I’m not sure what training NSW paramedics are getting on the Mental Health Act 2007 (NSW) but it does seem to be at odds with what the Act says. Today’s question asks
… in regards to writing a section for a patient in circumstances where a doctor is escorting the patient during a transfer with the treating paramedic. In the event that a section is required because a patient needs to be sedated and/or restrained whilst in transport which clinician should be writing the section? I am unable to find any documentation on this and would assume that the higher clinical level would be the responsible clinician in that case, however it is most likely that any medications being administered are the responsibility of the paramedic.
As I’ve noted in earlier posts, the Mental Health Act 2007 (NSW) s 20 says:
An ambulance officer who provides ambulance services in relation to a person may take the person to a declared mental health facility if the officer believes on reasonable grounds that the person appears to be mentally ill or mentally disturbed and that it would be beneficial to the person’s welfare to be dealt with in accordance with this Act.
Why is that important? Because s 81 says:
(2) A person authorised by this Act to take a person to or from a mental health facility or other health facility may:
(a) use reasonable force in exercising functions under this section or any other provision of this Act applying this section, and
(b) restrain the person in any way that is reasonably necessary in the circumstances.
(3) A person may be sedated, by a person authorised by law to administer the sedative, for the purpose of being taken to or from a mental health facility or other health facility under this Act if it is necessary to do so to enable the person to be taken safely to or from the facility.
The implication of both s 81 and the place of s 20 within that part of the Act dealing with involuntary treatment is that the treatment and transport can be provided even if the patient does not consent to the treatment.
But the idea of ‘writing a section’ rather than recording the observations that caused the paramedic to form the view that treatment was required and that ‘no other care of a less restrictive kind, that is consistent with safe and effective care, is appropriate and reasonably available to the person’ (s 12) is not referred to in the Act.
Section 19 says:
A person may be taken to and detained in a declared mental health facility on the basis of a certificate about the person’s condition issued by a medical practitioner or accredited person. The certificate is to be in the form set out in Part 1 of Schedule 1.
An accredited person is a person accredited by the Secretary of the Ministry of Health for that purpose. Ambulance officers could be accredited but I doubt they are given the presence of s 20. Action under s 19 certainly sounds like a traditional ‘schedule’ that is there is a prescribed a ‘Medical certificate as to examination or observation of person’ to be completed that allows the person to be taken and detained. When completing that certificate the doctor or accredited person must certify that he or she:
(a) has personally examined or observed the person’s condition immediately before or shortly before completing the certificate, and
(b) is of the opinion that the person is a mentally ill person or a mentally disordered person, and
(c) is satisfied that no other appropriate means for dealing with the person is reasonably available, and that involuntary admission and detention are necessary, and
(d) is not a designated carer, the principal care provider or a near relative of the person.
They are also required to note ‘The following medication (if any) has been administered for purposes of psychiatric therapy or sedation…’
The problem is that the question I have been asked:
In the event that a section is required because a patient needs to be sedated and/or restrained whilst in transport which clinician should be writing the section?
Doesn’t make sense. If the paramedics have been called to transport a person who has been examined by a doctor or accredited person and a ‘Medical certificate as to examination or observation of person’ has been completed then it is up to the doctor to identify what medication has been given. If the doctor is travelling with the patient and he or she wishes to prescribe or administer medication then he or she can then do that and would need to record that. If, on the other hand, the paramedics take the view (whether the doctor is there or not) that in compliance with the clinical practice guidelines and the patient’s condition they want to administer sedation then they could do that and record it. Where the doctor is travelling with the patient, then ideally the decisions in the ambulance are made with consultation between the practitioners (paramedic and medical).
But the question of who completes ‘the section’ just doesn’t make sense. If the paramedics have formed no view of the patient’s mental state but are transporting him or her because the doctor has completed the form then of course it’s the doctor who has completed the ‘Schedule’ and is responsible for the evidence in it and the opinions that are relied on to detain the person.
