Health (Mental Services) Bill, 1980: Committee Stage (Resumed).
NEW SECTION.
(Cavan-Monaghan): I move amendment No. 7d.
In page 7, before section 14 to insert the following new section:
"17. —(1) Where an applicant under section 16 is being treated in a psychiatric centre as a voluntary patient he may, at any time, give notice of his intention to leave the psychiatric centre not earlier than seventy-two hours thereafter and he shall be so entitled to discharge himself at any time after the expiration of such period.
(2) Where the applicant is the person himself the medical officer in charge of the centre shall, where practicable, notify the relatives of the applicant of his intention to discharge himself immediately upon receiving notice of the person's intention to do so.
(3) The Minister may, by regulation, vary the period of seventy-two hours as set out in subsection (1).
(4) Where it is proposed to make a regulation under this section, a draft of the regulation shall be laid before each House of the Oireachtas and the regulation shall not be made until a resolution approving the draft has been passed by each such House.
That is what I wanted the Minister to do in regard to another regulation earlier on. The Bill as it stands enables a voluntary patient to discharge himself without notice. It is true that, following a public demand and no doubt specialist demand, the Minister changed his mind and has put down amendment No. 25.
Amendment No. 25 is being discussed with amendment No. 7d.
(Cavan-Monaghan): Amendment No. 25 in the name of the Minister proposes to improve the position somewhat. It proposes that
(2) A person who is under care in a psychiatric centre otherwise than as a detained patient may give written notice to the medical officer in charge of the centre that he wishes to leave the centre not earlier than twenty-four hours after giving the notice and he shall be entitled and shall be allowed to leave the centre at any time after the expiration of the said twenty-four hours.
Were it not for these two amendments a voluntary patient would be entitled to discharge himself without notice. I am all in favour of treating patients afflicted with mental trouble in a kind and humane manner without putting a stigma on them, but at the same time we must have regard to the fact that many such patients are incapable of coming to reasoned decisions and are incapable of looking after themselves. In quite a number of cases they suffer from depression and they might damage themselves. We have had experiences where patients have caused fatal damage to themselves and some of us know of dreadful cases where patients who had discharged themselves or who had absented themselves from institutions have caused fatal injuries to near and dear relatives.
It behoves us to see that patients are taken care of when they need care. It is necessary that we should see to it that patients are looked after in such a way that they are not the cause of injury to other people. We all know that when a patient finds himself in a mental institution, even if he has been brought in on a voluntary basis or has been encouraged to come in, he often resents being there and develops a grievance against some person whom he thinks has put him there. There is always a risk that this unfortunate sick person might inflict injury on the person whom he thinks is responsible for his being there. Such people suffer from all sorts of obsessions and delusions. In my professional lifetime I have had knowledge of a fatal and dreadful case where some patient was given a certain amount of freedom, took more freedom than was allowed and actually got back to his place of domicile with fatal results before the Garda caught him. We have to have regard to this sort of thing. The Bill as initiated, with the right for patients to discharge themselves without notice, was very deficient. The Minister tells us that the whole object of this Bill and of his approach to mental illness is to care for sick people in the community where that is possible and to treat them in the same way as any other patient in a hospital. That means that the Minister will encourage people to admit themselves to psychiatric institutions on a voluntary basis. In the interests of the patients and their relatives it is essential that they be cared for in a kind and humane way. However, it is not too much to ask that the patient should have to give 72 hours' notice before leaving the hospital. That is all we are asking.
When the Bill was introduced the Minister did not want any provision regarding notice. He wanted to have the situation that the patient could go when he or she liked. Now the Minister is introducing an amendment providing for 24 hours' notice. Deputy Boland's amendment which I support requires 72 hours' notice. I do not think that is unreasonable. If at the end of 72 hours the patient is still in the same frame of mind he can simply leave and go to his place of residence. However, in a percentage of the cases the chief psychiatrist of the institution may be convinced that the person is not in a fit state to leave and in other cases he might have grave doubts. In those circumstances the status of the patient would switch from being a voluntary patient — which the Minister does not recognise — to the status of a detained patient.
What we are proposing is reasonable. The only difference of opinion between the Minister and myself on this matter is the length of notice. A period of 24 hours' notice is a short time to enable the chief psychiatrist to communicate with relatives, perhaps to get a second opinion or to observe the patient. This is a serious consideration. He may wish to observe how the patient reacts to a different drug or to observe how he reacts without any drugs. The patient would be under medication or sedation in the institution and there is no guarantee he would continue to take the prescribed medicine at home. I have a layman's approach to this matter. It might be necessary for the chief consultant to observe the patient over a period of 72 hours to see how he reacts to different medication.
We are adopting a reasonable, cautious approach. It is not a draconian approach. A person would not be in an institution in the first instance unless he needed medical attention for a condition, one that might prevent him coming to a reasoned, balance judgment about himself, his actions and other people. I urge the Minister to fall into line with the views of the best medical opinion in the country and to come down on the side of caution. If something undesirable should happen it will be too late to be cautious.
The Deputy will be aware I have circulated amendment No. 25 which provides for 24 hours' notice——
(Cavan-Monaghan): I said that.
Nearly all of the submissions received on the Bill, particularly those from the various medical and nursing interests, expressed unease about a situation that possibly could arise where a voluntary patient who is in an excited or overwrought state insists on discharging himself or herself from a psychiatric centre although the medical staff may think the patient to be totally unfit for discharge.
Initially I was opposed to imposing any restrictions whatever on the rights of a voluntary patient to take his discharge since my concern was essentially to ensure that psychiatric illness was treated in precisely the same way as any other illness. However in view of the submissions made and the depth of concern expressed, I introduced the amendment. I want to stress the fact that I am reluctant to concede on this because I know that in practice the 72 hours is rarely used. From discussions I have had with professional people I know that is the case. Nevertheless they are concerned that there should be some provision in the event of an exceptional case arising and it was for this reason I introduced the amendment providing for 24 hours' notice.
It was submitted that voluntary patients should be required to give notice of their intention to discharge themselves. Under the existing legislation voluntary patients are required to give 72 hours' notice prior to discharge. The giving of a period of notice would, it was argued, allow medical staff to calm a patient, to persuade him to remain in the centre or, in the most extreme cases, to effect the usual procedures leading to formal detention where such a course was considered necessary. The amendment now proposed specifies that a voluntary patient must give 24 hours' notice of intention to discharge himself. I consider this period meets the objections raised in a practical and sensible way.
I am very concerned that we do not prevent people from entering an institution in a voluntary way in order to get treatment. The 72 hours' notice is known to have a discouraging effect so far as people entering an institution are concerned. I am not prepared to go any further on this. Neither am I prepared to impose on a doctor in charge of a psychiatric hospital the statutory obligation to instantly notify relatives about what may turn out to be a transient whim. I ask the Deputy to consider that the voluntary patient might be fully recovered, might be single and might not like his immediate relatives to know anything about his illness.
(Cavan-Monaghan): Again, I am disappointed with the Minister's approach to this matter. It is difficult to understand the last argument he put forward. He seems to assume that relatives would not know the person was in an institution.
In many cases that would be so. The Deputy is thinking of extreme cases but if we base legislation on extreme cases it becomes draconian in relation to the health services.
(Cavan-Monaghan): It might happen in Dublin city where people are living away from home but it certainly would not happen in rural Ireland where people are in close tough with their relatives. The fact that a person admits himself or herself to a psychiatric institution and then wants to leave within hours of entering the institution is proof positive that that person is unsettled, unstable and is not capable of coming to a rational decision. I admit a person might be in an institution for 6 or 12 months before he wants to leave. Some forms of illness make the afflicted people quite cunning. It could be that they would go in on a whim. and want to leave again very quickly.
The Minister has been advised by the Royal College of Psychiatrists as follows:
Where an "informal patient" insists on discharging himself, although deemed not fit to do so by the Medical Director of the hospital or his designated deputy, either of these persons should be empowered to make a detention order for 72 hours. This would allow time for the relatives of the patient to be contacted so that the patient could be discharged to the care of these relatives or, alternatively, arrangements might have to be made to have the patient detained on a compulsory basis.
That is the advice the Minister has received from the most responsible body of psychiatrists in the country, people whose profession it is to make themselves acquainted in the best possible way with the method of caring for and curing these people.
I have spoken to them since.
(Cavan-Monaghan): I spoke to some of them quite recently and I have no reason to believe that that advice has changed. If one applies common sense to most things, if one applies common sense to most branches of the law, one comes up with the right answers. If one applies common sense to what we are talking about now, one can come up with the right answers. The approach of most laymen to this would be that a person who is sufficiently ill to find herself or himself in a mental institution needs care and that if the doctor in that place believes that the person should not be allowed out for a few days he should have the power to keep that person there. That is no more than common sense. The Minister has arrived at certain conclusions about this Bill and nothing will change his mind.
There is an amendment here in this connection.
(Cavan-Monaghan): But some time or other when there is a disaster, a tragedy, then there will be great concern shown — I do not want to get into extravagent language — then there will be a demand to change the law, the regulations. Then there will be an inquiry set up to inquire into this, that and the other thing. I say that common sense demands that 24 hours is not sufficient time in which to observe somebody about whom the chief psychiatrist has a doubt. Twenty four hours is not sufficient time in which to change the drugs a patient may be on to see how he reacts, or indeed reacts without drugs. What is the rush? People go into these hospitals to be cured; sometimes they go in for protection. Saying that they must give 72 hours notice before leaving will not prevent them from going in. I feel strongly about this and about the necessity for insisting on this.
As the Minister has said that he has been speaking to the Royal College of Psychiatrists recently might I ask him have they changed their minds? Have they told him that they are happy about 24 hours? Have they told him that 24 hours is sufficient and that they think it is unreasonable to keep somebody in for 72 hours? I doubt it very much. I have quoted from their written recommendation to the Minister. I wonder have they said positively to the Minister that they are now satisfied that they were wrong, that they have revised their advice to the Minister and are now quite happy about 24 hours because nothing less than happiness on the part of the medical advisers in this field is adequate here. This is something about which we cannot take chances or risks. One could continue to reiterate this. There is a positive possibility of danger to the patient and very many instances of fatal consequences. There is also a possible risk of danger to others and again plenty of instances of fatal consequences. Why should we take chances especially when medical opinion not so very long ago said that there should be 72 hours in which to observe, make up one's mind and act in the best interests of the patient and of the community?
We did meet the members of the Royal College of Psychiatrists and had discussions with them. We discussed the amendment I would be prepared to make. They expressed themselves as happy in that this would go some of the way to meeting what they saw as an important area. They expressed themselves happy with that. I subsequently sent that amendment to them and they have not expressed any other view since that time. Apart from that I must ask the Deputy one thing: if it was felt by the Deputy's neighbours, friends or by somebody else that it was time for him to go in and have a little psychiatric treatment, would he not be concerned at the fact that he would have to give 72 hours notice to discharge himself? I must take that into consideration. In 1945, or whenever that other Act was drafted, 72 hours notice was seen to be necessary. I know the medical profession have progressed to the extent that that length of time is not now necessary, that length of time is not used. With modern treatment and observation methods I do not see a problem arising in this area. I am providing the 24 hours for that reason. I am very anxious that people feel free to go and have treatment and not feel trapped if and when they do so.
(Cavan-Monaghan): The Minister has stated that following the submission of the memorandum from the Royal College of Psychiatrists, Irish Division, to him, he has had an opportunity of seeing them, that he told them about his proposed amendment. According to himself they stated that was going some of the way to allaying their fears, to meet their advice. I want to say to the Minister that I think some of the way is not far enough.
They expressed themselves as satisfied at the time.
(Cavan-Monaghan): That is not what the Minister said — he is improving his hand — he said that that went some of the way. In regard to the question the Minister put to me about a visit to a hospital myself, because my relatives or neighbours thought that a little rest would be good for me, I will put it to the Minister this way: some of us have, from time to time, been in hospital, not necessarily for psychiatric treatment, though some of our neighbours may think that would not do us any harm. Some of us have gone into general hospitals for observation, intending to stay there a week. The consultant, however, says “I would like you to stay until the end of another week. I have some more tests to do on you and would like to make up my mind about your case”. At that stage I am in good mental health and although I might want to come out to attend in the Dáil, go for a holiday, attend business, I am in a reasonably rational state of mind and will accept the consultant's advice. I will stay in the hospital for another week, although I do not want to stay.
