Mental Health (care and treatment) (Scotland) Act 2003: Code of Practice Volume 1

Chapter 10: Medical Treatment (Part 16)

Introduction

This chapter examines the provisions relating to the provision of medical treatment for mental disorder which are set out at Part 16 of the Act.

It looks at issues relating to the safeguards which are applied to treating any person with a mental disorder, including those linked to the Adults with Incapacity (Scotland) Act 2000, and the issue of consent. It then turns to safeguards which relate to specific forms of medical treatment, such as electro-convulsive therapy ( ECT) and urgent medical treatment.

Medical Treatment - Safeguards

01 The Act is designed to improve safeguards for patients in general. However, there are some treatments for mental disorder where further safeguards are justified particularly, but not only, in the circumstances where the treatment is given without the patient's consent. Part 16 of the Act makes provision for such safeguards for treatment for mental disorder.

02 Any medical practitioner giving treatment for mental disorder must have regard to the principles set out in section 1 of the Act, and to any advance statement made by the patient in accordance with sections 275 and 276. In particular, the views of the patient should be taken into account, and the patient should be given information and assisted to understand the treatment and its aims and effects.

03 The safeguards in relation to neurosurgery for mental disorder (and to any other treatments regulated under section 234 of the Act) extend to any person with a mental disorder for whom this treatment is considered whether or not they are subject to compulsory measures under the Act. The Mental Health (Medical treatments subject to safeguards) (Section 234) (Scotland) Regulations 2005 ( SSI No. 291) currently provide for the safeguards to also apply to the medical treatment known as "deep brain stimulation" ( DBS). Although not precluded by the Act, it would not be expected that a patient under 20 years of age would be considered for neurosurgery for mental disorder.

04 The safeguards in relation to ECT (and other treatments provided for in regulations made under section 237 of the Act) apply to anyone subject to compulsory measures under the Act. The Mental Health (Medical treatment subject to safeguards) (Section 237) (Scotland) Regulations 2005 ( SSI No. 292) have prescribed that the safeguards should also apply to the medical treatments known as vagus nerve stimulation ( VNS) and transcranial magnetic stimulation ( TMS).

05 Section 243 applies to urgent medical treatment required by patients who are detained in hospital under the Act or the 1995 Act.

06 Under section 244 Scottish Ministers may prescribe specific conditions that must be satisfied before certain treatments are given to informal child patients under 16 years of age, that is those children not being treated formally under the Act. The Mental Health (Safeguards for Certain Informal Patients) (Scotland) Regulations 2005 have prescribed ECT, TMS and VNS. (For further information about child patients, see Chapter 1 of this Volume of the Code of Practice.)

07 Section 249 provides a "child" is a person who has not yet attained the age of 18 years of age where they are being formally treated under the provisions of Part 16 of the Act.

08 A "child specialist" means a medical practitioner who has such qualifications or experience in relation to children as the Commission may determine.

Measures which do not provide authority to treat

09 The following measures which authorise detention do not authorise treatment under Part 16 of the 2003 Act:

• an emergency detention certificate issued under section 36 of the Act;

• a nurse's power to detain pending a medical examination under section 299 of the Act;

• the power to hold a person under the provisions relating to removal from a public place to a place of safety under sections 297 and 298 of the Act;

• a warrant granted under section 35 of the Act;

• a removal order under section 293 of the Act; and

• an order under section 60C of the 1995 Act, where an acquitted person may be detained for medical examination.

10 Any patient detained by virtue of the above provisions must therefore provide consent to any treatment for mental disorder. The exception is that a patient detained under an emergency detention certificate issued under section 36 of the Act may be given urgent treatment administered under the provisions of section 243, without their consent.

