Clinical Risk Assessment in Psychiatry – Part 2

This section should be read in conjunction with Clinical Risk Assessment in Psychiatry – Part 1. It is relevant to all medical staff working in Accident and Emergency (A&E) departments and acute hospital settings.

Management of Deliberate Self-Harm in Accident and Emergency

There are some basic principles that should be followed in all cases of deliberate self-harm, whether the patient is presenting with superficial lacerations or has been brought in following a serious suicide attempt. Always manage the patient as an individual and avoid making assumptions about the clinical risk based on the apparent severity of the act alone — superficial self-harm can be associated with high suicidal intent, and highly dangerous acts can sometimes be made with relatively low intent to die.

Step 1 — Ensure Medical Safety

Make sure the patient is medically stable and that all vital signs are stable. If not, treat accordingly. The physical medical needs of the patient take precedence and must be addressed first. Do not conduct a psychiatric assessment while the patient is medically unstable.

Step 2 — Manage the Overdose

In cases of overdose, find out what the patient has taken, the quantity, and the timing. If necessary, contact the National Poison Information Service (NPIS, available via Toxbase or the 24-hour phone line) for advice regarding immediate management. Specific antidotes (e.g. acetylcysteine for paracetamol overdose, naloxone for opioid overdose) should be initiated promptly where indicated.

Step 3 — Collateral History and Notes

Ask a colleague or nursing staff assisting you to contact the patient's family, who can provide an objective account of the patient's recent physical and mental health history, social circumstances, and relevant life events. They may also be able to assist in the management of the patient if discharge is being considered. Arrange for medical and psychiatric notes to be made available, and — in most NHS hospitals — check the patient's electronic record for previous presentations, medications, and outpatient letters.

Step 4 — Contact Psychiatric Team

Arrange to speak with the Community Psychiatric Nursing staff or other mental health professionals who have been involved with the patient, currently or in the past. They will be able to provide useful information about the patient's past and current mental health, social circumstances, current stressors, and current prescribed psychiatric treatment.

Step 5 — Arrange Investigations

Arrange the following essential investigations: full blood count, urea and electrolytes, liver function tests, paracetamol and salicylate levels (as a routine in all overdoses), blood glucose, and illicit drug and alcohol screening. If relevant, arrange a 12-lead ECG (particularly with antidepressant or antipsychotic overdose), chest X-ray, and CT brain scan. For anyone who is intoxicated with alcohol or drugs, CT brain imaging should be strongly considered to exclude a subdural haematoma — such patients may have banged their head prior to or during their presentation and may not be able to give a reliable history.

Step 6 — Psychiatric Assessment and Management Decision

Take a focused history and carry out a detailed Mental State Examination, followed by a formal risk assessment using the categories outlined in Part 1. Then make a management decision:

1. Minimum Risk: If the patient is medically fit for discharge and assessed as minimum risk for future adverse event:
   • Ensure the patient is discharged into the care of a responsible adult
   • Arrange for a Mental Health Crisis Assessment Team to see the patient within the next 48 hours, or sooner if clinically indicated
   • Notify the GP about the presentation
   • Provide the patient and their responsible adult with emergency contact details for the Mental Health Crisis Assessment Team
   • If a responsible family member or friend cannot be contacted — and the patient does not consent to contact with anyone — consider involving the Crisis Assessment Team or Psychiatric Liaison Service to assess the patient before they leave
2. Moderate Risk: Patients assessed as moderate risk should not be discharged home directly from A&E. These patients require assessment by the Crisis Assessment Team and/or Psychiatric Liaison Service, who will determine the appropriate management — which may include intensive home treatment or inpatient admission.
3. Severe Risk: Patients assessed as severe risk require transfer to a psychiatric inpatient unit for a period of further observation and treatment. This may be arranged informally (if the patient agrees) or under the Mental Health Act (if the patient refuses and the criteria are met).

Consent to Treatment and Mental Capacity

It is essential that all clinicians fully understand the principles of valid informed consent and apply them at all times in clinical practice. The Mental Capacity Act 2005 (MCA) provides the statutory framework for assessing mental capacity and making decisions on behalf of adults who lack capacity in England and Wales.

