Forced medical intervention under Mental Health Act and/or Mental Capacity Act

[flourella]

Does anyone know anything about being forced to have a physical health check under the Mental Health Act or Mental Capacity Act? Alleged lack of capacity is solely down to long-standing mental illness in a middle-aged adult (I am autistic as well, but have no learning disabilities, dementia, acquired brain injury, etc).

It's not even for treatment of a condition. I have refused health checks recommended by mental health professionals (comprising blood draw and ECG) many times before and been perfectly open about the reason why (severe OCD). Nothing has changed regarding my physical health, but suddenly the CMHT have become obsessed with the idea I could potentially have heart problems caused by my bulimia, and in an appointment with a psychiatrist last week detention in hospital under the MHA just to have these tests was mentioned many times. The MCA was mentioned once. Since the appointment I have learned from another source (NHS specialist OCD clinic at which I've recently started outpatient treatment) that a "best interests meeting" has been arranged for the week after; this sounded like a quite specific term so I googled it and it seems it is a MCA thing rather than MHA. I'm not sure whether best interest meetings happen when it's already been agreed a patient has no capacity, or if the meeting is to discuss this and then, depending on outcome, possible courses of action will be discussed at a later juncture. Does anyone know? Will I be invited, or can I insist I am present? I am in contact with an advocacy service but haven't yet spoken to an advocate because they weren't in on Friday afternoon and I don't really know what they do anyway.

I can't believe how quickly this is happening; the CMHT's change in attitude has come out of nowhere and I don't understand why they are suddenly threatening me with this. Well, I know what's precipitated it: the specialist OCD clinic got in touch with them and said that I should have checks done. But there is no justification I can see for removing my right to decide things for myself, when I've been allowed to decline the tests for years so far with no consequences. Do I have the right to appeal if I don't agree with them and their opinions on what is in my "best interests", or am I fucked? Can they seriously section someone over this?!

Contact MIND and get advice also ask about how to get a Mental health advocate

MCA as you say is the mental capacity act. Practitioner's must assume you have capacity unless it’s evident (by undertaking an MCA capacity assessment) That you don’t have capacity

Capacity is tested by asking you a specific question and then applying 4 points. The MCA says that a person is unable to make their own decision if they cannot do one or more of the following four things:

• Understand information given to them eg understand the decision they’re asked to make

• Retain that information long enough to be able to make the decision eg you receive, understand and process the information

• Weigh up the information available to make the decision eg the pros and cons

• Communicate the decision in any way

Best interests meeting is when the team believe you do not have capacity . Best interest meeting means that the have undertaken an MCA capacity assessment, determined you lack capacity and will now as a team meet and make a decision about your treatment . This is important they are making a treatment decision about you . You must ask to see the MCA capacity assessment documentation and I advise get a MH advocate .

Did anyone explicitly say they were undertaking a capacity assessment?

can you challenge it.? Yes get a MH advocate , if disputed ultimately it would go court of protection

MCA is not the mental health act
If you were to be detained an MHA would be required. However the principle of least restrictive option would apply eg can the treatment be given in community at home as opposed to administered hospital

would you let your GP do the health check?

the treatment team are right you do need a physical check in when they’re your treatment team and prescribing and they hold responsibility. If you were to be unwell the CMHT would rightly be asked to account for their interventions and monitoring of you

OP all mental health services are coming under huge pressure to assess and monitor their patient’s physical as well as mental health. This is because people with MH issues serious enough to be under these services have a very significantly higher incidence of both morbidity and mortality- all sorts of reasons for this but its absolutely right imo that physical health is given the attention it needs and deserves. Add to that the fact that many MH medications especially the antipsychotics can directly cause metabolic / cardiovascular disorders and that the person prescribing is held accountable if you are not properly monitored. Your care team are obviously sufficiently concerned to be looking at best interests decisions- however its not a given you will be forced into tests- I do believe that your advocacy service should be invited to contribute to the process.
Good luck and I hope you all the best in your recovery.

Pressed too soon on my long post
Yes The MCA can be used to make you take physical health treatments in a hospital setting. This would be after DoLS deprivation of liberty safeguards

if the CMHT are having a best interest meeting they believe you lack capacity and are meeting to make a decision regard your treatment

Given your history of ED and the interaction of some medications on cardiac function it’s responsible and necessary for you to have a physical check up. This won’t go away, as it is a necessary intervention

I have to have three monthly blood tests and if I don't go fast enough I get letters threatening not prescribe medication before tests have been conducted. Bit of a pain in arse to go but I don't want to stop my meds because I feel fine, so I go.

Hi Zone2NorthLondon. Thank you for replying.