Authority to treat

11 The remaining treatment provisions in Part 16 and their safeguards apply to all patients who are subject to compulsory measures where medical treatment is specifically authorised under the Act or the 1995 Act. This includes patients who are subject to the following compulsory measures:

• a short-term detention certificate under section 44(1) of the Act:

• an extension of detention, under section 47(1) of the Act;

• an extension of short-term detention pending determination under section 68 of the Act;

• a compulsory treatment order under section 64(4) of the Act;

• an interim compulsory treatment order under section 65(2) of the Act;

• an assessment order under section 52D of the 1995 Act;

• a treatment order under section 52M of the 1995 Act;

• a compulsion order (with or without a restriction order) under section 57A of the 1995 Act;

• an interim compulsion order under section 53 of the 1995 Act;

• a hospital direction under section 59A of the 1995 Act; and

• a transfer for treatment direction under section 136 of the Act.

Adults with Incapacity (Scotland) Act 2000

12 Part 5 of the 2000 Act makes provision for medical treatment for adults who are incapable of giving consent as a result of incapacity, including incapacity caused by mental disorder. Section 1 of that Act defines the term "incapable".

13 Section 47 of the 2000 Act allows the medical practitioner who is primarily responsible for the adult's treatment to complete a certificate certifying that in his or her opinion the adult is incapable of making a decision on the medical treatment in question. Where the medical practitioner complies with the certification requirements set out in section 47 of that Act, he or she then has a general authority to do what is reasonable in the circumstances in relation to medical treatment to safeguard or promote the physical or mental health of the adult.

14 For all patients, neurosurgery for mental disorder (and other treatments specified in The Mental Health (Medical treatments subject to safeguards) (Section 234) (Scotland) Regulations 2005 ( SSI No. 291) is safeguarded under the Act and may not be given to any person under the powers of Part 5 of the 2000 Act.

15 If a patient is subject to compulsory measures under the Act and is incapable in terms of the 2000 Act but also requires medical treatment for physical problems not related to the mental disorder, then the provisions of Part 5 of the 2000 Act may apply in relation to treatment of those physical problems.

Designated medical practitioners - section 233

16 The Act makes provision that certain treatments can only be authorised by an independent doctor, a "designated medical practitioner" (' DMP').

17 Section 233(4) confers powers on a DMP to:

• interview the patient in private at any reasonable time;

• carry out a medical examination of the patient in private, at any reasonable time;

• require those holding the relevant medical records to produce them; and

• inspect the records produced.

18 These powers will allow the DMP to consider and make a judgement on the benefit to the patient of the treatment proposed. Section 276(4) requires a DMP considering treatments under Part 16 to have regard to a valid advance statement made by the patient, if any, before making his or her decision about the treatment.

19 Although the Act allows for the DMP to interview the patient in private, the patient might request that their carer, relative, named person, independent advocate or other supporter attends the interview with them. In such circumstances it would be best practice for the DMP to allow a person requested by the patient to attend in support unless it is impracticable or contrary to the patient's best interests to do so.

20 Where the patient is aged under 18 and medical treatment under Part 16 is being considered, either the RMO in charge of the treatment, or the DMP who approves the treatment, must be a specialist in child psychiatry.

21 The Act requires the Mental Welfare Commission to appoint DMPs to undertake these duties and to ensure that they undergo specific training in their duties if required to do so by the Mental Welfare Commission. The Commission must include among these DMPs some who are specialists in child psychiatry.

22 It would be best practice that where the patient has a learning disability, either the RMO or the DMP is a specialist in learning disability treatment and care.

Provisions and Safeguards for Particular Treatments

Certain surgical operations for mental disorder under section 234

23 Where any treatment is being considered under the Act, section 1 (principles for discharging certain functions) and section 276 (advance statements: effect) must be taken into account.

24 Any DMP is required to take into account the principles of the Act and in particular the views of the patient and any advance statement made by the patient when considering whether the treatment should be authorised.

