High-Risk Medicolegal Conditions in Pediatric Emergency Medicine.

The top 5 reasons for pediatric malpractice are cardiac or cardiorespiratory arrest, appendicitis, disorder of male genital organs, encephalopathy, and meningitis. Malpractice is most likely to result from an "error in diagnosis." Claims involving a "major permanent injury" were more likely to pay out money, but of all claims, only 30% result in a monetary pay out. Consideration of "high-risk misses" may help to direct a history, examination, testing, and discharge instructions.

Gravely Disabled: The Vestigial Prong of 5150 Designations.

Effective July 1, 1972, California's Lanterman-Petris-Short Act (LPS Act) set the precedent for modern mental health commitment procedures in the U.S. named after its authors, State Assemblyman Frank Lanterman and State Senators Nicholas C. Petris and Alan Short, the LPS Act sought to "end the inappropriate, indefinite, and involuntary commitment of persons with mental health disorder"; to "provide prompt evaluation and treatment of persons with mental health disorders or impaired by chronic alcoholism"; and to "guarantee and protect public safety." Despite citing to these articles of intent, the LPS Act violates its own legislative intent through its inclusion of "gravely disabled" in its enforcement of involuntary psychiatric hold designations (also known as "5150 designations"). First, police officers are not required to make a medical diagnosis of a mental health disorder at the time of a 5150 designation; the broad scope of "gravely disabled" increases the number of persons police officers can involuntarily transport, increasing the likelihood of inappropriate and involuntary commitment of persons with mental health disorders. Second, the broad scope of "gravely disabled" produces an onslaught of 5150-designated persons (whether improperly designated or not) being sent to LPS-designated hospitals with limited resources (e.g., lack of beds and psychiatric staff); this results in patients waiting for an inordinate amount of time for a psychiatric evaluation and/or a hospital bed. Third, it is unclear whether the LPS Act sought to provide protection for the mentally ill or to provide protection from the mentally ill in its guarantee of protecting "public safety"; the inclusion of "gravely disabled" in 5150 designations indicates that the LPS Act provided the public with a duplicitous means of removing the mentally ill, impoverished, and houseless from the streets under the guise of "public safety." This Paper suggests the following to help remedy the effects of implementing the broadly defined "gravely disabled" in 5150 designations: (1) Remove "gravely disabled" from the 5150 criteria; (2) integrate the community with mental health advocacy efforts by creating outreach and education programs; and (3) implement a client-centric approach to interacting with persons with mental health disorders through restorative policing and the establishment of a restorative court.

Psychiatric commitment under the criminal law in China: An empirical perspective.

This article examines the legislation and practice of compulsory treatment in China. Part I traces the Chinese history of criminal commitment law, explains the research methodology, and highlights some general empirical findings. Part II provides a comprehensive empirical analysis of compulsory treatment law in China, it covers both substantial issues such as criteria of compulsory treatment and procedural issues such as the commitment hearing, enforcement, and discharge of compulsory treatment. It also explores the compulsory treatment law from the human rights protection perspective. Our primary objective is to present the empirical findings to enable the legislative and other involved government agencies to make informed decisions about the future evolution of Chinese law in this area.

"It's about how much we can do, and not how little we can get away with": Coronavirus-related legislative changes for social care in the United Kingdom.

The coronavirus pandemic, referred to here as Covid-19, has brought into sharp focus the increasing divergence of devolved legislation and its implementation in the United Kingdom. One such instance is the emergency health and social care legislation and guidance introduced by the United Kingdom Central Government and the devolved Governments of Wales, Scotland and Northern Ireland in response to this pandemic. We provide a summary, comparison and discussion of these proposed and actual changes with a particular focus on the impact on adult social care and safeguarding of the rights of citizens. To begin, a summary and comparison of the relevant changes, or potential changes, to mental health, mental capacity and adult social care law across the four jurisdictions is provided. Next, we critique the suggested and actual changes and in so doing consider the immediate and longer term implications for adult social care, including mental health and mental capacity, at the time of publication.several core themes emerged: concerns around process and scrutiny; concerns about possible changes to the workforce and last, the possible threat on the ability to safeguard human rights. It has been shown that, ordinarily, legislative provisions across the jurisdictions of the UK are different, save for Wales (which shares most of its mental health law provisions with England). Such divergence is also mirrored in the way in which the suggested emergency changes could be implemented. Aside from this, there is also a wider concern about a lack of parity of esteem between social care and health care, a concern which is common to all. What is interesting is that the introduction of CVA 2020 forced a comparison to be made between the four UK nations which also shines a spotlight on how citizens can anticipate receipt of services.

