The document details the use of the Mental Capacity Act (MCA) in admitting patients with complex needs, highlighting the importance of thorough documentation and teamwork in such cases. It illustrates the challenges in managing patients with substance abuse issues and fluctuating mental capacity through the case of a 44-year-old man with numerous health and behavioral problems. The text provides practical considerations for healthcare practitioners to facilitate successful admissions under the MCA.

1. Using the Capacity
Act
Maxine Radcliffe
Great Chapel Street Medical
Centre m.radcliffe@nhs.net

2. Housing
officers
Benefits
advice
Drug and
Alcohol
Services
Day centre
teams:
Passage,
WLDC
CSTM
Social
Services,
Specialist
Midwives
Voluntary
sector Night
Shelters:
SFTS
Churches
Other
Specialist
hospital
services
Other
Primary
care
outside
our clinic
Outreach
teams:
CSTM, St
Mungos,
Compass
JHT
A+E
teams/LA
S crews
Outreach
Nurse/
Case
Manager
My role at Great Chapel Street

3. Nicholson. T , Cutter. W Hotopf. M (2008)
BMJ Capacity Assessment Flowchart 1

4. Nicholson. T , Cutter. W Hotopf. M (2008)
BMJ Capacity Assessment Flowchart 2

5. Why this is important for nurses: My experience
 I’ve personally successfully admitted 3 patients from outreach
using the capacity act in the last 18 months.
 In all three cases the individuals were in ICU/HDU for at least
2 weeks initially and had extended hospital stays.
 In each case LAS had already attended multiple times and
there had been a lengthy ongoing process of concerns being
raised.
 In each case I wrote a lengthy letter outlining concerns. I
divided them into physical health, mental health social clear
bullet point lists.
 I also explicitly clarified why I felt they did not have capacity.
Eg Mr PC in my opinion is unable currently to weight this
decision as when we discussed x he said y..

6. Practical considerations when
admitting under MCA
 Admitting someone under the capacity act is a logistical challenge.
It requires Ambulance support and (usually) Police. This is not always
available concurrently and is often why attempts fail
 Liaise with services ahead of time: Police/Ambulance/Admitting
hospital/ Outreach. Things will run more smoothly.
 Accept that you may need to make several attempts. Even if you are
sure that the person doesn’t have capacity to make decisions around
their health on an ongoing basis
 Have as much supporting documentation ready as you can. Do a
letter outlining issues and any assessment. It may be an idea to leave a
copy of this with the person if they will accept it, if you are unable to
admit them. They may be picked up by another team.
 Discuss with your team. A common theme with these patients is that
they split teams, with different practitioners having different
perspectives. Get feedback, but if you are the primary caregiver trust
your judgement.

7. Case 1: The Behavioural Medical
Nightmare
 Mr PC 44yr old Irish man
 Hostel housing
 Substance misuse (Crack,
Heroin)
 Alcohol misuse
 Oedema (nephrotic syndrome)
 Amyloidosis
 Osteomyelitis
 Difficult personality

8. Case 1: Mr PC
 Presented to us September 2012. Previously known
in 2006
 On methadone
 IVDU incl large veins, crack, benzos
 Alcohol dependence
 History of drug-induced psychosis
 DVT, anaemia, peripheral oedema
 Loud, demanding, rude, abusive. Banned from local
chemists.
 Multiple A&E attendances

9. Case 1: Mr PC
 Challenges
Addressing physical health concerns
 Concordance with medications
 Leg ulceration and worsening oedema
 Concerns over mental state / capacity / memory
 Needed Admission but was more focused on
getting next giro.
 Conflicts of agendas between healthcare
practitioners and patient

10. Fluctuating Capacity
 Capacity varies – can be more or less
intoxicated etc.
 Important to remember that unwise decisions
do not equal No Capacity

11. References
 Nicholson. T , Cutter. W Hotopf. M (2008) Assessing mental
capacity: the Mental Capacity Act BMJ. 336(7639): 322–325