Unfortunately, the person who is a voluntary patient in a psychiatric hospital is at a disadvantage. The chief psychiatrist will say "You are coming on nicely now but I would like a few more days to see whether we will leave you on these tablets or place you on others. I would be happy if you would stay here until the end of next week, until I am completely happy." I am not so well mentally at this stage and I say "Oh no, I am away like a shot and I am not going to stay with you". That is the difference between the two cases. That is why I am asking the Minister to treat them differently. Not alone would the chief psychiatrist in the latter case like more time to assess the psychiatric patient, but he has doubts as to the safety of discharging that patient. I do not know what major principle is involved. A person would not be absolutely all right in the first instance if he wanted to go in and become a patient, felt bad enough, or looked bad enough and was acting queerly enough.
Most of these patients do not feel bad, do not look bad, are very normal. That is the whole point.
(Cavan-Monaghan): That is the danger. The Minister has mentioned the relatives. The man may feel bad enough to go in of his own volition, not being in the best of form, or he may be behaving badly enough for his relatives to encourage him to go in. The Minister may be sure that the public never know the symptoms which these patients who suffer from mental trouble display. These symptoms are very often confined to the notice of the wives, families and people living in the house with these people, who do not talk about them, except to doctors. Notwithstanding all that the Minister says about this being a delicate field, he will not accept the advice of the Royal College of Psychiatrists. He has told me that he has spoken to them again and I accept that. He did say without qualification, in reply to this first appeal, that they said 24 hours went some way. That would be a rational thing for them to say. Twenty-four hours is better than nothing, but is not as good as 72 hours. It is likely that they would say that.
To clarify that, they said in effect that it was adequate.
(Cavan-Monaghan): I am afraid the Minister is messing.
I am not. I am trying to meet the situation. It is the Deputy who is doing the messing. Half an hour on this amendment is a long time.
(Cavan-Monaghan): This is a most important Bill.
The Deputy is entitled to spend time on the Bill, but we are beginning to repeat the arguments and that is not in order.
(Cavan-Monaghan): In view of the Minister's two interventions, I am accepting this document as the advice of the psychiatrists because the Minister told me in his first intervention that they said that that went some of the way. In his second intervention he said that they were quite happy. These are contradictory statements. If I were a long-headed businessman and not a politician or anything else, that is the one I would accept, because it is safe advice. I would not speculate with the health of the patient and the safety of his relatives. On the Minister's head be it. I feel very strongly about it.
Is amendment No. 7d. withdrawn?
(Cavan-Monaghan): It is, on the principle that I will be putting it down again.
Amendment No. 7d, by leave, withdrawn.
SECTION 14.
I move amendment No. 8:
In page 7, paragraph (c), line 37, before "if" to insert "where the centre is a registered psychiatric centre.".
Submissions on the Bill made to the Department claimed that section 14, as drafted, would disqualify a registered medical practitioner who is a member of a health board from recommending detention in a psychiatric centre provided and maintained by that health board. While I am advised that this interpretation is not necessarily correct, it was desirable to put the matter beyond doubt by amending the Bill as proposed.
(Cavan-Monaghan): What is the effect of this amendment?
Its effect is to allow a registered medical practitioner who is a member of a health board to recommend detention in a psychiatric centre provided and maintained by that health board. He would not be excluded from being a person who would recommend it.
(Cavan-Monaghan): That is a separate matter. I am speaking off the top of my head. Supposing, instead of being a member of the health board, he was a proprietor of a psychiatric centre, would the Minister have the same view?
A proprietor is barred. I would not have the same view.
(Cavan-Monaghan): The proprietor should be barred. Great credit is due to members of the medical profession and other citizens who accept the position of members of voluntary boards like this and devote a lot of their time to them. However, certainly there could be a conflict of interest. I am not putting this very strongly but just thinking as I am talking. My present approach is that it is doubtful whether we should amend the Bill so as to enable the member of the health board to recommend a health board to a patient. Is he given the power to issue a recommendation that a patient be accepted there?
(Cavan-Monaghan): Then, what are we doing?
What we are doing is distinguishing between private centres and health boards. The effect of it would be to isolate the proprietor of the private centre from members of health boards and to allow a registered psychiatric medical practitioner who is a member of the health board to recommend detention.
(Cavan-Monaghan): I think that we should leave it as at present. It is my business as a member of the Opposition to be critical and careful. Section 14 says that a registered medical practitioner shall, for the purposes of section 15, 16 and 19 — these are the compulsory recommendation sections — be disqualified in relation to a person (a) if he bears a certain relationship to the person, (b) if the practitioner is employed in or by the psychiatric centre in which it is desired to have the person received or has charge of patients in the centre, or (c) if the practitioner is a member of the governing body of or is the person carrying on or in charge of that psychiatric centre.
We are not inflicting any real hardship on the psychiatrists or doctors concerned.
It is an ordinary doctor.
(Cavan-Monaghan): A GP, yes. This is only going to happen once in a while. It is better that the right thing be done and be seen to be done. There is a conflict of interest in the lives of professional men. Not alone would I not make it clear that the doctor would be included but I would make it clear that he would be excluded. That is the right thing to do. I have no doubt about it.
The medical profession asked for this. The GP does not have a vested interest. It is a question of one or two signatories for the recommendation and, as the Deputy said, it would have the effect of excluding such GPs from health boards. That is hardly what the Deputy wants.
(Cavan-Monaghan): I do not want to do that.
There is no basic vested interest.
(Cavan-Monaghan): I said conflict. I want to go on record now as saying that a person who is the owner of an institution, a member of the board of governors of an institution or a member of a board which runs an institution should not — I emphasise should not — sign recommendations or documents in connection with the admission of a person to that institution.
Amendment agreed to.
Question proposed: "That section 14, as amended, stand part of the Bill."
(Cavan-Monaghan): Subsection 14 (a) provides:
if the practitioner is the husband or wife, father, stepfather or father-in-law, mother, stepmother or mother-in-law, son, stepson or son-in-law, daughter, stepdaughter or daughter-in-law, brother, stepbrother or brother-in-law, sister, stepsister or sister-in-law or guardian or trustee of the persons.
That is a very long list but I notice that both uncle and aunt have been left out. We are excluding these because we apparently think they might be influenced by ulterior motives in signing patients in or making a recommendation. An uncle or an aunt could be influenced by a brother or sister. I would strongly recommend the inclusion of an uncle or an aunt. They would be nearer relatives than some of the in-laws and step-relatives.
I will certainly consider that. This is the existing law.
(Cavan-Monaghan): Precedents are dangerous.
(Cavan-Monaghan): We have had to deal with them in our time.
Question put and agreed to.
SECTION 15.
Amendment 8a in the name of Deputy Boland and 17d to section 24 are related and may be discussed together.
(Cavan-Monaghan): I move amendment No. 8a:
In page 7, subsection (1), line 44, after "detention" to insert "treatment and care".
This section provides:
(1) Where it is desired to have a person received and detained in a psychiatric centre application in the prescribed form may be made to a registered medical practitioner for a recommendation (in this Act referred to as a recommendation for reception) for the reception and detention of that person in that centre.
This is probably taken from an earlier Act, a very ancient Act, I believe, because the emphasis is on reception and detention. That is going back to the padded cell, the lock and the key. I know that is not what will happen. The patient will be taken care of and he will get treatment. Why not write that into the section? As it stands it sounds very crude, to say the least of it. It does not throw any emphasis on treatment and care which is what Deputy Boland has in mind.
The two amendments are related. In the first instance it is a purely technical matter with regard to the application of a recommendation for reception and detention. Section 17 (d) deals then with care. Section 23 provides for the making of an order for the reception, detention and treatment of the person. I do not accept that the word "care" should be added. The treatment will be comprehensive.
(Cavan-Monaghan): I would be satisfied with treatment.
It embodies the concept of care.
(Cavan-Monaghan): Is the Minister accepting the amendment?
No. Treatment covers care generally. If we were to start making this insertion we would have to start making amendments all over the place. I appreciate what the Deputy is trying to do but care is implied in treatment.
Is the amendment withdrawn?
(Cavan-Monaghan): I think this section is rather crude, because it means that somebody is applying for a recommendation for reception and detention. That language would be more applicable to Mountjoy or some other prison than to a hospital. “Treatment” should be indicated and if the Minister wants to cut out “care” he can.
I would accept it from the point of view of the appearance of it within the Bill. I presume I would have to put up that amendment.
(Cavan-Monaghan): Is the Minister accepting it in principle?
Amendment, by leave, withdrawn.
(Cavan-Monaghan): I move amendment No. 8b:
In page 8, subsection (2) (b), lines 5 and 6, after "person" to delete "being so resident and".
Subsection (2) of the same section reads:
(2) An application for a recommendation for reception of a person may be made——
(a) by a parent or guardian of that person,
(b) by the spouse of that person ordinarily resident with that person, or by a brother or sister of that person being so resident and being over 18 years of age,
The words that I object to there are "being so resident". They are unnecessary and unhelpful. A near relative may be living alone, may have nobody living with him and, unfortunately, these are the sort of people who usually are more inclined to need psychiatric help than people living with other people. A person could have a relative living on his or her own and the relative would know from the neighbours that all was not well and that the person would need help, and a neighbour would be the last person to sign anybody in or make a recommendation. A neighbour would not want to do that. It is the business of the relative. The neighbour will communicate with the relative and tell the relative what is going on and the relative then will make a recommendation. The deletion from the section of "being so resident and" would improve subsection (2) (b) enormously and immensely in a practical way.
I do not consider it necessary to provide as the Deputy proposes since a brother or sister who is not ordinarily resident with the person may request an authorised officer under the provisions of subsection (2) (b) to make an application for a recommendation for reception. It is only reasonable that the person authorised to make a recommendation in this case should be a person who is living with the spouse or the brother or sister or someone else living in the house ordinarily, being so resident. The Deputy leaves the residence qualification in for the spouse for the obvious reason that husbands and wives who live apart are not always in harmony with each other. Experience suggests that the relationship between brothers and sisters, particularly when they live away, is not always cordial and close and, indeed, brothers and sisters can be a good distance away. In any event the brother or sister who is not so resident has the option of making application to an authorised officer or person.
(Cavan-Monaghan): The Minister is beginning to have doubts about that and it is clear that the brother or sister who is not resident cannot request an authorised officer because the subsection says: “(d) at the request of any such parent, guardian, spouse, brother or sister”. “Such” there implies that he is residing with him and if he is not residing with him he cannot call on the authorised officer. The list of people who can make application for a recommendation are “(a) the parent or guardian of that person who need not be living with him, (b) the spouse of that person ordinarily resident with that person, (c) any brother or sister of that person being so resident and being over 18, or (d) the son or daughter of that person being over 18 years of age”. I would argue in any case that “brother or sister” there when read in conjunction with subsection (2) (b) means that a brother or sister must be resident there. If a sick person is living on his own and all he has in the world is a brother or sister not living with him he is then going to be at the mercy of the authorised officer.
There are also historically plenty of cases - they were mentioned on the Second Stage debate - where brothers and sisters have wanted one another put away for a whole variety of reasons.
(Cavan-Monaghan): That is so, I accept that.
Consequently, I think that this is a reasonable provision and it is open to a brother or sister not ordinarily resident with a person to request an authorised officer under the provisions of subsection (2) (d) to make a recommendation.
(Cavan-Monaghan): I do not think so.
Yes, they can go through the authorised officer. In the other case they can go directly in making an application.
(Cavan-Monaghan): The subsection says:
(d) at the request of any such parent, guardian, spouse, brother, sister....
"Such" there refers to subsection (2) (b), and means the brother or sister residing with him. There is no doubt about that, or I have gone stupid.
Any person who is not a brother or sister can make—
(Cavan-Monaghan): He can have an informal chat with the——
No, can request the authorised officer——
(Cavan-Monaghan): Where is that?
In any event, concerned people can make a request through an authorised officer. Those brothers and sisters would have a similar right.