25 Section 234 specifies the treatments given to any patient, whether or not that patient is subject to compulsory measures under the Act, to which the special safeguards as set out in section 235 and section 236 of the Act apply. It specifies only one type of treatment, namely any surgical operation that "destroys brain tissue or the functioning of brain tissue" (generally known as neurosurgery for mental disorder or NMD). The Mental Health (Medical treatments subject to safeguards) (Section 234) (Scotland) Regulations 2005 ( SSI No. 291) specify that the medical treatment known as "deep brain stimulation" ( DBS) will attract the same authorisation conditions and safeguards as NMD. (Regulations have also prescribed that statutory Form T1 must be used for certification by either the medical practitioner or DMP, as the case may be, for these treatments.)

26 NMD is a therapeutic procedure offered after extensive assessment to patients with intractable illnesses. Where the patient is capable of consenting, they must consent in writing to the treatment, and two lay persons appointed by the Mental Welfare Commission must certify that the patient is able to consent and has done so. In addition, a DMP must confirm both that the patient is capable of consenting and has done so and that the treatment is in the patient's best interests. The patient can withdraw consent to the treatment at any time. If the patient does so, the remainder of the treatment or any future treatment of the same type would be viewed as a separate treatment which could not be given on the basis of the earlier consent.

27 Where the patient is aged under 18 but capable of consenting, either the RMO in charge of the treatment, or the DMP who approves the treatment, must be a child specialist. Although the Act does not preclude this, it would not be expected that a patient under 20 years of age would be considered for neurosurgery for mental disorder.

28 For patients who are incapable of consenting, a DMP must certify that this is the case, that the patient does not object to the treatment and that the treatment is in the patient's best interests. Two lay persons appointed by the Mental Welfare Commission must certify that the patient is incapable of consenting and that the patient does not object to the treatment. In addition, the RMO must apply to the Court of Session, and the Court must make an order authorising the treatment specified. The Court of Session may only authorise the treatment if satisfied that, having regard to the likelihood of the treatment alleviating or preventing deterioration in the patient's condition, it is in the best interests of the patient, and the patient does not object.

29 Where the patient is aged under 18 and incapable of consenting, either the RMO in charge of the treatment or the DMP who approves the treatment must be a child specialist. As before, however, it should be noted that NMD is a therapeutic procedure offered after extensive assessment to patients with intractable illnesses, and that although the Act does not preclude this, it would not be expected that a patient under 20 years of age would be considered for NMD.

30 No patient who opposes the treatment, either by stating opposition or by resisting treatment, may be given such treatment. If the patient does not meet the conditions at any point, for example if they resist any part of the treatment, then the treatment cannot continue. This means that even where the Court of Session has made an order declaring that the treatment may lawfully be given, the treatment may not be given if the patient subsequently resists or objects.

31 The Commission may revoke any of the above certificates by giving notice to the patient's medical practitioner.

Safeguards for ECT and other treatments regulated under section 237

32 Where any treatment is being considered under the Act, section 1 (principles for discharging certain functions) and section 276 (advance statements: effect) apply. (Regulations have prescribed that statutory Forms T2 and T3 must be used for certification for these treatments.)

33 Any DMP is required to take into account the principles of the Act and in particular the views of the patient and any advance statement made by the patient when considering whether the treatment should be authorised.

34 The Mental Health (Medical treatment subject to safeguards) (Section 237) (Scotland) Regulations 2005 ( SSI No. 292) have prescribed the medical treatments such as VNS and TMS. As with ECT, these treatments may only be given to a patient who is subject to compulsion if:

• the patient can and does consent and that consent is given in writing; or

• the patient is incapable of consenting and the treatment is authorised by a DMP.

35 Section 243(5) of the Act provides that it is not possible to give ECT to a patient who is capable of making a treatment decision and refuses the treatment, even where the treatment would otherwise meet the requirements laid out in section 243.

