Too often in psychiatry we are faced with the problem of tail risk. The basic idea is ‘low probability high impact‘ events. This commonly presents among relatively stable patients in contrast to patients in an acute phase of disturbance. Some patients may have an established pattern of only one or two short-lived periods of disturbance ...
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The case of Black v Forsey arose from a complex set of circumstances involving the detention of a mentally ill patient at Argyll and Bute Hospital in November 1985. The key circumstances were as follows:
The core issue arose from this gap in statutory provisions – where a patient detained under section 26 improves initially but then deteriorates too late for a section 18 application to be processed before the section 26 period expires. The medical staff faced a difficult ethical decision between releasing a potentially dangerous patient or continuing detention without clear legal authority.
The Black v Forsey case elucidated several key legal issues, primarily centred around the relationship between common law powers and statutory provisions regarding the detention of mentally ill patients. These were:
Section 145 is lengthy and convoluted.
S145(1) – “medical treatment” includes nursing, psychological intervention and specialist mental health habilitation, rehabilitation and care (but see also subsection (4) below);]
S145(4) – Any reference in this Act to medical treatment, in relation to mental disorder, shall be construed as a reference to medical treatment the purpose of which is to alleviate, or prevent a worsening of, the disorder or one or more of its symptoms or manifestations.
S145(1) – Hospital: “hospital” means—(a) any health service hospital within the meaning of the National Health Service Act 2006 or the National Health Service (Wales) Act 2006]; and(b) any accommodation provided by a local authority and used as a hospital by or on behalf of the Secretary of State under that Act; and(c) any hospital as defined by section 206 of the National Health Service (Wales) Act 2006 which is vested in a Local Health Board;]
While the terms are often used synonymously, some legal scholars and commentators might use them slightly differently:
The terms are used interchangeably hereafter.
Parliamentary supremacy, a cornerstone of the British constitutional framework, refers to the principle that Parliament, consisting of the House of Commons, the House of Lords, and the Monarch, holds ultimate authority in making laws for the United Kingdom. This doctrine signifies that no other body within the UK has the power to override or invalidate legislation passed by Parliament. Essentially, Parliament is sovereign, meaning it can make or unmake any law it chooses, regardless of its content or perceived rationality. This principle was famously articulated by A.V. Dicey, who emphasised that Parliament’s legislative power is absolute and unlimited. For instance, even if a law appears absurd or irrational, such as the “Hogging Act” of 1610, which required certain individuals to provide lodging for swine, citizens are bound to follow it until it is repealed or amended by subsequent legislation. The concept of parliamentary supremacy underscores the primacy of legislative authority over all other branches of government, including the judiciary, which cannot declare an act of Parliament unconstitutional.
The idea of parliamentary supremacy is deeply rooted in historical developments and legal precedents. It emerged from the struggles between the monarchy and Parliament during the 17th century, particularly after the English Civil War and the Glorious Revolution. These events led to a gradual shift in power from the Crown to Parliament, culminating in the Bill of Rights of 1689, which further entrenched the supremacy of Parliament. Over time, this principle has been reinforced through various judicial decisions, most notably the case of De Keyser’s Royal Hotel Ltd v. Westminster City Council (1920), where the courts explicitly stated that they could not question the validity of parliamentary statutes. The principle of parliamentary supremacy also extends to the fact that Parliament can legislate for any subject matter, including matters previously reserved for the monarchy or the executive. This includes the power to alter fundamental rights and freedoms, provided that the necessary majority is secured in both Houses of Parliament. Despite the potential for abuse, the system relies on the accountability of elected representatives to their constituents to ensure that laws are reasonable and just.
None of the following automatically voids or nullifies Parliament’s laws.
While parliamentary supremacy grants Parliament the ability to make and unmake any law, it does not mean that there are no checks on its power. In practice, the legislative process involves significant scrutiny and debate, with opposition parties and independent members often challenging proposed legislation. Additionally, the public’s role in holding Parliament accountable is crucial, as demonstrated by public outcry leading to the repeal of controversial laws, such as the notorious “Lunacy Act” of 1890, which was eventually amended due to widespread criticism. Moreover, the European Union (EU) membership, prior to Brexit, imposed some constraints on parliamentary supremacy, as EU law took precedence over conflicting domestic legislation. Even after Brexit, international treaties and conventions may influence how Parliament exercises its powers. Nonetheless, the fundamental principle remains that Parliament retains the final say in lawmaking, and any law it passes must be obeyed, no matter how illogical or impractical it may seem. This underscores the importance of the democratic process in ensuring that Parliament acts responsibly and in the best interests of the nation.
In March of 2001, Mr Jones sustained physical and psychological injuries after being struck by a motor vehicle. Intending to pursue a personal injury claim against the driver, Mr Jones sought supporting medical evidence. Dr Sue Kaney, a clinical psychologist, was retained to provide expert medical opinion and subsequently diagnosed Mr Jones with post-traumatic stress disorder. The defendant driver also retained a medical expert, whose opinion differed from Dr Kaney’s. Consequently, the presiding judge directed the two experts to prepare a joint statement.