(Cavan-Monaghan): Why write all this rigmarole in at all? None of it is necessary. The Minister should have another look at it.
Amendment, by leave, withdrawn.
Amendments Nos. 18, 21 and 26 are related to amendment No. 9. The Minister will move amendment No. 9 and we can discuss amendments Nos. 18, 21 and 26 with it.
I move amendment No. 9:
In page, 8 subsection (3), line 14, to delete "for reception".
This is a technical amendment to make the Bill consistent in the use of terminology. In this section the words "for reception" are considered to be superfluous. Amendments Nos. 18, 21 and 26 similarily amend sections 24, 29 and 33 and are designed to ensure consistency in this regard.
(Cavan-Monaghan): It is not necessary because it says, “an application under subsection (2)(f)”. Is that right? Is that what makes it unnecessary?
Amendment agreed to.
Question proposed: "That section 15, as amended stand part of the Bill."
(Cavan-Monaghan): I do not want to say very much about it. I think the Minister was right to accept the amendment to section 15(1) and I am of the opinion that he should accept my amendment to section 15(2)(b) because the process of applying for a recommendation for reception only sets the machinery in motion and it does not mean that that person is really going to have a say in whether the person can be received. All it means is that he is saying to a doctor “Would you have a look at this person and see how he is going on because my information is that he is behaving in a very queer way?” That is all that is being done there.
I would say that a brother or sister should be included. I agree with the Minister's argument that a brother or sister might act in bad faith, but so might a parent or a guardian if a daughter was getting married to somebody they did not like. Perhaps I am going back a bit too far, but they could apply for a recommendation in regard to her. The argument the Minister made could be made about others in that category. No major principal is involved here. The Minister should have another look at subsection (2)(b). I would not be surprised if he came to the conclusion that he should delete "being so resident and". I strongly recommend that he should do that.
Question put and agreed to.
SECTION 16.
Amendment No. 16 is related to amendment No. 10. Amendments Nos. 16a and 16b are alternatives to amendment No. 16. The Minister will move amendment No. 10 and we will debate amendments Nos. 16, 16a and 16b with amendment No. 10.
I move amendment No. 10:
In page 8, subsection (1), to delete lines 21 and 22 and substitute:
"a person is suffering from mental disorder of such a degree that he should, in the interest of his own health or safety".
Essentially this amendment arises because it was necessary after consultation to amend the criteria for recommending the detention of a patient which were set out in subsection (5) of section 19, amendment No. 16. When the Bill was originally drafted it was decided to link the necessity for the detention and unwillingness or unsuitability to accept treatment with severe mental disorder as criteria for the recommendation. Severe mental disorder was not defined because of the difficulty of getting an agreed definition. This difficulty is accepted to exist worldwide.
In the consultation process which I initiated upon the circulation of the Bill I recognised that this was an area in which there would be considerable input from the medical profession and the amendment which I now propose largely follows the advice given to me by the organised medical profession and by psychiatrists who were particularly concerned in this respect that the connotation of "severe mental disorder" in the context of a medical recommendation should not hamper the full assimilation of a person who suffers from a condition requiring detention and treatment into society upon his discharge from hospital. The amended criteria are in accordance with contemporary thinking in psychiatry.
(Cavan-Monaghan): As amended the subsection would read “... a person is suffering from mental disorder of such a degree that he should, in the interest of his own health or safety or for the protection of other persons or property....” The Minister is defining the condition by saying the person is suffering from mental disorder of such a degree that in the interest of his own health or safety or for the protection of other persons or property he may be placed forthwith under care and control. The Garda may take the person into custody and remove him to a Garda station. The Minister uses the plural. He refers to “persons”. What does the parliamentary draftsman say about that if his mal-intention is against one person only?
That part of the section stands.
(Cavan-Monaghan): Perhaps I should agree to the amendment and then we will get on to the section.
Amendment agreed to.
Question proposed: "That section 16, as amended, stand part of the Bill."
(Cavan-Monaghan): The subsection will now read:
Where a member of the Garda Siochana is of opinion or is informed by an authorised officer that he is of opinion that a person is suffering from mental disorder of such a degree that he should, in the interest of his own health or safety or for the protection of other persons or property, be placed forthwith under care and control, he may take the person into custody and remove him to a Garda Síochána station.
I am looking for information. Does "persons" include "a person"? If the Garda has heard he has animosity towards his brother or his wife only — and that could happen; he might not be at war with humanity; he might be at mental war with one unfortunate person only — would that be sufficient?
I am advised that it is person or persons.
Cavan-Monaghan): Only “persons” are referred to in the subsection.
It includes person or persons.
(Cavan-Monaghan): Does the Interpretation Act say that?
(Cavan-Monaghan): The Minister should.
Question put and agreed to.
SECTION 17.
(Cavan-Monaghan): I move amendment No. 10a:
In page 8, subsection (1), line 33, after "sections" to insert "16."
Deputy Boland proposes to insert "section 16" before sections 29 and 31 in the first line of subsection (1). Section 29 deals with transfers to hospitals and section 31 deals with transfers to psychiatric centres. Section 16 is the section under which the Garda is entitled to arrest the person for the safety of the patient or other people or property. Deputy Boland wants the subsection to read: "Subject to sections 16, 29 and 31 it shall not be lawful to detain a person under this Act elsewhere than in a psychiatric centre designated for the area in which he ordinarily resides." Section 16 gives power to the Garda to take a person into custody and remove him to a Garda station. Subsection (2) provides:
(2) Where a member of the Garda Síochána removes a person under this section, he shall apply forthwith in the prescribed form to a registered medical practitioner for a recommendation for reception of the person in a psychiatric centre.
It is probably safer to insert section 16 into the first line of section 17(1) to take away to some extent the general right to bring a person to a psychiatric centre.
The placing of a potentially dangerous and deranged person under Garda custody, as a crisis intervention measure, pending full medical examination with a view to procuring the necessary recommendation for reception, is not to be confused with the actual process of reception and subsequent legal detention in a psychiatric centre. In brief, a Garda station is not a place where psychiatrically ill persons are detained for treatment. A dangerous person is held in Garda custody for a matter of hours only as a means of protecting either the person himself or herself or the general public, pending the initiation of the reception procedure.
Under section 16, as the Deputy recognised when he read through it, the Garda must apply forthwith to a doctor. Where a member of the Garda removes a person under subsection (2), he shall apply forthwith in the prescribed form to a registered medical practitioner for recommendation for reception of the person in a psychiatric centre. That covers the point that there is no question of the person being detained unduly in a Garda station. In effect, there is no particular desire on the part of the Garda in any event to detain the person.
(Cavan-Monaghan): Is the Minister satisfied with that?
Amendment, by leave, withdrawn.
I move amendment No. 11:
In page 8, subsection (1), to delete lines 34 and 35 and substitute:
"detain a person under this Act elsewhere than in a district psychiatric centre designated for the area in which he ordinarily resides or in a registered psychiatric centre approved in respect of such an area or generally.".
Amendment agreed to.
Amendments Nos. 11a and 11b not moved.
(Cavan-Monaghan): I move amendment No. 11c.
In page 8, subsection (2), to delete lines 38 and 39 and to substitute the following new subsection:
"(3) Subsection (1) shall not prevent the admission, care and treatment of a person as a private patient in a psychiatric centre."
Deputy Boland wants to make it clear that a person may be treated as a private patient. The Minister may argue that a small section like section 13, in which he warned us that voluntary treatment was not being abandoned, might be sufficient to cover this. Deputy Boland wants to make sure that subsection (1) shall not prevent the treatment of a private patient in a psychiatric institution. It is as reasonable as section 13.
I am advised that subsection (2) as drafted will not prevent the admission of a person as a private patient in a psychiatric centre. In practice, what happens is that private patients are assigned to consultants after admission. I do not propose, therefore, to accept this amendment. It is not necessary as this would be a voluntary admission.
(Cavan-Monaghan): I do not believe that Deputy Boland is speaking about a voluntary patient. He is speaking about private accommodation in a place of detention. It is clear that is what he is speaking about because he uses the word “private” which has not appeared any place else. It might need to be redrafted. The Deputy is not talking about a voluntary patient because this section deals with detained people. I believe the Deputy is saying that if there is a private room in a psychiatric centre and the person wants to avail of it he can be treated there.
I am advised that he can be treated there.
Amendment, by leave, withdrawn.
Section 17, as amended, agreed to.
SECTION 18.
Amendments Nos. 11d and 11e not moved.
Question proposed: "That section 18 stand part of the Bill."
(Cavan-Monaghan): We had a discussion about this section earlier. It provides that where after refusal of an application a further application for a recommendation for reception is made in relation to the same person within a period of three months after the date of the previous application, the applicant, so far as he is aware of the facts relating to the previous application and its refusal, shall state these facts to the registered medical practitioner to whom the application is made. Has that been amended?
There is no amendment to section 18.
(Cavan-Monaghan): This really places an obligation on an applicant for a recommendation to tell the doctor to whom he is applying that a previous application was made and refused. It is a warning section. It warns the doctor that this person has been the subject of an application for reception previously. I wanted to include that section in section 8, which later gave rise to the other discussion.
Question put and agreed to.
SECTION 19.
Amendments Nos. 12 and 14 are consequential on amendment No. 13 and amendments Nos. 15 and 16e are related. Amendments Nos. 12, 13, 14, 15 and 16e will be discussed together.
I move amendment No. 12:
In page 9, subsection (1), line 3, after "practitioners" to insert "(or, in a case to which subsection (1) (b) applies, one registered medical practitioner)".
The requirement that two doctors should sign the recommendation for the reception of a person in all cases proved to be a contentious provision. Nearly all of the submissions which we received on the Bill expressed unease and anxiety about the practical application of the requirements laid down in the section. The situation obtaining in some of the more sparsely populated rural areas was stressed in this regard.
Needless to say, any major universal amendment to this "two doctors provision" would seriously undermine the position concerning safeguarding of the individual's rights with respect to the possibility of unwarranted detention in a psychiatric centre. The two doctor requirement has worked satisfactorily so far in relation to the detention of a private patient. A major amendment is, therefore, clearly undesirable. However, in order to go some way towards meeting the concern underlying the criticisms made, a highly specific amendment to the section is proposed.
This amendment will simply provide the Minister with enabling powers allowing him to direct that the written recommendation of one doctor will suffice for the reception of a person into a psychiatric centre when circumstances are, in the Minister's opinion, such as to warrant such a procedure. A more general unrestricted amendment to the section would provide universal access to the one doctor procedure, and, unfortunately, as human nature tends to take the line of least resistance, one could anticipate that the ready availability of the one doctor procedure would be abused, with the one doctor situation tending to become the norm.
The enabling powers in respect of the one doctor procedure could be invoked if the provisions of section 19, as drafted, were found to be causing insurmountable difficulties on the ground, in regard to either a particular category of psychiatric illness or in respect of certain areas in the country. At the same time, the body of the section as drafted is being left intact, reflecting my determination that two doctors should sign the recommendation for reception in all but the most exceptional cases.
Deputy Boland has put down a similar amendment, No. 16e to this section. I think that Deputy Boland will, if he reflects, agree that, while I accept the intent of his amendment, expressing it statutorily in the terms he proposes would ensure that what he proposes to do, that is, to meet the abnormal situation, in the natural order of things becomes the normal and would defeat the essential purpose of certification which is to protect the individual from unnecessary detention.
The amendment which I propose will permit the Minister to make regulations specifying areas or circumstances in which the recommendation of one doctor will suffice and I think that is a better course to follow.
(Cavan-Monaghan): The Minister's amendment simply gives power to the Minister to decide that the second opinion may be dispensed with. Is that not so?
(Cavan-Monaghan): The Minister may make regulations designating an electoral area, a parish or a county, for instance.
It was claimed that there might be a problem in some areas that are very sparsely populated.
(Cavan-Monaghan): Under the present law, is the requirement for one or for two doctors?
In the case of a private hospital, one doctor was the requirement, while for a public hospital the requirement was for two doctors.
(Cavan-Monaghan): That was under the 1945 Act, as amended?