36 Where a patient who is liable to compulsory medical treatment can and does consent in writing to the treatment, then either the patient's RMO or a DMP (for example, where the RMO is unavailable) must certify that this consent has been given and that the treatment is in the patient's best interests, having regard to the likelihood of the treatment alleviating or preventing a deterioration in the patient's condition. The patient can withdraw consent to the treatment at any time. Any further treatment would not be authorised on the basis of the earlier consent.

37 Where the patient is aged under 18, liable to compulsory treatment and can and does consent, then either the RMO in charge of the treatment or the DMP who approves the treatment must be a child specialist.

38 Where a patient who is liable to compulsory treatment is incapable of consenting, a DMP must certify that the patient is incapable of making a decision and that the treatment is in the patient's best interests having regard to the likelihood of the treatment alleviating or preventing deterioration in the patient's condition.

39 If the patient resists or objects to the treatment, the treatment can only be given if the DMP certifies that the patient is incapable of making a decision, that the patient resists or objects, and that the treatment is necessary under the urgent medical treatment provisions of section 243(3). These provisions are that the purpose of the treatment is:

• saving the patient's life;

• preventing serious deterioration in the patient's condition;

• alleviating serious suffering on the part of the patient; and

• preventing the patient from behaving violently or being a danger to him/herself or to others.

40 No further treatment can be authorised under section 243(3) where the conditions of that section are no longer met.

41 Where the patient is given any of these treatments on the basis of urgent medical necessity, the RMO must notify the Commission, before the expiry of 7 days, of:

• the type of treatment given; and

• the purpose for which it was given.

42 Where the patient is aged under 18 and resists or objects to the treatment, either the RMO in charge of the treatment or the DMP who approves the treatment must be a child specialist.

43 The Commission may revoke any of the above certificates by giving notice to the patient's medical practitioner.

Safeguards for certain treatments in relation to informal child patients under the age of 16 - regulated under section 244

44 Section 244 provides for regulations to specify safeguards for specific treatments given to informal child patients under the age of 16. The Mental Health (Safeguards for Certain Informal Patients) (Scotland) Regulations 2005 have prescribed that the following treatments should be regulated:

• ECT

• TMS

• VNS

(There is no form prescribed in regulations for these treatments but a pro forma may be found on the Scottish Executive's website at www.scotland.gov.uk/health/mentalhealthlaw )

45 Bearing in mind that the child is not being treated under the compulsory provisions of the Act, the regulations make clear that it is not possible to give any of these treatments to a child unless consent to treatment has been obtained, that is where:

• the child can and does consent and that consent is given in writing; or

• the child is incapable of consenting, a person with parental responsibilities grants consent in writing.

46 It should be noted that where a child is capable of consenting and does not consent to these types of treatment, then their right to refuse treatment cannot be overridden. Capable children should be treated in the same way as capable adults and be entitled to accept or refuse treatment for mental disorder.

47 Where the child can and does consent in writing to the treatment, then certification must be given by either the medical practitioner primarily responsible for the child's treatment or a DMP under section 233 of the Act. Either the medical practitioner or the DMP must be a child specialist. The practitioner must certify that:

• the patient is capable of consenting to the treatment, and

• the patient consents in writing to the treatment, and

• treatment is in the patient's best interests having regard to the likelihood of the treatment alleviating or preventing deterioration in the patient's condition.

48 Where consent has been given in writing to the treatment, it would be best practice for the doctor who gives the certificate to send a copy of it to the Commission within 7 days.

49 A capable child can withdraw consent to the treatment at any time. Any further treatment would not be authorised on the basis of the earlier consent.

50 Where the child is incapable of consent, then consent must be obtained from a person with parental rights and responsibilities in relation to the child. If treatment is to proceed on the basis of this consent, then a DMP who is not the medical practitioner primarily responsible for the child's treatment must certify that:

• the patient is incapable of making a decision;

• a person with parental rights and responsibilities for the child has granted consent; and

• the treatment is in the patient's best interests having regard to the likelihood of the treatment alleviating or preventing deterioration in the patient's condition.

