Practice dilemma: An urgent request for a mental capacity assessment

A high-risk alcoholic patient continues to drink and smoke at home after starting a house fire. How would you ascertain whether she is a risk to herself and neighbouring residents?

The dilemma

In the middle of surgery, while you are on call, a receptionist informs you that an urgent task has been requested by social services, regarding a patient. Mrs Jones, recently discharged from hospital following a house fire caused by her smoking while intoxicated, is continuing to drink and smoke at home despite medical advice not to do so. Social services requires a GP to undertake an urgent mental capacity assessment, to determine whether she can remain at home.

This case has already been discussed during the morning's 'high risk patient' meeting. Mrs Jones is a 67-year-old known alcoholic and was rescued from the house fire two weeks ago, the fire service having been alerted to the incident by a passing schoolboy. Mrs Jones had been transported to hospital with severe smoke-related injuries and transferred to intensive care, where she was put on a ventilator.

Although she had sustained severe inhalation burns, she made a full recovery. While on the ward, Mrs Jones was not found to be delirious or have any cognitive impairment. She was advised not to smoke in the house, and deemed to have mental capacity prior to being discharged back to her fire-damaged home. She assured hospital staff she would smoke only in the back garden in future.

Mrs Jones was allocated a social worker while in hospital and, three hours after her discharge, he was informed by the patient's son that she had consumed a litre bottle of vodka at home and started smoking inside. Social services felt Mrs Jones was a risk to herself and her neighbours and requested an urgent GP visit to reassess her mental capacity and risk of harm to herself and others.

A GP's response

Dr Raj Thakkar is a GP in Wooburn Green, Buckinghamshire

This case highlights several important issues: the prioritisation of duty doctor tasks and how the practice manages problems perceived to be urgent; liaising and communicating with other healthprofessionals and agencies and understanding their agendas; knowledge of relevant legislation; plus understanding of competency and duty of care and who owns that duty.

While prioritisation by the duty doctor is important, as are robust systems within the practice, they are not the essence of the case. Nevertheless, they may play a part, depending on how busy the duty doctor is.

It is reasonable to assume Mrs Jones is vulnerable. She has already been deemed high risk by social services, and presumably requires attention under safeguarding legislation. While her son may have an agenda, given Mrs Jones' history, the risks have to be considered genuine and significant.

It is no surprise that she was considered to have capacity while in hospital as she was not intoxicated. More information regarding the circumstances of the hospital assessment, and who carried it out, would be essential background information.

If the social worker feels Mrs Jones is in immediate danger and cannot persuade her to be moved temporarily to a place of safety, you may advise him to call the police or ensure family stay with her. An assessment is required to understand the circumstances surrounding her drinking.

Mrs Jones' alcoholism, and its underlying drivers, need active management, particularly since the highrisk period appears to correlate to her drinking. She may, of course, refuse help. It is important to consider whether it is appropriate to make a lone assessment of risk, or whether that is the correct question; history dictates she is at high risk as long as she continues to drink.

This is not necessarily a question of Mrs Jones' capacity; after all, when not under the influence of alcohol, it is likely that she has situational capacity. Given the legal minefield and potential consequences, a joint assessment with a social worker and psychiatrist could be conducted, with shared responsibility, involving multiple agencies.

This case requires careful handling and the underlying alcoholism must be addressed.

A medico-legal opinion

Dr Zaid Al-Najjar is medico-legal adviser at the Medical Protection Society

As Mrs Jones was found to have capacity prior to discharge, you may initially consider a visit to be unnecessary. However, capacity can fluctuate and it may be worth talking to social services to determine why they feel the patient's circumstances might have changed.

In any case, it would appear that there is a clear risk to the patient and the public, as identified by social services, and you may feel obliged to visit and assess her, knowing this.

In Consent guidance: patients and doctors making decisions together, the GMC states that: 'You must assess a patient's capacity to make a particular decision at the time it needs to be made. You must not assume that because a patient lacks capacity to make a decision on a particular occasion, they lack capacity to make any decisions at all, or will not be able to make similar decisions in the future.'

Therefore, your assessment of the patient's capacity should focus on whether they are able to understand the information you provide, make decisions based on that information and relay it back to you.

Consider the risk the patient poses to herself and others because of her smoking and drinking, against a background of her already having sustained serious smoke-related injuries.

You may wish to seek specialist advice from mental health or addiction services if you feel Mrs Jones' drinking poses a serious risk to herself and others, such as her neighbours, or discuss your concerns with social services and obtain further advice about how to reduce the risk.

Finally, you should record the outcome of your assessment and the reasons for your decision in the patient's medical record.

A patient's view

Danny Daniels is an expert patient

First, Mrs Jones should be visited by the GP for an assessment of her mental capacity, so that he or she can decide on the best strategy to follow. It would be ideal if Mrs Jones were willing to undergo a programme of treatment which could result in behaviour change. Her health and wellbeing, and the safety of her neighbours, are of paramount importance. Unfortunately, the patient does not appear to recognise her responsibilities to herself or to other residents.

It would not be possible to make a judgement about the patient's mental health if she were still intoxicated or mentally impaired by alcohol misuse. If she were cognizant, it would be beneficial for an approved clinician or responsible clinician, as prescribed under the Mental Health Act 1983 Approved Clinician (General) Directions 2008, to undertake an assessment of her capacity.

If the attending GP (or approved clinician/responsible clinician) deemed, after testing, that she had capacity, then a different approach would be required. Under the Mental Health Act 1983, amended in 2007, a person can be detained for assessment under section 2, only if the following criteria apply:

  • The person is suffering from a mental disorder of a nature or degree that warrants their detention in hospital for assessment (or for assessment followed by treatment) for at least a limited period.
  • The person ought to be so detained in the interests of their own health or safety or with a view to the protection of others.

The patient must have a disorder or disability of the mind. Alcohol or drug addiction is, on its own, an insufficient reason for detaining a person under the Mental Health Act 1983.

Therefore, where the GP, following an assessment of the patient's mental capacity, felt that only the second part of the criteria applies, he or she could not action detention for Mrs Jones and subsequent treatment for her addiction, and alternative actions would need to be undertaken.

In the presented scenario we are not told the outcome of the 'high-risk patients' meeting, but an urgent meeting with social services may now be required.

Due to the dangers posed by Mrs Jones' behaviour, to herself and other people, it might be advisable to include representatives from the police force and the fire service.

Hopefully a solution could be found to mitigate risk. Mrs Jones' ongoing health and wellbeing also need to be addressed.

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