Socio-economic impact on involuntary admissions and coercive measures in psychiatric hospitals in Germany.

OBJECTIVE: The present study aimed to characterize involuntary psychiatric admissions and coercive measures within psychiatric hospitals regarding their temporal development and processual aspects. Moreover, the influence of socio-economic factors on involuntary admissions and coercive measures was investigated. METHODS: Different data sets from the federal state of North-Rhine Westphalia (NRW) were used in this study. In addition to a survey in which n = 33 hospitals responded (40.7%), official data from the Federal Health Ministry were analysed over a decade regarding involuntary admissions and coercive measures. These data were available for all n = 54 districts, respectively, all n = 81 psychiatric hospitals in NRW. Datasets were mainly analysed comparing different socio-economic clusters. RESULTS: The hospital admission rate increased significantly over time (from 1.12 to 1.34 per 1000 inhabitants) within ten years. However, whereas the admission rates differed significantly between socio-economic clusters, the amount of coercive measures used in the hospitals did not. Compared to general psychiatry and addiction medicine, geriatric psychiatry had the highest amount of involuntary admissions (12.2% under public law, 14.1% under civil law). Furthermore, most coercive measures lasted at least an hour. CONCLUSION: It seems that, despite intense discussions and enhanced efforts to reduce coercion, there are still some neglected aspects, such as the need for coercive measures and their duration, particularly in the geriatric psychiatric setting. In addition, the results show that further approaches to prevent involuntary admissions are needed to address other stakeholders beyond the hospitals and further aspects of the socio-economic environment.

Does legislative change affect the use and duration of compulsory treatment orders?

OBJECTIVE: Victoria, Australia, introduced reformed mental health legislation in 2014. The Act was based on a policy platform of recovery-oriented services, supported decision-making and minimisation of the use and duration of compulsory orders. This paper compares service utilisation and legal status after being on a community treatment order under the Mental Health Act 1986 (Vic) with that under the Mental Health Act 2014 (Vic). METHODS: We obtained two distinct data sets of persons who had been on a community treatment order for at least 3 months and their subsequent treatment episodes over 2 years under the Mental Health Act and/or as an inpatient for the periods 2008-2010 (Mental Health Act 1986) and 2014-2016 (Mental Health Act 2014). The two sets were compared to assess the difference in use, duration and odds of having a further admission over 2 years. We also considered the mode of discharge - whether by the treating psychiatrist, external body or through expiry. RESULTS: Compared with the Mental Health Act 1986, under the Mental Health Act 2014, index community treatment orders were shorter (mean 227 days compared with 335 days); there was a reduction in the mean number of community treatment orders in the 2 years following the index discharge - 1.1 compared with 1.5 (incidence rate ratio (IRR) = 0.71, 95% confidence interval = [0.63, 0.80]) - and a 51% reduction in days on an order over 2 years. There was a reduction in the number of subsequent orders for those whose order expired or was revoked by the psychiatrist under the Mental Health Act 2014 compared to those under the Mental Health Act 1986. The number of orders which were varied to an inpatient order by the authorised psychiatrist was notably greater under the Mental Health Act 2014. CONCLUSION: The reformed Mental Health Act has been successful in its intent to reduce the use and duration of compulsory orders in the community. The apparent increase in return to inpatient orders raises questions regarding the intensity and effectiveness of community treatment and context of service delivery.

Current appeal system for those detained in England and Wales under the Mental Health Act needs reform.

