FORENSIC PSYCHIATRY.pptx

FORENSIC
PSYCHIATRY
Thomas Owondo
Bwindi Community Hospital
© 2017 Thomas Owondo. All rights reserved.

DEFINITION
• Forensic psychiatry is a specialised branch of psychiatry
which deals with the assessment and treatment of
mentally disordered offenders in prisons, secure hospitals
and the community.
• It requires understanding of the interface between mental
health and the law.
© 2017 Thomas Owondo. All rights reserved. 2

LEGAL AND ETHICAL CONCEPTS
• Ethics
Study of philosophical beliefs about what is considered right or
wrong in society
• Bioethics
Ethical questions arising in health care
• Principles of bioethics
Beneficence: duty to act to benefit others
Autonomy: respecting rights of others to make decisions
Justice: duty to distribute resources equally
Fidelity: maintaining loyalty and commitment to patient
Veracity: duty to communicate truthfully

LAW
• This refers to a set of rules or norms of conduct which
mandate, prescribe or permit specific relationships among
people and organisations.
• It provides methods for the administration of punishments
to those who do not follow the established rules and
conduct.

ROLES OF A FORENSIC PSYCHIATRIST
• To carryout psychiatric assessment on the offenders suspected to
be of unsound mind.
• To make a comprehensible psychiatric report that is concise and
nonpartisan.
• To provide the court with specific information about clinical
diagnosis of the accused and probable interventions (whether or
not psychiatric treatment is indicated)
• Psychiatric disability evaluation for worker's compensation or
personal injury cases.

ROLES OF A FORENSIC PSYCHIATRIST
• To provide opinion whether psychiatric illness in the
accused affect the intent (mens rea [a guilty mind]) to
commit the crime.
• To give opinion on whether the accused is competent and
fit to stand trial.
Note: In general, the forensic psychiatrist works
with courts in evaluating an individual's Competency to
Stand trial (CST) and Mental State at the Time of the
Offense (MSO).

THE MENTAL TREATMENT ACT (MTA)
1964
• The MTA 1964 refers to a person having mental disability
as persons of unsound mind. This act was passed in 1964
by the parliament of Uganda. The reason for the act are;
 To address legal aspects for the management and
protection of persons with mental illness.
 To protect both the mental disabled persons from the
community and vice versa.
 To authorize the mental hospital to detain, treat and
discharge the same persons after recovering.

CIVIL RIGHTS AND DUE PROCESS
• Civil rights: people with mental illness are guaranteed
same rights under federal/state laws as any other citizen
• Due process in civil commitment: courts have recognized
involuntary commitment to mental hospital is “massive
curtailment of liberty” requiring due process protection,
including:
Writ of habeas corpus: procedural mechanism used to
challenge unlawful detention
Least restrictive alternative doctrine: mandates least drastic
means be taken to achieve specific purpose.

ADMISSION TO THE HOSPITAL
• Voluntary: sought by patient or guardian
 Patients have right to demand and obtain release
 Many states require patient submit written release notice to staff
• Involuntary admission (commitment): made without patient’s
consent
 Necessary when person is danger to self or others, and/or unable to meet
basic needs as result of psychiatric condition
• Emergency involuntary hospitalization
 Commitment for specified period (1-10 days) to prevent dangerous
behavior to self/others
• Observational or temporary involuntary hospitalization
 Longer duration than emergency commitment
 Purpose: observation, diagnosis, and treatment for mental illness for
patients posing danger to self/others

ADMISSION AND CLASSIFICATION OF MENTAL PATIENTS
ACCORDING TO THE MTA 1964
• According to what is in practice, psychiatric patients are
commonly admitted to the top hospital on voluntary basis,
Urgency order or as referred patient from other health facilities.
• According to the MTA 1964, mental patients were classified into
civil and criminal patients;
 Civil patients; These are patients admitted on the mental hospital
under civil orders.
 Criminal patients; These are patients who have cases with the
law.

Admission procedure for civil patients
• Urgency Order, section 7 of the MTA 1964:
 This is a simple and speedy order signed to get the patient from the
public to the mental hospital.
 It can be signed by any of the following people; qualified medical
personnel, a qualified police officer not below the rank of Assistant
Superintendent of police, gazette chief like sub county chief or
Chairman LC V.
 The order remains in force for 10 days and if the patient doesn’t
improve on expiry of those days, it can be renewed for more 10 days
and thereafter its not renewed and the patient has a right to sue the
hospital for illegal detention.

