see also:

• psychiatry and mental health
• forensic medicine, crimes and prisoners
• use of mechanical restraints

• the Mental Health Act 2014
• Vic. Govt resources

• forms:
  • MHA 101 Assessment Order
  • MHA 102 Receipt of person subject to Inpatient AO
  • MHA 103 Variation of AO
  • MHA 104 Extension of AO
  • MHA 105 Revocation of AO
• Enables a person to be taken to and detained in a DMHS to be compulsorily examined by an AP to determine whether treatment criteria apply to the person
• Made by a medical practitioner or MH practitioner
• AOs are valid for 24 hours and requires that the person be assessed by a consultant psychiatrist within 24hrs; IAO allows 72 hours for transport to DMHS and the 24 hours commences from time the person is received into ED
• May be varied from CAO to IAO or vice versa
• May be extended twice by an authorised psychiatrist (AP) to max 72 hours after examination has been conducted
• Treatment may only be provided with consent or if urgently required
• legal requirements for an AO to be appropriate:
  • person must be assessable - ie. be lucid & coherent; be able to participate in a meaningful conversation
  • the person appears to have mental illness
  • because the person appears to have mental illness, the person appears to need immediate treatment to prevent:
    • serious deterioration in the person’s mental or physical health, or,
    • serious harm to the person or to another person
  • if the person is made subject to an Assessment order, the person can be assessed
  • there is no less restrictive means reasonably available to enable the person to be assessed
• NB. if the above do not apply, the person may still require and be given involuntary treatment under the Duty of Care requirements (eg. cognitively incompetent and at risk to themselves or others)

• forms:
  • MHA 110 Temporary Treatment Order
  • MHA 111 Variation of TTO/TO
  • MHA 112 Revocation of TTO/TO
• Made by AP or delegate after assessing a person
• Enables the person to be compulsorily treated in the community or taken to and detained and treated in a designated mental health service (DMHS)
• The AP who made an AO in relation to a person may not make the person subject to a TTO as a consequence of that AO
• An AP may vary the setting of a TTO (from CTTO to ITTO or vice versa), having had regard to the views of the patient, nominated person and carer, if it will directly affect the carer or the care relationship
• Maximum duration 28 days

• community treatment order (CTO) or inpatient treatment order (ITO)
• forms:
  • MHA 113 Application for TO
  • MHA 111 Variation of TTO/TO
  • MHA 112 Revocation of TTO/TO
• An Order made by the Mental Health Tribunal that enables a person to be compulsorily treated in the community or taken to and detained and treated in a DMHS
• An AP may vary the setting of a TO (from CTO to ITO or vice versa), having had regard to the views of the patient, nominated person and carer, if the variation will directly affect the carer or the care relationship
• CTO has maximum duration of 12 months; ITO maximum of 6 months.
• All TOs for patients <18 are maximum of 3 months

• The MHA 2014 presumes that all persons, regardless of age or legal status, have capacity to make or participate in decision making. The following legal mechanisms promote supported decision making.

• Document that sets out a person’s treatment preferences in the event they become a compulsory patient
• Must be dated, signed and witnessed by authorised witness to be valid; same process applies to revocation of an AS
• AP must have regard to views & preferences expressed in AS
• May be overridden (s73) if the specified preferred treatment is (a) not clinically appropriate; or (b) not ordinarily provided by the service

• Person (who is willing, available and able), nominated by the patient to provide support, help represent the patient’s interests, receive information and assist the patient to exercise their rights. May be <18.
• Nomination must be dated, signed and witnessed by authorised witness to be valid; same process applies to revocation of a nomination
• Nominated person must be consulted with & informed at critical points
• Nominated person can decline to act as nominated person at any time

• the person is not a prisoner; and
• the person appears to have mental illness; and
• because the person appears to have mental illness, the person appears to need immediate treatment to prevent‐
  • serious deterioration in the person’s mental or physical health; or
  • serious harm to the person or to another person; and
• if the person is made subject to an Assessment Order, the person can be assessed; and
• there is no less restrictive means reasonably available to enable the person to be assessed

• the person is not a prisoner (Secure Treatment Order may be applicable to prisoners); and
• the person has mental illness; and
• because the person has mental illness, the person needs immediate treatment to prevent‐
  • serious deterioration in the person’s mental or physical health; or
  • serious harm to the person or to another person;
• and the immediate treatment will be provided to the person if the person is subject to a Temporary Treatment Order or Treatment Order; and
• there is no less restrictive means reasonably available to enable the person to receive the immediate treatment