51 It would be best practice for the person who gives the certificate to send a copy of it to the Commission within 7 days.

52 Should consent subsequently be withdrawn, then any further treatment would not be authorised.

53 If, at any time, the child resists or objects to the treatment, then treatment can only be given under the provisions of section 243(3)(a) to (c), which relate to giving urgent medical treatment. Treatment can only be given if DMP certifies that:

• the patient is incapable of making a decision;

• a person with parental rights and responsibilities for the child has granted consent; and

• the patient resists or objects, and that urgent medical treatment is necessary to:

• save the patient's life, or

• prevent serious deterioration in the patient's condition, or

• alleviate serious suffering on the part of the patient.

54 Section 243 only authorises medical treatment if the treatment is not likely to entail unfavourable, and irreversible, physical or psychological consequences and if the treatment does not entail significant physical hazard to the patient.

55 Either the medical practitioner primarily responsible for the child's treatment must be a specialist in child psychiatry, or the DMP who certifies the treatment must be a child specialist.

56 No further treatment can be authorised under section 243(3) where the conditions of that section are no longer met.

57 Treatment cannot be administered by force where the child is not in hospital. However, it would be expected that where a child objects to or resists treatment, the medical practitioner would give further consideration as to whether it would be in the child's best interests to be treated under the formal provisions of the Act.

58 Where a child is treated on the basis of urgent medical necessity, it would be best practice for the medical practitioner primarily responsible for treatment to notify the Commission of the type of treatment given and the purpose for which it was given, within 7 days.

Treatments given over a period of time - section 240

59 For clarity, the undernoted treatments are not included within the provisions of section 240. These treatments have separate authorisation processes and safeguards as set out in the Act and described in the Code as follows. You should therefore refer to the appropriate parts of the Code and sections of the Act.

• neurosurgery for mental disorder (and other treatments specified by The Mental Health (Medical treatments subject to safeguards) (Section 234) (Scotland) Regulations 2005) ( SSI No. 291) (paragraphs 23 to 31);

• ECT (and other treatments specified by The Mental Health (Medical treatment subject to safeguards) (Section 237) (Scotland) Regulations 2005) ( SSI No. 292) (paragraphs 32 to 43);

• treatments given to informal child patients (specified by The Mental Health (Safeguards for Certain Informal Patients) (Scotland) Regulations 2005) (paragraphs 44 to 58).

60 Section 240 of the Act specifies the treatments which require the special safeguards as set out in sections 238 (patients capable of consent and not refusing consent) and section 241 (patients incapable of consent or capable of consent but refusing consent). These apply to any patient liable to compulsory treatment under the Act or the 1995 Act being treated for mental disorder or in consequence of having a mental disorder. (Regulations have prescribed that statutory Forms T2 and T3 must be used for certification for these treatments.)

61 The safeguards apply immediately for the following treatments:

• any medication (other than the surgical implantation of hormones) given for the purpose of reducing sex drive;

• provision of nutrition to the patient by artificial means; and

• such other types of treatment specified in any regulations made under section 240(3)(d).

62 Drug treatment for mental disorder attracts these safeguards after 2 months of compulsory treatment have elapsed.

63 Treatment may be given where the patient can and does consent in writing (section 238). The patient's RMO or a DMP must certify that having regard to the likelihood of it alleviating, or preventing deterioration in, the patient's condition, it is in the patient's best interests that the treatment should be given. The RMO or DMP must certify in writing that:

• the patient is capable of consenting to the treatment;

• the patient consents in writing to the treatment; and

• medical treatment is authorised by virtue of the Act or 1995 Act.

64 The Act has been amended by The Mental Health (Care and Treatment) (Scotland) Act 2003 (Modification of Enactments) Order 2005 to provide that a person who gives a certificate under section 238 (where the patient consents in writing to the treatment) must send a copy of it to the Commission within 7 days.

