical data.Where the role ofthe sender was identified, the majority were fromhealth and social care workers.Publications ProgrammeWe are currently preparing for the implementationof the Freedom of Information (Scotland) Act 2002,which will give new rights of access to records heldby public bodies, from January 2005. A PublicationScheme is being developed,which will detail the classesof information regularly published by the Commission.All our publications are available on our website atwww.mwcscot.org.uk/publications.htm Our generalinformation leaflets can also be downloaded as audioclips from the web site. Audio cassettes of ourgeneral leaflets can be posted out, on request.We are currently developing guidance on the use of‘wandering technologies’ in care homes and hospitals(see Section 3.5 of this Report), and on the use ofPart 6 of the Adults with Incapacity Act (see Section4.1).A full list of our current publications is providedin Section 6.2.2.9 IMPLEMENTATION OF THEMENTAL HEALTH (CARE ANDTREATMENT) (SCOTLAND) ACT2003April 2005 sees a major advance in mental healthcare in Scotland. Most of the provisions of the newMental Health (Care and Treatment) (Scotland) Act,passed by the Scottish Parliament in 2003, areexpected to come into force then.The Commissionhas been involved with the Act throughout itsdevelopment and implementation. We are verysupportive of the Act’s principles, which reflect amove towards greater rights for the service user andgreater recognition of the role of the carer.We havetaken account of the understandable concernsexpressed by many people about some of the newprovisions. At present, we are examining our newroles and responsibilities under the Act, and aregiving great attention to these concerns. This is aprogress report on how we see the Commissionfunctioning when the Act is implemented.General DutiesWe have a general duty to monitor the operation ofthe Act and to promote best practice in relation toits operation. It is a large and complex piece oflegislation and we will receive notifications of manyinterventions.We are developing a new computerisedinformation system to record and analyse these. Wewill publish information on our web site and inreports. We should be able to provide particularinformation on request, as long as it does notidentify any individual person.Promotion of best practice is an exciting new dutyfor us. The Act makes special reference to our dutyto promote the principles of the Act.We will do thisactively in all our work relating to the Act. Theprinciples include giving users information, takingaccount of their wishes and involving them in theirtreatment; treatment must give users maximumbenefit and restrict their freedom as little as possible.While we cannot enforce the principles, we willhighlight situations where they are not being followedand make recommendations on how practice couldbe improved.Specific FunctionsAs described in Section 4.1 of our last AnnualReport, the Act contains many functions for theCommission. It also specifies actions or events aboutwhich we have to be notified in order to do ourwork. In some cases, we will have a statutory duty toreview events brought to our attention. We areexamining all our responsibilities in detail and willhave procedures to address all of them. Some deserveparticular mention here.• Under the new Act, we retain the duty to visitpeople receiving treatment, including thosesubject to compulsion. For an individualsubject to the Act, we will consider whether heor she meets the criteria for compulsion andwe will examine whether the care plan meetsthe principles of the Act. We may refer the24

ANNUAL REPORT 2003-2004person’s case to the Tribunal, if we are notsatisfied. It is unlikely that we will use ourpower to discharge, but we may do so undercertain circumstances.We will be giving this alot of thought prior to implementation.• Although we retain the power to dischargepeople from certain compulsory orders, we willnot review their orders on request. The Actmakes it clear that the Mental Health Tribunalis the body to do this.• At present, we visit people who have beendetained for more than two years, and continueto visit them at two yearly intervals. Because wewill not be considering requests for reviews ofcompulsion, we will have the resources to visitmore individuals.We will visit people subject tocommunity-based compulsory orders, at anearly stage of their treatment, because these areinnovative orders and service-users haveexpressed anxiety about whether they will bemisused. Repeat visits will dovetail withreviews by the Tribunal.• We will continue to visit other peoplereceiving treatment in hospitals and otherresidential settings.We plan to visit a number ofpeople who have been in hospital for over a year,but are not subject to compulsory treatment.• We will continue to give advice on the Act andto publish this.• We will continue to conduct investigations andmake recommendations.• We will continue to appoint doctors to giveindependent opinions for regulated treatments.We particularly welcome the sections of theAct that prohibit the administration of ECT topeople who have the capacity to consent butwho refuse the treatment.• We welcome the introduction of advancestatements. We will receive notification ofsituations in which a person is given treatmentthat conflicts with an advance statement. Inview of anxieties expressed about this, we willpay close attention to such situations, at least inthe first year of implementation.• We will also monitor the use of restrictions,searches and other restrictions of freedom forpatients in hospital.• From May 2006 we will take great interest inthe outcome of appeals against conditions ofexcessive security. Under the Act, we willpossibly have a role in taking some appealsforward.In summary, we view this as a very good piece oflegislation. While we applaud much of it, we havelistened to people’s concerns and, as far as possible,we are developing our policies and procedures toaddress these.2.10 IMPLEMENTATION OFSCOTTISH EXECUTIVERELOCATION POLICYIn December 2003, Scottish Ministers announcedthat the Commission would be considered forrelocation in April 2006, when its present lease isdue for renewal. This was in line with the ScottishExecutive policy of considering relocation of allexisting public bodies, at appropriate points.Relocation Work so FarFollowing the Executive’s guidance, we haveundertaken an option appraisal of locations aroundScotland, to determine a shortlist of possible sites.We have been assisted in this work by a firm ofconsultants, because we did not have sufficientresources of our own.The Executive advised us thatthe level of social and economic deprivation inpotential locations should be the single mostimportant factor in selecting sites. Other factorswere taken into consideration, such as: our ability tosustain our work; the adequacy of transport links;and the availability of property.At the time of writing, we have submitted a shortlistof possible locations to Scottish Ministers and arecurrently awaiting their approval. If it is approved,the next step will be to carry out a detailedcomparison of the short-listed sites, to assess theirsuitability. This comparison will be based oneconomic grounds.Our Concerns about the Timing of PossibleRelocationWe are very supportive of the principle of dispersingpublic bodies, such as ours, around Scotland,especially to areas that would benefit from additional25

THE MENTAL WELFARE COMMISSION FOR SCOTLANDjobs. However, in our case we have considerableanxieties about the timing of a possible move.Thereare already signs of staff being unsettled, because ofconcerns about their future, and it is likely that wewill lose a considerable number in the period leadingup to a possible relocation.This anxiety is heightened by the work agenda weface over the next two years.We will have a crucialrole in monitoring the new Mental Health (Care andTreatment) (Scotland) Act 2003; we will be checkingthat compulsion is being used appropriately, that theprinciples are being observed, that the treatmentsafeguards are working properly and that patientsrights are being respected. To do this, we need toensure that our staff are fully trained to fulfil theirnew roles.At the same time, we will be setting up the newcomputerised information system we will need tokeep track of what is happening to patients and howthey are faring.The new system will alert us to anyproblems with compulsory orders and allow us togive people information about how the Act is beingused. Again, our staff will require comprehensivetraining to ensure the new system works.The Immediate FutureWe will press on with the preparatory work that isnecessary to allow Ministers to take a decision onour future location.This will require significant staffinput, at a time when, as is explained above, we willalready have a heavy workload.This gives us concernsabout the effects on the service we can give to users,carers and practitioners.Further AheadThe full impact of a possible relocation would not befelt until 2005-06 and 2006-07. By the time of ournext Annual Report, decisions will have been takenand we will report on progress.While developmentstake place, the challenge for us will be to continue toprovide the same high level of service to people withmental disorder, and people who care for them.26

ANNUAL REPORT 2003-2004SECTION 3 MENTAL WELFARE IN SCOTLAND: OUR OVERVIEW3.1 DETENTION UNDER MENTALHEALTH AND CRIMINALPROCEDURE LEGISLATION3.1.1 DETENTION STATISTICS,2003-04In this section of the Annual Report, we have triedto bring together all our figures about the use of theMental Health (Scotland) Act 1984 and theCriminal Procedure (Scotland) Act 1995.Tables 1 and 2 show the total number of episodes ofdetention, under civil procedures, during 2003-04,and the way individuals progressed from onecompulsory order to another, or to discharge. Thefigures are very similar to those in 2002-03.For the first time, we have been able to break thedetention figures down by age and gender, and theseare shown in Table 3. It can be seen that men aremore often detained than women, under every typeof order. However, the difference between men andwomen is small for emergency orders (52%compared with 48%) and much more marked forlong-term orders (56% compared with 44%). Thismay reflect an increased prevalence of long-termmental illness among men, or a greater tendency forthe treatment of their mental illnesses to becomplicated by drug and alcohol misuse.Table 1: Emergency and short-termdetentions under the Mental Health(Scotland) Act 1984, 2003-04Type ofDetentionSection 24/25,toDischarge toinformalSection 24/25,toSection 26,toDischarge toinformalNo. ofPatients1572136173111730Episodes ofDetention1234571919Table 2: Detentions under Section 18 of theMental Health (Scotland) Act 1984,Type ofDetentionSection 24/25,to Section 26,to Section 18150698711612No. ofPatients10284103212341727Episodes ofDetention121036Informal toSection 18 156 15627

THE MENTAL WELFARE COMMISSION FOR SCOTLANDTable 3: Episodes of detentions initiatedunder the Mental Health (Scotland) Act 1984by Age and Gender, 2003-04Emergency Detentions*Age Range Male Female Totals (%)01-14 1 8 9 (0)15-24 392 222 614 (13)25-44 1070 939 2009 (43)45-64 586 576 1162 (25)65-84 328 429 757 (16)85- 37 94 131 (3)Totals (%) 2414 (52) 2268 (48) 4682 (100)Short-Term DetentionsAge Range Male Female Totals (%)01-14 1 6 7 (0)15-24 241 119 360 (13)25-44 648 532 1180 (43)45-64 327 336 663 (24)65-84 214 270 484 (18)85- 22 47 69 (3)Totals (%) 1453 (53) 1310 (47) 2763 (100)Long-Term DetentionsAge Range Male Female Totals (%)01-14 0 4 4 (0)15-24 90 45 135 (11)25-44 309 214 523 (44)45-64 161 141 302 (25)65-84 95 110 205 (17)85- 8 15 23 (2)Totals (%) 663 (56) 529 (44) 1192 (100)*Includes emergency detentions extended to short-termdetentionsRates of Detention in Health Board andLocal Authority AreasFigure 1 shows the frequency with which differenttypes of detention are used within the various healthboard areas of Scotland.The Figure shows episodes ofdetention per 100,000 of a health board’s population,so that health boards can be compared with eachother. The high use of emergency detention, unders24 and 25 of the Mental Health (Scotland) Act 1984,is notable in Greater Glasgow, Argyll and Clyde andTayside. These health boards also have the highestuse of short-term detention, under s26.Dumfries and Galloway had, by far, the highest rateof long-term detention under Section 18 of the Act;people living there were nearly a fifth more likely tohave a long-term detention than people in GreaterGlasgow, and over twice as likely as those inForth Valley.The reasons for these differences are likely to becomplex. In the cases of Greater Glasgow and Argylland Clyde, the high rates of emergency and shorttermdetention might be due to these areas havingmore people with social difficulties, such ashomelessness and drug and alcohol problems, all ofwhich can make detention more likely. However, ifthis was the only reason, the rates of long-termdetention might also be expected to be high in theseareas, and this was not the case. In addition,Lanarkshire, a health board area that also has asignificant proportion of people with these socialproblems, had low rates of all types of detention.It seems very likely the differences in rates of detentionalso reflect differences in mental health resources andclinical practice.The rates may be affected by factorssuch as:• The effectiveness of community mental healthservices• The availability of hospital beds• The availability and assertiveness of MentalHealth Officer (MHO) services• The attitude to risk of psychiatrists and MHOs.28

ANNUAL REPORT 2003-2004Figure 1: Number of Detentions under Sections 24/25, 26 and 18 per 100,000 of Health BoardPopulation, 2003-04*140120112116S24/25S26S18110100806989838182757670857297706040202749264922463349234313451926482438185827260Argylland ClydeAyrshireand ArranBordersDumfriesandGallowayFife Forth Valley Grampian GreaterGlasgowHighlandLanarkshire Lothian Tayside* Figures for Western Isles omitted, because of very low numbers. Detentions for Shetland Isles and Orkney included in Grampian.Table 4 shows the rates of long-term detention foreach local authority area, per 100,000 of itspopulation. These figures only reflect successfulapplications for detention under s18 of the Act.We are unable to get information about unsuccessfulapplications.To some extent, the figures reflect those for healthboard areas. However, it is difficult to draw exactcomparisons between Table 4 and Figure 1, becausethe local authority areas are smaller than those ofhealth boards, and their boundaries may be different.It is interesting to examine the changes in localauthority rates between this year and last. For example,Renfrewshire and E. Dunbartonshire have shownsharp rises between 2002-03 and 2003-04, whereasthe rate for Dundee City has fallen by almost half.Table 4: Section 18 Applications by Local Authority, 2002-04Local Rate per 100,000Authority 2002-03 2003-04Inverclyde 47.3 42.1South Ayrshire 24.5 37.6Edinburgh, City Of 39.9 36.8Perth & Kinross 31.5 32.4Dumfries & Galloway 25.8 31.9Glasgow City 24.1 30.7Argyll & Bute 26.8 30.7Clackmannanshire 14.4 27.3Aberdeen City 26 26.1Renfrewshire 16.3 25.1Highland 23.5 23.9Fife 22.9 23.3Scottish Borders 37.6 23.1West Dunbartonshire 24.3 22.7Dundee City 41.3 21.7North Ayrshire 21.5 21.3South Lanarkshire 15.3 19.8Local Rate per 100,000Authority 2002-03 2003-04West Lothian 19.5 18.6Moray 15.1 17.2East Lothian 13.3 16.5East Dunbartonshire 9.1 15.9Falkirk 22.1 15.1East Ayrshire 15.7 15.1Midlothian 18.5 15.1North Lanarkshire 8.9 14.9Angus 11.8 13.0Aberdeenshire 14.1 10.9East Renfrewshire 12.4 10.0Shetland 0 4.6Western Isles 7.2 3.8Stirling 10.8 3.5Orkney 0 0Total 21.4 23.329