(Cavan-Monaghan): There is no doubt but that there is a problem here. The Bill provides that a person cannot be recommended for detention unless he is certified by two doctors; but, simply and solely because there may be only one doctor easily or readily available in some areas, the Minister proposes to have different laws for different places. Obviously, that is highly undesirable. It means that if I am living in one part of Cavan I cannot be detained without a recommendation from two doctors, but if I am living in another part of the county I can be detained on the recommendation of one doctor. I do not imagine that these committals arise very often and I should like the Minister to give us the number of recommendations and the number of detention orders that are signed in any 12-month period in respect of an average mental hospital. I cannot visualise any case in which it would not be possible to obtain the opinion of a second doctor. There is no part of the country so remote as that. Mental institutions are always situated in large towns where there would be plenty of doctors so that a patient, having seen the doctor in his area, could be either taken to see another doctor en route to the mental institution or could see one in the town in which that institution is located. I am very much against the concept of different laws for different areas, especially on a topic so delicate as the one we are dealing with.
Deputy Boland's amendment is much more acceptable than the one proposed by the Minister, in which he applies subsection (1) and says that one medical practitioner will suffice.
My solution would be to leave the matter to two medical practitioners and, if necessary, to find a second one on the way to the mental hospital with the patient. In no case would there be likely to be a distance of more than 20 miles within which a doctor could not be found. Deputy Boland's amendment reads as follows:
In page 9, between lines 41 and 42, to insert the following new subsection:
"(7) Where a registered medical practitioner, being the first such registered medical practitioner to do so, signs a recommendation for reception and states in such recommendation that he is satisfied—
(a) that because of the person's state of mind it is particularly urgent that he should be transferred forthwith to a psychiatric centre, and
(b) that because of the delay which would be occasioned before a second registered medical practitioner could examine the person such delay would be detrimental to the health and safety of the person or of other persons,
such recommendation shall be deemed, for the purposes of this section, to have the same effect, for a period of seventy-two hours as if it had been signed by two registered medical practitioners.".
Deputy Boland is endeavouring to provide for detention on the basis of one medical recommendation for a period of 72 hours, whereas the Minister is going the whole way and dispensing with the second medical opinion.
I do not think that the difficulty that has been highlighted is one that cannot be overcome. In any area it should be possible to get a second medical opinion within hours. Deputy Boland's amendment is well drafted and it would overcome the difficulty that has been highlighted, that is, if there is such difficulty.
I agree that it is highly undesirable that there should be reference to one doctor only and that is why my amendment proposes to leave the legislation as it is and simply to make provision for a subsequent regulation if it is shown in practice that such is necessary in some circumstances. It simply means that there will be an enabling provision within the Bill but that the two-doctor recommendation should apply across the board. That situation can be considered in the light of practice subsequently. In that sense I am not dispensing with the two-doctor requirement but I am providing a measure which will enable the Minister by regulation to designate an area or circumstances in which the requirement may be dispensed with.
(Cavan-Monaghan): I am not clear on this. I know what the Minister intends doing but I cannot see how he is doing it. There is reference to subsection (1) (b). Is that a new subsection that has been inserted?
It is; in 19 (1) (a) and (1) (b). The (1) (b) clause says: "The Minister may by regulations designate an area or prescribe the circumstances in which...."
Amendment No. 13 may be the appropriate one.
In effect what I am doing is leaving it as two but putting in the provision that the Minister may by regulation designate a situation—
(Cavan-Monaghan): I am sorry. I should have noted amendment No. 13. But it is clear now that what the Minister is doing is amending section 19 by putting in a new paragraph in subsection (1) which will read:
The Minister may by regulations designate an area or prescribe the circumstancess in which the written recommendation of one registered medical practitioner shall be sufficient.
In other words, he will be saying that, if an area is sparsely populated and has only one doctor, he may say that one doctor is sufficient. If this were not such a serious matter, and to some extend such a pathetic one, it could be said that what the Minister is really doing is creating second class citizens in a very delicate area. He is saying that in one part of the country, say east Cavan, people cannot be brought to a psychiatric institution unless a recommendation is signed by two doctors, but in west Cavan a person may be brought to such an institution if the same recommendation is signed by only one doctor.
I do not think the difficulty is so great as to necessitate this discrimination. That is a word I hate to use but it is what I mean. If a patient from west Cavan were being brought to Monaghan on the recommendation of one doctor — if it were a remote part of west Cavan I agree there would have to be some travelling done to get another doctor — surely he would pass through the towns of Ballyconnel, Belturbet and other towns where there are doctors. We are not so completely isolated as all that. It might be that the person would be brought home again from the half-way house instead of being brought on, but would that not be a good thing if it were necessary? We are not that isolated in the country.
That would be my solution but, under any circumstances, I would not accept the Minister's way out, which says we will leave the general situation as it is. There must be two doctors, but if it is not easy to get the second doctor the Minister will make geographical and circumstantial exceptions and do with one doctor. That is the least desirable. Deputy Boland suggests that if this crisis arises we will detain the person for 72 hours on one doctor's recommendation and after that we must get a second doctor. My personal proposal would be to leave the situation as it is. I would accept Deputy Boland's suggestion but I do not find the Minister's proposal acceptable.
I am largely in agreement with the Deputy in leaving the position as it is, but because of the various representations made I am providing the means whereby if that problem appears to be a serious problem as time goes on — as several Deputies have suggested in the House and as medical people have suggested — at least within the Act there would be provision now without having to go and re-enact the measure to introduce regulations relating to that situation specifically. These could be either the circumstances or an area. Circumstances would probably cover the point made by Deputy Boland in his amendment.
Amendments Nos. 12 and 13 should really be taken together.
Actually they are. Amendments Nos. 12, 13, 14, 15 and 16e are all being debated together. Amendment No. 12 is first and it is the only one moved as yet.
I find it difficult to accept the Minister's solution, doubly so because I believe the Minister does not personally agree with that solution himself. He suggests that he is putting it forward because of representations made to him by medical and other interests. I find it difficult to see how the Minister will be able to prescribe circumstances where the recommendation of one practitioner will be sufficient because the sort of circumstances and examples that have been envisaged vary from case to case and place to place. I do not think a regulation made by a Minister will be able to cover the variety of circumstances where, because of the urgency of the situation and the danger to the health and safety of the person involved or of other people, a second doctor cannot be obtained. It is difficult to envisage that any Minister by regulation could manage to prescribe all the circumstances where that might occur. What is more likely to happen is to have a set of circumstances prescribed where in certain cases it will not be necessary at all that there should only be a single doctor and in other cases where the necessity to use a single doctor and get the person into hospital quickly will not have been covered in the regulations. It will make it very difficult for doctors — and in this case we are talking about GPs — to determine where their power lies in this matter. Realistically, I do not think you could expect every GP in the country — they are not accustomed on a day to day basis to dealing with circumstances like this — to know whether they were in a situation where their recommendation and signature alone would suffice for reception or not.
I should have thought that the suggestion I put forward later in amendment No. 16e is a better one, where in an emergency situation a practitioner signs a certificate because he is satisfied that the person's state of mind is such that it is particularly urgent that he should be transferred to a psychiatric centre and the doctor himself signs a statement suggesting that the delay that might be occasioned if he had to look for a second doctor might be detrimental to the health or safety of the person or of other persons and that that order would have effect for 72 hours. The suggestion contained in that amendment is that permission would be given to doctors, who I think are generally accepted as being a responsible body of people, to make temporary emergency recommendations for reception orders where they felt it urgently necessary that the person should be got to a psychiatric hospital quickly and where it was not possible to get the advice of a second doctor.
I do not think this situation I envisage might occur only in remote parts of the country. You could have — it is regrettable, but it is true — especially at weekends and at night time even in urban centres a situation where a person could become violently deranged and would be a danger to himself and to the safety of other people. It could be virtually impossible at 4 o'clock in the morning during the weekend even in an urban situation to get a second GP to sign a recommendation for a reception order. In those circumstances the signing of an order by a single doctor ought to suffice so as to get the person quickly into the environment in which his condition can be best dealt with. When such a person is brought to the psychiatric centre the psychiatrist in charge of the centre has to adjudicate within a reasonable length of time on whether the person ought to be detained. I would be the last person to suggest that we should allow a situation where a doctor could sign away a person's freedom for an indefinite time.
In general I agree with the principle that two doctors should be used for referral purposes. However, it should be simple for GPs to know that, if there is an emergency situation, they can sign an order to have the person referred. GPs will not abuse this. They are not the type of people who would want to use this power and they would use it only in unusual and urgent circumstances. I have genuine reservations on how the Minister would adequately prescribe the circumstances where only one doctor would need to sign an order. With more success a Minister might be able to designate remote areas where it was likely that there would only be one doctor. But in urban areas late at night and at the weekend it may be just as difficult to get a second GP. I gather from the Minister's references that his intention to designate areas does not refer to urban areas but to remote rural areas. The Minister cannot prescribe all the circumstances, and it would be plainer to set out that in emergency circumstances, where the GP was making the signed statement that he felt the situation was an emergency and that he could not get a second doctor, one doctor could sign the temporary emergency recommendation for reception.
None of the solutions is perfect, neither the Minister's nor mine. We are talking about a very sensitive area when we talk about making a person an involuntary patient. It is not a task that would be taken lightly by any individual or group of individuals, but the solution put forward in my amendment is one that a responsible medical practitioner would find more workable than having to make himself familiar with a set of regulations drafted by the Minister, a set of regulations which would have to be vague and fairly tatty at the edges and which could leave GPs in a considerable amount of doubt as to whether they were in circumstances prescribed by the Minister.
On my amendment we are going ahead with two doctors signing and we would then look at any of the circumstances which might arise. The measure which I have introduced will give us all the power we need to deal with that situation.
Could the Minister explain how he would envisage prescribing the circumstances and what type of circumstances?
The Deputy has prescribed several sets of circumstances, like temporary emergencies, weekend emergencies and various other examples. They can be prescribed under the regulations if they are seen to be necessary. That is why we said "areas or circumstances". It is quite widely embracing. We could end up with a measure which provided in certain circumstances for that kind of reference, but one would have to specify them. I would have to have it proved to me that this was necessary. Like Deputy Fitzpatrick, I am very much in favour of two doctors signing. At this stage I am providing this measure to meet the suggestions that were put during the Second Stage and by the medical profession. If it can be shown subsequently that there are circumstances, there is a measure there which will enable the Minister of the day to deal with them.
That is my fear of the Minister prescribing circumstances. Once the Minister prescribes ten sets of circumstances that means that he excludes the eleventh, the twelfth and so on. No human being could prescribe every conceivable circumstance in which it might be necessary for only one doctor to sign the order. Once the Minister tries to make regulations which prescribe circumstances he will eliminate certain circumstances by not including them in the regulations. There is no way in which any Minister with advice from the best experts can possible prescribe the circumstances in which a doctor might find himself unable to get a second signature when he knows in his heart and soul and because of his experience and training that the person urgently needs to be brought into a psychiatric centre. That is why the suggestion of the Minister making regulations will be unworkable. I am suggesting not just a personal viewpoint but the view of people whose daily occupation is the practice of psychiatry in a number of our most eminent psychiatric centres. If they do not believe that the situation outlined by the Minister will be entirely workable there ought to have been more heed paid to their representations than there appears to have been.
Is amendment No. 12 agreed?
(Cavan-Monaghan): Having regard to the Minister's attitude to one or two doctors, I would be happy if I thought that the Minister would be dealing with this secula seculorum. But we are putting this on the Statute Book and it will then be up to the discretion of the Minister of the day to make regulations. I know one county registrar who thinks that everybody should have a vote and that it is better for a man to have two votes than none at all, and his ambition is to get people on the register and let them vote. A successor of the Minister's similarly might think that it was foolish in the extreme to have two doctors, that one would be plenty, and he might make regulations that if one doctor was out playing golf he should not be disturbed and that the other doctor should sign the recommendation.
The regulations would have to come before the House.
(Cavan-Monaghan): For annulment or for——
(Cavan-Monaghan): If the Minister would bring them before the House for confirmation I would be happy.
The Bill provides for them coming before the House for annulment.
(Cavan-Monaghan): If the Minister were to bring it before the House for confirmation I would be happier about it.
Amendment agreed to.