• includes seclusion, bodily restraint - physical and/or chemical restraint
• see also: Victorian Govt guidelines on restrictive practices
• restrictive interventions may only be used if either:
  • under Duty of Care principles
    • only if the patient is not the subject of an Assessment Order (S28) in which case he requirements of the Mental Health Act take precedence
    • the treating staff MUST have documented, clear and justifiable reasons for applying a Duty of Care restrictive intervention
  • whilst under a S351:
    • when all reasonable and less restrictive options have been tried or considered and have been found to be unsuitable
    • restraint is needed to prevent serious and imminent harm to the person or to another person.
  • whilst subject of an Assessment Order (S28) in which case, restrictive interventions can only be applied under the Mental Health Act requirements:
    • after all reasonable and less restrictive options have been tried or considered and have been found to be unsuitable. Must be stopped immediately if no longer necessary
    • Bodily restraint may be used in a DMHS to prevent imminent and serious harm to the person or another person; or to administer treatment or medical treatment
    • Restrictive interventions require notification of the nominated person, a guardian, the carer, (if the AP is satisfied the carer or care relationship will be affected), the parent of a person <16 and the Secretary to DHS (where relevant)
    • Bodily restraint requires continuous observation by a registered nurse or registered medical practitioner, clinical review no less than every 15 mins and examination by the AP every 4 hours
    • The restrictive intervention provisions of the Act apply to persons subject to Orders under the MHA 2014 (eg. Inpatient Assessment Order) and restrained in the ED
    • forms:
      • MHA 140 Authority for use of restrictive interventions
      • MHA 141 Approval for urgent physical restraint
      • MHA 142 Restrictive interventions observations

• police have powers to apprehend a person who appears to have mental illness and needs to be apprehended to prevent serious and imminent harm to themselves or another person
• police must arrange for the person to be taken to a registered medical practitioner or MH practitioner for examination
• person may be released from police custody into the care of a hospital when there are no significant safety risks or concerns
• Vic Govt Department of Health and Human Services – Victoria Police protocol for mental health A guide for clinicians and police
  • 2.1.7.2. Examination at a hospital
    • “Where an examination is to occur at a hospital, the apprehended person should be taken to the hospital emergency department that covers the location where the apprehension occurred. This should happen whether the person is an existing client or they live outside the catchment area. Where possible, police should alert the relevant mental health triage of the apprehension and provide an estimated time of arrival (ETA).”

• authorised persons may enter premises, apprehend, search, use force and bodily restraint and transport people to DMHS in prescribed circumstances

• must be provided to patients, nominated persons, carer and parent of someone <16 at key points, including when an Assessment Order is made

• If a patient is involuntary under the Mental Health Act 2014 (MHA), this means they do not have capacity to make decisions regarding their mental health treatment but they CAN be asked to consent to physical health treatment, i.e. medical/nursing interventions for physical health concerns.
• Best practice also dictates that they are to be involved in all decision making process where able to.
• If the patient’s mental illness is affecting their capacity to consent to required medical treatment / interventions, they need to be assessed by a Psychiatrist who can provide consent for them via the MHA130 – Substitute consent to medical treatment by authorised psychiatrist.
• forms:
  • MHA 130 Substitute consent to medical treatment by authorised psychiatrist
• where a patient lacks capacity to consent, medical treatment may be administered with the consent of the first person listed in section 75 of the MHA 2014 who is reasonably available, willing and able to make a decision concerning the proposed medical treatment
• urgent medical treatment may be provided without consent (s77).

• the Act mandates when a patient’s mental health information must be disclosed and to whom, and also sets out when information may be disclosed

• The patient’s NOK should be contacted at each stage of their treatment:
  • When they are put on/taken off an order
  • If they are mechanically restrained
  • If they leave the hospital (AWOL)
• Consent to contact NOK IS REQUIRED from the patient, UNLESS it is necessary to manage significant risk to the patient and/or NOK (such as when a patient is away without leave ie. AWOL).

• This is obtained from people involved in the patient’s care, including NOK and community health practitioners (e.g. GP, Psychologist, Psychiatrist, carers).
• As with contacting NOK, CONSENT to obtain collateral information IS REQUIRED from the patient, UNLESS it is necessary to manage significant risk to the patient.
• Collateral information is often vital in the care of a mental health patient for a few reasons:
  • Collateral information helps to corroborate the story the patient has given us, sometimes a very far-fetched story can actually be true and this can change the trajectory of a patient’s care requirements
  • Collateral information helps to allow the NOK/carer/support person to give their version of events and concerns that has led up to this point
  • Collateral information helps to involve the NOK/carer/support person in the planning of care for the patient