Allegations of negligence against Dr Kaney stemmed from her participation in formulating this joint statement. Mr Jones asserted that Dr Kaney acted negligently by signing a joint statement that inaccurately reflected her professional opinions and the discussions conducted between the experts. This joint statement purportedly proved detrimental to Mr Jones’s claim, ultimately leading to an unfavourable settlement. Mr Jones subsequently initiated legal proceedings against Dr Kaney, seeking damages for the alleged undervaluation of his claim resulting from her actions.
The Supreme Court found that the expert had failed to provide adequate reasoning for these concessions and had acted in a manner that favoured the defendant. This case demonstrates the potential consequences for expert witnesses who do not fulfil their duties to the court.
Semmelweis Reflex: A reflex-like tendency to dismiss or reject new evidence, information, or thinking -outright because it contradicts established beliefs, norms, or paradigms. This rejection occurs pre-emptively, avoiding the mental discomfort that might arise from having to reconsider or challenge one’s existing views.
Optional: See a comparison of four mechanisms of mind.
This explains how S62(1) should be applied and not.
25.40 These are strict tests. It is not enough for there to be an urgent need for treatment or that the clinicians involved believe the treatment is necessary or beneficial.
25.41 Urgent treatment under these sections can continue only for as long as it remains immediately necessary. If it is no longer immediately necessary, the normal requirements for certificates apply. Although certificates are not required where treatment is immediately necessary, the other requirements of parts 4 and 4A of the Act still apply. The treatment is not necessarily allowed just because no certificate is required.
When we refer to the high taxes on tobacco, that encompasses the specific duties, ad valorem duties, and VAT. This combined tax burden is a significant factor in the final price of tobacco products.
It typically falls within the range of 70-75%.
Note: The exact percentage will vary slightly depending on the retail price of the cigarettes. The calculations below are the most conservative estimates arising from a manufacturer’s cost price of £2/pack and profits of only £2/pack.
| Stage | Cost/Price (£) | Tax/Duty (£) | Tax/Duty Type | Calculation | Calculation |
|---|---|---|---|---|---|
| 1. Manufacturer’s Cost | 2 | 0 | N/A | This is a hypothetical cost of production. | |
| 2. Specific Duty Added | 2 | 5.89 | Specific Duty | £294.72 per 1000 cigarettes / 1000 * 20 | Fixed amount per pack. |
| 3. Manufacturer’s Profit | 7.89 | 0 | N/A | (Assumed to bring the total to £7.89) | This is a hypothetical profit margin. |
| 4. Ad Valorem Duty Included | 9 | 1.11 | Ad Valorem Duty | 16.5% of £9.00 (approx. retail price before VAT) | Included within the retail price, not added separately. |
| 5. Retailer’s Profit | 10.11 | 0 | N/A | (Assumed to bring the total to £10.11) | This is a hypothetical profit margin. |
| 6. Final Retail Price (excl VAT) | 13 | 0 | N/A | (Includes specific duty and ad valorem duty) | This is the price displayed on the shelf, excluding VAT. |
| 7. VAT Added | 13 | 2.6 | Value Added Tax (VAT) | 20% of £13.00 | Applied at the point of sale. |
| Total | 15.6 | 9.6 | Approximately 61.5% of the final price (£15.60) is tax – due to the simplified conservative assumptions about manufacturer and retailer costs and profit margins. | ||
It is undeniable that chronic smoking wreaks havoc on the body. Patients who interface with psychiatric services often ask, “So why are they selling it legally if it is causing so much harm?” That is very good question but the answer should come from politicians – not doctors.
The scale of physical harm backed by facts and figures:
These figures highlight the devastating impact of chronic smoking on physical health.
BIRP format documentation
Behaviour: Known to have EUPD. Patient presented in a distressed state, reporting feelings of emptiness and fears of abandonment. She expressed difficulty managing her emotions and described intense anger triggered by a minor disagreement with a family member.
Interventions: Explored coping mechanisms for distress tolerance. Discussed strategies for managing anger and interpersonal conflict. Provided psychoeducation on emotional regulation.
Response: Patient engaged in the session and expressed some understanding of the concepts discussed. She reported feeling slightly calmer by the end of the session but remained concerned about her ability to manage her emotions effectively.
Plan: Continue to work on developing distress tolerance skills and anger management strategies. Encourage the patient to practice the techniques discussed between sessions. Monitor the patient’s emotional state and risk of self-harm.