THE MENTAL WELFARE COMMISSION FOR SCOTLANDFigure 2: LOA Episodes Notified to the MWC per 100,000 of Health Board Population, 2003-04Compared with Previous Three Years*9075604530154438 386636 3431628054402030 30 32 545334272022 25 21342127 263937 37295021 20162000-012001-022002-032003-04452613 16 195238 3727443129190Argylland ClydeAyrshireand ArranBordersDumfriesandGallowayFife Forth Valley Grampian GreaterGlasgowHighland Lanarkshire Lothian Tayside* Figures for Western Isles, Shetland and Orkney omitted, because of very low numbers.Rates of Leave of Absence in Health BoardAreasFigure 2 shows episodes of leave of absence (LOA)from hospital, in each health board area, for each100,000 of the population.The figures for this yearare compared with those for the previous three years.In comparing health board areas, it should beremembered that the figures reflect rates of detention,to some extent.These differ between health boards, asdiscussed above. However, in all areas, the use of LOAappears to have increased markedly during 2003-04,compared with previous years. This may be due tofactors such as:• Less restrictive approaches to treatment, so thatmore detained patients are being dischargedinto the community.• The reduction of available inpatient beds inmany areas, due to either closure of wards ordelayed discharges.The use of LOA is particularly high in the Bordershealth board area; it has increased fourfold since2000-01. Lanarkshire has the lowest rate; it is only athird of that in the Borders, though its rate of longtermdetention is similar.The Use of Other Compulsory PowersTable 4 shows the number of Community CareOrders granted during 2003-04.Table 4: Community Care Orders under theMental Health (Scotland) Act 1984, 2003-04Number of patients 7Table 5 shows the total number of episodes ofdetention imposed under various sections of theCriminal Procedure (Scotland) Act 1995 (CPSA)and the sections of the Mental Heath (Scotland) Act1984 (MHSA) that apply to prisoners transferred tohospital. The number of detentions under criminalprocedures rose markedly in 2003-04, 447 comparedwith 347 in the previous year. Increases in remandsto hospital, under Section 52 of the CP(S)A, anddetention under hospital orders (Section 58 CP(S)A),accounted for most of the total increase. Table 6shows all these episodes broken down by age andgender. As expected, men are more often detainedthan women; in both sexes, the majority of detentionstake place among individuals aged 25 to 44.30

ANNUAL REPORT 2003-2004Table 5: Episodes of Detention under theCriminal Procedure (Scotland) Act 1995 andPart VI of the Mental Health (Scotland) Act1984, 2003-04Number ofProcedureEpisodesRemand to hospital before trial 155(CPSA* 52)Transfer Order from prison before 30trial or sentence (MHSA** 70)Remand Order (CPSA 200) 72Interim Hospital Order (CPSA 53) 39Temporary Hospital Order 8(CPSA 54(1)(c)Hospital Order without a 90Restriction Order (CPSA 58)Hospital Order with a Restriction 12Order (CPSA 58 + 59)Not fit to stand trial or acquitted 8(CPSA 57(2)(a))Not fit to stand trial or acquitted 3(CPSA 57(2)(b))Not fit to stand trial or acquitted 1(CPSA 57(2)(d))Transfer Direction from prison 9without a Restriction Order(MHSA 71)Transfer Direction from prison with 20a Restriction Order (MHSA 72)Total 447* Criminal Procedure (Scotland) Act 1995** Mental Health (Scotland) Act 1984Table 6: Episodes of detention under theCriminal Procedure (Scotland) Act 1995 andPart VI of the Mental Health (Scotland) Act1984 by Age and Gender, 2003-04Age Range Male Female Total (%)01-14 0 0 015-24 69 24 93 (21)25-44 218 70 288 (64)45-64 35 28 63 (14)65-84 2 1 3 (1)85- 0 0 0Totals (%) 324 (72) 123 (28) 447 (100)The use of the nurses’ holding power during 2003-04is shown in Tables 7 and 8.As seen in previous years,it appears to be used in only a minority of hospitalsand the frequency varies greatly, between apparentlysimilar hospitals. For example, it appears to have beenused 14 times in Whyteman’s Brae Hospital, but not atall in Murray Royal or Monklands.These differencesmay reflect differences in the immediate availabilityof doctors, differences in nursing practice ordifferences in the recording and reporting of thesedetentions.We suspect that the last is the most likelyexplanation. As we have noted in previous years, itappears to be used more often among women thanmen. This finding is puzzling, and rather worrying;the reasons for it are not clear.Table 7: Episodes of Nurses Holding Powerby Hospital, 2001-042001-02 2002-03 2003-04Gartnavel Royal 17 26 32Royal Edinburgh 39 36 26Borders Primary Care 9 11 23Dykebar 15 15 20Crichton Royal 23 14 19Whyteman’s Brae 20 10 14Inverclyde 2 2 5New Craigs 13 13 4Crosshouse 1 3 4Herdmanflat 1 1 4Carseview 2 3 3Ailsa 9 7 2Royal Cornhill 5 8 2Stratheden 9 6 2Queen Margaret 3 5 2Stobhill 1 6 2Royal Alexandra 3 7 1Dr Grays 4 4 1St Johns 0 0 1Argyll and Bute 1 2 1Cameron 0 0 1Royal Dundee Liff 4 3 0Rosslynlee 7 1 0Parkhead 4 1 0Leverndale 2 1 0Woodlands 2 1 0Falkirk DRI 1 1 031

THE MENTAL WELFARE COMMISSION FOR SCOTLANDTable 7 (continued) 2001-02 2002-03 2003-04Strathlea 1 1 0Royal Victoria 2 0 0Sunnyside 0 1 0Western Isles Hospital 0 1 0Lennox Castle 1 0 0Murray Royal 1 0 0Wishaw General 1 0 0Kirklands 1 0 0Lynebank 1 0 0Monklands 1 0 0Strathmartine 1 0 0Craig Dunain 0 0 0Craig Phadrig 0 0 0Southern General 0 0 0William Fraser Centre 0 0 0Ruchill 0 0 0Ladysbridge 0 0 0Total 207 190 169Table 8: Use of Nurses Holding Power byGender, 2003-04Hospital Female MaleGartnavel Royal 12 20Royal Edinburgh 15 11Dykebar 13 7Borders Primary Care Trust 14 9Crichton Royal 13 6Whyteman’s Brae Hospital 10 4Inverclyde 3 2New Craigs 0 4Crosshouse 1 3Herdmanflat 3 1Carseview 2 1Ailsa 2 0Royal Cornhill 0 2Stratheden 2 0Queen Margaret 0 2Stobhill 2 0Royal Alexandra 0 1Dr Grays 0 1Argyll and Bute 1 0Cameron 1 0St John’s 1 0Total 95 743.1.2 TRENDS IN THE USE OFDETENTIONIn 2003-04, there were 4682 emergency detentionsunder Section 24 and 25 of the Mental Health(Scotland) Act 1984, 2763 short-term detentionsunder Section 26 and 1192 long-term detentionsunder Section 18. These figures are very similar tothose in the previous year. They confirm ourimpression that there is now a levelling out in thenumber of civil detentions, which had beenincreasing steadily since the implementation of thecurrent Act in 1985. Figure 3 shows total episodes ofdetention under these Sections each year since1994-95.On the other hand, there was a sharp rise in thenumber of detentions under the Criminal Procedure(Scotland) Act 1995, and Part VI of the MentalHealth (Scotland) Act 1984, which applies toprisoners. There were 447 of these detentions in2003-04, compared with 347 in the previous year;this was an increase of nearly 30%. Figure 3 showsthat, until now, the numbers of these detentions hadbeen steadily dropping, in marked contrast to theincrease in civil detentions.Figure 3: Detentions under Civil andCriminal* Procedures in Scotland, 1994-95to 2003-200410000900080007000600050004000300020001000067441994-199546674331995-199649274191996-199750678301997-19981998-1999Civil Procedures1999-20002000-20012001-2002Criminal Procedures*CP(S)A 1975 and 1995, Part VI MH(S)A 1984478797646877953487965369875637886533472002-200386344472003-200432

ANNUAL REPORT 2003-2004Table 9 shows a comparison of the number ofdetentions under hospital orders (s58 of the CPSA),with and without restriction orders (s59 of the Act),for each year between 1997-98 and 2003-04. Asreported in previous Annual Reports, these detentionshad decreased by 46% between 1997-98 and 2002-03 (from 119 to 64). However, in the last year, theyhave risen by 59%. It will be interesting to seewhether they continue to rise in 2004-05.Table 9: Hospital Orders with and withoutRestriction Orders (CPSA Sections 59 and 58),1997-20041997- 1998- 1999- 2000- 2001- 2002- 2003-98 99 00 01 02 03 04S58 103 94 88 68 64 56 90S59 16 18 8 9 8 8 12Figure 4 shows the numbers of detentions undercivil and criminal procedures in England and Walesfrom 1994-95 to 2002-03, which is the most recentyear for which we have been able to obtain figures.The numbers of civil detentions still appear to beincreasing, whilst those under criminal procedureshave levelled out, but are still considerably lowerthan they were nine years previously.Care should be taken in interpreting the actualnumbers of detentions in Scotland, compared withEngland and Wales, because of the differences in thelegislation. These are explained further in Section3.1.3 of the Annual Report.Figure 4: Detentions under Civil and Courtor Prison Procedures in England and Wales,1994-1995 to 2002-03*700006000050000400003000020000100000456011994-19952111Civil Procedures474811995-19961947494981996-199718731997-1998* Mental Health Act 1983531781855575441998-1999Criminal Procedures1999-20002000-20012001-20022002-2003*3.1.3 USE OF DETENTION IN THEUNITED KINGDOMEarlier this year, a newspaper article claimed thatpeople in Scotland were twice as likely to be detainedunder mental health legislation as people in Englandand Wales.There was some debate about the reasonsfor this.We were surprised by this claim, which wasnot supported by our figures.We have sought furtherinformation to check its accuracy.1860573971641576761478584931496600701516The differences in mental health law and practiceacross the UK make comparison of detention statisticsdifficult. Figures about different types of detentionmust be interpreted using a knowledge of the differentmental health legislations. For example, under presentScottish legislation, it is not possible for an episodeof civil detention under any order, other than anemergency order (lasting up to 72 hours), to bestarted without the approval of a Sheriff. On theother hand, in England and Wales, a person may bedetained under both a short-term (28-day) and along-term order by two doctors and an approvedsocial worker, without the need for court approval.33

THE MENTAL WELFARE COMMISSION FOR SCOTLANDAn episode of detention in Scotland could involvethree orders, progressing from an emergency order(Section 24 or 25 of the Mental Health (Scotland)Act 1984) to a short-term order (Section 26 of theAct) and then to continued detention under a longtermorder (Section 18 of the Act). A short-termorder can only be an extension of an emergencyorder. In England and Wales, an episode of detentionis more likely to involve only one or two orders: itcould start with either an Emergency Order(Section 4 of the Mental Health Act 1983) or a shortterm order (Section 2 of the Act) and progress to along term order (Section 3 of the Act). In bothScotland and England and Wales, detention couldalso begin with a long term order, but this is muchmore common in England and Wales.We compared figures for Scotland, from our AnnualReport 2002-03, with the Department of Health’sstatistics for England and Wales, during the sameyear. For the reasons described, we did not think itwas valid to make direct comparisons betweendifferent types of order.We therefore compared thetotal number of “detention episodes” in Scotlandand England and Wales. We defined a “detentionepisode” as any period of time during which anindividual is continuously liable to be detained,regardless of the number or type of orders usedduring that time. We also broke down detentionepisodes into emergency orders and orders lastingmore than 72 hours.Table 10: Rates of detention per 1000population, for Scotland and England andWales, 2002-03As shown in Table 10, we found that the overall rateof detention in Scotland is broadly similar to that inEngland and Wales. However, because emergencyorders are the usual route into a detention episode inScotland, they are much more common here thanthey are in England and Wales, where patients usuallygo straight onto a short or long-term order andwhere the use of emergency orders is discouraged.Table 10 shows that orders of over 72 hours are,therefore, more common in England and Wales.We have not compared the use of long term orders,because the differences in practice between thecountries would make such a comparison difficultto interpret.In interpreting the figures in the table, it should beborne in mind that they may also be affected by theway they are collected. In Scotland, the Commissionis directly notified of all individual detentions; inEngland and Wales, the Department of Health relieson aggregated returns from mental health services,and therefore its figures may be more affected byunder-reporting.In addition to episodes of detention, we think itwould be helpful to compare the total number ofpeople detained and the total length of time ofdetention (‘detention days’). Unfortunately, thosefigures are not available. From 2005, we aim tocollect these figures for Scotland, in order to assessthe impact of the new mental health legislation.In the meantime, we believe that people can beconfident that they are no more likely to be detainedunder mental health legislation in Scotland thanthey would be in England and Wales.EnglandandType of detention Scotland WalesAll detention episodes 0.97 0.94Emergency orders(72 hours) 0.94 0.26Orders lasting more than72 hours 0.59 0.7834