I'd never met this psychiatrist before. He'd read my notes I suppose and after a bit of general conversation going over how things were, he pretty much said I absolutely needed the health checks done and that if I refused again I could be assessed under the MHA. This has never been suggested to me before for any reason. He told me a MHA assessment wouldn't be happening today, at which I laughed in disbelief. I asked if that could mean being put in hospital and he said yes. I'm sure he then said the MCA might be used at that point to force the tests on to me, but I'm not sure that makes sense now(?)

He definitely did not say that I had been or was currently being assessed for lack of capacity under the MCA, but he did say that my thinking around the risks of having the tests and the risks of not having them was impacted by my illness. That I was weighing things up wrongly. He used the terms capacity, and lack of it. I suppose that means I fail on point 3 (in his opinion)? There's no way anyone could say I fail on any of the other points you listed.

That appointment ended with them saying they'd be speaking to the OCD clinic, but not when or in what context. Afterwards I spoke on the phone to my therapist from there and she said she'd been invited to a meeting and used the term "best interests". First time I'd heard it, I think.

She did say that in her opinion a detention would not be in my best interests, and that she'd be saying so at the meeting. I have felt a bit better after that, but if they've already decided I lack capacity and they will be making the decision regarding the health check, I suppose the best I can expect is that the tests will be done in the community with the threat of a MHA assessment and detention hanging over me? There's no way they will go back to allowing me to refuse? I don't want the tests and I don't understand this change in their approach! Nothing has changed, in either my physical health or in my stated reasons for avoiding them.

I left a message with the advocacy service in my town and hope someone calls me back tomorrow. I will ask them about disputing it and ask the CMHT about any MCA documentation. Thanks for that tip.

The MHA can't be used to give treatment for physical health - unless the physical issue is a symptom of / the cause of a MH issue.

Generally you should be able to decline physical health interventions.

However, your care team might feel that your OCD (Mental disorder - I don't like this term but it's how it's described in the law) is causing you to neglect your physical health by declining necessary tests. Refusing the tests is therefore a symptom of your OCD and could mean you could be treated under the MHA for your own safety. The team would need to show there was a risk to you in order to use MHA powers though.

Honestly it's a sticky area and you would be best talking to an IMHA (independent mental health advocate).

The MCA is another option and physical health treatment can be given but they would need to prove you didn't have capacity AND that the treatment was needed now and couldn't wait for you to regain capacity to decide yourself. If they go this route you need an IMCA (independent mental capacity advocate) to support you.

Just to give a bit of context: things often happen one way within the NHS, until another part of the NHS that might have more expertise or authority, says it should be done another way. And then the original team will do the other recommended way, they kind of have to. That is a very normal thing in the NHS. So the fact it was fine before doesn't carry much weight I'm afraid.

VerityUnreasonable the psychiatrist kept mentioning potential risk of death from currently undiagnosed and unsymptomatic heart issues caused by bulimia. There is no reason to think I have a potentially fatal heart problem apart from the fact that I have an eating disorder, and eating disorders can cause them. Given there's nothing to suggest the tests are suddenly urgent, and that I am currently receiving treatment from an NHS highly specialised service that will hopefully reduce my OCD symptoms and therefore could restore my allegedly missing capacity regarding such tests, would you say that I could argue there is no reason to use the MCA to force them now? And no reason to assess under MHA either?

The website for the advocacy service mentions IMHAs and IMCAs so they have both. Looks like that's good, but I was talking about the MHA to the person who answered the phone and now I think I should have mentioned the MCA. Might mean the wrong person will call me back. Unless the advocates do both.

They may be just going through processes to assess whether they need to make changes to how you access health care.

If something happened to you, and there was an inquiry, there would be questions to be asked about why they didnt consider whether you had capacity to continue to refuse this care

They may well find you do have capacity and tht its just a questio of you having the right and ability to make poor choices for yourself.

housingplanningquestion I understand what you are saying, and I do think this has been prompted by the more specialist service bringing up the subject. I still think the CMHT have gone off the deep end though!

I think the issue here is that you require the tests due to the risks posed by the bulimia. That, and the OCD are impacting on your decision to have the tests.

The tests are for a physical health condition secondary to the mental illness (bulimia)

Bulimia can cause sudden death due to low potassium for example, and they need to be able to assess this risk and treat if required.

I think maybe you should discuss what they can do to support with the blood tests and ECG. This could be medication to help with your anxiety, someone with you to support with relaxation techniques or whatever you think would be helpful.

There is a possibility that this could be enforced, and it would be much more beneficial for you to have some control and support.