Amendment No. 13 has been discussed with amendment No. 12.
I move amendment No. 13:
In page 9, subsection (1), between lines 4 and 5, to insert:
"(b) The Minister may by regulations designate an area or prescribe the circumstances in which the written recommendation of one registered medical practitioner shall be sufficient."
Amendment agreed to.
I move amendment No. 14:
In page 9, subsection (3), line 11, after "where" to insert "in a case to which subsection (1) (a) applies".
Amendment agreed to.
I move amendment No. 15:
In page 9, subsection (5), lines 19 and 20, to delete ", in respect of each registered medical practitioner".
Amendment agreed to.
I move amendment No. 16:
In page 9, subsection (5) (b), to delete lines 26 to 31 and substitute:
"(i) that the person is suffering from mental disorder of such a degree that detention and treatment in a psychiatric centre are necessary in the interest of the person's health or safety or for the protection of other persons or property, and".
Amendment agree to.
Amendments Nos. 16a and 16b not moved.
I move amendment No. 16c.
In page 9, subsection (5) (b) (iii), lines 32 and 33, after "accept" to delete "or is not suitable for".
The effect of the amendment would be that the doctor would have to certify that the person was rejecting treatment as a voluntary patient rather than the doctor stating that the person was not in his opinion suitable for treatment.
I cannot accept this amendment because I am advised that there are seriously disturbing psychiatric conditions involving danger to patients and families in which it would be unwise to accept the patient's own word that he would undergo treatment voluntarily. It is a characteristic of such conditions that a person can swing from rational to irrational behaviour. In many cases such patients are no sooner in hospital than they are looking to get out, thus interrupting treatment.
This amendment relates to the practitioner making a recommendation for a person to become an involuntary patient. In the recommendation for reception the practitioner would have to certify that the person was suffering from severe mental disorder; secondly, that his detention and treatment were necessary in the interests of the person's health or safety; and thirdly, that the person was not prepared to accept treatment — in other words, that the person was not prepared to accept voluntary treatment. If the practitioner by virtue of subsection (5) (b) (ii) certifies he is satisfied that the detention and treatment of a patient is necessary he should not have to certify again, as set out in subsection. (5) (b) (iii), that the person is not suitable for treatment as a voluntary patient because he has already done this. It appears to be unnecessary and questionable as to why it is inserted in subsection (5) (b) (iii) that the practioner should have to make the same statement as was made in the preceding sentence.
Members of the medical profession have reservations on this point. If a GP has to sign an order stating that a person is not suitable for treatment as a voluntary patient, this may prove a deterrent so far as some doctors are concerned. I give as an example a situation of a GP who has been a medical doctor in a small community for many years or the case of a practitioner who has been the family doctor for the patient concerned. We know that doctors will be loathe to sign such orders because they will be forced to certify certain matters — that the patient is suffering from severe mental disorder and needs to be detained and treated. It has been represented to me that a GP will baulk at the idea of being forced to put on a certificate that the fact that he now certifies his neighbour is not suitable for treatment as a voluntary patient. The provision appears to be superfluous and it could cause administrative and other difficulties for doctors in the context of dealing with their patients in the local community.
The problem here is that the patient may say he is prepared to accept treatment and that aspect has to be covered. If in the medical practitioner's view the patient is in need of detention he must be covered in the event of the patient saying he is prepared to accept treatment. The purpose here is to cover that situation.
In subsection (5) (b) (ii) the doctor has to certify that the detention and treatment of the patient are necessary. The fact that the patient is not prepared to accept treatment is covered by subsection (5) (b) (iii) and that provision would still exist if my amendment were accepted. In other words, the doctor has to certify that the patient is not prepared to accept treatment. The suggestion is the doctor will not be prepared to certify that the patient is not suitable for treatment as a voluntary patient. It is an odious enough task to ask a doctor to sign an order stating that a patient needs to be detained for treatment, but it has been represented to me that a doctor will not be prepared to sign a statement stating that the patient is not suitable for treatment.
It is only where the doctor recognises the patient is not suitable for treatment in the first place that that will arise. Otherwise he does not have to put that down. The Deputy's amendment would remove the situation where a doctor considers a patient is not suitable for treatment. If he considers the patient not suitable for treatment it is only right he should have to say so.
Amendment, by leave, withdrawn.
I move amendment No. 16d.
In page 9, subsection (6), line 40, after "relates" to insert ", and the applicant,".
Earlier sections dealt with a person who can make an application for a recommendation for reception. Subsection (6) states that the doctor should notify the person concerned of his intention to make a recommendation. I felt it was important that the applicant, who is defined in section 15(2) — the parent or guardian, spouse, son or daughter, all those other people, possibly a garda, an authorised officer — for recommendation for reception should be informed as well as the potential patient.
I do not think this amendment is really necessary. The applicant is involved in the whole process of seeking the recommendation. It is somewhat unreal to envisage a situation in which the applicant would not know the outcome. Nevertheless, I have no particular axe to grind here. Essentially I would not be against putting it in. It imposes further administrative necessity on the medical practitioner. All of our experiences will probably show that the applicant will be fairly closely involved and normally will want to know. I have no particular objection, so I would be prepared to accept it if the Deputy feels it necessary.
Amendment agreed to.
Amendment No. 16e has already been discussed.
Amendment No. 16e not moved.
Section 19, as amended, agreed to.
SECTION 20.
I move amendment No. 17:
In page 9, delete lines 43 to 45 and substitute:
"of a special psychiatric centre.".
This amendment is consequential upon the necessity to amend the definitions of special psychiatric centre. An amendment is necessary to ensure that a recommendation for reception cannot be made in respect of the Central Mental Hospital and also to ensure that district psychiatric centres are not excluded from receiving persons in respect of whom a recommendation for reception has been made where part of the centre is designated as a special psychiatric centre. Such an eventuality, of course, does not arise at present.
(Cavan-Monaghan): Would the Minister tell us exactly what he has in mind by a special psychiatric centre? Is that for a limited category of patients?
Yes, it is the Central Mental Hospital in Dundrum.
(Cavan-Monaghan): I take it it has nothing to do with voluntary patients?
The original section 20, in effect, excluded Dundrum. It also excluded any other portion of a psychiatric hospital in other parts of the country that might at any time be designated a special psychiatric centre, in other words, where criminally insane people might be lodged. Do I take it from the Minister's amendment now that the concept of having places other than the Central Mental Hospital is being removed from the Bill and that that is the reason for the amendment?
No, the amendment is necessary to ensure that a recommendation for reception cannot be made in respect of the Central Mental Hospital and also to ensure that the district psychiatric centres are not excluded from receiving persons in respect of whom a recommendation for reception has been made where part of the centre is designated as a special psychiatric centre.
In other words, the effect of the section as amended is that a person, in the first instance, cannot go from being free to being a detained person in a special psychiatric centre. Is that the effect of the amendment?
Amendment agreed to.
Section 20, as amended, agreed to.
SECTION 21.
Amendment No. 17a in the name of Deputy Boland. Amendment No. 17b is cognate and may be discussed with amendment No. 17a.
I move amendment No. 17a.
In page 9, subsection (1), line 49, to delete "the medical officer in charge of the centre" and substitute "the chief executive officer of the health board in whose area that centre is".
This section, as it stands, leaves the onus on the medical officer in charge of a psychiatric centre to provide an escort for a patient to bring him into the centre if he himself does not co-operate in being brought in after a recommendation for reception has been signed. The situation will be that where two doctors sign a recommendation for reception, two doctors in the community say: we think this person is in need of treatment in a psychiatric centre, and where one of those doctors says: we think this person is in such a state that he may be a danger to himself or possibly to other people, we think that he needs to be escorted from his home, or wherever he may be, to the centre, the onus will be on the doctor in charge of that hospital to find an escort, send that escort out to collect the patient and bring him into the hospital. It has been suggested to me that in practice this will be unworkable. We all know the situation obtaining in relation to gardaí and all the rest is fairly unhappy even as it is. The feeling is that the onus should not be on a medical man in charge of a centre to have to arrange these escorts.
The purpose of my two amendments is to place the burden of arranging for the escort on the senior public official of the health board in that area, in other words, the chief executive officer of that health board. That is the purpose of each of those amendments.
I would not be prepared to accept this amendment. The escort will be provided by the hospital. In my view the medical officer in charge of the hospital is the appropriate person to initiate this procedure. Apart from anything else the medical officer would have the clinical judgment to initiate procedures. To provide as the Deputy requires would be to interfere with the long established lines of authority and responsibility obtaining.
The Minister appears to miss the point. The medical officer in charge having the clinical judgment does not arise under the Minister's section, as drafted; the clinical judgment of the medical officer in charge does not enter into it. If one of the general practitioners out in the field who signs the recommendation for a reception order says that, in his opinion, an escort is necessary, that is it. The clinical judgment of the doctor in the hospital does not enter into it. It is the professional judgment of the general practitioner out in the field perhaps some 30 miles away — and this is one of the reasons that the doctors in charge of the hospitals find this type of suggestion so repugnant, because they are talking about a patient whom they have not seen, about whom they know nothing. They are merely notified that some doctor out there, whom they may never have met, has certified that an escort is necessary for some patient way out there. The clinical judgment of the doctor in the hospital does not come into it. That doctor in the hospital may not even know the general practitioner out in the field, never mind the patient. But the onus is on him to find an escort for that patient, collect him and bring him in. The suggestion is that, because there is no medical, clinical judgment involved, it is a question of administration, that the burden should be on the administrative personnel of the health board rather than on the clinical directors of the psychiatric hospitals.
The medical officer is the chief person in charge in the hospital and is the person who would be most competent to judge who should be sent, what will be necessary when an escort is sent, what level of escort is necessary, what sort of people should go to take care of the patient. The medical officer would be in a better position to judge any of these elements, especially since the potential patient is coming to his institution, rather than bring in somebody who could be described as an administrator and who would certainly be much further removed from the scene in that respect.
Obviously I think the suggestion in my amendment, administratively, would be better. I went to the trouble, before tabling these amendments, of discussing this with personnel with experience of the operation of the present system. The view I have put forward is not merely mine but that of the personnel in the field, including the medical directors of a number of these hospitals. They feel that it would be better for the executive officer of the health board to carry out this task rather than themselves. As the Minister has told us earlier, the representatives of the psychiatrists also had discussions with the Minister. I presume that they put their points of view to him and that he apparently did not accept them.
(Cavan-Monaghan):
It would appear that the chief medical officer of the institution which have been asked to accept the patient would not know anything about the patient until he actually arrives there. He will take over when the patient is delivered to him. Deputy Boland is probably correct that it should be a matter for the health board of the area to get the patient into the institution and then hand him over to the chief medical officer.
I do not agree with the Deputy. It is not as simple as that. The reasons seem to me fairly obvious, that the chief executive officer of the health board is well removed from the scene and, indeed, if it is a question of deciding what executive function the medical officer has in his responsibility for making these arrangements, I believe that as it stands, it is preferable.
Amendment, by leave, withdrawn.
Amendment No. 17b not moved.
I move amendment No. 17c:
In page 10, subsection (3), line 5, to delete "arrange" and substitute "provide".
Section 21 (3) would then read:
The Garda Síochána shall, if so requested, provide for the escort.
The doctor in charge of the hospital would be obliged to arrange for an escort under section 21 (1). Under section 21 (2) the doctor in charge of the hospital may, if he thinks it necessary, request the assistance of the Garda Síochána in arranging for such an escort. There does not appear to be any onus upon the Garda to provide an escort, except under section 21 (3) where it says that the Garda Síochána shall, if so requested, arrange for the escort. It was suggested that the onus should be clearly placed upon the Garda by the substitution of the word "provide" for the word "arrange" in section 21 (3).
(Cavan-Monaghan): Subsection (3) is badly drafted, anyway. I have never heard, or seen, it stated that the Garda Síochána would arrange something or the Garda Síochána would do something. The usual thing to say is that something shall be provided by the Commissioner of the Garda Síochána, or a Superintendent of the Garda Síochána, in whose district the patient resides. “Garda Síochána” is a very loose term. I have never seen that kind of loose description when we are trying to say that some member of the Garda Síochána will be responsible for something. Invariably, the rank in question is specified and it should be specified.