ANNUAL REPORT 2003-20043.1.4 CONSENT TO DETENTIONThe most common route into hospital, on acompulsory basis, is through an emergency detention,under Section 24 or 25 of the Mental Health(Scotland) Act 1984. These orders can be extendedunder Section 26 of the Act.Emergency and short-term detentions can beimplemented on the recommendation of one doctoralone, with the consent if ‘practicable’ of a relative ora Mental Health Officer (MHO), who is a socialworker with additional training in mental health.The Code of Practice to the Act advises that, ifrelatives would rather not take on the formal role ofconsidering consent, they should be informed thatan MHO can be asked to do it. Consent providessome measure of safeguard for the patient. If theurgency of the situation makes it impracticable towait for consent, the doctor must give anexplanation. Failure to give an explanation for lackof consent makes the detention invalid.Tables 11 and 12, show that, in 2003-04, theproportion of detentions occurring under Section24 and 25, without consent, was similar to that in2002-03.Table 11: Section 24: Consents and NonConsents, 2002-042002-03 2003-04Number (%) Number (%)MHO consent 1311 (59) 1466 (63)Relative consent 558 (25) 484 (21)No consent 369 (16) 361 (16)Total 2238 2311Table 12: Section 25: Consents and NonConsents, 2002-042002-03 2003-04Number (%) Number (%)MHO consent 1911 (78) 1858 (78)Relative consent 184 (7) 165 (7)No consent 362 (15) 348 (15)Total 2457 2371Table 13 shows that, in 2003-04, the great majorityof detentions under Section 26 took place with theconsent of an MHO, and only 23 (1%) with noconsent at all.Table 13: Section 26: Consents and NonConsents, 2002-042002-03 2003-04Number (%) Number (%)MHO consent 2672 (96) 2678 (97)Relative consent 97 (3) 57 (2)No consent 22 (1) 23 (1)Total 2791 2758One way in which we monitor the possibility ofimproper detention is to study the detaining doctor’sreasons for not obtaining consent. If the explanationgives insufficient information or fails to give a validreason, we seek further information. If the lack ofconsent is due to the unavailability of an MHO, wecontact the service manager in the relevant localauthority.The reasons for lack of consent are, in order offrequency: serious risk to self; serious risk to others;risk of absconding; and unavailability of MHO.Very few short term sections go ahead withoutconsent.This is rightly so, because they always followemergency detention, which provides time to planan assessment of the ongoing need for detention.The reasons for the failure to obtain consent in the23 cases shown in Table 13 mostly involve poorplanning or poor communication between psychiatristand MHO. The new Mental Health (Care andTreatment) (Scotland) Act 2003 will not allow shortterm detentions to go ahead without MHOconsent. Joint plans between mental health andsocial work services will be necessary to ensure thatthey have good communication and clear proceduresfor assessing the need for short term detention underthe new Act, so that the necessary consent can begiven, when justified.35

THE MENTAL WELFARE COMMISSION FOR SCOTLAND3.1.5 SOCIAL CIRCUMSTANCESREPORTSIn 2003-04 the Commission received 1,050 SocialCircumstances Reports (SCRs); this was 300 lessthan two years ago. The Mental Health (Scotland)Act 1984 required that a statutory SCR should havebeen written on 191 occasions.Table 14 shows thatwe received only 29% of these reports, compared to46% in 2002-03.Notwithstanding the low completion rate, thestandard of reports remains good; they have broughtto our attention issues such as slow follow up by healthteams, and shortages of key personal or resources.When there is no report, these important mattersmay be missed. The absence of an SCR may meanthat a care team cannot take proper account of anindividual’s social circumstances, when planning hisor her treatment and care. Factors such as financialproblems, poor housing, employment problems, anddifficulties in relationships with others, may nevercome to the knowledge of the health practitioners inthe hospital. Vital information, that may speed apatient’s recovery or assist in his or her earlydischarge, may therefore be missed.Lack of a care plan in the SCR is the most frequentreason for us to seek further information from theMental Health Officer (MHO) who wrote it. SomeMHOs acknowledge that they do not have enoughinformation to prepare a care plan, and they provideit at a more appropriate time. Although the mainpurpose of the SCR is to assist the ResponsibleMedical Officer (RMO) to formulate the treatmentand discharge plan, those which include care plansgreatly assist us in our duty to enquire into a patient’scare and treatment. The Mental Health (Care andTreatment) Act 2003 will require MHOs to preparea care plan as part of an application for a compulsorytreatment order.In addition, under the new Act, MHOs will have astatutory duty to provide an SCR (unless this wouldserve little or no practical purpose) after all relevantevents, as defined under Section 232 of the Act.Under the new Act, there are likely to be moreSCRs and their content will have to be more precise,with the format being prescribed by regulations.Table 14: Statutory Reports Required andReceived, 2003-04Reports Reportsrequired received (%)* CPSA, S58, 111 18 (16)71 and 57(2a)**MHA, S26 with 57 30 (53)relative consentMHA, S26 with 23 8 (35)no consentTotal 191 56 (29)* Criminal Procedure (Scotland) Act 1995**Mental Health (Scotland) Act 1984People detained under the Criminal Procedure(Scotland) Act 1995(CPSA) have the feweststatutory SCRs (just 16%). The awareness that areport is required may not be as high as it was,because there appear to be fewer MHOs in CriminalJustice Teams. Under the new Act, an SCR will be astatutory requirement for compulsion orders, interimcompulsion orders, hospital directions, or transfer fortreatment directions. If they have not already doneso, local authorities should plan now how they willmeet these obligations, when the Act is implementedin 2005.We have recently trained senior administrative staffto scrutinise all SCRs. They look for the problemsthe MHO has identified and the thoroughness of theassessment and treatment provided.They check thatall other relevant matters, including the care plan, areadequately discussed. Any report that does notprovide this information, or that highlights concerns,is passed to an appropriate Social Work Officer; arandom selection of others is also passed to him orher, as a quality check.The new system is subject tocontinuous review and we welcome feedback about it.3.2 GUARDIANSHIP ANDINTERVENTION ORDERSGuardianship OrdersThe second year of the Adults with Incapacity(Scotland) Act 2000 has seen the increase in welfareor joint welfare and financial guardianship ordersthat was expected with the implementation of theAct. Compared with the first year, 52% more36

ANNUAL REPORT 2003-2004applications were granted. The increase in 2003-04may be, in part, because of the slow take up in thefirst year of the Act, (23 orders in the first quartercompared to an average of about 100 in for eachquarter since then). It may also be due to some largehospital closures: there were over 30 applicationsfrom one closure alone in 2003. The geographicaldifferences in the use of guardianship remainstriking. This may reflect differing views betweenlocal authorities about the circumstances in whichthey should apply for an order (see Section 4.1.1 ofthis Report).Compared to the previous year, there has also been anincrease in private applications during 2003-04, risingfrom 18% to 29% of all applications. In some localauthority areas, there are no private guardianships,while, in others, between a third and a half ofapplications for guardianships are made by relatives;in some areas, more than half of applications areprivate. We think that the reasons for these strikinggeographical differences should be examined. Wehave heard of some cases in which family members saythat they have had to apply for guardianship, becausethe local authority refused to do so. Compared withlocal authority guardianship, the duration of privateorders is more likely to be indefinite, with a widerrange of powers.The Mental Health Officer (MHO)reports which accompany private applications tendto contain less detail, particularly when the adult issomeone with whom the local authority has had noprevious contact, and about whom there has been nocase conference.Table 1 shows the proportion of allapplications made by private individuals. Table 2shows the duration of the guardianship ordersapproved during 2003-04.Table 1: Applicants for Guardianship, 2002-042002-03 2003-04Applicant Number (%) Number (%)Local Authority 213 (82) 283 (71)Relative 46 (18) 104 (26)Solicitor 1 (-) 3 (1)Joint 0 (-) 6 (2)Citizen Advocate 1 (-) 1 (-)Carer 0 (-) 1 (-)Total 261 (100) 398 (100)Table 2: Duration of GuardianshipsApproved, 2002-042002-03 2003-04Period of Approval Number (%) Number (%)1 year 4 (2) 12 (3)2 years 2 (1) 2 (1)3 years 178 (68) 243 (61)5 years 6 (2) 6 (2)Not Stated 30 (11) 21 (5)Indefinite 30 (11) 107 (27)Other 11 (4) 7 (2)Total Approved 261 (100) 398 (100)More than half of local authority and two-thirds ofprivate guardianship applications are made in respectof older adults with dementia. The power soughtmost often by local authorities is the authority todecide where the adult should live. Sometimes this isto resolve a conflict of opinion, but, in many cases,there is general agreement about the benefit ofmoving the adult and she or he is not objecting to it.A quarter of all applications are made in respect ofadults with a learning disability. Many of these are toauthorise complex packages of care and support forpeople in their own tenancies. Private applicantsfrequently say they have made the application becausethey wish to be recognised as having the authority totake decisions for a son or daughter with a learningdisability. Sometimes they want to use guardianshippowers to influence local authority care.As shown in Table 2, most guardianship orders aregranted for three years. Some local authorities arebeginning to consider that these should be recalledonce the adult has settled and the grounds for theapplication are no longer fulfilled. Other localauthorities are allowing orders to continue until theyexpire. So far few orders have been recalled. Underthe 1984 Mental Health (Scotland) Act, very fewguardianships lasted longer than a year.We think thatregular review of the guardianship is consistent withthe Act’s principles and we wonder if prolongedguardianship may be unnecessarily restrictive.Some local authorities are finding it difficult to carryout all their supervision and visiting duties in relation37

THE MENTAL WELFARE COMMISSION FOR SCOTLANDto individuals on guardianship orders. Some haveestablished local protocols for complying with theregulations in respect of these duties.Table 3 shows the number of guardianship orders ineach local authority area in 2003-04, together withthe changes over the year.Table 3: Guardianship Cases by Local Authority, 2002-04*AWIA Approved Discharge/ Approved Discharge/ NumberGuardianships** 2002-03 Lapsed**** 2003-04, Lapsed**** 31.03.04*** 2002-03 of which ( ) 2003-04were privateHighland 29 0 34 (3) 5 58Edinburgh (City) 15 1 42 (15) 3 53West Lothian 27 0 30 (3) 7 50Fife 14 2 28 (10) 6 34Glasgow (City) 25 3 14 (5) 3 33Aberdeen (City) 17 0 17 (0) 3 31Argyll and Bute 14 0 18 (4) 4 28Angus 10 0 20 (11) 4 26North Lanarkshire 6 0 19 (5) 0 25Aberdeenshire 6 0 19 (8) 0 25Perth and Kinross 13 1 15 (5) 2 25South Lanarkshire 5 0 16 (5) 1 20North Ayrshire 7 0 14 (3) 1 20Dumfries and Galloway 8 0 11 (1) 2 17Scottish Borders 4 0 14 (3) 2 16Renfrewshire 5 0 10 (6) 1 14East Ayrshire 5 1 9 (0) 0 13Moray 9 0 6 (1) 2 13East Dunbartonshire 3 0 9 (6) 0 12East Lothian 6 0 6 (1) 0 12South Ayrshire 9 0 5 (3) 3 11Falkirk 7 0 7 (2) 5 9Dundee (City) 3 0 6 (2) 1 8West Dunbartonshire 3 1 7 (1) 1 8Inverclyde 2 0 5 (1) 0 7East Renfrewshire 0 0 7 (5) 1 6Stirling 4 0 2 (2) 0 6Midlothian 1 1 5 (3) 0 5Western Isles 2 0 3 (1) 0 5Clackmannanshire 1 0 0 (0) 0 1Shetland Islands 1 0 0 (0) 0 1Orkney Islands 0 0 0 (0) 0 0TOTAL 261 10 398 (115) 57 592* Excluding cases with Tutor Dative** A small number of MHA Guardianships were granted in 02-03*** Some of the figures in this column differ from those in last year’s Report because of late notifications received by the Commission.**** Includes cases where adult died.38

ANNUAL REPORT 2003-2004Table 4 shows the rates of guardianship per 100,000 ofthe population in each local authority area: the rate for2003-04 is compared with the previous two years. Itcan be seen that there was a wide range, from WestLothian, with a rate of 25/100,000 in 2003-04, toOrkney, with no guardianships in 2003-04 and nonein the preceding two years.The Western Isles, whichis a similar community to Orkney, had a rate of14/100,000. There are marked differences betweenlarge urban areas also. For example, Edinburgh city hada rate four times greater than Glasgow. Differences inpractice must account for some of these geographicaldiscrepancies. It is inconceivable that these areascould vary so widely in the proportion of theirpopulation which has incapacity and requires theprotection of guardianship.Table 4: Changes in Rates of Guardianship*,by Local Authority, 2001-042001-02 2002-03 2003-04West Lothian 11 21 25Argyll and Bute 0 15 24Angus 4 11 23Highland 26 22 20Borders (Scottish) 7 8 16Perth and Kinross 9 12 14Western Isles 13 9 14North Ayrshire 7 6 13Edinburgh (City) 7 4 12Aberdeenshire 6 3 11East Dunbartonshire 4.5 6 10East Renfrewshire 2 0 10Aberdeen (City) 12 10 10Fife 10 5 10West Dunbartonshire 6 3 9Moray 7 13 9East Ayrshire 5 6 9Dumfries and Galloway 8 11 9East Lothian 8 14 8Midlothian 1.5 2 8North Lanarkshire 6 2 8Inverclyde 6 4.5 7Renfrewshire 2 3.5 7South Lanarkshire 3 2 7Dundee City 8 3 6Table 4: (continued)Falkirk 9 9.5 6South Ayrshire 6.5 10 4Stirling 4.5 7 3Glasgow City 10 7 3Clackmannanshire 8 5 0Shetland Islands 0 6 0Orkney Islands 0 0 0Total 7.9 7.5 9.7*Rate per 100,000 Local Authority Population, aged 16 and overTable 5: Causes of Incapacity in GuardianshipApplications, 2002-042002-03 2003-04Type of Incapacity Number (%) Number (%)Dementia/Alzheimers 134 (51) 211 (53)Learning Disability 59 (23) 100 (25)Mental Illness 13 (5) 29 (7)Multiple diagnoses 18 (7) 22 (6)Alcohol Related 29 (11) 19 (5)DisordersAcquired Brain Injury 6 (2) 16 (4)Other 2 (1) 1Total 261 (100) 398 (100)Intervention OrdersAs shown in Table 6, the use of intervention orderswith welfare powers remains very low. In 21 out of32 Local Authorities there were no applications forintervention orders in 2003-04. One local authority(Fife) accounted for nearly half of all applicationsgranted: these applications related to the closure of alearning disability hospital, and were used to authorisetenancy agreements and transitional housing benefit.The low use of intervention orders is probably due,in part, to the perception that they have no practicaladvantage over guardianship. It may also be due, inpart, to the uncertainty over whether the IncapacityAct should be used to authorise all decisions madeon behalf of a person lacking capacity: applicantsmay think that it is prudent to obtain a guardianship39

