DOLS

  • MM & PJ in the Supreme Court [2018]

    Keywords: Mental Health Act, Conditional Discharge, CTOs, Deprivation of Liberty

    These cases both address aspects of the interaction between the Mental Health Act 1983 (MHA) and Article 5 of the European Convention on Human Rights (ECHR) via the Human Rights Act 1998.

    Secretary of State for Justice v MM [2018]

    A restricted patient cannot be discharged by either a Mental Health Tribunal or the Secretary of State for Justice on the basis of conditions which amount to a deprivation of liberty.

    This case concerned MM, a 35-year-old man with diagnoses of autistic spectrum disorder, mild learning disabilities and pathological fire setting. Following a conviction for a serious offence of arson in 2001, he had been made the subject of a hospital order and a restriction order (under s.37 & 41 MHA). He was considered to pose significant ongoing risks of fire setting and sexually inappropriate behaviour. He had applied for conditional discharge. It was envisaged that any suitable plan for his discharge would involve requiring him to live at a particular place, which he would not be free to leave (in the sense of moving to a different address), and that he would not be allowed out without an escort. This level of restriction, supervision and monitoring would amount to a deprivation of liberty within the meaning of article 5 of the ECHR. It was agreed that the patient had capacity to consent to being deprived of his liberty and he was willing to consent to restrictive conditions in order to be able to leave hospital.

    Under the MHA, a patient with a restriction order can only be discharged either: with the approval of the Secretary of State for Justice (s.42(2) & (3) MHA 1983) or by the First Tier Tribunal (Mental Health) (s.73(1) & (2) MHA 1983). In both cases a patient can be discharged absolutely (which would mean a complete end to all restrictions) or conditionally. The MHA does not specify the kinds of condition which can be imposed and provides no sanctions for their breach, other than the possibility of recall to hospital[1]. However, the purpose of conditional discharge is to provide a step in a patient’s progression from the more institutional setting of a hospital to a less institutional setting in the community. Transition through progressively less secure hospital conditions before discharge into the community is common and conditional discharge forms part of that process.

    So, the issue was whether conditions imposed via conditional discharge by a tribunal under the MHA could provide a lawful basis for the patient to be deprived of their liberty where the patient was willing to consent and had capacity to do so.

    It was argued that the fundamental purpose of the MHA is to rehabilitate patients and that this purpose would be frustrated if it were not possible for patients to step down to lower levels of supervision in the community and the result would be patients remaining in hospital for longer. Lady Hale, giving the majority judgement, recognised the practical logic of this argument. However, she took the view that it did not necessarily follow that the MHA actually provided sufficient legal basis for such a power.

    It was argued that there was nothing in either the MHA or Article 5 which actually prevented the imposition of such a condition. The main textual argument in favour of a power to impose such a condition was that a conditionally discharged patient remains “liable to be detained” within the meaning of the MHA. However, Lady Hale’s analysis identified the lack of any general principle of “least restrictive alternative” within Article 5 or related case law. She also concluded that the court could not ‘read into’ the MHA a power to impose deprivation of liberty via conditional discharge because of the principle of legality i.e. that only explicit provisions in Acts of Parliament could render lawful substantial inference with fundamental rights. Additionally, Lady Hale’s analysis of powers of detention contained in the MHA identified that, both for patients detained in hospital and those detained (temporarily) in a place of safety, the Act provided explicit powers to convey, detain and retake the patient. Therefore, if the MHA had intended to create a power for a patient to be detained as a condition of discharge, it was inconceivable that the Act would not have provided similar explicit powers relating to that form of detention. Similarly, she reasoned, the less frequent rights to apply to tribunal provided for conditionally discharged patients, as compared to ‘detained’ patients in hospital, indicated that it was not thought that such patients required the same level of protection as those deprived of their liberty and, therefore, could not have been intended to be subject to the same level of interference with their fundamental rights.

    Whilst consent from a patient with capacity, did generally provide a valid legal basis for depriving a person of their liberty, it was clear from ECtHR cases[2] on Article 5, that (a) consent can be withdrawn at any time; and (b) consent given in circumstances where the choice was between greater and lesser forms of deprivation of liberty may not be valid consent at all. The consequence of (a) was that the patient could withdraw his consent to the deprivation at any time and demand to be released and was not bound by any contract (or anything else) not to do so. Therefore, consent could not be a valid basis for ongoing deprivation of liberty under a conditional discharge. There would need to be a power to impose the deprivation on the patient regardless of consent.

    It was also argued that, if it were not possible for a capacitated patient to be conditionally discharged on the basis of their consent to deprivation of liberty, this would constitute unjustified discrimination on the basis that an incapacitated patient’s deprivation of liberty could potentially be authorised by the Court of Protection, enabling conditional discharge in their case. Lady Hale declined to engage in speculation as to whether conditional discharge of an incapacited patient in such circumstances would be possible, concluding that the issue would make no difference to the outcome of the current case[3].