I will certainly look at that point. As far as amendment No. 17c is concerned, the word "arrange" was deliberately chosen to impose a clear obligation on the Garda Síochána to make all the arrangements necessary to escort the person concerned to hospital.
In clarification, there may have been a mistake, probably on my part, in the submission of the amendment. The amendment ought to have provided for the deletion of the words "arrange for" and their substitution by the word "provide". The subsection would now read——
The Garda Síochána, shall, if so requested, provide the escort.
——not provide for the escort. If you take subsections (2) and (3) together, it would appear that in a certain case where the doctor in a hospital says "I think we need the guards to bring this patient into the hospital", and the section says that he may, if he thinks it necessary, request assistance of the Garda in arranging an escort and the next subsection says that the Garda shall arrange for the escort, the purpose of the two subsections could be thwarted if the Garda in a particular case said that this was a rather repugnant task which was being given to them.
The two subsections will not place the onus on the Garda to provide a Garda escort. They probably intend to do that, but they do not. They put an onus on the Garda Síochána to arrange for the escort. If the Garda do not, for any reason, want to provide an escort — and I am given to understand that, quite understandably, the Garda very often at present are very loathe to provide escorts in these cases — this is one of the difficulties which can arise when a potentially violent patient needs to be transferred urgently to hospital. The effect of the amendment if it had appeared in the list of amendments in the way I originally intended, would have been that subsection (3) would clearly make the Garda Síochána provide the escort and a member of the Garda Síochána be the escort, rather than at present the Garda being obliged to arrange for the escort, which might not necessarily be a member of the Garda Síochána at all.
Obviously, subsection (21) (2) envisages that the doctor in charge of the hospital will ask for a Garda escort and will presumably expect that a Garda would be the escort. Subsection (21) (3) as it stands does not, in effect, implement that. That was the reason for the amendment. Perhaps the Minister would, in the light of what I have said, consider that aspect?
I will certainly consider it. It changes the meaning of the words somewhat.
I appreciate that. The mistake was probably my own, as it is quite some time since the amendments were submitted.
Is the amendment withdrawn?
Yes. The Minister has said that he will have a look at it.
Amendment, by leave, withdrawn.
Section 21 agreed to.
Sections 22 and 23 agreed to.
SECTION 24.
Under section 24, amendment No. 17d has been discussed with amendment No. 8a.
Amendment No. 17d not moved.
Amendment No. 18 in the name of the Minister has been discussed with amendment No. 9.
I move amendment No. 18:
In page 11, subsection (4), line 7, before "reception" to insert "recommendation for".
Amendment agreed to.
I move amendment No. 18a:
In page 11, subsection (4), line 8, after "person" to insert ", and the registered medical practitioners who signed the recommendation for reception and the nearest living relative of the person".
Up to this, we have been dealing with the GPs making recommendations for reception orders. This is the vehicle which should be used to have the involuntary patient brought into the hospital for assessment. Section 24 sets out the form of the reception order, that is the order which would be made by the doctor within the hospital which would provide for the person to be held in the hospital for a period not exceeding 28 days from the date of his or her admission.
Subsection (4) says:
Where a reception order or extension order is made in respect of a person in any centre the medical officer in charge of the centre shall forthwith inform the person and the applicant for the reception of the person of that fact, of the reason for the extension and of his right to a review under section 38.
This is interesting in the light of the earlier amendment which the Minister has accepted, that in this subsection the person involved is to be informed and, reasonably enough, the person who originally applied to have the patient referred to hospital is also to be informed of the fact that the reception order has been made or the reason for the extension order, and, indeed, of the patient's right to a review, which is a very important right, by the Tribunal of the detention order under section 38, which we will come to later.
The purpose of my amendment would be to notify also the two GPs who signed the recommendation for reception. This patient could not come into the hospital in the first case unless these two doctors out in the community signed an order referring the patient to the hospital for assessment and possible detention over a long time within the hospital. It is reasonable that not only should the patient be notified that he is now going to be held in the hospital for a month, or that an order has been made for his detention in the hospital for some longer period and that the applicant who went to the GP in the community in the first place and asked that the patient be referred to the hospital should be notified; also the two GPs signing the order, because it is a very onerous obligation on any doctor from the point of view of signing a recommendation in the first instance to send a patient in in a voluntary capacity. If the hospital decides to detain the patient and lock him up for a month or a longer period then the two GPs who signed the initial order should also be informed. They should also be informed if the patient is later on discharged. It could be that a patient might harbour feelings of resentment against those who had been involved in the distasteful process of having the patient referred and forcibly detained. Not only should the applicant for reception be informed but so also should the two doctors involved in signing the certificate putting the machinery into operation. Likewise the nearest living relative of the patient should be informed.
I would accept the amendment in so far as it relates to the notification of the doctors who made the recommendation for reception. I could see difficulties arising in searching out the nearest relative. That could create conflict if it were not the nearest relative. I could not accept that part of the Deputy's proposal. On Report Stage I shall have an amendment providing for notifying the doctors.
The purpose here was to ensure the safeguarding of the patient's rights. That was the purpose in putting in the notification of the nearest living relative. As the Minister said, the person who initiated the process might not always be the nearest living relative.
Amendment, by leave, withdrawn.
Question proposed: "That section 24, as amended, stand part of the Bill."
(Cavan-Monaghan): This section provides:
A reception order shall be in the prescribed form and shall provide for the reception, detention and treatment of the person for a period not exceeding 28 days from the date of his admission to the specified psychiatric centre.
We had this already on the definition section. I take it at least two consultant psychiatrists would be available.
Question put and agreed to.
SECTION 25.
Question proposed: "That section 25 stand part of the Bill."
(Cavan-Monaghan): Although the Minister has been emphasising that treatment and care are the keynote in the approach to mental illness the draftsmanship seems to emphasise detention rather than treatment. Section 25 reads:
Where a reception order is made the medical officer in charge of the psychiatric centre to which the order relates and the officers and servants of the centre shall receive the person to whom the order applies and detain him subject to the provisions of this Act.
This is crude draftsmanship. Servants will detain the patient. This is the sort of antiquated language we should avoid. One can visualise an unfortunate patient being dragged down a corridor. That is the sort of picture it conjures up. That is not the sort of picture we want to paint in 1981 when we are scrapping a huge volume of legislation.
(Cavan-Monaghan): It is not legal language. Talking about “servants” is definitely last century.
Question put and agreed to.
SECTION 26.
I move amendment No. 18b:
In page 11, between lines 22 and 23, to insert the following new subsection: "(3) The boarding out of a person shall only take place——
(a) when it has been recommended by the authorised medical practitioner caring for and treating such person,
(b) when the authorised medical practitioner certifies that the person does not require in-patient services in the psychiatric centre and is not a danger to the health and safety of himself or of other persons.
(c) if such a person is a person in respect of whom a reception or extension order is in force, after the applicant for reception and the registered medical practitioners who signed the recommendation for reception and the nearest living relative of the person have been notified"
If a patient is to be boarded out the doctor in charge of the hospital should sign a certificate saying that the person does not require continuous in-patient treatment and will not be a danger either to the health and safety of himself or to others in the community. This boarding out process was also provided in the 1945 Act. It is a very desirable process because it is designed to reinstate the patient in the community but there must be some safeguards. Two doctors sign a recommendation for a reception order and the patient goes perhaps under some protest into hospital, is examined there within 48 hours and two other doctors, qualified consultant psychiatrists, have to sign an order to keep him in hospital for 28 days. In the case of boarded-out patients we can assume that before the 28 days expires two other doctors or the same two doctors will sign the extension order. In most cases patients have been detained in care at least a number of months before they were boarded out. A lot of legal safeguards and steps are provided in the different sections of this Bill and if it comes to the stage — although a reception order is still in force in relation to him, in other words two consultant psychiatrists have said that this patient needs to be detained in hospital in their opinion — that that patient then is let out into the community, you need first of all a qualified consultant psychiatrist to say that it will not be a danger to the health or safety of this patient or of his neighbours and the people he associates with if he goes out into the community. That is the reason for parts (a) and (b) of my amendment.
The reason for part (c) is that the doctors who originally signed the recommendation for reception are going to be notified that the patient is being held in hospital and so also will the applicant who originally went to those doctors. For some reason a lot of examples have been given around the county of Cavan here today. If the local GP from, say, Arva is strolling down the main street in Cavan town and discovers suddenly some client for whom he signed a recommendation for reception order about two months earlier coming down the street, serving him in a shop and so forth, it is going to be a fair surprise for that GP, and also the applicant and the relations. Therefore, it seems fairly sensible that if the stage is going to be reached in the treatment of a patient where he will be allowed to be boarded out, the people who originally participated in the process of boarding him in permanently should be told of the situation.
Section 26 provides for the making of regulations governing the boarding out of persons undergoing care in the psychiatric centres. Of course, not all of these would be detained patients. The provisions which the Deputy seeks to make are more appropriate for inclusion in the regulations and I will bear them in mind in drawing up such regulations.
(Cavan-Monaghan): This idea of boarding out mentally ill people is a comparatively recent innovation which I think is a move in the right direction towards rehabilitation of people in the community. I agree with it fully, but I suggest that when selecting houses — usually houses are taken over by the health boards and people go and reside in them — health boards should be careful in selecting these houses where they select them. They should not select them in local authority housing estates because, first of all, there is a great demand for houses among the local community and there are usually a number of applicants for every house that is built.
(Cavan-Monaghan): It is on the section.
Is the Deputy's amendment withdrawn?
I do not really accept that this is more appropriate to regulations than to legislation. I accept what the Minister says. In fact, he justifies a point that I made earlier on Second Stage, that the vast bulk of people receiving psychiatric treatment are being treated in a voluntary capacity. The Minister may say, "OK, this section in relation to boarding out will apply in the main to people who are there in a voluntary capacity" but if they are there in a voluntary capacity you do not have to put a section into the Bill saying that they can be boarded out. They boarded themselves in voluntarily, so they can just agree to participate in the boarding-out arrangements. You do not put in a section to say that power will be given to the health boards to make boarding-out arrangements. If the people are in the hospitals in a voluntary capacity then they themselves can voluntarily enter into an arrangement with their doctor and the health board to be boarded out into the community.
The real reason for a section like section 26 is so that you can board out those who otherwise are locked up. Consequently, you need to define clearly in section 26 that a person who is locked up on foot of a reception or extension order is to be allowed out into the community. It is not good enough to provide for it in regulations because under the rest of this Bill that patient is legally obliged to be detained in a psychiatric centre on foot of the extension or reception order in force at that time signed by the authorised medical practitioners. If you want to envisage any situation where that patient who legally should be within that hospital confines is to be out in the community, that needs to be defined in the legislation also. It is not appropriate to try to define it in regulations. Anyone picking up this Bill afterwards and reading it is going to ask himself the question that I ask, how can somebody be boarded out and be free to participate in the life of the community if at the same time a consultant psychiatrist has signed an order saying that in his opinion that person should be detained within a hospital? If you want to do it in the way that the Minister suggests, then the consultant psychiatrist needs to sign an order saying that the reception or extension order no longer needs to be in force. You cannot have it two ways. You cannot have an order in existence signed by a qualified consultant psychiatrist which says that the person in his own interest needs to be locked up in hospital while at the same time the person is out walking the streets.
It is regrettable to say that over the years we will get at least one incident where somebody who is boarded out will behave irresponsibly and possibly will do something injurious to himself or to others. On the law of averages that is bound to happen even with the maximum care possible and possibly the situation will be ambiguous. If an order signed by a consultant psychiatrist is in force at that time that means that this person should be locked up, and yet the person is out in the community. For instance, supposing a patient in respect of whom an order says he should, in his own interest, be locked up in a psychiatric hospital to receive treatment, steps out underneath a bus and is killed, are his relations not entitled to ask what he was doing out there anyway, when there is a certificate in existence which says that he should be detained in hospital? There is nothing in this Bill that will explain how it is that he is out in the community. The Minister on behalf of his successors as well as himself is taking on far too much in regulations under section 26 to suggest that the cancellation of the reception order would be provided for under ministerial regulations, or if not, that, the orders made by the consultant psychiatrist would be temporarily placed in cold storage.