THE MENTAL WELFARE COMMISSION FOR SCOTLANDorder with a range of powers to anticipate possiblefuture needs, rather than an order which authorises asingle intervention, but requires the same legal process.In the first year of the Act, it was noted thatintervention orders were used for people who lackedcapacity but did not resist the intervention, usuallyto move them from a risky home environment toresidential care. This practice has not developed. Itmay have been curtailed by the legal debate aboutthe use of Part 6 of the Act, which is discussedfurther in Section 4.1.1 of this report.Tables 7 and 8 give further details about successfulapplications for intervention orders in 2003-04. Itcan be seen that, compared with guardianship orders(see Table 4), they were used for adults with similarsorts of incapacity, with the exception of alcoholrelatedand other acquired brain damage.It is our policy to visit adults subject to interventionorders when the effect of the intervention is a majorone, such as a move from their home to otheraccommodation.Table 6: Intervention Orders by LocalAuthority 2003-04Local AuthorityFife 17South Lanarkshire 4Shetland Islands 3West Lothian 3Falkirk 2East Dunbartonshire 1East Lothian 1Glasgow City 1Moray 1North Ayrshire 1Perth & Kinross 1Aberdeen City 0Aberdeenshire 0Angus 0Argyll & Bute 0Table 6: (continued)Clackmannanshire 0Dumfries & Galloway 0Dundee City 0East Ayrshire 0East Renfrewshire 0Edinburgh, City Of 0Highland 0Inverclyde 0Midlothian 0North Lanarkshire 0Orkney 0Renfrewshire 0Scottish Borders 0South Ayrshire 0Stirling 0West Dunbartonshire 0Western Isles 0Total 35Table 7: Powers Granted under InterventionOrders, 2003-04Powers GrantedNumberResidency/Tenancy 27Attend day programme 0Give access to care staff 0Financial control 0Buy or sell property 0Medical Treatment 0Hour Supervision 0Legal Proceedings 0Access to confidential documents 0Other 8Total 3540

ANNUAL REPORT 2003-2004Table 8: Causes of Incapacity in Applicationsfor Intervention Orders, 2003-04Type of Incapacity Number (%)Dementia/Alzheimers 16 (47)Learning Disability 16 (47)Mental Illness 2 (4)Multiple Diagnoses 1 (2)Acquired Brain Injury 0 (0)Alcohol Related Disorders 0 (0)Other 0 (0)Total 35 (100)3.3 MENTAL HEALTH SERVICESFOR CHILDREN ANDADOLESCENTSFor the past three years, the Commission’s AnnualReport has highlighted our concern about theadmission of young people to adult mental healthwards. We know we are not alone in this concernand that there is wide acceptance that such admissionsare inappropriate and potentially detrimental. Sevenyears ago, in 1997, the Framework for Mental HealthServices in Scotland required that “children and youngpeople should not be admitted to adult generalpsychiatry wards”. In 2002, the Royal College ofPsychiatrists recommended that any admission of ayoung person under 16 years old to an adult wardshould be treated as an untoward critical incident andbe considered as a sign of inadequate resources. TheNeeds Assessment Report on Child and Adolescent MentalHealth (SNAP), commissioned by the ScottishExecutive and completed in May 2003, recognisedan urgent need for investment in, and developmentof, inpatient services for young people; it alsohighlighted the inappropriateness of admitting themto wards designed for adults.Yet, in our experience,such admissions continue to be as common as ever.Forthe young people involved, and those close to them,it must seem that nothing has happened, despite allthe expressions of concern and calls for action.A young person, now 16, who has been an inpatientin an adult ward for nearly a year, wrote to theCommission about her environment, saying“it’s totally unacceptable, I have seen things I shouldn’thave been subjected to”. We entirely agree. Sadly, hersituation is not unique.We have continued to drawthis matter to the attention of the ScottishExecutive, most recently in February and April 2004.We are taking up the offer of a meeting to discussit further.Between March 2003 and April 2004, we identified25 formal and informal admissions of young peopleunder 16 (23 individuals: 15 girls, 8 boys) to adultmental health wards across the country. In the case ofnon-detained patients, we rely on mental healthservices to notify us about these admissions, andknow they do not always do so; therefore thesenumbers are probably an under-estimate. Examplesof cases brought to our attention include:A 15 year old in the West of Scotland required urgentadmission for the assessment of a possible serious mentalillness. She was admitted to an adult ward, as no bed wasavailable in a young person’s unit. She was later detainedunder the Mental Health Act. She remained in hospital for4 weeks, during which time it was not possible to secure anassessment for her transfer to a young person’s unit.A 15 year old in the North East of Scotland becameabruptly mentally unwell.There were also serious concernsabout her physical health.The nearest young person’s unitwas more than 60 miles from her home. She was thereforeadmitted to a local adult mental health ward. She had afurther admission to the same ward a few weeks later.Table 1 shows the numbers of young people detainedunder the Mental Health (Scotland) Act 1984 andthe Criminal Procedure (Scotland) Act 1995. Thetable also shows the type of ward in which theywere detained.Table 1: Episodes of Detention by InpatientFacility, 2003-04Detentions Detentions Allunder 16 years 16 and 17 years detentionsM F M F under 18Adolescent 3 7 1 9 20unitsAdult Wards 3 10 55* 38** 106Medical 2 2*** 3 2 9WardsTotal 8 1 9 5 9 4 9 1 3 5* Includes 3 admissions under Criminal Procedure Act 1995** Includes 2 admissions under Criminal Procedure Act 1995*** Includes 1 paediatric ward41

THE MENTAL WELFARE COMMISSION FOR SCOTLANDAs highlighted in our Annual Report for 2001-02,we think that, when admission of adolescents toadult wards becomes absolutely necessary, then healthservices should have clear policies for providing ageappropriate care, as far as possible.We are aware thatsome regions have developed such policies, butmost, from our experience, have yet to do so. Clearlythe duty placed on health boards under Section 23of the Mental Health (Care and Treatment)(Scotland) Act 2003, makes it imperative that theprovision of services for young people is givengreater attention than has been the case in the past;this includes their inpatient care.Following an earlier consultation with service users,we have commissioned the Scottish DevelopmentCentre for Mental Health to gather the experiencesof young people who have been admitted to hospitalfor psychiatric treatment. This will involve meetingwith young people and their families in the courseof 2004. It is intended that this project willcontribute to the development of good practiceguidance for the in-patient care of young people. Itis hoped that it will be helpful to service managers,as well as young people and their families, when thenew legislation is implemented in 2005.Our information about the use of detention inyoung people raises another important issue, inaddition to inappropriate admission to adult wards.A number of emergency detentions, under Section24 and 25 of the Act, occur in the aftermath ofepisodes of self-harm or because of concern aboutthreatened self-harm. Most of the detentionsoccurring in medical wards are in this category.Detention in these circumstances is generally toensure further assessment of physical and mentalhealth. Often the outcome is that the young personis not considered to have a mental disorder anddetention is quickly terminated: many suchdetentions are discharged within 24 hours. It may bethat this points to a need for greater development ofcrisis services for young people, including servicesthat offer co-ordinated multi-agency support andalternatives to hospital admission.The Mental Welfare Commission will visit allinpatient services for young people, on at least anannual basis, to meet with the service-users, theirfamilies and staff. In the future, we hope to be ableto extend our visiting to include young people usingday and out-patient parts of mental health andlearning disability services. When our resourcesallow, we also hope to include visits to secure facilitiesfor children and young people.3.4 SAFE TO WANDER?: GOODPRACTICE GUIDANCEThe Commission has been considering its positionon the use of technology in caring for people withdementia, learning disabilities and related disorders,in care homes, hospitals and their own homes. Webelieve that, in general, technology can be a valuabletool, which helps people to maintain theirindependence; it can enhance a person’s freedom,without unduly increasing any risks that he or shemay face, and this is to be welcomed.In 2002, we published Rights, Risks and Limits toFreedom; this was practice guidance for situations inwhich individuals may require physical restraint orother restrictions of their freedom. This guidanceidentified the use of electronic tagging, amongstother interventions which can constitute restraint.In response to several inquiries about our view onthe use of electronic tagging in care homes andhospitals, we are producing more detailed guidanceabout this specific intervention.Later this year, we will be publishing Safe to Wander?which discusses principles and practice in the use ofwandering technologies in care homes and wards forpeople with dementia and related disorders. By a‘wandering technology’ we mean an electronicsystem which alerts staff if an individual residentcrosses a particular boundary. Though care staff arewarned that an individual is at risk of leaving, thesystem does not actually prevent him or her fromdoing so.Although it is not our role to licence the use of thesetechnologies or endorse individual systems orproducts, we wish to ensure that there is goodpractice in this area and that appropriate principlesand guidelines are considered, prior to their use. Inaddition to the principles which should be appliedwhen considering the use of these technologies, theguidance will discuss the current legal implicationsof its use. All technologies have the potential for42

ANNUAL REPORT 2003-2004abuse, if not used within a proper legal frameworkand with reference to good practice guidance. Greatcare needs to be taken to ensure that the individual’srights are protected and that technology is neverbeing used to replace direct human contact or as asubstitute for effective and compassionate care.In our view, the way that technology is applied canmake a huge difference to the quality of life forresidents in care homes and hospitals; care must betaken to ensure that the difference is beneficial ratherthan detrimental.Safe To Wander? Will be available on our website,www.mwcscot.org.uk3.5 USE OF RESTRAINTThroughout the year, the Commission has receiveda number of reports of patients in hospitals beinginjured while being restrained by staff.We have alsobeen made aware of complaints by patients, whobelieve that they have been inappropriately andunnecessarily restrained. In gathering informationabout these cases, we have found common themes.We believe that they may reflect national issuesabout standards of training in the management ofviolence and aggression. Clearly, this is not a problemlimited to Scotland. Last year, there was extensivereporting of an English inquiry into the case ofDavid “Rocky” Bennett, who died in 1998, whilstbeing restrained. The inquiry report made manyrecommendations, including the requirement for anational system (in England and Wales) of training incontrol and restraint.Listed below are some of the issues arising from thecases reported to the Commission:• Male only staff teams restraining female patientsThis can be particularly distressing for femalepatients, and great care should be taken to provide anappropriate mix of staff, so that female staff areavailable to deal with the restraint of female patients,when the need arises.• Inadequate attempts at de-escalationRestraint is a last resort, to protect the patient andothers. De-escalation is a skilled task, and staff mustbe trained and equipped to help angry and distressedpatients.• Injuries arising directly from restraintRestraint is used to bring control to an out-ofcontroland dangerous situation. Restraint techniquesused should not, in themselves, cause injury topatients or staff.• Debriefing and support of the person who has beenrestrainedRestraint is a traumatic experience.Anyone who hasbeen restrained should have an opportunity todiscuss what happened, in order to understand whythe restraint was necessary. It is common for thepatient’s perception of what happened to him or herto be entirely different to that of the staff involved.• Debriefing of other patients who have witnessed arestraintRestraint can be frightening for other patients whohave witnessed the event.They need to be offered anopportunity to discuss it.• Location of resuscitation equipmentStaff must know where resuscitation equipment isstored and how to access it quickly.• Availability of supporting staff and adequacy ofalarm systemsThere must be clear arrangements for alertingadditional staff, and effective alarm systems tosummon them. There should be clear guidance inrespect of patients who require assistance in anemergency.• Analysis of restraint techniques and of trainingCritical incident reviews should examine, in detail,the way restraint techniques are used. Servicesshould audit incidents in which restraint has beenused, and relate the findings back to the local trainingthey provide for staff.43

THE MENTAL WELFARE COMMISSION FOR SCOTLAND• Objectivity of critical incident reviewsCritical incident reviews are an opportunity toanalyse the events surrounding incidents of restraint.Great care should be taken to ensure that the reviewinvolves a practitioner who is sufficiently independentto provide objectivity. Where possible, service usersshould be involved. Critical incident reviews shouldnever be used to justify the actions that were taken.Services have increasingly adopted a “zero tolerance”approach to violence in health care settings. Thispolicy does not sit easily in services which providecare to people whose judgment and behaviour isaffected by mental disorder. We recognise that carestaff have to deal with people who are disturbed andaggressive, in what are often stressful circumstances.However, many incidents appear to be avoidableand, in some cases, appear to have been caused, or atleast exacerbated, by staff communicating poorlywith patients, or overreacting to their distress anddisturbance. We are aware that NHS Scotland isplanning the production of advisory standards, andthe Scottish Executive is considering further actionin this area. We welcome this development, as webelieve that training and guidance should be moreconsistent throughout Scotland, in terms of bothquality and delivery.3.6 UNAUTHORISED REMOVAL OFADULTS WHO LACK CAPACITYIn the past two years, the Commission has beeninvolved in some cases of people who lack capacityand have been removed by relatives from theirhomes or care homes. These removals have takenplace either without the knowledge of primarycarers, or against their wishes. For example, relativeshave persuaded an individual to leave a care home,when he or she lacks capacity to consent, but staffhave no authority to prevent it. Relatives have saidthey can provide better care for these individuals. Ithas also been suggested that some removals mightbring financial advantage for relatives.Such events are rare but they are serious, becausethey cause an unplanned disruption in individuals’care and bring great anxiety to their primary carers.Arranging an individual’s return to his or heroriginal place of residence can be an extremelylengthy and expensive process, because it usuallyrequires a guardianship order with the appropriatepowers. Applications for guardianship in thesecircumstances may be disputed, or different familymembers may make two separate guardianshipapplications. One case involved an individual withdementia; it took over 15 months to resolve, withlegal and other costs of over £100,000.Guardianship powers were eventually given to theindividual’s primary carer, after the individual hadlived, for more than a year, in unfamiliarsurroundings with a different quality of care thanpreviously. The individual and the carer had livedtogether for over 25 years and their separation hadcaused considerable anguish and anger.In another case, a young woman with a learningdisability, who was happily settled in a care home,was removed by relatives, with whom she had hadfew contacts. She was taken to live with them inanother local authority area, where she had nofriends or outside activities.The local authority waseventually made her guardian, and she returned toher care home after a delay of several months. Thedelay was caused, in part, by an unfortunatedisagreement between local authorities about whoshould make the guardianship application.In the cases known to the Commission, the policehave been unable to take action because no statutoryoffence has been committed. We have thereforeasked the Scottish Executive to consider whatstatutory measures are required to deter the removalof a person who lacks capacity.There are other important lessons to be learnt fromthese cases.• First, there must be swift decisions about themost appropriate legal measures to prevent aremoval (when this is anticipated).An applicationcan be made to the Court of Session or to theappropriate Sheriff Court to obtain an interiminterdict against a removal. An application to asheriff for an interim guardianship order maybe sought, with the power to decide a person’sresidence. If the guardian’s decision is ignored aSheriff can make a compliance order underSection 70 of the Adults with Incapacity Act.Such measures can, however, be traumatic; it istherefore far preferable to have a statutoryprovision to deter unauthorised removals.44