The approach to managing the involuntary detention of people suffering from psychiatric conditions can be divided into those with clinicians at the forefront of decision-making and those who rely heavily on the judiciary. The system in England and Wales takes a clinical approach where doctors have widespread powers to detain and treat patients involuntarily. A protection in this system is the right of the individual to challenge a decision to deprive them of their liberty or treat them against their will. This protection is provided by the First-tier Tribunal; however, the number of successful appeals is low. In this paper, the system of appeal in England and Wales is outlined. This is followed by a discussion of why so few patients successfully appeal their detention with the conclusion that the current system is flawed. A number of recommendations about how the system might be reformed are offered.

Changes in the use of the Mental Health Act 1983 in England 1984/85 to 2015/16.

BACKGROUND: Concerns have been raised about the increase in the use of involuntary detentions under the Mental Health Act in England over a number of years, and whether this merits consideration of legislative change.AimsTo investigate changes in the rate of detentions under Part II (civil) and Part III (forensic) sections of the Mental Health Act in England between 1984 and 2016. METHOD: Retrospective analysis of data on involuntary detentions from the National Archives and NHS Digital. Rates per 100 000 population were calculated with percentage changes. The odds of being formally admitted to a National Health Service hospital compared with a private hospital were calculated for each year. RESULTS: Rates of detention have at least trebled since the 1980s and doubled since the 1990s. This has been because of a rise in Part II (civil) sections. Although the overall rate of detentions under Part III (forensic) sections did not rise, transfers from prison increased and detentions by the courts reduced. The odds of being detained in a private hospital increased fivefold. CONCLUSIONS: The move to community-based mental health services in England has paradoxically led to an increase in the number of people being detained in hospital each year, and in particular an inexorable rise in involuntary admissions. This is likely to be partly because of improved case finding with an increased focus on treatment and risk management, and partly because of changes in legislation. An increasing proportion of this government-funded care is being provided by private hospitals.Declaration of interestNone.

Demographic and clinical characteristics of patients involuntarily hospitalized in an Italian psychiatric ward: a 1-year retrospective analysis.

BACKGROUND: In Italy, psychiatric compulsory treatments are regulated by Law 180 of 13-5-1978 that establishes three criteria: 1) acute psychiatric conditions requiring urgent treatment, 2) patient's refusal of treatment, 3) inpatient treatment is necessary and cannot be postponed. AIM: To highlight demographic and clinical risk factors for involuntary treatments. METHODS: We retrospectively collected all hospitalizations in the Service of Psychiatric Diagnosis and Treatment of a northern Italian town from 1-1-2015 to 31-12-2015. We statistically compared demographic and clinical variables related to voluntarily and involuntarily admitted patients and their hospitalizations. RESULTS: We divided our sample into patients voluntarily hospitalized (PVH=236) and involuntarily (PIH=160) according to their voluntary (VH= 304) and involuntary (IH=197) hospitalizations. PIH were older than PVH and, more frequently, lived alone and were unemployed (p<0.001). "Acute worsening of psychopathology" for IH and "Suicidality" for VH were the prevalent reasons (p<0.001). IH was longer than VH (p<0.001). Among PIH, the most frequent diagnoses were "Schizophrenia and Other Psychosis" (ICD-9-CM) and "Ineffective Impulse Control + Disturbed Personal Identity" (NANDA-I) (p<0.001). During hospitalizations, PIH more often than PVH presented aggressive behavior (p<0.001). At discharge, PIH were more frequently sent to another psychiatric ward or protected facility with long-acting injectable antipsychotics (p<0.001). CONCLUSIONS: Our involuntarily admitted patients were affected by severe psychiatric disorders with social maladjustment and required complex therapeutic and rehabilitative programs to counteract aggressive behaviour, poor therapeutic compliance and prolonged hospitalizations. The assessment of patients' characteristics can help clinicians recognize who are at risk for compulsory treatment and prevent it.

European Psychiatric Association (EPA) guidance on forensic psychiatry: Evidence based assessment and treatment of mentally disordered offenders.