65 Where the patient is incapable of consenting or does not consent to the treatment, the patient's RMO is required to arrange through the Mental Welfare Commission for a DMP to examine the patient and consider whether the treatment should be authorised under section 241.

66 When authorising any of the above treatments, a DMP must certify in writing that:

• the patient does not consent to the treatment; or

• the patient is incapable of consenting to the treatment; and in either case

• the giving of treatment is authorised by the Act or by the 1995 Act; and

• having regard to the likelihood of its alleviating, or preventing deterioration in, the patient's condition, treatment is in the best interests of the patient.

67 The DMP is required to take into account the principles of the Act and the views of the patient and any advance statement made by the patient when considering whether the treatment should be authorised. In particular, the DMP should take into account the views of a capable patient who refuses consent. If that DMP agrees that the treatment should still be given, then the reason for that decision should be stated in the certificate.

68 Where the patient is a child under 18 years of age, either the RMO in charge of the treatment must be a child specialist, or the DMP who approves the treatment must be a child specialist approved by the MWC to give an opinion in relation to the treatments.

69 The Commission may revoke any of the above certificates by giving notice to the patient's medical practitioner.

Nutrition by artificial means - section 240

70 Artificial means of feeding might include feeding through a nasogastric tube, an intravenous drip or directly into the stomach through a gastrostomy. These methods of nutrition by-pass the patient's need to swallow food. They all carry risks and require an immediate second opinion by a DMP where the patient is capable of consent but does not consent to treatment. Passing a nasogastric tube can be particularly dangerous if the patient resists or struggles and force should not be used to insert a tube.

71 There is a difference between forcible feeding and these artificial means of feeding someone. Forcible feeding involves using direct force to make an individual swallow food. It may involve methods such as forcibly pushing food into the individual's mouth or forcibly holding his or her mouth open to receive food. Forcible feeding carries the risk of inhalation of food or asphyxiation and is not allowed under the Act and should never be used.

Consent - General provisions for treatment for mental disorder - section 242

72 Section 242 contains authority to give medical treatment where a patient is liable to be given such treatment compulsorily and the treatment is not specified elsewhere as requiring particular safeguards.

73 There is a general requirement under section 242 of the Act that where medical treatment is authorised under the Act or the 1995 Act with respect to a patient who is capable of consenting and does consent to treatment, then that consent must be recorded in writing and signed by the patient. The record of consent should be retained in the patient's medical notes. This provision is, however, subject to the specific requirements of sections 234(1), 237(2), 240(2), 243 and 244, which set out additional safeguards.

74 Any person who consents to treatment can withdraw that consent at any time. It would be best practice, where the person subsequently changes his or her mind and refuses a treatment, for a record of that refusal to be signed by the person and recorded in the patient's notes.

75 Where a patient who has previously consented to a treatment changes his/her mind and subsequently refuses treatment, further treatment cannot be authorised on the basis of the previous consent. The medical practitioner responsible for the patient's treatment must reconsider the appropriate safeguards for the treatment in question, once that consent has been refused.

76 Where the patient is incapable of consenting, or is capable and does not consent, or consents but not in writing, then medical treatment for mental disorder may be given provided that the RMO determines that it is in the patient's best interest that the treatment be given, having regard to:

• the reason for a patient's non consent where they are capable of consent (if this has been disclosed to the RMO);

• any views expressed by the patient;

• any views expressed by the patient's named person;

• any advance statement made by the patient; and

• the likelihood of the treatment's alleviating, or preventing a deterioration in, the patient's condition.

77 Treatment must be given by, or under the direction of, the patient's RMO who must record the reasons for giving the treatment in writing.

78 It should be noted that medical treatment can not be given by force to a patient who is not in hospital.

Medical treatment for mental disorder where a patient is subject to an assessment order - section 242

79 Where the patient is subject to an assessment order and the patient is capable of consenting to the treatment but does not consent, consents other than in writing, or is incapable of consenting to the treatment, then another approved medical practitioner, who is not the patient's RMO, must determine that it is in the patient's best interest that the treatment be given.