My amendment spells out quite reasonably that the boarding out will only take place when it has been recommended by the authorised medical practitioner caring for and treating the person, and when the authorised medical practitioner certifies that the person does not require in-patient services in the psychiatric centre and is not a danger to the health and safety of himself or of any other person.
It is entirely reasonable that that should be enshrined in the legislation to make the situation crystal clear for the consultant psychiatrists, for the staff of the hospital, and for the staff in the homes to which the patients might be boarded out. It does not suffice to provide for that in regulations. It needs very definitely to be enshrined in the legislation that the doctors who originally signed the order referring the person into the hospital for examination should be notified if that person is being discharged, even on a temporary basis, back into the community. It is especially reasonable when you think of instances where people were discharged from psychiatric hospitals and their relatives and those involved in having them referred to the hospital were not aware of it. When such people arrive home suddenly and unexpectedly that could lead to unhappy and tragic consequences. For that reason the legislation and not the regulations should spell out clearly what needs to be done.
Section 28 provides for permitted absences. The medical officer in charge of a psychiatric centre and the authorised medical practitioner with specific responsibility for the care of a particular person detained in the centre may permit the person to be absent from the centre for a period or an extended period amounting to less than the unexpired number of days provided for in the current detention order. This is a matter for the judgment of the medical officers in charge. That is covered within the Bill as it stands.
Under the existing legislation a health board may board out a patient detained in one of their institutions. In practice very few patients are boarded out, but it is considered desirable to continue to give power to the health board to do so. The Commission of Inquiry on Mental Illness recommended that there should be a properly supervised system of what is called family care for the mentally ill. The provision in this section provides a broad statutory basis to enable the boarding out of any suitable mentally ill or mentally handicapped person. It is considered that the details of the boarding out procedures and safeguards would be more appropriately dealt with by regulations.
Amendment, by leave, withdrawn.
Question proposed: "That section 26 stand part of the Bill."
(Cavan-Monaghan): I agree with rehabilitating people in the community rather than in institutions when they are suitable for boarding out. Health boards should be careful in selecting houses in which to board out these patients. I do not think it is desirable that they should be boarded out in a house acquired in a local authority housing estate. There is great demand for these houses by local people. Usually there are three or four applicants for every house. Resentment is created against the health board and the occupants for the time being.
These houses are occupied by patients who are boarded out for some months and then they are vacant for another few months. That continues the local resentment. The health boards should be more selective about where they choose these boarding out houses. The community in general should accept these patients into their localities as boarded out patients.
It is a feature of the development of the services for the psychiatrically ill that it is important to provide treatment within a community environment. This is very desirable. I accept what the Deputy says about being careful about this matter and about patients who might be discharged into such a situation. Broadly speaking, I am in favour of making provision within the community.
(Cavan-Monaghan): I am all in favour of making provision within the community. Why not make it in some avenues or more sedate localities? I am not making any comparison. I want to make that clear. I will not spell it out any further because I would be misrepresented. There are too many demands on the scarce number of houses available to the local authorities. If people are not welcome there, it is not good for the locality and it is not good for the patients. That is all I am saying.
Question put and agreed to.
SECTION 27.
I move amendment No. 19:
In page 11, subsection (1), line 24, after "place" to insert "under an order made under section 23 (2) or".
As the Bill is drafted, a person who is detained for a period of 48 hours under the provisions of subsection (2) of section 23 pending examination in a centre by a consultant psychiatrist and who escapes cannot be re-taken and brought back to the psychiatric centre. Neither could a person who was transferred from a psychiatric centre to a special psychiatric centre under the provisions of subsection (7) of section 31 be re-taken and brought back. These were oversights in drafting which it is necessary and desirable to correct.
Amendment agreed to.
I move amendment No. 20:
In page 11, subsection (1), line 25, after "section 29 (5)" to insert "or 31 (7)".
Amendment agreed to.
Question proposed: "That section 27, as amended, stand part of the Bill."
(Cavan-Monaghan): The drafting in section 27 is much more desirable than the drafting in section 25. Section 25 talks about the officers and servants of the centre receiving the patient and detaining him. The Minister told me that was legal jargon. I think it is ignorant jargon, but that is beside the point. Section 27 says that the person may be brought back to the centre or place by persons employed at that centre. That is put much better than it is in section 25. I want to compliment the draftsman on section 27 and say I do not approve of section 25.
Question put and agreed to.
NEW SECTION.
(Cavan-Monaghan): I move amendment No. 20a.
In page 11, before section 28, to insert the following new section:—
"Where any person—
(a) induces or assists the escape or attempted escape of any person in respect of whom a reception order or extension order is currently in force, from a psychiatric centre or special psychiatric centre or,
(b) induces or assists a person who
(i) has been boarded-out by a health board in accordance with the provisions of section 26 (1),
(ii) is absent, as permitted by section 28, from a psychiatric centre.
(iii) has been removed from a psychiatric centre for treatment or for the benefit of his health,
to escape or leave the place where he is maintained while boarded-out, absent as permitted by section 28, being treated or for the benefit of his health or
(c) harbours or conceals a person who has so escaped
such person shall be guilty of an offence under this section and shall be liable on summary conviction thereof to a fine not exceeding five hundred pounds or, at the discretion of the Court to imprisonment for a term not exceeding six months or to both such fine and such imprisonment."
Section 28 is the section which permits absence by a patient from hospital with the consent of the officers in charge of the hospital. It says that he may be brought back if he exceeds his parole. The amendment proposes to make it an offence for anybody to assist or encourage a patient to absent himself from the institution. If the patient may be apprehended and brought back, it is obvious that anybody who encourages him to stay away or assists him to stay away is guilty of an offence.
In the new section being proposed a special psychiatric centre is mentioned. I understand that the Central Mental Hospital in Dundrum is such a psychiatric centre. I imagine that the law applies there, even without this section, in respect of some detained patients there. I believe this new section is necessary and I recommend the amendment to the Minister.
I could not contemplate accepting such an amendment, the affect of which would be to put the person undergoing treatment for psychiatric illness on a par with persons undergoing treatment for criminal offences. Obviously, it would be very undesirable for relatives to take psychiatric patients away from treatment centres, but I would not be prepared to expose such a misguided person to the rigours of the law. The Deputy has mentioned the Central Mental Hospital in Dundrum. There would, of course, be the question of breaking and entering, which would arise in the normal way, as one would have difficulty otherwise.
(Cavan-Monaghan): Deputy Boland's amendment goes on to deal with harbouring people. A lot of the people in Dundrum have been sent there by the courts because they were found guilty of serious offences but found not responsible for their actions. They are confined there either at the pleasure of the Government or under a court order. I imagine that it is a serious offence to assist in an escape from Dundrum or to harbour a person who has escaped from Dundrum. I would like the Minister to tell me what is the difference between the two so far as this is concerned. If I was the Minister I would not be pushing the matter aside, I would be thinking about it.
I do not want to introduce any draconian measures which would create the situation where people undergoing treatment for psychiatric illness were put on a par with people who are imprisoned. I do not think it is necessary. There is not any evidence to show it is necessary and for that reason I am not prepared to accept the amendment.
(Cavan-Monaghan): Does the Minister not accept that there have been escapes from Dundrum that could only have been organised with the assistance of people from outside?
The Garda have been very effective in pursuing any of those cases. I do not believe they have any problem in dealing with that situation. That is why I would not like to enlarge this to apply to every situation.
(Cavan-Monaghan): Has the Minister looked into this? Can he say exactly what the law is in regard to the matter raised by Deputy Boland?
I can certainly look further into it but, to my knowledge there are not such penalties for such a person. With regard to Dundrum, there does not seem to be any problem in dealing with people who interfere with the institution or try to take people away from it. In relation to the general patients receiving treatment for psychiatric illness, I do not believe this is necessary. There are not such penalties and I do not believe it is necessary to have them.
Amendment, by leave, withdrawn.
SECTION 28.
(Cavan-Monaghan): I move amendment No. 20b:
In page 11, line 37, to delete "detention order" and substitute "reception or extension order, provided that he has first notified—
(a) the applicant for the reception of the person,
(b) the registered medical practitioners who signed the recommendation for reception and
(c) the nearest living relative of the person".
The effect of this will be that the medical officer in charge of a psychiatric centre or the authorised medical practitioner with specific responsibility for the care of a particular person detained in a centre may permit the person to be absent from the centre for a period or extended period amounting to less than the unexpired number of days provided for in the current detention order provided, as Deputy Boland says, he notifies the applicant for the reception of the person, the registered medical practitioner who signed it and the nearest relative. I believe that Deputy Boland has in mind that those people should know the whereabouts of the patient and, if he is allowed out or transferred to some place, those people should be notified. Relatives might be concerned if they just happened to hear that the patient was seen in a neighbouring town, for instance. The amendment is reasonable and well-intentioned and I recommend it to the Minister.
This section will relate normally to a patient who is being allowed out on trial by his consultant psychiatrist. The amendment could have the effect of impeding the psychiatrist in his endeavours to ease back into conditions of normal living a person suffering from psychiatric illness. Psychiatrists must be allowed exercise their discretion as to who should be notified and for that reason I cannot accept the amendment.
(Cavan-Monaghan): I find it difficult to agree with the Minister's approach to this amendment. It is not a question of anybody trying to impede a consultant psychiatrist or to make his work more difficult.
What is proposed could make his work considerably more difficult.
(Cavan-Monaghan): In what way?
First, he would have to find the nearest living relative and then various other people, including the medical practitioner concerned.
(Cavan-Monaghan): The “nearest living relative” may be an unfortunate choice of words. We all know that anybody being admitted to a hospital even if only for the removal of an appendix is asked for, among other information, details of his nearest living relatives and these relatives are the people that should be notified in the type of cases we are talking about in the context of this section.
There is not yet an accepatance in rural Ireland of psychiatric hospitals as everyday institutions but we are well on the way to their being accepted as such. It is still something of a traumatic experience in rural Ireland to find that it is necessary to send a relative to a psychiatric institution. If, instead of treating a patient at place A it is decided that he is to be treated at place B which may be 25 miles away, the least his relatives might expect would be a notification to that effect from the hospital. Without provision for such notification, the first a relative might know of a patient's transfer would be when he had been seen by someone miles away form the institution at which he was detained in the first place. In such circumstances the relative would be forgiven for thinking that the patient had escaped. I find that the Minister can be quite unreasonable in some instances but he is being absolutely unreasonable in this case.
If the relatives are in contact in any way either with the institution concerned or with the patient they will have no difficulty in knowing that he is reaching a stage where a move might be contemplated. A problem arises in that relatives generally, as we know from recorded facts and from surveys, do not visit patients in such institutions. I hope that we are fast approaching the time when this situation will be changed. As the Deputy says, there are improvements in that regard but if they are keeping in contact and if they have an interest they will know what is going on.
(Cavan-Monaghan): I do not accept what the Minister says. It is unfair to give the impression that people do not visit their mentally-ill relatives. That is not so. There are exceptions and there are long-stay patients who have gradually lost touch with their people but by and large near relatives keep in touch with their mentally-ill relatives in hospitals and visit them frequently. I wish that the Minister would acquaint himself more with the situation. It is not right that it should go out from here that nobody visits mentally-ill patients.
It would not be a very big job to send a letter to the next-of-kin of a patient informing them of his transfer. In the event of the death of a patient, the next-of-kin would be notified. It could hardly be regarded as imposing too great an administrative task on the staff of hospitals to draft a simple form to the effect that So-and-So was being allowed out of hospital and would be residing at such a place until further notice. I have witnessed uproar in this House and among the community about people being detained by the Garda without their relatives being informed of where they were being detained. The Minister's reaction to this reasonable suggestion of ours makes one despair of democracy and of improving legislation even in a simple way in this House. In the event of a patient being transferred or being allowed out into the community for rehabilitation purposes his next-of-kin should be so notified. It would suffice if, say, a relative visited the patient some days prior to the change and was so notified but in other cases relatives should be notified by post.
The psychiatrists can be allowed exercise their discretion in this respect. I do not foresee any problem in relation to these permitted absences.
(Cavan-Monaghan): I give up.
Amendment, by leave, withdrawn.