• Temporary Detention Order, Section 3 of the MTA 1964:
 This is a standard procedure for detaining a patient in a mental hospital.
 Before its signed, there is need to have enough information of lunacy from
any of the close relatives or friends.
 The person providing information of lunacy gives his or her full name,
relationship with the client and must also swear before the magistrate.
 The magistrate asks simple questions about the mental state of the client
before he signs the order.
 It remains in force for 14 days and if the patient doesn’t improve, its renewed
for more another 14 days, thereafter its not renewed but another order
(reception) is signed.

• Reception Order, Section 5 of the MTA 1964:
 This order is signed by the magistrate. However, before its signed, the
magistrate appoints two medical personnel who are not known to each
other nor related to the patient to dig out the background information
concerning this patient’s illness.
 They submit two separate findings which are then carefully examined
by the magistrate. When he is satisfied that the person is sick, he signs
the order.
 This order remains in force for 1 year. If the patient doesn’t improve in
that one year, its renewed for another one year and thereafter its
renewed every after 3 years.

• Voluntary detention Order (Not under MTA 1964)
 This order is not stipulated in the MTA 1964.
 Here a client is escorted to the hospital voluntarily by the
attendant and presented to the clinician who assess
him/her.
 When found sick, the patient is admitted after promising
to abide by hospital rules and regulations.
 Whenever the client wants to leave, he/she notifies the
hospital in three days time.

Discharge of civil patients
• Discharge of recovering pts, Section 8 of the MTA 1964:
 Civil patients admitted on urgency order and voluntary basis, the
ward doctor recommends his/her mental and physical fitness to
the medical superintendent who in turn writes to the director of
medical services who authorizes the discharge of the patient.
 In case of those admitted on Temporary detention order and
Reception order, the medical superintendent writes to the
magistrate who in turn replies him to discharge the patient on
treatment.

• Discharge under the care of relatives, Section 19 of the MTA
1964:
 If the relatives so wish to take the patient, they will make a
statement that they are going to take care of their patient at home.
 No drugs are usually provided.
 If the patient proves unmanageable at home, he cannot be
readmitted if 28 days expire from the time he was taken home.
 If he is to be readmitted, anew order is signed.

• Discharge of paying patients, section 20 MTA 1964:
 If the relatives feel they cannot meet the hospital
expenses, they request the medical superintendent to
discharge the patient.
 If the patient is not well enough and the relatives insist to
take him home, he shall be discharged on condition that
the hospital will not be liable of anything that happens
there after.
No drugs are given unless they pay for them.

• Discharge on Trial Leave, section 21 MTA 1964:
 After the nurses’ observation, the ward doctor
communicates to the medical superintendent who will
inform the director of medical services who in turn
authorizes him to discharge the patient on treatment.
 The patient should come back within a given period of
time for review. If he comes back after a period of 28
days, he shouldn’t be readmitted unless he comes on
fresh order. This client is considered as an escapee.

• Discharge of escapee patients, section 22 MTA 1964:
 If a patient escapes and doesn’t return after 28 days from
the day of escape, he should not be admitted unless he
comes on fresh order.
 It authorizes the hospital to discharge the patient in
absence on the day after escaping.
 This section caters for the safety of the hospital and ward
staff.

• Discharge of a person with a sound mind, section 23 MTA:
 This provide for a person with a sound mind who might have
been detained against his will.
 The magistrate examines the patient and if found sound he
directs the medical officer to discharge him thereafter.

Admission procedure for criminal
patients
• According to MTA 1964, criminal patients are admitted
under the penal code and criminal procedure act.
• The chapter categorizes criminal patients into four
classes;
 Remand patients.
 Class A patients.
 Class B patients.
 Class C patients.

patients
 Remand patients, Chapter 106 penal code act MTA 1964:
 These are accused persons charged with an offence but are
suspected to be of unsound mind while under going court proceedings.
 They are admitted to a mental hospital for observation, investigations
and medical reports as requested by the magistrate.
 They are admitted on warrant of commitment on remand signed by a
judge or magistrate for a fixed or open date of appearing in court.
 Open date: Here the next date of appearing in court is not indicated.
The patient is collected any time to appear in court.

patients
• Fixed date: Here the date is indicated. The patient is
accompanied with a medical form stating whether he is
capable of leading in court. If capable, he is sentenced
straight away and if not, he is brought back to the hospital
as a Class B patient.

patients
• Class B patients:
 These are clients admitted from court having been incapable
of making their own defense due to reasons of insanity.
 They are unable to follow court proceedings and evidence
presented in court cannot understand the nature of the
charge.
 These clients are brought to the hospital for treatment on
warrant of detention of the accused person incapable of
making his/her own defense signed by a judge or magistrate.