If, on the other hand, assume the patient has attended his or her GP and the GP has formed the view that the patient is mentally ill and has called for an ambulance but has not completed any paperwork, then the ambulance crew when attending may take the view that it ‘appears to be mentally ill or mentally disturbed and that it would be beneficial to the person’s welfare to be dealt with in accordance with this Act’ then the ambulance officers can transport the person to hospital under s 20. In that case the paramedics have to record their observations and treatment as they would with any patient.
Australian Emergency Law 
I don’t think a ‘doctor’ was travelling with Hanibal Lector in THAT movie …..
I have NEVER seen or heard of a ‘doctor’ travelling in the back of an ambulance, for the purpose of a ‘mental health escort’ . Doesn’t happen ( in NSW ).
Doctors don’t have the time, nor do they get that involved in any Mental Health patient.
I’ve done such ‘escorts’ myself, both as an RN from the transferring hospital, and as a Community Nurse escorting a person from home to hospital ( often with a police officer in the back too ).
There isn’t a requirement for the professional who ordered the Schedule, to actually travel directly with the patient.
If the doctor involved was coming in the hospital for some reason, he/she would most certainly be driving their own Merc./BMW in …..
The person who wrote the question says that they are a NSW paramedic and they wanted to know about ‘writing a section for a patient in circumstances where a doctor is escorting the patient during a transfer with the treating paramedic’ so presumably it does happen in their experience. It may well vary depending on what part of NSW a person is working in. It is certainly correct that there is no obligation that a doctor or accredited person who completes a certificate under s 19 is required to travel with the patient.
Another point …
It seems, there are STILL a number of ‘myths’ relating to Mental Health ( in Australia, anyway ) …
Eg. Being ‘mentally ill’ does not mean you MUST be sent to a hospital. Nor does it mean you MUST be ‘managed’ by a Health Professional against your free will.
People living with Mental Illness of any degree, have certain ‘rights’ to self-determination.
Having a ‘diagnosis’ doesn’t mean you are a ‘second class’ citizen, subject to a ‘1984-styled’ political world, where at any time of day or night, you may be ‘taken’ to a facility and held against your will for a time until ‘the Governor’s pleasure be known’ !!
For many, many years now, people living with mental illness have a right to refuse treatment, which can mean “I don’t want to take that medication” ( often because of previous ‘side effects’, weight gain or skin irritation ). They can decline to see a particular Health Professional, including a doctor / psychiatrist, and opt to choose their own doctor.
The main issue that ‘may’ arise, where a particular provision of the Act kicks in, is where the person presents as a ‘greater than average risk’ to the Public, their family, and or themselves.
To highlight this, I give you two very common scenarios. YOU decide who should be taken to hospital AGAINST their will ….
John ( a pseudo. ) with a formal diagnosis of Bipolar Affective Disorder ( occasionally & unfortunately abbreviated to BAD ), has been seen his neighbors to be taking the garbage out at about 3am every week. The lights are usually on all night, with music playing. Police have been called, though they have never taken John away with them. The neighbors also complain, that John dresses ‘strange’, and walks up and down the street rapidly, mumbling to himself.
Has John actually done anything ‘wrong’ ? Does he NEED to be taken to hospital ?
Mary ( a pseudo ) has recently been to a dance party, and was given a few ‘pills’ to try. She thought it was a ‘good idea at the time’ ….
A few hours later, Mary couldn’t be found by her friends. Mary had left the party. Local police began to receive reports of a young woman naked, walking down the centre of a busy road. One motorist stopped to offer her ‘assistance’ with a jacket to wear, but she ran away screaming “they will kill us all”. Police locate Mary. She refused to wear the clothing they offered her.
Does Mary NEED to go to a hospital against her will ?