80 To ensure the approval of the second medical practitioner is independent, while still observing timely and effective decision-making and treatment procedures, it would be best practice for the second medical practitioner to be based in a different medical clinical team, separate from the team which usually has responsibility for the patient's care and treatment decisions. To avoid any conflict of interest, best practice would also mean that the second medical practitioner could not be anyone who has a line-management relationship to the RMO.

Urgent Medical Treatment - section 243

81 Section 243 applies to any patient who is detained in hospital under this Act or the 1995 Act. It describes the circumstances in which urgent medical treatment may be administered to a patient who does not consent, or is incapable of consenting to that treatment. It does not apply to patients who are liable to be treated on a compulsory basis as part of a CTO but who are not detained in hospital. Section 243(2) applies to any form of medical treatment for mental disorder, and authorises the treatment being given without consent or the special procedures set out elsewhere in the Act in specified circumstances.

82 It should be noted that section 243(5) explicitly forbids the giving of ECT to the patient under the authority of section 243 if the patient is capable of consenting to the treatment but does not consent.

83 Under section 243(3), treatment may be given without consent if it is both urgent and necessary to save life. Provided that the treatment is not likely to have any unfavourable, and irreversible, physical or psychological consequences, it may also be given in the following circumstances:

• to prevent serious deterioration;

• to alleviate serious suffering by the patient;

• to prevent the patient from behaving violently; or

• being a danger to themselves or to others.

84 Under section 243(4), in the last two scenarios, treatment must not entail significant physical hazard to the patient. It would be expected that where urgent treatment is given under 243, the usual clinical guidance regarding best practice will also be taken into consideration.

85 Where urgent medical treatment is given under the authority of section 243, the patient's RMO must notify the Commission of the type of treatment given to the patient and the purpose for which it was given ( i.e. in terms of the purposes outlined in section 243(3)) within 7 days of the treatment being given. This 7 day period begins at midnight of the day on which the treatment was given. (There is no form prescribed in regulations for this notification however the non-statutory form T5 may be used for this purpose. It can be found on the Scottish Executive's website atwww.scotland.gov.uk/health/mentalhealthlaw.)

86 While there will be situations when the need to administer urgent medical treatment is clear and unequivocal, it is recommended that practitioners exercise caution regarding recourse to the powers under section 243 of the Act. A decision to provide urgent treatment will be based on the best professional judgement available under the necessarily difficult circumstances of the case. However, it is important to recognise that the assessment of the likelihood of "serious deterioration" and "serious suffering" is a subjective process. A patient who is experiencing symptoms and behaviours as a result of mental disorder can be difficult to manage and may become oppositional or verbally aggressive or abusive. It would be expected that such behaviour would not, in itself, be seen as criteria for the giving of urgent medical treatment. On the other hand, it is recognised that verbal aggression may be a clear manifestation of a mental disorder which is causing the patient distress. The decision to administer urgent medical treatment will therefore need to be informed by the presence of a level of risk commensurate with the criteria listed at section 243 of the Act rather than as a means of managing a "difficult" patient. Best practice would dictate that recourse to the use of sedative medication would be restricted to the exceptional circumstances envisaged in section 243(3) and 243(4) and not as a way of subduing a patient who is difficult to manage or is demanding of staff time and attention.

87 Where a decision is made to administer urgent medical treatment under the authority of section 243 of this Act and this treatment is to be administered by force, it is important to ensure that such an intervention is undertaken only by staff who are fully trained in appropriate control, restraint and resuscitation techniques. As it is not expected that such intervention would happen often, it would be best practice for hospital managers to ensure that staff trained in these techniques are given regular opportunities to keep their skills current by taking refresher training from time to time. Where treatment has been administered by force, it would be best practice to note this in the report to the Mental Welfare Commission.