prescription – Investigative Psychiatry

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.

Historical Context:

1689 Bill of Rights: Established the supremacy of Parliament over the monarchy, laying the foundation for modern Parliamentary sovereignty.

Parliamentary Sovereignty: Core Concepts

Definition: Parliamentary sovereignty means that Parliament has the ultimate legal authority in the UK. It can create or end any law, and its decisions and directions cannot be overturned by any other body or individual (even the Monarch).
Legislative Supremacy: Parliament can make, amend, or repeal any law.
Legal Supremacy: Courts cannot overrule legislation passed by Parliament.
No Parliament can bind its successors: Each new Parliament can amend or repeal laws passed by previous Parliaments.
Overriding Policies and Subordinate Legislation: No other policy, regulation, or subordinate legislation can override or conflict with Acts of Parliament. Parliament’s laws take precedence over any other form of legislation within the UK.
No Legal Limitations: Parliamentary sovereignty means that no legal or constitutional limits can be imposed on Parliament by itself or any external body.
Ethical and Moral Principles: While Parliament may consider ethical and moral principles in its legislation, these principles do not legally bind Parliament. It retains the freedom to legislate and enforce via the Courts on any matter as it sees fit, even across matters widely considered unfair or unethical.
Unchallengeable Legislation: Once a law is enacted by Parliament, it cannot be declared invalid by the judiciary or any other authority.

Limited Caveats

None of the following automatically voids or nullifies Parliament’s laws.

Judicial Review: While courts cannot override primary legislation, they can review the actions of public bodies to ensure they comply with the law. This can indirectly influence the application of Parliamentary laws.
Human Rights Act 1998: Allows UK courts to declare legislation incompatible with the European Convention on Human Rights. Although Parliament can choose whether to amend the law, this process provides a mechanism for challenging legislation.
European Union (Withdrawal) Act 2018: While the UK was a member of the EU, EU law took precedence over national law. Post-Brexit, this act manages the transition of EU laws into UK law.
Devolution Acts: Establishing devolved administrations in Scotland, Wales, and Northern Ireland creates legislative bodies with powers over certain areas. While Westminster retains ultimate sovereignty, these bodies can challenge specific laws through their legislative powers.
Parliament Acts 1911 and 1949: Limit the power of the House of Lords to block legislation, allowing the House of Commons to pass certain types of legislation without Lords’ consent after specific time periods.

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.

Estimated final cost of a pack of 20 cigarettes

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’s 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’s 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:

Premature Death:
- Smoking is the leading cause of preventable death globally, responsible for over 8 million deaths per year. (WHO)
- In the UK alone, smoking causes around 100,000 deaths annually. (ASH)
- Smokers lose on average 10 years of life expectancy. (ASH)
Respiratory Diseases:
- Smoking is the primary cause of Chronic Obstructive Pulmonary Disease (COPD), a debilitating lung condition. (WHO)
- In England, smoking accounts for 16% of all hospital admissions for respiratory diseases. (NHS England)
- COPD is responsible for an estimated 30,000 deaths each year in the UK. (BLF)
Cancer:
- Smoking is a major risk factor for various cancers, including lung, throat, mouth, bladder, kidney, and cervical cancer. (WHO)
- Lung cancer is the most common cause of cancer death in the UK, with smoking accounting for around 70% of cases. (Cancer Research UK)
- Smoking also increases the risk of secondhand smoke-related cancers in non-smokers. (WHO)
Cardiovascular Diseases:
- Smoking damages blood vessels and increases the risk of heart disease, stroke, and peripheral vascular disease. (WHO)
- Smoking is responsible for around 7% of all hospital admissions for cardiovascular diseases in England. (NHS England)
- Coronary heart disease (CHD) is a leading cause of death in the UK, with smoking significantly increasing the risk. (BHF)
Other Health Problems:
- Smoking weakens the immune system, making smokers more susceptible to infections.
- It can cause fertility problems in both men and women.
- Smoking increases the risk of type 2 diabetes, osteoporosis, and eye diseases. [People who smoke cigarettes are 30%–40% more likely to develop type 2 diabetes than people who don’t smoke – The CDC]
- It also has detrimental effects on oral health, skin, and hair.

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.

Key components of decison-making

Cognitive activities in decision-making

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

The following paragraphs are excerpted from the 2012 UKSC judgement.

Melanie Rabone was born in 1981. During 2000, she was diagnosed as suffering from depression and received medical treatment. There was some improvement in the next few years, although she had intermittent episodes of anxiety. On 4 March 2005, she tried to commit suicide by tying a pillow case round her neck. She was admitted to Stepping Hill Hospital following an emergency referral by her General Practitioner. On 7 March 2005, she was diagnosed by Dr Meagher, a consultant psychiatrist, as suffering from a severe episode of a recurrent depressive disorder. On 18 March, she was assessed as having made a sufficient recovery to be discharged. She went on holiday for a week with her family to Egypt.
On 31 March, she cut both of her wrists with broken glass. Dr Meagher advised that she should be readmitted to the hospital. No beds were available on Warren Ward, which is part of Stepping Hill Hospital’s Mental Health Services Unit. On 6 April, she was seen by Dr Cook, a senior house officer, as an outpatient. She was noted as having occasional thoughts of suicide and frequent thoughts of deliberate self-harm. On 11 April, she tied lamp flex round her neck. She was assessed by Dr Cook who noted: “Impression: severe depressive episode…..? Psychosis, High risk DSH [deliberate self-harm] and suicide”.
Melanie agreed to an informal admission to the hospital. Dr Cook noted that, if she attempted or demanded to leave, she should be assessed for detention under the MHA. She was prescribed a course of drugs and thereafter kept under 15 minute observation. A full mental state examination was carried out on admission by Nick Tatnall, one of the ward nurses. He assessed Melanie as a moderate to high suicide risk. On 13 April, Mr Rabone expressed his grave concern to Nurse Tatnall about Melanie’s condition and urged that she should not be allowed home on leave or discharged too soon. There were further conversations during the week in which Melanie’s parents told the hospital staff that they were concerned about her impulsiveness and the risk of self-harm.
At 13.00 hrs on 18 April, Mr Rabone spoke to the ward to state his concern that Melanie was not improving and that she had expressed fleeting suicidal thoughts since her admission and had asked her parents to “get her out” of the hospital.
On 19 April, Dr Meagher returned from leave. He was told that Melanie was requesting home leave. On his late afternoon ward round, he met Melanie and Mrs Rabone. He agreed to allow her to have home leave for two days and nights. Mrs Rabone said that she was concerned about Melanie coming home for the weekend, but Melanie was keen to do so. She left the ward at 19.40 hrs. She spent most of the following day with her mother. In the late afternoon, she said she was going to see a friend. Some time after 17.00 hrs, she hanged herself from a tree in Lyme Park.
On 31 August 2005, Mr Rabone wrote to the trust criticising the decision to grant home leave on 19 April. On 13 September, the trust informed Mr Rabone that a thorough internal investigation was to be carried out, but that this would take some time. They said that his complaint would be “put on hold” until the completion of the investigation. On 15 September, they duly established a Serious Untoward Incident (“SUI”) investigation.
On 29 September, the Coroner for the Greater Manchester South District conducted an inquest and retuned a verdict of suicide. In the summer of 2006, Mr Rabone contacted the trust on more than one occasion, expressing his concern about delays in the investigation. Its report was not sent to Mr and Mrs Rabone until 16 March 2007.