Thank you for your reply, Michael. It seems I must clarify that the incident that formed the basis of the question posed to you was NOT a ‘mental health transfer’. I can assure you that most of the time our obligations are relatively clear concerning the difference between schedules and sections and who is responsible for them. I agree that there is still misunderstanding and misinformation amongst the workforce that can create instances of uncertainty. However, as with any legislation, the Mental Health Act cannot always foresee every circumstance that may need to be addressed. The transfer being referred to was occurring due to an urgent, MEDICAL problem. Hence the decision by the doctor to remain with their patient for the transfer. The patient began to display disordered behaviour after leaving the hospital that progressively deteriorated en route. The patient refused treatment that had originally been consented to (as is the right of a person with competency and capacity) but then began to pose a risk to both the doctor and the paramedic attempting to provide care and themselves, as at this time a provisional diagnosis had been made of a serious, medical problem that had the potential to lead to significant patient deterioration. The patient DID NOT have any previously diagnosed mental health disorders and no known history of same. The reason for their behavioural change was unknown as they were refusing all observations. This was a highly unusual situation that unfolded during an urgent medical transfer and not one that had ever been encountered before by the treating paramedic or the doctor.
In my experience the illnesses and behaviours of human beings, whilst often falling within common and known parameters, can occasionally present clinicians with extremely difficult dilemmas. This was one such occasion. A great deal of reflection has occurred with regards to this incident and the principle of using the least restrictive options in order to maintain the patient’s autonomy and dignity were followed by both clinicians throughout. This is, understandably, an emotive subject for many and often a source of confusion and frustration. There are clearly problems that can arise for which there is no black and white answer and at that point it seems that individual circumstances become more relevant than a generalised rule.
Gordon, as an RN, your experiences are certainly going to be different to a paramedics in any field. The points you made in regards to a person with a mental health illness are certainly correct. In an ideal world, regardless of the reason for the behavioural disturbance, the least restrictive and most dignified approach for the patient should always be the aim. I am of the belief that de-escalation should form our first, middle and last approach and is potentially under-utilised. Unfortunately, as we know, a person, for whatever reason, may become so disturbed as to pose a genuine and immediate risk to themselves or others. This particular situation unfolded in real time in front of both clinicians, in a moving vehicle and was entirely unpredictable and unforseen.
My apologies for any confusion caused by lack of clarity in the original question. I had thought that the ‘whilst in transport’ part of the question provided the information needed.
Thank you for your input and advice.
I think that does help put it all in context and makes the answer clear. In this scenario you’re treating and transporting a person with an urgent medical problem and no doubt you are taking them to a hospital not a dedicated mental health facility. If the patient begins to show signs of mental illness the doctor can’t sign a s 19 certificate because presumably they don’t have one in their pocket. But they can treat the person for all their illnesses and symptoms as can you. You no doubt have protocols and procedures for treating people who are showing signs of acute mental illness and as with any complex presentation (ie their mental and their medical illness) you need to treat both so you can in accordance with your protocols and if necessary sedate and restrain the patient as you take them to hospital for holistic care.
When you get to hospital the doctor could complete a s 19 certificate if he or she wanted to, but you can’t complete a s 20 certificate because there is no such thing. You have transported a person to a hospital because they were acutely sick and you provide the treatment warranted by their complex condition. Section 20 really has no role to play in the circumstances you’ve described.
Thank you for clarifying that. On reading further posts it is becoming more and more obvious that Section 20 is the cause of much confusion among paramedics. I wonder if the reason (to your frustration) we all keep referring to ‘writing a section 20’ is due to the fact that the service provides us with a separate and specific duplicate form that we must fill out in the event that we have invoked s20 in order to transport a patient? It seems we are forming the belief that this paper form is the ‘official’ representation of s20. From everything you have explained to date it’s clear that the form we are required to complete is actually just another part of the patient’s clinical record for the health service and ambulance service and is not in fact an official legal document.
It seems that it is this misunderstanding that must be addressed as I certainly had been led to believe that the form I was filling out was a legislative requirement of the s20 process when from everything you have explained, it is only a separate requirement of our employer.
So my understanding is that as long as we document our findings and treatment, and the fact that we have invoked our power to involuntarily transport and treat based on those findings, on the patients medical record then we have fulfilled our legal requirements under the act and that there is no official, legislative form or certificate that we are required to fill out. The paperwork we are currently filling out is actually of our employers design only and simply forms part of the patient’s medical record outlining our clinical findings and treatment for the purposes of handing over our patient to other care.
I sincerely hope that I have got this right now 🙂
Thank you again for your assistance. I have found this whole conversation to be extremely helpful.
That’s correct