Forensic psychiatry in Europe is a specialty primarily concerned with individuals who have either offended or present a risk of doing so, and who also suffer from a psychiatric condition. These mentally disordered offenders (MDOs) are often cared for in secure psychiatric environments or prisons. In this guidance paper we first present an overview of the field of forensic psychiatry from a European perspective. We then present a review of the literature summarising the evidence on the assessment and treatment of MDOs under the following headings: The forensic psychiatrist as expert witness, risk, treatment settings for mentally disordered offenders, and what works for MDOs. We undertook a rapid review of the literature with search terms related to: forensic psychiatry, review articles, randomised controlled trials and best practice. We searched the Medline, Embase, PsycINFO, and Cochrane library databases from 2000 onwards for adult groups only. We scrutinised publications for additional relevant literature, and searched the websites of relevant professional organisations for policies, statements or guidance of interest. We present the findings of the scientific literature as well as recommendations for best practice drawing additionally from the guidance documents identified. We found that the evidence base for forensic-psychiatric practice is weak though there is some evidence to suggest that psychiatric care produces better outcomes than criminal justice detention only. Practitioners need to follow general psychiatric guidance as well as that for offenders, adapted for the complex needs of this patient group, paying particular attention to long-term detention and ethical issues.

40th birthday of the Italian Mental Health Law 180 - perception and reputation abroad, and a personal suggestion.

How things are perceived from a distance may help better understand their nature. Perceptions at home are likely to shape perceptions abroad. The mutual cross-references between local and distant perspectives on the Italian Mental Health Law 180 may help understand the process which preceded and resulted in the reform. This editorial argues that Law 180 came about at a unique - enabling - time in history. It argues that the run-up to and passing of Law 180 constituted a great accomplishment by professionals, the wider public and politicians/administrators. This editorial goes on to argue that the profession managed to cope with (many) adverse effects of the reform. The attention that Law 180 has received internationally should be devoted to other national (or regional) mental health reform processes as this may help us to understand how mental health care systems evolve and what defines 'windows of (operative) opportunity' or 'moments for (public) action'.

Financing of forensic psychiatry in view of treatment quality and threat to public safety. / Finansowanie psychiatrii sadowej a jakosc leczenia i zagrozenie bezpieczenstwa publicznego.

Stay in a psychiatric hospital of persons who committed the gravest criminal acts while in a state of insanity aims to ensure their effective treatment (therapeutic function), but above all to prevent the repetition of prohibited acts of significant harm to the community (preventive function). Forensic patients are provided with suitable medical, psychiatric, rehabilitation and resocialization care. The court imposes an indefinite detention. In view of the dual purpose of the stay in a psychiatric hospital, both therapeutic and preventive, the treatment costs generated by forensic wards are higher than those of general psychiatric wards. This prompts person from outside psychiatry, who do not understand the nature of preventive measures, to call for continuing reductions in the expenditure on forensic psychiatric care. It is, therefore, worth analyzing the possible meaning and results of the attempts to economizeforensic psychiatry, to find savings and to manipulate financing system under the pretence of economic incentive to improve treatment quality. In this paper, the authors address and discuss the above and other issues.

Involuntary admission and treatment experiences of persons with schizophrenia: Implication for the Mental Health Care Bill 2016.

BACKGROUND: Involuntary admission and treatment experiences may affect the attitude of patients toward subsequent treatment and further outcomes. This issue has received relatively less research attention in persons with schizophrenia from developing countries. METHODOLOGY: In this hospital based prospective observational study, involuntary admission, treatment and coercion experiences among 76 persons with schizophrenia, admitted under special circumstances of Mental Health Act -1987 were studied. Demographic, clinical and assessments related to coercion experiences were completed within 3days of admission. In 67 subjects, a reassessment was done just before discharge. RESULTS: Mean (SD) age was 33.1 (±11.5) years, 47.8% (n=32) were males and 32.8% (n=22) were married. 92.5% (n=62) had absent insight at admission. Mean CGI Severity score at admission was 6.27 (±0.53). Mean (SD) score on MacArthur Perceived Coercion Scale at admission was 4.04 (±1.61). This reduced to 2.43(±1.91) [p<0.001]. This reduction correlated significantly with improvements in global functioning (r=-0.40, p <0.001), insight level(r=0.26, p<0.001) and as well as symptom severity(r=0.36, p<0.001). At discharge, 70% (n=47) patients reported that their involuntary admission was justified. CONCLUSION: Perceived coercion in schizophrenia though common clinical phenomena, it is a dynamic state which reduces over course of treatment. At Discharge, majority reported that their admission was justified, even though they were admitted involuntarily. The study underlines the need for a standardized rule of conduct based coercive practice in psychiatry.

