Psychiatric hospital had no legal authority when it prevented patient leaving

A Dublin psychiatric hospital had no legal basis for preventing a voluntary patient from leaving a locked secure unit when he tried to go, the Court of Appeal has ruled.

In a significant decision concerning the rights of voluntary patients under the Mental Health Act 2001, the three judge court granted the man’s appeal against the High Court’s rejection of his case.

The proceedings were against the hospital and a consultant psychiatrist with the Attorney General as a notice party and the Irish Human Rights and Equality Commission an amicus curiae, assistant to the court on legal issues.

The core issues concerned whether the man was a “voluntary patient” as defined in the 2001 Act and whether there was a legal basis for preventing him leaving the hospital on November 21st 2011.

Voluntarism "remains a cornerstone of our system of medical treatment" and, while there are exceptions to that provided by statute, the legislative quid pro quo is that compulsory medical treatment and detention must have appropriate safeguards, Mr Justice Gerard Hogan stressed.

If the High Court ruling stood, its net effect meant voluntary patients may, in some circumstances, be prevented leaving an approved centre otherwise than in accordance with Section 23 of the 2001 Act and thereby left in "a form of detention without the safeguards carefully provided for detained patients".

In a judgment with which Court of Appeal president Mr Justice Sean Ryan and Ms Justice Mary Irvine agreed, he said there was "no doubt" that actions of hospital staff and the man's treating psychiatrist on November 21st 2011, when the man was restrained from leaving, were entirely motivated by "best considerations" and an understandable desire to ensure a "vulnerable and ill patient" received the best and most appropriate treatment.

He agreed with the High Court that, in many respects, the man’s best overall interests were “quite probably best served by remaining within the secure care unit”.

However, the issue is whether the man was legally detained, he said.

Having found the man was a voluntary patient on November 21st 2011, he was free in law to leave the secure unit that day, he said. The fact that, when he tried to leave, he was physically restrained from doing so was an interference with his personal liberty with no legal basis.

The case concerned provisions of the Mental Health Act 2001, particularly Section 23, setting out what must be done when a person detained on a voluntary basis indicates they want to leave. It provides, if the consultant psychiatrist responsible for a patient’s care is of the “opinion” the patient is suffering from a mental disorder, they may detain them for a maximum 24 hours.

Section 24 provides, where a person is detained under Section 23, their treating psychiatrist should either discharge them or arrange for them to be examined by a second consultant psychiatrist. If the second psychiatrist is “satisfied” the person has a mental disorder, they should certify detention but, if not so satisfied, they should certify discharge.

The man first became a voluntary patient at the hospital in late August 2011 after a psychotic episode at home. His psychiatrist considered effective management of his psychosis required he stay in a safe stable environment and also ordered a forensic assessment from another psychiatrist which was not done until November 21st 2011.

His solicitor, who said the man had told her he had asked to leave the secure unit a number of times but was refused permission to do so, secured leave on November 21st 2011 for judicial review. She was informed later that day the man had sought to leave and became violent and was restrained and sedated.

Mr Justice Hogan said a voluntary patient who expresses a desire to leave a secure unit remains free in principle to do so at any convenient time and may not be restrained except in accordance with the detention power under Section 23. While a hospital may lawfully try and persuade a patient to stay, this must involve “persuasion” and not restraint, he added.