Class B patients:
 When the patient is capable of pleading, the medical
doctor writes a certificate of fitness to plead and takes to
the Director of Public Prosecutor who arranges with the
court for the hearing of the accused.
 After pleading, the accused is either found guilty and
taken to prison to serve the sentence or if not found guilty
for reasons of insanity, he is brought back to the hospital
as a class C patient.

patients
• Class C patients:
 These are criminal lunatics who have attended court several
times and are found not guilty for reasons of insanity.
 These patients remain on remand and treatment on minister
of justice’s orders signed by the judge or magistrate.
 If such a patient recovers, he is either sent back to prison or
discharged home directly on minister’s order.

patients
• Class A patients:
 These are prisoners who develop mental illness while
serving their sentence in prison. They are transferred to
mental hospital on appropriate orders.
 Temporary Detention order or reception order to confirm
that he/she is mentally sick, warrant of commitment on
sentence or imprisonment warrant slip indicating the date
when the sentence expires.

patients
If the patient improves before expiry of the sentence, he is
taken back to the prison to complete his sentence. If the
sentence expires when the client is still ill, he is cancelled
from the criminal register and transferred to the top
hospital as a civil patient.

PATIENTS’ RIGHTS
• Right to treatment: requires that medical and psychiatric care and
treatment be provided to everyone admitted to public hospital
• Right to refuse treatment: right to withhold or withdraw consent for
treatment at any time
 Issue of right to refuse psychotropic drugs has been debated in courts
with no clear direction yet forthcoming
• Right to informed consent: based on right to self-determination
 Informed consent must be obtained by physician or other health care
professional to perform treatment or procedure
 Presence of psychosis does not preclude this right

Rights Regarding issue of Legal Competence
• All patients must be considered legally competent until they
have been declared incompetent through legal proceeding
Determination made by courts
If found incompetent, court-appointed legal guardian, who is then
responsible for giving or refusing consent
• Implied consent
Many procedures nurse performs has element of implied consent
(e.g., giving medications)
Some institutions require informed consent for every medication
given

Rights Regarding Restraint and Seclusion
• Doctrine of least restrictive means of restraint for shortest time
always the rule
• Legislation provides strict guidelines for use
 When behavior is physically harmful to patient/others
 When least restrictive measures are insufficient
 When decrease in sensory overstimulation (seclusion only is needed)
 When patient anticipates that controlled environment would be helpful and
requests seclusion
• Recent legislative changes have further restricted use of these
means and some facilities have instituted “restraint free” policies

Rights Regarding Confidentiality
• Ethical considerations
 Confidentiality is right of all patients
• Legal considerations
 Health information may not be released without patient’s consent, except to
those people for whom it is necessary in order to implement the treatment plan
• Exceptions
 Duty to Warn and Protect Third Parties
 Most states have similar laws regarding duty to warn third parties of potential life
threats
 Staff nurse reports threats by patient to the treatment team

STANDARDS OF CARE
 Child and Elder Abuse Reporting Statutes
• All states have enacted child abuse reporting statutes
Many states specifically require nurses to report suspected
abuse
• Numerous states have also enacted elder abuse reporting
statutes

STANDARDS OF CARE
 Protection of self and patients:
• Legal issues common in psychiatric nursing are related to
failure to protect safety of self and patients
• Protection of self
Nurses must protect themselves in both institutional and
community settings
Important for nurses to participate in setting policies that create
safe environment

STANDARDS OF CARE
Negligence/Malpractice
• Negligence or malpractice is an act or an omission to act that breaches the duty of due care and results in or is
responsible for a person’s injuries
• Elements necessary to prove negligence
 Duty
 Breach of duty
 Cause in fact
 Proximate cause
• Damages Cause in fact
 Evaluated by asking “except for what the nurse did, would this injury have occurred?”
• Proximate cause or legal cause
 Evaluated by determining whether there were any intervening actions or individuals that were in fact the causes
of harm to patient
• Damages
 Include actual damages as well as pain and suffering
• Foreseeability of harm
 Evaluates likelihood of outcome under circumstances

Determination of Standard of Care
Hospital policies and procedures set up i.e; institutional criteria
for care
NOTE; Substandard institutional policies do not absolve nurse of
responsibility to practice on basis of professional standards of
care

FORENSIC PSYCHIATRY.pptx

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