ANNUAL REPORT 2003-2004• Secondly, in disputes of this kind, theindividual’s health and social care needs mustbe independently assessed, using all appropriatemeans of communication and observation, andtaking the individual’s past and present wishesinto account. If the person has been moved,then there must be a careful comparison of thequality of care provided in both environments.Adequate care is not an acceptable alternativeto excellent care.If there is strong disagreement amongst relativesabout the care of an individual who has been removedfrom his or her home, we think the local authorityshould consider applying for a guardianship order,with the appropriate powers. Although thisapplication may be opposed by family members, it islikely that the case can be resolved more speedilythan when applications for guardianship are made bydifferent family members, amongst whom there maybe major disputes and ill feeling.We have asked theScottish Courts Service and Sheriffs Principal toprioritise these cases so that they are resolved quickly.In comparable cases of children who have beenremoved from their homes, this is considered goodpractice; we think that an adult who lacks capacityshould have equal priority in these circumstances.45

THE MENTAL WELFARE COMMISSION FOR SCOTLANDSECTION 4 MENTAL HEALTH LAW AND POLICY4.1 ADULTS WITH INCAPACITY(SCOTLAND) ACT 20004.1.1 PART 6: THE USE OF WELFAREGUARDIANSHIP ANDINTERVENTION ORDERSIntroductionEarly in the implementation of Part 6 of the Adultswith Incapacity (Scotland) Act 2000, it becameobvious that there was considerable uncertaintyabout the appropriate circumstances in which to usePart 6 applications for welfare interventions. It wasnot clear whether a significant intervention (such asa change of residence) should always require theauthority of a guardianship or intervention order.The Commission was frequently consulted about this.Legal advice given to some local authorities wasunequivocal: an adult who lacked capacity shouldnot be removed to a care home, without an orderunder the Act.Whether the adult objected, or not, tothe proposed intervention, was not regarded aslegally relevant. Local authorities were advised thattheir failure to obtain an order could be open tochallenge, on the grounds that they had both failedto comply with their responsibilities under the Actand had also breached the individual’s human rights.On the other hand, we consulted some lawyers whoheld the firm view that it was not the intention ofthe Act that every welfare intervention should requirethe authority of the court. In fact, one eminentlawyer commented that one of the aims of the Actwas to reduce unnecessary interventions.Some local authorities initially followed the legaladvice they had received, and ran into seriousdifficulties, because of the number of applicationsneeded. The problems included: delayed dischargesfrom hospital, while Part 6 applications wereprocessed; delays in the courts; and significant use oflocal authority resources (legal and social work) inprocessing applications. Private individuals, who wereadvised to make applications for their relatives, oftenfaced heavy legal expenses.If Part 6 orders were used in all cases of individualswho lacked capacity and required a welfareintervention, the numbers could run into thousands.This would put pressure on local authorities andwould also place heavy burdens on the courts andthe Commission.It appears that most local authorities are not nowusing Part 6 of the Act for every significant welfareintervention. The number of Part 6 orders has notincreased to the extent that would have beenexpected, if they were being used whenever an adultlacking capacity was moved to a care home.We asked Hilary Patrick, Honorary Fellow in theSchool of Law at Edinburgh University, to prepare adiscussion paper about the use of Part 6 in respect ofsignificant welfare interventions. Neither we nor MsPatrick can give a definitive view about when Part 6should be used, but it was hoped that the paper mightassist local authorities, and others, to decide when itwould be appropriate to apply for an order.Ms Patrick consulted relevant legal authorities andmental health practitioners in preparing a paper,whichwas published at the end of August; and sent out tointerested parties. The content of her paper issummarised below.Ms Patrick’s Discussion PaperMs Patrick identified genuine disagreement amongstlegal experts, about the appropriateness of seeking aPart 6 order in every case of an adult lacking thecapacity to decide about a particular intervention.She suggested that there was a difference in philosophybetween those who were concerned to see practicalbenefits from use of the Act and those who weremore concerned with human rights and legalprotections for vulnerable people.She considered various legal arguments including:the background and intention of the Act; the impactof the innovative principles set out in Section 1 ofthe Act; the need to protect vulnerable adults; andthe human rights considerations.46

ANNUAL REPORT 2003-2004Those supporting the selective use of Part 6 arguethat it was not the intention of the Parliament thatan order should be sought in every situation. MsPatrick was unable to identify conclusive groundsfor this view. However, it was suggested that theprinciples of the Act could justify a selectiveapproach, in particular the principles of benefit andleast restrictive intervention; the benefit to the adultof a Part 6 order should be weighed against thepotential restrictions of the order.Both sides agreed that an adult’s apparent lack ofobjection to a proposed intervention was no reasonto deprive him or her of the safeguards which theAct provides. However, those arguing for a selectiveapproach believed that the Act’s principles could beused to protect the adult, without a Part 6 orderhaving to be made.Some commentators have argued that a local authoritydoes not have the statutory power to move an adult,who cannot consent to the move, unless it has a Part6 order. However, she drew attention to the duties oflocal authorities under the Social Work (Scotland)Act 1968, to promote the welfare of people in needand to provide residential care.This includes the right(and the duty in certain circumstances) to makesuitable arrangements to care for clients, whether ornot the client has capacity.She addressed concerns that failure to use Part 6could be a breach of the adult’s rights under Articles 5(no illegal detention), 6 (right of access to the courts)or 8 (respect for family life) of the EuropeanConvention on Human Rights. She concluded that,to comply with Article 5, an order would always berequired, if the adult demonstrates unwillingness tomove. However, Article 6 may not require an orderin every case: for example where the adult appears tobe willing to move.To seek an order, when an adultdoes not appear to object to the intervention, couldconstitute a breach of Article 8.The ECHR makes itimperative that adults are helped to understand theirright to challenge decisions in the courts.She stressed the importance of proper assessment ofcapacity, pointing out that it is not appropriate toapply for a Part 6 order, if an adult can take decisionsor action him or herself, with help if necessary. Shesuggested that practitioners needed further guidanceto assist them in assessing and maximising the capacityof their clients. The involvement of advocacy wasseen as an important way in which practitionerscould show respect for adults’ wishes and feelings,even if the adult lacked capacity.The need for private individuals and carers to seekPart 6 orders was discussed.While families and carersmay have some rights, deriving from their commonlaw duty of care, this might not be sufficient to enablethem to move an adult, in the absence of a valid powerof attorney. However, Ms Patrick did not consider itwas appropriate for local authorities to put pressureon individuals to apply for Part 6 orders. She arguedthat if a local authority believed a Part 6 order wasrequired, and family or carers were unwilling toapply for one, the local authority should apply forthe order, as guardian of last resort.The relationshipbetween local authorities and private carers raisesvery complex issues. Ms Patrick suggested that therewas a need for these issues to be discussed between theScottish Executive, local authorities and carers’ groups.Ms Patrick concluded that different views on theuse of Part 6 orders stemmed from a differentunderstanding of the purpose of the Act.While therewere strong arguments on both sides, it was her viewthat a selective approach was more in accordancewith the principles of the Act.She also considered possible practical solutions tothe continued disagreements over the interpretationof the law. She argued that increased use of welfarepowers of attorney would reduce the size of theproblem, and recommended that the ScottishExecutive launch a public education campaign toincrease the use of these powers.She suggested that, if problems remain, it might benecessary to amend the Incapacity Act. A simplersystem could be introduced to deal with significantwelfare interventions to which the adult does notappear to object. She suggested reforms in the legalsystem, which might make applications under Part 6less costly. She drew attention to the provisions ofSection 3(3) of the Act, whereby a local authoritymight apply to the sheriff for directions, instead ofseeking a Part 6 order.She concluded that, whenever a local authority dealswith a person lacking capacity, it should do so withinthe framework of the Act. This does not, however,mean applying for a Part 6 order for every case inwhich a significant intervention is proposed. An47

THE MENTAL WELFARE COMMISSION FOR SCOTLANDassessment of the need for an order should be carriedout, in accordance with the principles of the Act. Ifa local authority decides not to apply for an order ina particular case, the paper suggested a procedurewhich would ensure that the adult, and those closeto him or her, were made aware of their rights tochallenge the decision.The Scottish Executive received an early draft of thispaper and has now considered these issues. On thebasis of the legal advice it has received, it has nowissued guidance on the use of Part 6.Whilst pointingout that local authorities should make their owndecisions, its advice leans towards a selectiveapproach by local authorities.The full text of Ms Patrick’s paper is available on theCommission’s website at www.mwcscot.org.uk.4.1.2 PART 5: MEDICAL TREATMENTPart 5 of the Adults with Incapacity (Scotland) Act2000 concerns medical treatment and research. Beforethe implementation of the Act, people who did nothave the capacity to consent to medical treatmenteither had to be treated on a “common law” basis, orhave a tutor dative appointed by the Court ofSession. Now the doctor primarily responsible forthe patient’s treatment issues a certificate ofincapacity, under Section 47 of the Act (a “Section47 certificate”), that permits treatment to proceed.There are exceptions and regulations that limit thisgeneral authority to treat. Research is possible understrict conditions and with ethical approval.During our visits to patients, we note howcertificates of incapacity are being used. Sometimesthe certificates are accompanied by treatment plans.For some patients, these are reviewed regularly, theirrelatives are consulted about their treatment andtheir care clearly follows the principles of the Act.However, in many places that we visit, we havefound that this Part of the Act is not being usedcorrectly. Many people who lack capacity aretherefore being treated outside the law that exists toprotect them.We have drawn this to the attention ofthe appropriate doctors and managers and we willcontinue to monitor the situation.Part 5 of the Act is working well in some respects. Itprovides a mechanism to allow surgery and otherprocedures, which would normally require thepatient’s signed consent. It also introduces importantsafeguards for treatments that are controversial, suchas ECT, or that can have long-term consequences,such as sterilisation. However, there are practicalproblems in the use of Part 5. When people withincapacity need treatment that would not normallyneed signed consent (such as medication andstraightforward investigations), there is no mechanismto ensure that certificates of incapacity are beingused. In addition there is no systematic monitoringprocess. Certificates sit in case-records and are notlogged locally or nationally.The Scottish Executive has consulted over possiblechanges to both Part 5 of the Act and the Code ofPractice, to address other difficulties in the use ofPart 5. We have supported this exercise and lookforward to commenting on a revised code. Thechanges we support include:• The maximum duration of a Section 47certificate should be extended from one year,to three.• If an appropriate doctor has examined thepatient recently, he or she should be allowed tocomplete a Section 47 certificate of incapacity,without having to see the patient again.• The Code of Practice should recognise thatthe thoroughness of the doctor’s assessment ofcapacity needs to be proportional to theseriousness of the proposed treatment: forexample, the adult’s capacity to understand andconsent to complex treatment for cancer mayneed much more thorough assessment than itwould for more straightforward treatments.• Other health professionals, as well as doctors,should be allowed to assess and certify incapacityfor some investigations and treatments, providedthat they are appropriately trained.We welcome the commitment given by the ScottishExecutive to introduce changes to the Act and hopethat they will make this part of the Act easier to use,and more beneficial to the people who need medicaltreatment, but cannot give consent to it. However,we doubt whether everyone who needs it will get thebenefit of this part of the Act, unless the recordingand monitoring arrangements are strengthened.48