The key principles of valid informed consent are:

• Consent from a patient is required prior to any examination or treatment of an adult.
• Consent must be voluntary — free from any pressure or undue influence from the medical profession, family, or others.
• Consent can be oral, written, or non-verbal. A signature on a form does not necessarily mean the consent is well-informed or valid.
• The patient needs sufficient information about the proposed treatment or procedure — its purpose, benefits, risks, and alternatives — before they can give valid consent. Information must be presented in plain, understandable language. For complex procedures, written information should also be provided.
• Ideally, the treating doctor should take the consent. However, a junior doctor may do so if they feel confident in providing all the relevant information and have appropriate training.
• It is always advisable — both medically and legally — to record the patient's decision about the proposed treatment in the notes.

Refusal of Treatment

• A competent adult has the legal right to refuse treatment, even when that refusal is likely to be seriously detrimental to their health or lead to their death. This is an expression of their autonomous right to self-determination.
• Similarly, a competent pregnant woman can refuse treatment even if her decision may be detrimental to the foetus.
• No other person can give or withhold consent on behalf of a competent adult (unlike for children, where parental authority applies).

Children and Consent to Treatment

• Under English law, an adult aged 18 years and over is considered capable of giving or refusing consent to treatment.
• Young people aged 16 to 17 are presumed capable of giving consent under the Family Law Reform Act 1969 and can consent to treatment without parental involvement, though parental involvement is often appropriate.
• A competent child under the age of 16 may give consent for treatment if they demonstrate sufficient understanding and intelligence — the "Gillick competent" child (established by the House of Lords in Gillick v West Norfolk and Wisbech Area Health Authority, 1985). This is assessed on a case-by-case basis.
• In complex medical or surgical treatments, or where the child is not Gillick competent, parental consent is required.
• If the child is unable to understand the details of the proposed procedure or treatment, a person with parental responsibility can give consent on their behalf.

Adults Who Lack Capacity to Consent to Treatment

Under the Mental Capacity Act 2005, all adults are presumed to have capacity unless proven otherwise. The MCA establishes a two-stage test for capacity:

1. Is there an impairment or disturbance in the functioning of the mind or brain? (e.g. mental disorder, intoxication, delirium, brain injury)
2. Does this impairment mean the person is unable to make a specific decision at this time?

A person lacks capacity to make a specific decision if they are unable to understand the information relevant to the decision; retain that information; weigh it up and use it to make a decision; or communicate their decision.

Note: capacity is decision-specific (a patient may have capacity for some decisions but not others) and time-specific (capacity can fluctuate). The mere presence of a mental disorder does not mean the patient lacks capacity.

Where a patient is found to lack capacity:

• No other person can give consent on behalf of an incompetent adult (except a person with a valid Lasting Power of Attorney for health and welfare, or a court-appointed deputy).
• However, you may still treat them if it would be in their best interests and if, without treatment, the outcome is likely to involve grave harm or death.
• You may treat a patient who lacks capacity in an emergency where without immediate medical intervention the outcome may be seriously harmful or fatal.
• Decisions made under the MCA must be in the patient's best interests, taking into account their previously expressed wishes, values, and beliefs, and the views of those close to them.
• Any treatment decision should be discussed with senior colleagues and documented clearly, including the reasons why the patient was found to lack capacity and why the treatment was considered to be in their best interests.
• A note should be made that the prescribed treatment, as far as can be determined, is not in any way contrary to the patient's previously expressed religious or spiritual beliefs.

The Mental Health Act in the A&E Context

Under the Mental Health Act 1983, you have the right to treat an adult against their valid informed consent if they are suffering from a mental disorder of a nature or degree warranting compulsory admission, and if their own safety or the safety of others requires it. This is a significant exception to the general principle of autonomous consent. The MHA does not override a patient's physical consent for medical treatment — it applies only to mental disorder and its treatment. A competent adult retains the right to refuse physical medical treatment even if they are detained under the MHA.

Summary: Capacity and Consent

• A competent adult has the civil right to self-determination and cannot be forced to receive medical treatment simply because it is in their best interest, in your opinion.
• However, you have the right to treat an adult in a life-threatening emergency — even without consent — where without immediate medical intervention the outcome may be death or serious harm.
• Under the Mental Health Act 1983, you have the right to detain and treat an adult against their will if they are suffering from a mental disorder that meets the statutory criteria.
• A competent adult has the autonomy to withdraw their consent at any time, even mid-procedure.

The next section deals with the management of suicidal and deliberate self-harm patients in the community: Clinical Risk Assessment in Psychiatry – Part 3.