Section 28 agreed to.
SECTION 29.
Amendment No. 21 has been discussed with amendment No. 9.
I move amendment No. 21:
In page 12, subsection (1), line 4, before "reception" to insert "recommendation for".
Amendment agreed to.
(Cavan-Monaghan): I move amendment No. 21a:
In page 12, subsection (1), line 4, after "centre" to add ", the registered medical practitioners who signed the recommendation for reception, and the nearest living relative of the person.".
The subsection would then read: "A person detained in a psychiatric centre may in his own interest be transferred to another psychiatric centre in accordance with this section after consultation with the person and, if available, with the applicant for the reception of the person in the centre, the registered medical practitioner who signs the recommendation for the reception and the nearest living relative of the person."
Instead of the words "nearest living relative" I would prefer to use the words "the next-of-kin" as notified to the institution. I would not be too particular regarding the medical practitioner in this sense. However, I despair of the Minister accepting this reasonable request just as I despair of his giving us any rational reason for not accepting it. Surely relatives are entitled to know where their sick relations are. If a person is in a county hospital in provincial Ireland and is being transferred to Dublin, if it is in an acute hospital in the country, he will be told. Why have a change here? Really what we are doing is handing these patients into the custody of the chief medical officer or chief psychiatrist and leaving everything to his mercy. We are prescribing many things here. Why not prescribe that?
The section makes it clear that where a patient is being transferred to a psychiatric centre it will be because it is considered to be in his own interest. This is another instance where we must assume that the psychiatrist concerned will consider all the circumstances including the views and attitudes of relatives and any others closely concerned with his welfare. I should not like unduly to impede him in his judgment or actions in this respect. As it stands, the applicant will be consulted. Certainly, I would be prepared to consider an amendment for the Report Stage including the two registered medical practitioners — taking that part in —"the applicant and the registered medical practitioners who signed the recommendation for reception".
(Cavan-Monaghan): I think the relatives are more important.
The applicant would normally be somebody closely associated and who is available.
(Cavan-Monaghan): It is proposed to include the applicant?
The applicant is already included.
(Cavan-Monaghan): I would be more concerned about the relatives but if the relatives and the applicant are one and the same, there is no problem. If the applicant and the relatives are not the same, there is a problem. The Minister might thaw a bit and think about the whole matter.
I shall think about it but normally if the relative is interested, the relative will be the applicant.
(Cavan-Monaghan): I wish the Minister would not go on saying, “if the relatives are interested”, because the majority of relatives are interested.
If they are, they will be the applicants.
(Cavan-Monaghan): They might or might not. There might be some other consideration.
If they are not, it could be difficult to locate them or they could be somewhat uninterested. I will consider the matter in any case.
Amendment, by leave, withdrawn.
As amendments Nos. 21b and 22b are related they may be discussed together.
(Cavan-Monaghan): I move amendment No. 21b:
In page 12, after subsection (5), line 35, after "detained" to add "save that the medical officer in charge of that centre or place shall be the medical officer responsible for that person for so long as the person is detained in such centre".
Subsection (5) says:
Where a person is transferred under this section, the reception order under which he was detained shall have effect as if it specified the centre or place to which he is to be detained.
We are proposing to add "save that the medical officer in charge of that centre or place shall be the medical officer responsible for that person for so long as the person is detained in such centre". The object of the amendment is to make it clear that the medical officer who will be responsible for the patient is the medical officer in the centre to which he has been transferred. It seems reasonable.
It is unnecessary. It is obvious that responsibility for the patient at any particular time must rest with the medical officer in charge of the centre or place where the patient is at that time. This is the position in any case where a patient is transferred from a psychiatric centre to a special psychiatric centre or from a psychiatric centre to a general hospital or from a special psychiatric centre to a general hospital. There is no purpose in making any specific reference to such responsibility.
Amendment, by leave, withdrawn.
Section 29, as amended, agreed to.
SECTION 30.
Question proposed: "That section 30 stand part of the Bill."
(Cavan-Monaghan): This is the section that deals with the Central Mental Hospital, Dundrum. How many special psychiatric centres are there in the country at present?
(Cavan-Monaghan): This section gives the Minister authority to designate other psychiatric institutions or portions of them as special psychiatric centres if he considers it necessary at any time — obviously an enabling section.
Question put and agreed to.
SECTION 31.
(Cavan-Monaghan): I move amendment No. 21c:
In page 13, subsection (3), lines 1 to 4, to delete paragraph (a), and substitute:
"(a) the applicant for the reception of the person in the district or psychiatric centre,".
This section provides for the transfer of patients to special psychiatric centres, in other words to Dundrum. Deputy Boland's amendment proposes to delete section 31 (3) (a) which reads:
the applicant for the recommendation for reception in pursuance of which he is detained, where the application was made under paragraph (a), (b), (c), (d) or (g) of section 15 (2)
and to substitute
the applicant for the reception of the person in the district or psychiatric centre,
It reads at the moment that before the person is transferred, the review board shall give at least seven days' notice of its direction to that person and to the applicant for the recommendation for reception in pursuance of which he is detained. Deputy Boland wants to delete that and substitute to "the applicant for the reception of the person in the district or psychiatric centre".
To me it is clear that is the person who should be notified and whether that is the same person as the person in the existing paragraph I am not too clear. Could the Minister say who is the applicant for the recommendation for reception in pursuance of which he is detained where the application was made under paragraph (a), (b), (c), (d) or (g) of section 15(2). It may be the same person and if so there is not much involved.
The amendment proposes to include in the list of persons to whom notice must be given of the transfer of a patient to a special psychiatric centre, the Garda Síochána, where relevant, and the authorised officer in circumstances where he acted on his own initiative as distinct from the request of the relations. Neither a garda nor an authorised officer can necessarily be expected to have the same continuing interest in the patient as have the patient's relatives. I do not deem it necessary to notify them and for this reason I do not propose to accept the amendment. These are the only two categories excluded, the garda who may have been involved in the reception and the authorised officer who are not taken to have a longer-term interest.
(Cavan-Monaghan): Deputy Boland's amendment would put them back into it?
(Cavan-Monaghan): Who is included in paragraph (a) that now stands?
They are listed there — (a) a parent or guardian of that person, (b) a spouse of that person ordinarily resident with him, (c) is a son or a daughter and so on.
(Cavan-Monaghan): It is clear now. The Minister is excluding the Garda and the authorised officer?
Amendment, by leave, withdrawn.
I move amendment No. 22:
In page 13, subsection (5) (a), to delete line 11 and substitute:
",the applicant for the recommendation for reception or the person to whom notice was given under subsection (4)".
I decided on this amendment because it is desirable to add to the list of those who may appeal to the High Court against a decision of the review board to transfer a person to a special psychiatric centre, those relatives mentioned within the categories in section 15(2), which are parents, spouses, brothers or sisters, sons or daughters. Provision already exists in subsection (4) to notify them of the review board's decision.
Amendment agreed to.
(Cavan-Monaghan): I move amendment No. 22a.:
In page 13, between lines 23 and 24, to insert the following new subsections —
"(6) Where the medical officer in charge of the centre in which the person is detained makes a recommendation under subsection (1) of this section and further states in such recommendation that he is satisfied —
(a) that because of the person's state of mind it is particularly urgent that he should be transferred without delay to a special psychiatric centre and
(b) that because of the delay which would be occasioned through the provisions of subsections (2) to (5) of this section such delay would be detrimental to the health and safety of the person or of other persons,
the review board shall forthwith arrange for the examination of that person by two independent authorised medical practitioners, to be selected from a panel to be nominated for such purpose from time to time by the Minister.
If, following examination by the authorised medical practitioners, such practitioners sign a certificate concurring with the views of the medical officer in charge the person shall forthwith be temporarily transferred to a special psychiatric centre on foot of such certificate but only for such period as is necessary to allow the provisions of subsections (2) to (5) to occur.
(7) The certificate authorising the temporary transfer and signed by the two authorised medical practitioners shall be known as the ‘emergency temporary transfer order'.
(8) Immediately upon the review board arranging for the examination of the person under subsection (6) of this section the board shall notify —
(a) the applicant for reception,
(b) the committee of the person and
(c) the nearest living relative of the person
and such persons shall have the same rights under this subsection as under subsection (5)."
It is obvious that when a person is being transferred to a special psychiatric centre it is because he has become difficult to handle, to put it mildly, difficult to control and possibly dangerous to himself and others. The purpose of Deputy Boland's amendment is to facilitate the speedy transfer of the person without the necessity of going through the provisions laid down in subsections (2), (3), (4) and (5) as a temporary measure only. If it was a matter of extreme necessity and the advice of three consultants had not been obtained, it would be the two authorised medical practitioners and the medical officer in charge of the board. This is a practical and well thought out amendment. It is a facilitating amendment and it could do a lot of good.
The amendment comes from a perception of the need for urgency in certain cases. The delay involved in effecting transfer is not great, and I would remind the Deputy that psychiatric centres are institutions which are designed and whose staff are trained to cope with seriously disturbed people who on occasions can be dangerous to themselves or to others. I am reluctant to pre-empt the appeals system and therefore I am not prepared to accept this amendment.
Amendment, by leave, withdrawn.
Amendment No. 22b. was debated with amendment No. 21b. Amendment No. 21b was withdrawn so I take it that this one is not moved.
Amendment No. 22b not moved.
(Cavan-Monaghan): I move amendment No. 22c:
In page 13, between lines 41 and 42, to insert the following new subsection:
"( ) Where a person is to be discharged under this section the medical officer in charge of the special psychiatric centre shall first notify—
(a) the applicant for the reception of the person.
(b) the registered medical practitioners who signed the recommendation for reception.
(c) the nearest living relative of the person, and
(d) the medical officer in charge of the psychiatric centre from which the person was originally transferred".
Deputy Boland in putting down this amendment is continuing his desire to see that the people who were responsible or on whose recommendation or certificate the patient was received in one institution should be notified before the patient is either transferred to another centre or is discharged. Deputy Boland has argued with considerable clarity the reasoning behind these amendments. The reasoning is sound and I recommend this amendment to the Minister.
I do not see the necessity for the notification process which the Deputy seeks to impose. The medical officers and the review board which directed his transfer to the psychiatric centre will both be satisfied that the patient should be discharged having presumably evaluated all the circumstances of the case. There is no necessity to impose a statutory obligation of notification of discharge.
(Cavan-Monaghan): Will the Minister make regulations dealing with these things among others?
I will certainly consider the point raised by the Deputy.
(Cavan-Monaghan): Perhaps the points made by Deputy Boland on these amendments could be covered by regulations which the Minister might make.
Amendment, by leave, withdrawn.
(Cavan-Monaghan): I move amendment No. 22d.
In page 14, subsection (10), between lines 4 and 5, to insert the following new paragraphs—
"(c) Where a person is so temporarily transferred and detained under the provisions of this subsection the medical officer in charge of the centre or place where he is shall be the medical officer responsible for that person for so long as he is detained in such centre or place.
(d) A person temporarily transferred and detained under the provisions of this subsection shall be regarded as detained under the reception order made in respect of him under this Act"
This is an amendment to section 31. Deputy Boland proposes to insert new paragraphs in section 31(10) as follows:
(c) Where a person is so temporarily transferred and detained under the provisions of this subsection the medical officer in charge of the centre or place where he is shall be the medical officer responsible for that person for so long as he is detained in such centre or place.
(d) A person temporarily transferred and detained under the provisions of this subsection shall be regarded as detained under the reception order made in respect of him under this Act.
We had a discussion on paragraph (c) in relation to another amendment in the name of Deputy Boland but we did not have a discussion about what is involved in paragraph (d).
This amendment seeks to insert two new paragraphs. The first is essentially the same in context as amendment Nos. 21b and 22b proposed with regard to sections 29 and 31. It is obvious that the primary responsibility for a patient at any time rests with the medical officer in charge of the centre or place where the patient is at that time. That is the position in any case where a patient is in a special psychiatric centre and has to be transferred to, say, a general hospital for an operation. The medical officer in charge of the general hospital assumes responsibility for the patient during his residence at the general hospital.
Amendment, by leave, withdrawn.
Progress reported; Committee to sit again.