ANNUAL REPORT 2003-20044.1.3 PART 4: MANAGEMENT OFRESIDENTS’ FINANCESPart 4 of the Adults with Incapacity (Scotland) Act2000 was implemented in October 2003. It replacedSections 93 and 94 of the Mental Health (Scotland)Act 1984; these sections of the 1984 Act allowedhealth and social work services to manage thefinances of people in hospital who lacked thecapacity to do this for themselves.The Incapacity Acthas now taken over this aspect of care for residentsin hospitals and registered care establishments.Thereis a robust Code of Practice that clarifies howresidents’ money can be used. Health Boards and theCare Commission supervise this process.For hospital patients whose finances were beingmanaged by the hospital managers in October 2003,the existing arrangements continued to apply.However, new arrangements, under the IncapacityAct, must be made within three years. Registeredcare homes have the duty to manage residents’funds unless they formally “opt out”. Unregisteredestablishments can “opt in”to the Part 4 arrangements.Managers can receive, hold and spend money onbehalf of residents, in accordance with the Act andthe Code of Practice, keeping the principles of theAct in mind at all times.We welcomed the introduction of this part of theAct. Large numbers of people with mental illnessand learning disability, who are not in hospital, couldbenefit from the new arrangements. However, wehave heard of problems with the implementation ofthis part of the Act. In some cases, problems withinterpretation of the law have caused difficulty.Also,the exclusion of many people from this part of theAct has led to difficulty in protecting their moneyand using it for their benefit.One problem is that the Act excludes Department ofWork and Pensions (DWP) benefits, which aregoverned by the UK Parliament.These benefits canbe managed by appointing someone to receive themon behalf of the incapable person. Managers of careestablishments can be appointees for DWP benefitsbut, for legal purposes, may be best advised tomanage these benefits separately from any othermoney they hold for residents, e.g. private incomeand inheritance.The biggest problem is the position of people whohave been discharged from hospital to their owntenancies, with housing support, and who haveincome or savings, in addition to their weekly DWPbenefits.This is a common situation for people withlearning disability. There is no easy mechanism formanaging their finances, especially when they have amoderate amount of capital, but not enough tojustify the cost of Financial Guardianship. People inthis situation may not get the benefit of the moneydue to them. They may also be at risk of financialexploitation.These cases enhance our view that we need amechanism for low-cost public Financial Guardianshipfor people with moderate amounts of money.Occasionally, a charity takes on this work, but this isthe exception rather than the rule. We havehighlighted this issue in our response to the ScottishParliament’s review of the Act through the Justice 2Committee.4.2 DEVELOPMENTS IN MENTALHEALTH LEGISLATION ACROSSTHE UNITED KINGDOMDevelopments in ScotlandThe last five years have been an exciting period ofdevelopment in Scottish mental health law. TheAdults with Incapacity (Scotland) Act was passed in2000, and has been implemented in stages since2001, with the last Part (Part 4) being implementedin October 2003.The Act was much welcomed, as along-overdue protection for people who lack thecapacity to make decisions. However, some problemshave emerged in its interpretation and operation;these were discussed earlier in this section of theAnnual Report (see Section 4.1). The ScottishExecutive has already held a consultation exercise onthe use of Part 5 and has issued guidance on the useof Part 6.Parliament passed the Mental Health (Care andTreatment) (Scotland) Act in 2003, following theMillan Committee’s report in 1999. The new Actwill finally be implemented in 2005.The Executiveand parliament consulted widely on the MentalHealth Bill as it went through its various stages.49

THE MENTAL WELFARE COMMISSION FOR SCOTLANDSince the Act was passed, there have been furtherconsultations about regulations, the Code of Practiceand the practical aspects of implementation. Thesepractical aspects have included: setting up the MentalHealth Tribunal for Scotland; developing trainingprogrammes; developing appropriate informationand guidance; and identifying the research needed toevaluate how the Act is working. The Commissionhas been closely involved in all of these.We think that the new Act will greatly strengthenthe rights of service-users and the voice of carers.Wehope it will improve standards of care for bothindividuals subject to compulsory powers and thosereceiving voluntary treatment (see Section 2.9 formore information about our work towardsimplementing the Act).In its consultations about the Act, the Executive hasactively sought the views of a great range ofindividuals and organisations.These include: serviceusers;carers; voluntary organisations; health andsocial work practitioners; advocacy organisations;professional bodies; and statutory organisations, suchas ourselves. We think that the Mental HealthDivision, and, in particular, its Implementation Team,has been thorough, inclusive and accessible in itsconsultation work.For further information about the Act and itsimplementation, see the Mental Health Law Team’swebsite, www.scotland.gov.uk/health/mentalhealth,and our Annual Report for 2002-03, which isavailable on our website, www.mwcscot.org.uk.The consultation that has gone into the new Act isin some contrast to the way a new Mental HealthBill has been developing in England and Wales.Developments in England and WalesMental Health Act 1983An expert committee, chaired by Professor GenevraRichardson, reported on the Mental Health Act1983 in the same year as the Millan Committeereported on the Scottish Act. Its recommendationswere very similar.They included:• The legislation should be based on explicitprinciples (which were very similar to those inthe Scottish legislation).• Individuals should only be subject to acompulsory order if they do not have thecapacity to make treatment decisions.• A tribunal should approve all detentionsbeyond 28 days.• Learning disability should be included in a newAct, but this should be reviewed.In one respect its recommendations differed fromthose of Millan: it proposed a broader definition ofmental disorder. This was combined with arestrictive set of criteria for compulsion, so thatcompulsory powers could only be applied to theindividuals with the most severe mental disorders.Unfortunately, when the government published itsDraft Bill in 2002, the Richardson Committee’scareful safeguards had been omitted. The principlesin the Bill were rudimentary. Three provisions inparticular caused concern:• The grounds for compulsion had beensignificantly loosened, in comparison with notonly the Committee’s recommendations, but alsothe current 1983 Mental Health Act. Unlike thenew Scottish Act, mental disorder was definedvery broadly, with no conditions excluded.Impaired decision-making ability was notincluded as one of the grounds for compulsion.• Benefit to the patient was not one of thecriteria for compulsory treatment.• The practitioner in charge of treatment had noabsolute right to discharge the patient from acompulsory order.This led practitioners and service-users to fearthat the new law could be used excessively andinappropriately. There was particular anxiety that itcould be used to impose ‘preventive detention’ onpeople with severe personality disorders who werethought to be dangerous, but had not committedan offence.There was unprecedented unity in the opposition tothe Draft Bill, involving a wide range of practitioners,professional bodies, voluntary organisations, serviceusergroups and civil liberties groups. As a result ofthis opposition, the Draft Bill did not go ahead inthe proposed form. The Department of Health hasrecently published a further Draft Bill.50

ANNUAL REPORT 2003-2004Further details about the progress of this legislationcan be found on the Department of Health’s website, www.dh.gov.uk.Mental Capacity BillIn 2003, the Department of Constitutional Affairs atWestminster introduced a Draft Mental IncapacityBill. The Mental Capacity Bill followed in 2004.The Bill is similar to the Adults with Incapacity(Scotland) Act 2000 in some respects, including: astatement of principles; a clear definition ofincapacity: and a requirement that the assessment ofincapacity should be related to specific decisions.The Bill requires people, who are making decisionsfor an individual who lacks capacity, to act in his orher ‘best interests’.In some respects, the Bill is less complex than theScottish legislation. In essence, it has three mainmeasures:• Protection from legal liability for any personacting on behalf of individuals who lackcapacity, provided he or she observes thegeneral principles of the Act.• The creation of a single ‘lasting power ofattorney’ with both welfare and financial powers.• The appointment, by the Court of Protection,of ‘deputies’ who have similar functions toguardians under the Scottish Act.A deputy canbe a private individual or an office-holder in anorganisation, such as a local authority, and canhave both welfare and financial powers.In addition, it introduces two provisions which arenot in the Scottish Act.• It allows individuals to make advancestatements refusing future treatments.• It introduces a new criminal offence of illtreatment or neglect of a person who lackscapacity.Concerns have been expressed about some aspects ofthe Bill. In particular, there are concerns that itcontains insufficient safeguards to protect theindividual with incapacity. In particular, there arefears that there could be abuse of the general provisionto allow other people to act on the individual’sbehalf. Concerns have also been expressed inrelation to medical treatment. Apart from advancestatements, there are no specific safeguards inrelation to medical treatment, with the exception of‘serious medical treatment’. For ‘serious’ treatments,the Bill requires the appointment of ‘independentconsultees’, who have to be consulted, if there is noone else to speak on the patient’s behalf.Further information about this legislation can befound on the Department for Constitutional Affairsweb site, www.dca.gov.uk.Developments in Northern IrelandThe Department of Health, Social Service andPublic Safety in Northern Ireland is currentlycarrying out a major review of all its mental healthand learning disability services and legislation. Thisreview involves service-users, carers, civil servants,mental health practitioners and statutory bodies,including our sister Commission.The Review is extremely comprehensive,combining a review of the legislation with a reviewof health and social work services for people withmental illness and learning disability. This may leadto legislation and services which are more integratedthan is the case elsewhere. The Review is alsoexploring the advantages and disadvantages ofcombining incapacity and mental health legislationor keeping them separate, as in the rest of the UK.The Review started its work in October 2002 and islikely to take up to three years to complete.Further information about this review can be foundon the Review body’s website, www.rmhldni.gov.uk51

THE MENTAL WELFARE COMMISSION FOR SCOTLANDSECTION 5 FINANCIAL STATEMENTIndependent auditors’ statement on the summary financial statement of the Mental WelfareCommission for ScotlandWe have examined the summary financial statement of the Mental Welfare Commission for Scotland set outon pages 53 to 54.This statement is made solely to the Mental Welfare Commission for Scotland, as a body, in accordance withthe terms of our engagement. Our work has been undertaken so that we might state to the Mental WelfareCommission for Scotland those matters we are required to state to it in such a statement and for no otherpurpose.To the fullest extent permitted by law, we do not accept or assume responsibility to anyone other thanthe Mental Welfare Commission for Scotland as a body, for our work, for this statement, or for the opinions wehave formed.Respective Responsibilities of the Commission, Accountable Officer and AuditorThe Commission and its Accountable Officer is responsible for preparing the summary financial statement.Our responsibility is to report to you our opinion on whether the summary financial statement is consistentwith the audited financial statements of the Commission.We also read the other information contained in thesummarised annual report and consider the implications for our report if we become aware of any apparentmisstatements or material inconsistencies with the summary financial statement.Basis of opinionWe conducted our work having regard to Bulletin 1999/6 ‘The auditor's statement on the summary financialstatement’ issued by the Auditing Practices Board for use in the United Kingdom. Our report on the MentalWelfare Commission for Scotland's full annual financial statements describes the basis of our audit opinion onthose financial statements.OpinionIn our opinion the summary financial statement is consistent with the audited financial statements and annualreport of the Mental Welfare Commission for Scotland for the year ended 31 March 2004. We have notconsidered the effects of any events between the date on which we signed our report on the full financialstatements and the date of this statement.KPMG LLPChartered AccountantsSaltire Court20 Castle TerraceEdinburgh EH1 2EG52

ANNUAL REPORT 2003-2004OPERATING COST STATEMENTFOR THE YEAR ENDED 31st March 20042003 2004£ £Clinical Services Costs0 Hospital and Community 00 Family Health 00 Total Clinical Services Costs 02,132,106 Administration Costs 2,550,6400 Other non clinical services 00 Local Health Councils 02,132,106 Net Operating Costs 2,550,640SUMMARY OF RESOURCE OUTTURN2003 2004£ £2,132,106 Net Operating Costs (per above) 2,550,6400 Less: Capital Grants to/(from) Public Bodies 00 Less: FHS Non Discretionary Allocation 00 Less: Local Health Council Allocation/Expenditure 00 Less: Other Allocations [Please specify] 02,132,106 Net Resource Outturn 2,550,6402,178,000 Revenue Resource Limit 2,549,00045,894 Saving/(excess) against Revenue Resource Limit (1,640)MEMORANDUM FOR IN YEAR OUTTURN0 Brought Forward deficit/(surplus) from previous financial year 045,894 Saving/(excess) against in year Revenue Resource Limit (1,640)53

THE MENTAL WELFARE COMMISSION FOR SCOTLANDBALANCE SHEETAS AT 31st MARCH 20042003£ £ £Fixed Assets0 Intangible fixed assets 00 Tangible fixed assets 00 00 Debtors falling due after more than one year 0Current Assets0 Stocks 014,088 Debtors 23,7250 Investments 0540 Cash at bank and in hand 6214,628 23,787Current Liabilities111,288 Creditors due within one year 130,779(96,660) Net Current assets/(liabilities) (106,992)(96,660) Total assets less current liabilities (106,992)0 Creditors due after more than one year 00 Provisions for liabilities and charges 00 0(96,660) (106,992)Financed by:(96,660) General Fund (106,992)0 Revaluation Reserve 00 Donated Asset Reserve 0(96,660) (106,992)Adopted by the Commission on 26th July 200454

ANNUAL REPORT 2003-2004SECTION 6 FURTHER INFORMATION6.1 BODIES WE MEET WITHThe Commission maintains regular contact with thefollowing organisations:Alzheimer Scotland – Action on DementiaAssociation of Directors of Social WorkBritish Association of Social WorkersCare CommissionColleges of NursingConvention of Scottish Local AuthoritiesClinical Resources and Audit GroupCrown OfficeDepartment for Work and PensionsENABLELaw Society of ScotlandLocal Associations of Mental HealthLocal AuthoritiesManic Depression Fellowship ScotlandNational Schizophrenia Fellowship (NSF)NHS Trusts & BoardsNHS Quality Improvement ScotlandOffice of the Public GuardianRoyal College of General PractitionersRoyal College of NursingRoyal College of PsychiatristsScottish Association of Mental Health (SAMH)Scottish Consortium for Learning DisabilityScottish Courts AdministrationScottish Development Centre for Mental HealthScottish General Practitioners Committee (BMA)Scottish Law CommissionScottish ExecutiveScottish Public Services OmbudsmanScottish Prisons ServiceSheriffs’ AssociationSocial Work Services Inspectorate6.2 OUR PUBLICATIONSWe provide a variety of publications for people withmental disorder, and for carers and practitioners:General Information Leaflets:• Mental Welfare Commission for Scotland – whatwe do and how we can help.• Information For Detained Patients.• For People With Learning Disabilities.• In Your Interests – a guide for all patientsadmitted to a psychiatric ward after criminalproceedings.Good Practice Guidance:• Emergency Detention – Use of Sections 24and 25 of the Mental Health (Scotland) Act1984.• Filling in Mental Health (Scotland) Act 1984Forms.• General Hospitals and the Mental Health(Scotland) Act 1984 (2002).• Guidance on Androcur to Reduce Sex Drivein Male Incapable Patients (1991).• Guidance on Clozapine, for ResponsibleMedical Officers (1997).• Reporting Accidents and Incidents (fromMWC Annual Report, 1992-1993).• Reporting Accidents and Incidents for LocalAuthorities, Independent Providers andVoluntary Organisations (from MWC AnnualReport 2000-2001).• Research and Detained Patients/ Patients WithIncapacity (2002).• Rights, Risks and Limits to Freedom (2002).• Authorising Significant Interventions for AdultsWho Lack Capacity (2004).55