[Healthcare research in forensic commitment or poking around in the dark : Consensus paper on the necessity for more uniform and better data]. / Versorgungsforschung im Maßregelvollzug oder das Stochern im Nebel : Konsenspapier zur Notwendigkeit einheitlicher und besserer Daten.

Complex trends in occupancy determined by many influencing factors, clear state-specific differences in imprisonment practices as well as recently implemented statutory alterations to the appropriate paragraphs in criminal law, underline the necessity for qualitative high-grade concomitant research of German forensic commitment; however, neither the structural prerequisites nor an adequate data situation are currently present in order to do justification to this aim. Not even the total number of patients currently accommodated in forensic commitment can be elucidated from the publicized (partial) statistics. This consensus paper, which was formulated by three research institutes active at the state level, describes the limited possibilities for current forensic healthcare research and raises the demand for a nationwide uniform data situation on patients in forensic commitment. Furthermore, how the appropriate elicitation instrument should be organizationally and structurally achieved, is sketched from a scientific perspective. This article aims at initiating a discussion on a sustainable improvement in the prerequisites for healthcare research in German forensic commitment and targets a sensitization of decision makers in politics and administration for this topic.

Controversies Concerning the Canadian Not Criminally Responsible Reform Act.

In Canada, individuals found not criminally responsible on account of mental disorder are subject to the disposition recommendations of the Provincial or Territorial Review Board of the jurisdiction where the offense was committed. Bill C-14, known as "The Not Criminally Responsible Reform Act" made changes to the postverdict disposition process of these individuals. This legislation was consistent with a broader "tough-on-crime" agenda of the previous federal government. The legislative changes codify that Review Boards take public safety as the "paramount consideration" in making their recommendations. The legislation also creates a new "high-risk" category for certain offenders and imposes limitations on their liberty. Further, Bill C-14 seeks to enhance victim involvement in the disposition process. The passage of this legislation has generated significant controversy in the medical and legal fields. Critics have stated that there is an absence of empirical evidence on which to base the amendments, that the legislation was an overreaction to high-profile cases, and that Bill C-14 is in questionable compliance with the Canadian Charter of Rights and Freedoms. In this review, we explore the potential catalysts involved in the creation of Bill C-14, the controversy surrounding the legislation, and the potential future impact on practicing forensic psychiatrists and on the forensic mental health system in Canada.

["Even the best law will never replace reflection in the field"]. / « La meilleure des lois ne fera jamais l'économie d'une réflexion sur le terrain ¼.

Implemented in 2006 by the French minister for health, the resource centres for people working with sex offenders (CRIAVS) provide support for professionals and non-professionals, concerned with transgressive sexual behaviour. They offer tools for legal, health and social professionals to facilitate the supervision of sex offenders. Florent Cochez, a psychiatrist and medical examiner, manager of the Aquitaine CRIAVS, describes in this interview the missions of these regional structures, their link with court-ordered therapy and his practice.

The impact on clinical practice of the 2015 reforms to the New South Wales Mental Health Act.

OBJECTIVES: The Mental Health Act 2007 (NSW) ( MHA) was recently reformed in light of the recovery movement and the United Nations Convention on the Rights of Persons with Disabilities. We analyse the changes and describe the impact that these reforms should have upon clinical practice. CONCLUSIONS: The principles of care and treatment added to the MHA place a strong onus on clinicians to monitor patients' decision-making capacity, institute a supported decision-making model and obtain consent to any treatment proposed. Patients competently refusing treatment should only be subject to involuntary treatment in extraordinary circumstances. Even when patients incompetently refuse treatment, clinicians must make every effort reasonably practicable to tailor management plans to take account of any views and preferences expressed by them or made known via friends, family or advance statements.