| Documentation Issue | Critique |
|---|---|
| Vague Descriptors | Terms like “distressed state,” “emptiness,” and “intense anger” lack specific behavioural anchors. The descriptions are mere observations without any real substance. How was the intensity of the anger manifested? What did the patient say? How did she appear? Was she grimacing? Without concrete examples, these descriptors are open to interpretation and do not provide a clear picture of the patient’s presentation. |
| Generalised Interventions | Phrases like “explored coping mechanisms” and “discussed strategies” are so general that they amount to padding. No one will know what specific coping mechanisms were explored. How did this worker actually attempt to help the patient? What exact strategies were discussed? How were these tailored to the patient’s individual needs and the nature of their emotional instability? |
| Lack of Measurable Outcomes | The record mentions the patient feeling “slightly calmer” but lacks objective measures to assess the effectiveness of the interventions. How was this improvement gauged? Is it just ‘your’ word for saying so? Many services will accept such records as ‘standard’ because of cultural norms. |
| Ambiguous Plan | The plan to “continue to work on developing skills” and “encourage the patient to practice techniques” is vague and lacks specific, measurable goals. What specific skills will be targeted? What techniques were discussed ‘between sessions’? How will progress be monitored? What constitutes “practice” in this context, and how will adherence be assessed? |
| Omission of Risk Assessment | Given the nature of EUPD and the potential for self-harm, the record should include a formal risk assessment. What specific risk factors were considered? How was the risk of self-harm evaluated and managed? |
| Limited Patient-Specific Insight | While the record mentions EUPD, it does not provide specific insights into how this diagnosis informs the interventions or the plan. How were the chosen strategies tailored to the patient’s unique challenges related to their personality disorder? |
Annex A | Characteristics of high quality data
The following is a summary of the characteristics of high-quality data (CARAT) as suggested by organisations such as PRIMIS:
1. Complete | Data can be considered complete when all the required data for a particular purpose is present and available to be used. Completeness relates to determining that the patient’s record has all diagnoses, allergies, vaccinations, operations, or events present within the record. Consider a patient record with missing allergy information. The consequences of this could be profound, and the omission clearly constitute an incomplete record.
Completeness for an individual patient could reflect that it contains all the relevant codes for all diagnoses, allergies, vaccinations, operations, or events. Across a population it means that all patients with a particular condition diagnosed have it correctly coded in all the records.
2. Accurate | This is when the data reflects reality or a genuine real-world occurrence. Accuracy can be quite challenging as it can change over time and is, therefore, difficult to monitor. An example may be a patient that presents with chest pain and is coded as such. At that point in time there is no clear cause for the chest pain, and this is, therefore, an accurate reflection in the data. That diagnosis may, however, change from chest pain to myocardial infarction following further investigations. Uncertain symptoms can become certain diagnoses.
Recording a diagnosis of stroke based on clinical symptoms and then later being it being proved not to be the case would render the initial diagnosis inaccurate and would need evolving/correcting.
This highlights the transient nature of accuracy especially when the diagnosis is uncertain and also the importance of maintaining and evolving problems.
3. Relevant | When considering data quality, relevance implies there is a reason to collect or record the information in the patient record. You must consider whether you really need this information, and for what purpose. Relevant data is usually closely linked to the purpose for which it is being collected. For example a diabetic review might record blood pressure as this is relevant in the context of diabetes. Recording the patient’s temperature in the record during the diabetic review would not, however, be relevant as it adds nothing to the diabetic review and is unrelated to diabetes in this context.
4. Accessible | Data may be recorded completely and accurately, but if we cannot extract information that we need this can been seen as an accessibility issue. Accessibility describes how easy it is to retrieve the required information as and when it is needed. Coded data is typically more accessible than free text and can be displayed and organised in various ways by the GPIT system as the codes themselves are understandable to the system. With modern GPIT systems there can also be vast qualities of information being drawn into the record from multiple sources, how this information is organised and coded can aid accessibility.
5. Timely | Data that is available when expected and when needed is timely. The purpose determines what would be considered timely. In the context of a clinical interaction, most professional bodies consider the contemporaneous entry of medical information as one of the most important aspects of healthcare. Contemporaneous entry of clinical information also supports the other aspects of data quality including accuracy and completeness.
| Cognitive Activity | Description |
|---|---|
| 1. Information synthesis | Gathering and integrating diverse information; evaluating reliability and relevance of each piece |
| 2. Evidence evaluation | Critically assessing quality and strength of available evidence; identifying gaps |
| 3. Principle balancing | Weighing competing ethical principles; reconciling guidelines with case-specific considerations |
| 4. Stakeholder consideration | Analysing individual patient needs/rights; considering regulatory and societal requirements |
| 5. Consequence projection | Anticipating potential outcomes; assessing short-term and long-term consequences |
| 6. Risk-benefit analysis | Systematically evaluating risks; weighing risks against potential benefits |
| 7. Legal framework integration | Incorporating relevant legal standards; ensuring compliance with statutory obligations |
| 8. Ethical reasoning | Applying ethical frameworks; resolving ethical dilemmas in forensic psychiatric practice |
| 9. Interdisciplinary integration | Synthesising perspectives from various disciplines; reconciling conflicting viewpoints |
| 10. Decision refinement | Iteratively reviewing and adjusting decisions; fine-tuning to address all relevant factors |
| 11. Uncertainty management | Acknowledging areas of uncertainty; developing mitigation strategies |
| 12. Prioritisation | Determining relative importance of factors; focusing on critical elements |
| 13. Cognitive bias recognition | Identifying potential biases; implementing strategies to minimise their impact |
| 14. Justification formulation | Developing clear, logical rationale; ensuring transparent and defensible reasoning |
| 15. Contextual adaptation | Tailoring approach to specific case factors; recognising unique case influences |