    In Lady Hale’s words:

    “The outcome of this case depends upon whether it is possible to read the words “discharge … subject to conditions” in section 42(2) (dealing with the Secretary of State’s powers) and “conditional discharge” in section 73(2) (dealing with the FtT’s powers) as including the power to impose conditions which amount to a deprivation of liberty within the meaning of article 5.” [para. 27].

    Giving the majority judgement, she concluded that it is not. Therefore, at least until parliament amends or reforms the Mental Health Act, it is not possible for either the FtT or the Secretary of State for Justice to conditionally discharge a patient who has capacity to consent imposing conditions which amount to an objective deprivation of liberty (i.e. continuous supervision and control and not free to leave).

    Lord Hughes, in the sole dissenting opinion, argued that authority for the deprivation of liberty was to be found in the original combination of orders imposed by a court. In his view the situation was manifestly different to that of a free citizen being deprived of their liberty and, therefore, the arguments of legality and the practical construction of the MHA did not outweigh the practical necessity of such a power to the purpose of conditional discharge.

    Full judgement at: https://www.supremecourt.uk/cases/docs/uksc-2017-0212-judgment.pdf

    Welsh Ministers v PJ [2018]

    A Community Treatment Order (CTO) cannot impose conditions which amount to a deprivation of liberty.

    It is important to note that, despite the case name, this judgement applies to England as well as Wales because the same legislation governs CTOs in both jurisdictions (i.e. the MHA).

    This case concerned PJ, a 47-year-old man with mild to borderline learning disability and autistic spectrum disorder who had a history of violent and sexual offending. Following convictions for assault and threatening behaviour in 1999, he received a Hospital Order (although not a restriction order) from which he was discharged (although he remained in hospital as a voluntary patient). He had been redetained under s.3 MHA in 2009 and subsequently discharged to a care home on a Community Treatment Order (CTO) in 2011.

    At a tribunal hearing in May 2014, the case put on behalf of PJ was that the arrangements under the CTO amounted to an unlawful deprivation of liberty and he should therefore be discharged from it. The resulting series of appeals culminated in the Court of Appeal ruling that it was lawful for a Responsible Clinician (RC) to impose conditions in a CTO which had the effect of depriving a person of their liberty, provided this was a lower level of restriction than that to which they had been subject in hospital.

    As many have pointed out since the Court of Appeal ruling, and as Lady Hale set out in this judgement, the current edition of the Mental Health Act Code of Practice (drawn up under s.118 MHA and revised in 2015) states quite clearly that “The conditions [included in a CTO] must not deprive the patient of their liberty” (para 29.31).

    It was argued at this hearing, on behalf of the Welsh Ministers, that, because the conditions in a CTO cannot be enforced[4], they cannot amount to a deprivation of liberty and it is therefore permissible to impose them[5]. In other words, because a CTO does not provide any powers: to detain the person; to impose medical treatment (widely defined) without consent; to impose sanctions for failing to comply with the care plan, other than the limited power of recall; or to recapture an absconder; it is therefore lawful to impose these conditions, because they do not amount to a deprivation of liberty.

    Lady Hale, giving the sole judgement of the Supreme Court, rejected this argument. Whilst she accepted the limitations of the statutory powers contained in a CTO, in her view it did not follow that a person was not in fact deprived of their liberty as a result of the conditions to which they were subject. Determining deprivation of liberty required looking at the concrete situation of the person concerned. In this case, despite occasional short periods unsupervised, the overall circumstances of PJ’s care amounted to continuous supervision and control and he was not free to leave. Therefore, he was deprived of his liberty by the conditions in his CTO. The question was whether the Responsible Clinician (RC) had the power, under the MHA, to impose conditions which had that effect.

    It was common ground that s.17B(2) of the MHA contains no explicit power to impose conditions in a CTO which have the effect of depriving a community patient of his liberty. The Court of Appeal had nevertheless held that such a power was a necessary implication from the purpose of a CTO which was the gradual integration of the patient into the community. Therefore, they had reasoned, a CTO must be able to provide for a lesser restriction than detention in hospital, even if those restrictions amounted to an objective deprivation of liberty. Lady Hale took the view that this was putting the “cart before the horse” [para. 24]. Again drawing on the principle of legality, she considered that the Court of Appeal had erred in ‘reading in’, from the purpose of a CTO, a power to interfere with a fundamental right, without an explicit statement of such a power in the MHA itself. She concluded: “The very general words in section 17B(2) cannot authorise the RC to impose conditions which deprive a patient of the fundamental right to liberty.” [para. 24]

    Lady Hale also considered whether such a power was actually a ‘necessary implication’ of the purpose of CTOs. She considered that ‘integration of the patient into the community’ was not necessarily or invariably the purpose of a CTO. Making further reference to the Code of Practice, she identified additional and alternative purposes including: providing a way to help prevent relapse and any resulting harm to the patient or to others; helping patients to maintain stable mental health outside hospital; and promoting recovery. As in the case of MM above, Lady Hale drew on comparison between the MHA sections providing for CTOs with the specific and detailed nature of other MHA provisions which explicitly intended to provide for deprivation of liberty (such as those providing for detention and treatment in hospital).