To add to the points made by previous posters - if you have a MCA and are found to have capacity, you have the right to make an "unwise" decision. This includes refusing tests and treatment.

I don't actually take any medication, so that is not a factor in them requiring the tests. It's just down to the restricted eating and drinking, and bulimia.

They have in the past tried to prescribe antidepressants and an antipsychotic for supposed delusional thinking, but I've refused those as well, also in part due to the OCD. I hope they are not going to force that issue as well. I am more open to an antidepressant and I did say that but no prescription yet.

https://www.rcpsych.ac.uk/improving-care/campaigning-for-better-mental-health-policy/college-reports/2022-college-reports/cr233

This has a document to download (free) with the guidance.

You should absolutely be invited to the meeting and have an advocate there which may be a friend or relative or may be an independent mental capacity advocate.
They must have confirmed in an assessment that you lack capacity to make this decision, having provided all practicable help for you to make the decision yourself.
Supposing that has been done, they would still have to determine that it is in your best interests to be deprived of your liberty in order to have the tests. Best interests doesnt just mean safer, it must take into account your wishes, feelings, past wishes and the mental and emotional impact of having the tests.
If they decided it was in your best interests and you refuse, they would have to go to court and you would have a solicitor to advocate for you and ultimately a judge would make the decision.

OP, kindly, I hope you will be okay and that you understand that any tests they wish to do would be done with your best interest at heart. They have no other reason to wish to do this and I say that as someone who has been sectioned before due to truly not understanding how unwell I was. Take care 🥰

@AmserGwely that document is interesting and I've read through the section on risk, but it says that blood results showing normal electrolyte levels don't necessarily mean the patient is healthy. So what is the point?! Even if my levels are fine, they could still say I'm at risk of death, and then what?

@oitnw if I refused to comply with what they decide at the best interests meeting and it goes to court, could they fall back on to the MHA and do it that way in the meantime? It seems they have options but are going the MCA route first. Can I even refuse to comply with being deprived of my liberty? Do they not just cart you off?(!)

Being in hospital even for a night would be impossible. I wouldn't be able to eat or drink anything, use the toilet, or sleep in one of the beds, due to risk of contamination. I think if they continue to insist I will have to try and have the tests done, but they'll have to be done my way. I don't understand why all the components for a blood draw aren't individually wrapped and sterile. The vacuum tubes aren't and they are the problem. I don't like the way the needle is connected to the tube holder either, and don't really want the needle going under my skin even if it is sterile, but I had a cannula inserted for an MRI scan the other year and with extra time and care from the radiographers I managed it. Everything used that day came from its own single pack. I don't know what I can do to make a blood draw acceptable to me with the equipment that I know is used.

MCA and MHA are different acts,different powers royal college of psychiatrists MEED guidance
mental capacity and the law
On balance I’d say get the test from a wellbeing pov
yes, it’s potentially unpleasant for you but not compared to the potential angst of DoLS and MCA

Not an expert in the mental health act sorry but I know mental capacity is a consideration within such an assessment.
I am truly sorry you are going through this without adequate support. You really need an advocate.

@flourella could you ask them to use a butterfly needle and a syringe to take your blood? Both come in sterile packages. They could then fill the blood bottles from the syringe.

Re. The ECG, could you ask them to use a fresh packet of stickers, so they are newly opened in front of you? They could use a dressing pack to lay a sterile sheet on your tummy so that the leads don't lie on your skin.

You do need these tests, but I think there are ways of doing it that will make it easier for you.

Thank you to everyone who has replied.

@Lougle I have watched videos of blood draws on YouTube and I actually thought I'd like a butterfly needle less than a straight needle because of the length of flexible tube meaning that the vacuum tube holder could flop about and touch a surface. I wouldn't even want it falling against my own arm to be honest because it might touch a bit of skin that hasn't been adequately cleaned. I'm not sure I can picture what you mean, but could it be done with a straight needle, or are there butterfly needles without the flexible tube attached? Would the syringe go back and forth from the needle to each blood bottle while the needle stays in place, so I could ask them to use a new syringe for each one, or could you take a lot of blood in one go into a big syringe from which all bottles could be filled? I don't know how much blood is needed for tests.

The ECG I was already thinking I could manage because they do use single-use stickers as a matter of course. I'm not sure about the wires or other parts of the equipment; they'd have to clean those in front of me. That idea about a sterile sheet is brilliant if the stickers don't have to directly touch the skin, so thanks for that.

With a bit of,planning this is achievable. Talk it through each stage and see what can be done to manage your anxieties

have that dialogue, it’ll make you feel more empowered and involved in the treatment planning

finally, good luck