THE MENTAL WELFARE COMMISSION FOR SCOTLANDInquiry Reports:Full Anonymised Reports:• Report of the Inquiry into the Care and theTreatment of Noel Ruddle. 2000.• Report of the Inquiry into the Care andTreatment of Mr B. February 2001.• Report of the Inquiry into the Care andTreatment of Mrs K. October 2001.• Report of the Inquiry into the Care andTreatment of Mr J. September 2002.• Report of the Inquiry into the Care andTreatment of Mr C. October 2002.• Investigations into Scottish Borders Counciland NHS Borders Services for People withLearning Disabilities: Joint Statement from theMental Welfare Commission and the SocialWork Services InspectorateInquiry Summaries:• Inquiry Summary – Mrs K.• Inquiry Summary – Mr J.• Inquiry Summary – Mr C.Visit Reports:• Unannounced Visits to Scottish IntensivePsychiatric Care Units (2000).• Greater Expectations: unannounced visits tocontinuing care facilities (2003)• Race & Culture Visit Theme Report (updatetitle)An introductory leaflet on the Commission is availablein Arabic, Bengali, Cantonese, Hindi, Punjabi andUrdu.The leaflet is also available in Gaelic.All our publications are available in print on our website. Our general information leaflets and summarypublications are also available in audio format. Backcopies of our Annual Report are available onrequest. Please get in touch if you require ourinformation in alternative formats. Contact detailsare on page iv)6.3 BIBLIOGRAPHYLegislationAdults with Incapacity (Scotland) Act, 2000.The Stationery Office, Edinburgh, 2000.Community Care and Health (Scotland) Act 2002.The Stationery Office, Edinburgh, 2002.Criminal Procedure (Scotland) Act 1995. HMSO, 1995.Data Protection Act 1998. HMSO. 1998.Freedom of Information (Scotland) Act 2002.The Stationery Office, Edinburgh., 2002.Human Rights Act 1998. HMSO, 1998.Mental Health Act, 1983. HMSO, 1983.Mental Health (Care and Treatment) (Scotland) Act2003. The Stationery Office, Edinburgh, 2003.Mental Health (Scotland) Act, 1984. HMSO, 1984.Mental Health (Scotland) Act, 1984 Code of Practice.Scottish Office Home and Health Department.The Stationery Office, Edinburgh, 1990.Mental Capacity Bill. UK Parliament House ofCommons, June 2004.The Stationery Office.Draft Mental Health Bill. Department of Health, 2002.The Stationery Office.Adults with Incapacity (Scotland) Act 2000. Code ofPractice for persons authorised to carry out medicaltreatment or research under Part 5 of the Act.The Stationery Office, Edinburgh, 2002.Adults with Incapacity (Scotland) Act 2000. Supplementto Code of Practice for persons authorised to carryout medical treatment or research under Part 5 ofthe Act.The Stationery Office, Edinburgh, 2002.Adults with Incapacity (Scotland) Act 2000. Code ofPractice for manager of authorised establishmentsunder Part 4 of the Act. The Stationery Office,Edinburgh, 2003.Adults with Incapacity (Scotland) Act 2000. Code ofPractice for supervisory bodies under Part 4 of theAct.The Stationery Office, Edinburgh, 2003.56

ANNUAL REPORT 2003-2004Adults with Incapacity (Scotland) Act 2000. Code ofPractice for persons authorised under interventionorders and guardians. The Stationery Office,Edinburgh, 2002.Adults with Incapacity (Scotland) Act 2000. Code ofPractice for local authorities exercising functionsunder the Act.The Stationery Office, Edinburgh, 2001.OtherAcute In-patient Psychiatric Care for Young People withSevere Mental Illness. Recommendations forCommissioners, Child and Adolescent Psychiatristsand General Psychiatrists. Royal College ofPsychiatrists. London, 2002.A Framework for Mental Health Services in Scotland.The Scottish Office. Edinburgh, 1997.Learning Disability Quality Indicators. February 2004.NHS Quality Improvement Scotland.Needs Assessment Report on Children and AdolescentMental Health – Final Report, March 2003. PublicHealth Institute of Scotland. Edinburgh, 2003.Scottish Executive Health Department, CommunityCare Circular (CCD) 2/2003Safety First. Five Year Report of the NationalConfidential Inquiry into Suicide and Homicide byPeople with Mental Illness. Report 2001.Engaging People. Observation of People with AcuteMental Health Problems. August 2002. ClinicalResource and Audit Group, Scottish Executive HealthDepartment.Nursing Observation of Acutely Ill Psychiatric Patients inHospital. Good Practice Statement, 1995. CRAG/SCOTMEG Working Group on Mental Illness.Guidance on the Use of Electroconvulsive Therapy.May 2003. National Institute for Clinical Excellence.Independent Inquiry into the death of David Bennett.Report, December 2003.The European Convention on Human Rights. Councilof Europe. Strasbourg, 1966.New Directions: Report on the Review of the MentalHealth (Scotland) Act 1984. (Report of the MillanCommittee). Scottish Executive. The StationeryOffice, Edinburgh, 2001Risk Management. Scottish Executive. Edinburgh,2002.Promoting Health – Supporting Inclusion: Healthy Lives,Part of the Community: How nurses and midwives cansupport children and adults with learning disabilities andtheir families. NHS Scotland, Scottish Consortium forLearning Disability, FAIR. Edinburgh, 2002.The Same as You? A Review of Services for Peoplewith Learning Disabilities. Scottish Executive.The Stationery Office, Edinburgh, 2001Quinquennial Review: Report of a Policy andFinancial Management Review of the Mental WelfareCommission for Scotland. Deloitte and Touche,September 2002.People with Learning Disabilities in Scotland: Health NeedsAssessment Report. February 2004. NHS HealthScotland.New Statutory Rights for Carers: Guidance. CommunityCare and Health (Scotland) Act 2002. March 2003.57

THE MENTAL WELFARE COMMISSION FOR SCOTLANDSECTION 7 PRACTITIONERS’ FIVE-YEAR INDEX 1999-2004Subject: Date of PageAnnual Number: *Report:ABSENCE WITHOUT LEAVE– Power to return 1999/0 23ABUSE OF PATIENTS– and Vulnerable Adults legislation2001/2 47-48ACCIDENTS & INCIDENTS (see also REPORTS)2001/2 262002/3 16-172003/4 17-20– and CS spray 2001/2 26– Guidelines for reporting 2000/1 402003/4 20– Reporting by health services 2003/4 19– Reporting by Local Authorities2000/1 39-402003/4 18– Reporting by Trusts 2000/1 38-39– Reporting by GPs 2003/4 19-20ACT OF SEDERUNT– and Adults With Incapacity (Scotland) Act, 20002001/2 44ADOLESCENTS– and Detention 2001/2 39-402002/3 392003/4 41-42– Services for 2000/1 7, 16-172001/2 39-402002/3 39-402003/4 11-12,41-42– Health Advisory Service Report2000/1 16ADULTS WITH INCAPACITY(SCOTLAND) ACT, 2000 (seealso CODES OF PRACTICE) 1999/0 22, 51-522000/1 23-24,59-602001/2 22-26, 41-452002/3 37-39,40-432003/4 46-49– Assessment of capacity 2001/2 17– and ARBD 2002/3 40-41– and Complaints 2000/1 592001/2 45ADULTS WITH INCAPACITY(SCOTLAND) ACT, 2000 (continued)– and Continuing (Financial)Powers of Attorney 2000/1 23– and General Practitioners 2000/1 23-24– and Guardianship 2000/1 30-31, 592001/2 16, 43-452002/3 40-432003/4 46-48– and Intervention Orders 2001/2 17, 43-452003/4 46-48– Implementation of 2001/2 17, 43-45principles 2002/3 37-39– Management ofResidents’ Finances 2003/4 49– and Medical Treatment 2000/1 59-60,692003/4 48– and Medical incapacity 2001/2 16-182002/3 42-43– and Mr. B. Inquiry 2000/1 12-13– and Welfare Powers of 2000/1 23, 59-60– AttorneyADVOCACY SERVICES– and Dementia 2000/1 50– and Ethnic Minorities 2001/2 12– and Learning Disability 2000/1 60– and Visiting Programme 2000/1 22ALCOHOL MISUSE– and ARBD 2002/3 40-41– and Comorbid mental illness2001/2 36-37– and Discharge Policies 2000/1 27-28– in Social Circumstance Reports2000/1 35-36ASSISTANCE BY WAY OF REPRESENTATION(see LEGAL AID)CAPACITY 2002/3 42-43– Assessment of under Adults With Incapacity(Scotland) Act, 2000 2001/2 17– and Medical treatment 2001/2 17-18– and Mr. B. Inquiry 2000/1 9-14– and Mrs K Inquiry 2001/2 13-14– and Probation Orders 2000/1 11, 14– and Responsibilities of Local Authorities2000/1 9-12– and Responsibilities of solicitors2000/1 10-11,14* Page number in bold denotes a major entry58

ANNUAL REPORT 2003-2004CARE HOMES (see RESIDENTIAL CARE)CARE PLANNING 2000/1 9-12,47-502002/3 8-10– and Discharge from Hospital 2000/1 52– in Mr J Enquiry 2001/2 9-12CARE PROGRAMME APPROACH– in Dual Diagnosis 2001/2 37– and Mr. B Inquiry 2000/1 11-13CARERS (see also RELATIVES)– involvement in treatment 2000/1 51-52CHILDREN– and Detention 2001/2 39-402003/4 41-42– services for 2000/1 7, 16-172001/2 39-402002/3 39-402003/4 11-12,41-42CLARKE AMENDMENT/ACT(see Mental Health Legislation)CLINICAL STANDARDS– Clinical Standards Board for– Scotland 2000/1 7, 16, 52– for Schizophrenia 2000/1 7, 522001/2 36-37CODES OF PRACTICE– Adults With Incapacity (Scotland) Act, 20002000/1 60– Mental Health (Scotland) Act 19842000/1 31, 34– Commission for Racial Equality2000/1 18COMMISSION FOR RACIAL EQUALITY2000/1 18COMMUNICATION– with Carers/Relatives 1999/0 34, 492003/4 14-15– Users 2000/1 34-35,51-522001/2 34-352002/3 10-112003/4 14-15– in Mr J Enquiry 2001/2 9-12COMMUNITY CARE ASSESSMENT– and Mr B Inquiry 2000/1 10-142001/2 12, 13– and Mr C Inquiry 2002/3 3-5COMMUNITY CARE ORDERS– review by Commission 2000/1 44-46COMMUNITY TREATMENT ORDERS(see MILLAN REPORT)COMORBIDITY– misuse 2001/2 36-37– mental illness and– learning disability 2001/2 37-38COMPLAINTS 1999/0 33-352000/1 36-38,63-652001/2 25-26, 45,50-512002/3 21-23– Consent of Patient 1999/0 34– Independent Reviews 1999/0 35– Investigation of 2001/2 25-26– Role of Commission 1999/0 35, 55-562000/1 63-65– Role of nurses 2000/1 28CONFIDENTIALITY– and Mental Health Officers 2000/1 35– and Relatives 2000/1 53CONSENT TO DETENTION1999/0 39-442000/1 31-342001/2 31-322002/3 32-332003/4 35– and MHOs (see MENTAL HEALTH OFFICERS)– and Nearest Relative 1999/0 492000/1 35, 41-43– and Nurses 1998/9 32– Refusal of 2001/2 31-32– Simultaneous consent tos24/25 and s26 2000/1 32– by Telephone 2000/1 32CONSENT TO TREATMENT 2002/3 18-19, 462003/4 20-21– and Continuation ofDetention 1999/0 21, 49-50– and Adults with Incapacity 1999/0 49CONSULTING PSYCHIATRISTS– Continuing Care 2003/4 7-9CONTINUING CARE PATIENTS2002/3 8-10– and Mr J Inquiry 2001/2 9-12– and Mr C Inquiry 2002/3 3-5CRITICAL INCIDENT REVIEWS– and Suicides 2000/1 392001/2 28-302002/3 1459

THE MENTAL WELFARE COMMISSION FOR SCOTLANDCURATOR BONIS– in Mr B Inquiry 2000/1 10, 11DEATHS– by Suicide 1999/0 35-392001/2 28-302002/3 13-152003/4 15-17– and National ConfidentialInquiry 2001/2 292003/4 16DEFICIENCY IN CARE INQUIRIES– and Ethnic minorities 2000/1 202001/2 9-12– Mr A Inquiry 2003/4 7-10– Mr B Inquiry 2000/1 9-14– Mr C Inquiry 2002/3 3-5, 72003/4 10– Ms H and Mr E Inquiry 2003/4 5-7– Mr J Inquiry 2001/2 9-122002/3 7– Mrs K Inquiry 2000/1 47-502001/2 13-14– Ruddle Inquiry 1999/0 6, 10-132001/2 13DELAYED DISCHARGES 2002/3 3-5– and Funding Issues 1999/0 17-19DEMENTIA 2002/3 3-5– and Adults With IncapacityAct 2001/2 14, 44– and Guardianship 2000/1 47-50– Mrs K Inquiry 2001/2 13-14– Services 1999/0 24-25– and Vulnerable Adultprovisions 2001/2 47-48DETENTION UNDER MH(S)A 1984(see also CONSENT TO DETENTION)– Appeals against level of security2001/2 41– Applications by LocalAuthorities 2000/1 332001/2 22-232002/3 312003/4 29– Conveyance of Patients 2000/1 25, 28,51– De facto Detention 2000/1 26– Discharge from 1999/0 54-552000/1 62-642001/2 42, 49-502002/3 19-212003/4 22-23– Emergency Detention 1999/0 21(S24/25) 2000/1 25, 28,41-442002/3 25-26,29-312003/4 27-28– and General Practitioners 2000/1 25– ‘Forwarding’ 1999/0 45-46– in General Hospitals 1999/0 47-48DETENTION UNDER MH(S)A 1984(see also CONSENT TO DETENTION)(continued)– and Legal Aid 2001/2 46– Section 18 1999/0 20, 462000/1 32-33, 522002/3 25-26,29-312003/4 27-2933-34– Section 26 2000/1 31-32, 442002/3 25-26,29-312003/4 27-28– Section 28 1999/0 23– Rates of detention acrossUK 2003/4 49-50– Review by MentalWelfare Commission 2000/1 44-46,62-632001/2 32-34,41-42,49-502002/3 19-212003/4 22-23– Timing of medicalrecommendations 2000/1 33– and Treatment for physicaldisorders 2000/1 34– use of Detention byHealth Boards 2000/1 712001/2 572002/3 262003/4 27-29– Trends 2002/3 29-312003/4 32-33DETENTION UNDERCP(S)A 2001/2 562003/4 31, 32-33– Interim Hospital Orders 1999/0 48– and Legal Aid 2001/2 46DISCHARGE PLANNING– and Mr J Inquiry 2001/2 11– and Mr C Inquiry 2002/3 4,5DRUGS– Adverse Effects ofNeuroleptics 2000/1 37-38– Illicit drugs (see also SocialCircumstances Reports) 2000/1 27-282001/2 36-37– and Discharge Policies 2000/1 27-28– Searching for 2000/1 27-28– Treatment 2000/1 37, 38DUAL DIAGNOSIS (see COMORBIDITY)EDUCATIONAL NEEDS– Assessment in Mr. B. Inquiry 2000/1 1260

