The Irish Court of Appeal has found that a hospital had no legal basis for keeping a voluntary psychiatric patient against their wishes under section 23 the Mental Health Act 2001.
The applicant, PL, was a voluntary patient in St. Patrick’s Hospital, having admitted himself in August 2011 following a psychotic episode. The applicant was admitted to the Special Care Unit of the hospital where he was seen to display aggressive behaviour. From 13 September 2011, the applicant began to express his wish to leave the hospital. He was detained under a renewal order affirmed by the Mental Health Tribunal until 18 October 2011, at which time it was revoked. Thereafter he was considered once again to be a voluntary patient, however he was detained in a locked ward with limitations on his movements.
Judicial review was granted by the High Court on 21 November 2011 based on events up to that point. On 22 November, the applicant indicated again that he was withdrawing his consent to remaining on a voluntary basis. The attending psychiatrist believed that following a period of not taking his medication, acute symptoms of psychoses were re-emerging andtherefore decided to make an order under section 23 of the 2001 Act, pursuant to an assessment for the purposes of section 24 of the Act.
Section 23 sets out what must be done when a person detained on a voluntary basis seeks to leave. It provides that if the consultant psychiatrist responsible for a patient's care is of the opinion that the patient is suffering from a mental disorder, they may detain them for a maximum of 24 hours. Under section 24 of the Act, during this period the patient must be examined by a second doctor in order to confirm the person is suffering from a mental disorder and authorise detention.
The doctor who performed the second review did not form the opinion that the applicant should be detained under section 23 of the Act. The secondary assessment noted, however, that the applicant had agreed to take his medication and engage in further treatment as a voluntary patient. The applicant was therefore returned to the secure unit. The question then became was there a legal basis for the decision to restrain the applicant from leaving the hospital on 21 November 2011 in circumstances where section 23 was not invoked on the day.
It was submitted by the applicant that there was no lawful basis for his detention and that the net result was that he was being detained without the benefit of the panoply of protections afforded to detained persons by the 2001 Act. The hospital argued, however, that it was necessarily implicit in section 23 of the Act that the hospital personnel could refuse to permit a voluntary patient to leave in order to persuade them to stay, or to obtain an initial assessment that they are suffering from a mental disorder, and that it could do so without having to invoke the provisions of that section.
Judge Hogan in the Court of Appeal acknowledged that the treating medical staff were entirely motivated by ensuring the most appropriate treatment for the patient, and that the overall best interests of the applicant were served by him being detained. However, overturning the judgment of the High Court, he found that a lawful basis did not exist under the Act for keeping the applicant detained against his wishes. Hogan J was of the view that a voluntary patient who seeks to leave a secure unit at a psychiatric institution remains free to do so at any time and may not be restrained by the hospital save in accordance with the provisions of section 23 of the 2001 Act.
Hogan J agreed that a patient could be persuaded to stay, but restraint could not be used in order to detain. Hogan J noted that reasonable restraints may be necessary where exit might not be considered safe – such as climbing over the garden wall at night, as had occurred – but the hospital could not prevent a voluntary patient leaving at any appropriate time and by an appropriate means.
Click here for judgement in P.L. -v- Clinical Director of St. Patrick's University Hospital &anor.
Click here for the High Court judgement in PL.
Click here for the press release from the Irish Human Rights and Equality Commission, which acted as amicus curiae in the case.