    For these reasons, it was held that there is no power to impose conditions in a CTO which have the effect of depriving a patient of his liberty.

    Having concluded that CTOs cannot be used to deprive a person of their liberty, a subsidiary question arose as to the powers of the tribunal if it were to find, in a given case, that a community patient was being deprived of their liberty. However, Lady Hale considered the issue was more theoretical than real since, now that RC’s would know that a CTO could not be used to deprive a person of their liberty, they would not impose conditions which would do so. In the event such a situation did arise, the remedy would be either habeas corpus or judicial review.

    Full judgement at:https://www.supremecourt.uk/cases/docs/uksc-2018-0037-judgment.pdf

     

    [1] A patient can only be recalled, however, if the statutory grounds for detention are met (that he is suffering from mental disorder or from mental disorder of a nature or degree which makes it appropriate for him to be liable to be detained in a hospital for medical treatment; or that it is necessary for the health or safety of the patient or for the protection of other persons that he should continue to receive such treatment; or that appropriate medical treatment is available for him) and not simply because of breach of a condition.

    [2] Storck in relation to (a); Buzadji v Moldova[2016] in relation to (b).

    [3] The implication is that any resulting discrimination would lead to a declaration of incompatibility under the Human Rights Act in relation to primary legislation: a situation which could be remedied only by parliament amending legislation and not by a court ‘reading into’ primary legislation because of parliamentary sovereignty.

    [4] In the sense that, although compliance or otherwise with the conditions would inform decision making about whether to recall the patient to hospital, failure to comply is not by itself sufficient for recall, nor does it enable the imposition of any sanction.

    [5] An argument that, if it had been successful, would also have applied to Conditional Discharge.

  • DOLS reform: Interim update, interim position

    Today the Law Commission has published an interim statement on their current thinking on reform of the Deprivation of Liberty Safeguards. Anyone who has followed the saga so far will be aware that the initial proposals put forward for consultation by the Law Commission received a decidedly luke-warm reception from the government. Mostly the government's position seemed to be that the proposals were too expensive. Oh and they didn't seem too keen on the idea that protection of an individual's fundamental human rights and freedoms should involve anything remotely resembling law either!

    The response put the Law Commission in a tricky position. How far to go in fighting for a strong legal basis as the only defence of the vulnerable? How far could projected costs be cut whilst still retaining anything approaching adequate safeguards?

    Today we got some hints as to the way the wind is blowing.

    Substantially simplified and somewhat watered down proposals.

    The Commission is teetering on the fence as to whether to stick with its original tribunal proposals or retain the jurisdiction of the Court of Protection. Having experienced how quickly the fairness and adequacy of tribunals can be undermined by being severely underfunded I am hoping like mad they will ultimately plump for the latter.

    Out has gone the multi-level/multi-environment proposal in favour of a slimmed down scheme focussed narrowly on deprivation of liberty (article 5) and the attempt to introduce serious protection for rights to family life (article 8) has been scrapped.

    The most worrying changes are:

    • that the proposed role of Approved Mental Capacity Professionals (beefed-up Best Interests Asssessors) has been scaled back
    • responsibility for "making the case" shifts to the commissioning body (from the care provider)

    These changes reduce independent scrutiny whilst increasing the responsibility on those commissioning the care to protect the rights of those receiving it. In a world of austerity-led commissioning and care planning where knowledge and understanding of the law is not deeply embedded and 'human rights' has been turned into a dirty term in public discourse, I have reservations that this will be enough. Those who know their case law will be all too aware that, historically, it hasn't been.

    The Commission has held fast though to its insistence on legally enforceable rights to advocacy. This is a potentially encouraging safeguard, but it remains to be seen whether it will survive the ultimate taking forward of the final proposals by a government with strong cost cutting motivations and little respect for (or understanding) of the relevance of law. Even if it does, the usefulness will depend on well trained, knowledgeable independent advocates. And in an advocacy market driven by short-term contracts and driving down of prices, it will be difficult to maintain and grow the needed workforce.

    Even if proposals similar to those outlined today were implemented, the onus would be on friends, family and advocates to know their legal rights and act to enforce them. With such poor knowledge and understanding of human rights and the Mental Capacity Act amongst those working in social care, advocates and the public at large, it seems frustratingly inevitable that little improvement will ensue.

    It is hard to blame the Law Commission. They are trying to walk a precarious tight rope in a highly adverse climate. They need to focus on what is realistically achievable and hope for the best. We have yet to see the final proposals and I am sure they will do their best to make them as legally robust and sound as they think they can get away with. I am much more dubious, however, about the odds that a system with any legal teeth will ultimately be passed into legislation in the current political climate.