ANNUAL REPORT 2003-2004ENVIRONMENT– in Residential Care 2000/1 26– and Guardianship 1999/0 31– and Visiting Programme 1999/0 7, 14, 162000/1 212001/2 152002/3 92003/4 11, 12ETHNIC MINORITY GROUPS2000/1 17-202002/3 122003/4 13-14– and Mr J Inquiry 2001/2 9-122002/3 7– and Restraint 2001/2 38-39EUROPEAN CONVENTION ON HUMANRIGHTS (see HUMAN RIGHTS ACT)FINANCIAL BENEFITS– Benefits Surgery 2002/3 9FINANCIAL PROTECTION– in Mr. B. Inquiry 2000/1 9, 142001/2 12-13– and Part 4 AWIA 2003/4 49– and Responsibilities ofLocal Authority 2000/1 10, 11-122001/2 12-13– and Responsibilities of Trusts2000/1 11, 132001/2 12-13FORMS– 9 and 10 2001/2 52-532002/3 18-192003/4 21– K 2000/1 34FRAMEWORK FOR MENTAL HEALTHSERVICES IN SCOTLAND– Services for Children and Adolescents2000/1 16-172001/2 39-40FUNDING ISSUES 1999/0 7, 17-19GENERAL HOSPITALS– Detention in 1999/0 47-48GENERAL PRACTITIONERS ANDTHE MENTAL HEATH ACT 1999/0 19-21– and Adults With Incapacity(Scotland) Act, 2000 1999/0 222001/2 16-18– and Guardianship 1999/0 20– and National Assistance Act 1999/0 20– and Nursing Homes 1999/0 21– Section 24 1999/0 21– Section 117 1999/0 21– Removal of Patients fromList 1999/0 21GUARDIANSHIP 1999/0 29-332000/1 29-31,47-502001/2 22-232002/3 32-35,40-432003/4 36-39– and ARBD 2002/3 40-41– and Adults With Incapacity(Scotland) Act, 2000 2000/1 302001/2 22-23,43-452003/4 46-48– Discharge from 1999/0 32-33– and Medical Certification 2002/3 42-43– and Mrs K Inquiry 2001/2 13-14– Reports 1999/0 31GUIDELINES(see also CLINICAL STANDARDS)– Royal College of Psychiatrists2000/1 52HOSPITAL CLOSURE/CONTRACTIONS 2002/3 302003/4 12HUMAN RIGHTS ACT 1998– and Restraint 1999/0 552001/2 38-39– and Review of detentionprocedures 2000/1 442001/2 32INCAPAX– and Mental Health(Amendment) Act 1999 1999/0 52– and Responsibilities ofLocal Authority 2000/1 10-12– and Responsibilities of Trusts 2000/1 10, 13INFORMATION TO PATIENTS2001/2 34-352002/3 10-1123-24INTERPRETATION SERVICES 2000/1 192003/4 13– and Mr. J. Inquiry 2001/2 10INTENSIVE PSYCHIATRICCARE UNITS 1999/0 15-16– and Children & Adolescents 2001/2 37-382002/3 40– and Availability of beds 2003/4 12INTERVENTION ORDERS 2002/3 35-362003/4 39-41JOINT FUTURE 2000/1 7LAW SOCIETY OF SCOTLAND– and Mr. B. Inquiry 2000/1 142001/2 1361

THE MENTAL WELFARE COMMISSION FOR SCOTLANDLEARNING DISABILITY– and Comorbid mentalillness 2001/2 37-38– and Environment 1999/0 142001/2 14-16– and Mental WelfareCommission 2002/3 12-13– Review 2000/1 60-61– Scottish Consortium for– Learning Disability 2000/1 61LEAVE OF ABSENCE 2002/3 262003/4 30– and Informal Admission 1999/0 48-49– and Interim Hospital Orders 1999/0 48– Recall from 1999/0 23LEGAL AID (ABWOR) 1999/0 6, 7, 452001/2 7, 462002/3 46– and Adults With Incapacity(Scotland) Act, 2000 2001/2 462002/3 37– and Restricted patients 2001/2 462002/3 46MACLEAN REPORT 1999/0 51MACPHERSON REPORT 2000/1 18MEDICAL TREATMENT– under Adults With Incapacity 2001/2 17-18(Scotland) Act, 2000 2002/3 42-432003/4 48– in Mr J Inquiry 2001/2 10-12MENTAL HEALTH (SCOTLAND) ACT(see also CODES OF PRACTICE,DETENTION, GUARDIANSHIP)– Places of Safety 2000/1 50-51– Section 19 2000/1 35,51– Section 25(2)(see NURSES HOLDING POWER)– Section 92 2000/1 10-12– Section 94 2000/1 11, 13– Section 117 1999/0 21MENTAL HEALTH IMPROVEMENTNETWORK 2000/1 6-7, 16-17MENTAL HEALTH LEGISLATION– Mental Health (Scotland) Act 1984(see Detention)– Mental Health (Care and Treatment)(Scotland) Act 2003 2002/3 44-462003/4 24-25,49-50– Mental Health (Public Safetyand Appeals) Act 1999 1999/0 52-53– MacLean Committee(see MACLEAN REPORT)– Millan Committee(see MILLAN REPORT)– Notes on the Mental– Health Act 2000/1 52– Renewing Mental HealthLaw 2001/2 41-42,47-48MENTAL HEALTH OFFICERS 2000/1 31-362003/4 36– and Consent to Detention 1999/0 28-29– without interviewing patient 2001/2 31-322002/3 32– and Continuity of Care 2000/1 34– Outside own Local Authority– Area 1999/0 47– and Relatives 2000/1 34-35– and Telephone Consent 2000/1 32– and Timing of Consent 2000/1 32MENTAL HEALTH AND WELL-BEINGSUPPORT GROUP 2000/1 7, 16MENTALLY DISORDEREDOFFENDERS– and Legal Aid 2001/2 46MILLAN REPORT 1999/0 512000/1 8, 54-572001/2 34, 41, 472002/3 442003/4 49– and Community TreatmentOrders 2000/1 24, 55-56– and General Practitioners 2000/1 24– and Grounds for Compulsion 2000/1 55– and Mental WelfareCommission 2000/1 82001/2 41– and Mental Health (Public Safety andAppeals) (Scotland) Act 2000/1 56– and Treatment Safeguards 2000/1 56– and Tribunals 2000/1 24, 56-57NATIONAL ASSISTANCEACT 1948 1999/0 20NATIONAL CARESTANDARDS 2000/1 582001/2 48NEUROSURGERY FORMENTAL DISORDER 2000/1 65-662001/2 51-522002/3 182003/4 20NURSES1999/0 22-23– Escorts 2000/1 28, 50-51– Holding Power 1999/0 242000/1 282001/2 202002/3 27-282003/4 31-32– Interaction with patients 2001/2 19-20– and Observations 2001/2 19-21NURSING HOMES(see RESIDENTIAL CARE)62

ANNUAL REPORT 2003-2004NURSING OBSERVATION– Accidents and Incidents 2003/4 19– In Mr A Inquiry 2003/4 7-9OMBUDSMEN– Local Authority 2000/1 8, 65– NHS 2000/1 8, 36, 65– Public Services 2001/2 452002/3 21OUR NATIONAL HEALTH 2000/1 6– and Children andAdolescents’ Services 2000/1 7PERSONALITY DISORDER– and Criminal Justice(Scotland) Act 2002/3 47– Mental Health (Public Safetyand Appeals) Act 1999/0 52-532000/1 56– Ruddle Inquiry 1999/0 6, 10-132000/1 152001/2 13PHYSICAL HEALTH– under Adults With Incapacity(Scotland) Act, 2000 2001/2 17– and Mr C Inquiry 2002/3 3-5– and Mr J Inquiry 2001/2 9-12POWERS OF ATTORNEY(see ADULTS WITH INCAPACITY(SCOTLAND) ACT, 2000)PRACTICE GUIDANCE– Access to Mail/Telephones 2000/1 53– Children & Adolescents inAdult Wards 2001/2 39-402003/4 41-42– Dual diagnosis patients 2001/2 36-37,37-38– Early Response to RecurrentSevere Mental Illness 2000/1 51-52– Nursing Observation 2003/4 19– Restraint 2001/2 38-39– Safe to Wander? 2003/4 42-43PRISON SERVICE– and Visiting Programme 2000/1 562002/3 45PUBLIC GUARDIAN 2000/1 24, 59-602001/2 17– Relationship with Mental– Welfare Commission 2000/1 592001/2 43– Web-site 2000/1 24RACE RELATIONS(AMENDMENT) ACT 2000/1 182002/3 12REGULATION OF CAREACT 2000/1 57-59RELATIVES (see also CARERS)– Communication with 1999/0 34, 492000/1 34-35,– Rights of (see RIGHTS)51-522003/4 14-15REPORTS (see also SOCIALCIRCUMSTANCE REPORTS)2000/1 38-412001/2 26-282002/3 16-172003/4 20– Guardianship 1999/0 31– Suicides 1999/0 35-392001/2 28-302002/3 13-152003/4 17RESIDENTIAL CARE– Administration of Medication 1999/0 21– and De facto detention 2000/1 26– Environment (see ENVIRONMENT)– Funding of Places 1999/0 17-19– and General Practitioners 2000/1 26– and Guardianship 1999/0 312000/1 29-30,47-50– and medication 2000/1 26– and Mr C Inquiry 2002/3 3-5– and Mrs K Inquiry 2001/2 13-14– and Restraint 2001/2 39– Standards of care 1999/0 31RESTRAINT 2001/2 38-392003/4 43-44– and Care Commission 2001/2 39– Investigation of complaintsabout 2001/2 50-51– Reports of injuries 2001/2 27RIGHTS– Civil 2001/2 46– Explanation of 1999/0 23– and Legal Aid 2001/2 46– of Nearest Relative 2000/1 35, 51RISK MANAGEMENT– and Guardianship 2000/1 47-50– Report of Mental HealthReference Group 2000/1 27– and Substance Misuse 2000/1 27-28SCOTTISH COMMISSION FORREGULATION OF CARE 2000/1 57-592001/2 39, 48SCOTTISH HEALTHADVISORY SERVICE 2000/1 7, 16, 52– Learning disability services 2001/2 37-38SCOTTISH SOCIALSERVICES COUNCIL 2000/1 58-59SCOTTISH CENTRE FOR LEARNINGDISABILITY (see LEARNING DISABILITY)SEARCHING– in Millan Report 2000/1 27– and Substance Misuse 2000/1 27-2863

THE MENTAL WELFARE COMMISSION FOR SCOTLANDSOCIAL CIRCUMSTANCESREPORTS 2000/1 342001/2 23-252002/3 332003/4 36– Statutory Reports 2001/2 23-252002/3 332003/4 36– and Patient Confidentiality 1999/0 492000/1 35– S.E. Survey of 1999/0 282000/1 34– and Substance Misuse 2000/1 35-36SOCIAL WORK– Exchange with LocalAuthorities 1999/0 582000/1 692001/2 58– and Mr B Inquiry 2000/1 9-142001/2 12– and Mr C Inquiry 2002/3 3-5, 7– and Ms H, Mr E Inquiry 2003/4 5-7– and Mr J Inquiry 2001/2 11-12– and Mrs K Inquiry 2001/2 14– Responsibilities under s92Mental Health (Scotland) Act 2000/1 10-12SOCIAL WORK INSPECTORATE2000/1 7, 13,16– and Ms H, Mr E Inquiry 2003/4 5-7STATE HOSPITAL– Ruddle Inquiry 1999/0 10-132000/1 152001/2 13SUBSTANCE MISUSE– and Mental illness 2001/2 36-37– in Social CircumstanceReports 2000/1 35-37SUICIDES (see DEATHS)TELEPHONE– Advice Service 2000/1 67-682001/2 53-542002/3 23-242003/4 23– Consent to Detention(see CONSENT TO DETENTION)– Use of Mobile Phones 2000/1 53THERAPEUTIC ACTIVITIES 2000/1 212001/2 152003/4 12TRIBUNALS (also seeMILLAN REPORT) 2002/3 44-46– and Renewing MentalHealth Law 2001/2 42TUTOR DATIVE– and Guardianship 2002/3 35UNANNOUNCED VISITS 1999/0 15-162001/2 152002/3 9-10UNAUTHORISED REMOVALOF ADULTS WHO LACKCAPACITY 2003/4 44-45VULNERABLE ADULTS– Legislation 2001/2 47-48– and Mr. B. Inquiry 2000/1 9-14– and Ms H, Mr E Inquiry 2003/4 5-7WEBSITES– Adults With Incapacity 2001/2 16– Chief Medical Officer’s 2000/1 24– Mental Welfare Commission’s 2000/1 4– Public Guardian’s 2000/1 24– Regulation of Care Legislation2000/1 5964

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