A paramedic from the Northern Territory writes:
I’ve had a number of Mental Health patients recently and still have some confusion on involuntary detainment, treatment and emergency management. As it stands in the NT, Paramedics treat mental health patients, however we cannot section them, initiate a Section 9 nor 42, and need Police assistance if the patient is to be taken to hospital.
I’m confused only by what Paramedics can lawfully do with mental health patient treatments. There is also confusion in how the Act influences the management of Minors
We have had limited training or introduction to the changes on the new Mental Health Act, unfortunately.
The relevant Act is the Mental Health and Related Services Act 1998 (NT). I note that my correspondent says the ‘new’ Mental Health Act and I’m not sure what that refers to. The Mental Health and Related Services Act is the current Act. It has been in place since 1998 and the sections I discuss, below, were last amended in 2012. There does not appear to be a Mental Health Bill or any other relevant Bill before the NT Parliament.
Section 9 of the Mental Health and Related Services Act says:
Principles relating to provision of treatment and care
When providing treatment and care to a person who has a mental illness, mental disturbance or complex cognitive impairment the following principles apply:
(a) the person is to be provided with timely and high quality treatment and care in accordance with professionally accepted standards;
(b) where possible, the person is to be treated in the community;
(c) as far as possible, the person’s treatment and care is to be designed to assist the person to live, work and participate in the community and to promote and assist self-reliance;
(d) the person is to be provided with appropriate and comprehensive information about:
(i) the person’s mental illness, mental disturbance or complex cognitive impairment; and
(ii) proposed and alternative treatment and services available to meet the person’s needs;
(e) where possible, the person is to be treated near where he or she ordinarily resides or where relatives or friends of the person reside;
(f) as far as possible, the person’s treatment and any service to be developed for the person is appropriate having regard to the age and gender of the person;
(g) as far as possible, the person is to be involved in the development of any ongoing treatment plan or any discharge planning;
(h) the person is to be given medication only for therapeutic or diagnostic purposes and not as a punishment or for the convenience of others;
(j) except as provided by this Act, the person is not to be given treatment without his or her consent;
(k) the person’s treatment is to be carried out, wherever practicable, within a multi-disciplinary framework;
(m) the person’s treatment and care is to be based on an individually developed plan that is discussed with the person, reviewed regularly and revised, as necessary, and is provided by qualified professional persons;
(n) the person’s treatment and care is, as far as possible, to be appropriate to and consistent with the person’s cultural beliefs, practices and mores, taking into account the views of the person’s family and community;
(p) any assessment of the person to determine whether he or she needs to be admitted to an approved treatment facility is to be conducted in the least restrictive manner and environment possible.
The most important part for the purpose of this discussion is s 9(j) which says ‘except as provided by this Act, the person is not to be given treatment without his or her consent’. Having said that, section 9 is a statement of general principles, it doesn’t authorise anyone to do anything. Accordingly it is not possible to ‘initiate a Section 9’. There is nothing to initiate.
Section 42(1) says “A person admitted to an approved treatment facility as an involuntary patient on the grounds of mental disturbance may be detained for up to 72 hours on those grounds.” Section 42(2) then provides circumstances where that detention can be extended up to 7 days. Section 39 makes similar provisions in relation to the involuntary detention of a person because of a mental illness (rather than mental disturbance). Neither section here is relevant to paramedics. These sections set time limits for the detention of a person ‘admitted to an approved treatment facility as an involuntary patient’ but say nothing about how they might come to be admitted. Again, it is not possible to ‘initiate a … Section 42’ (or 39).
My correspondent said ‘As it stands in the NT, Paramedics treat mental health patients, however we cannot section them… and need Police assistance if the patient is to be taken to hospital’ but that is wrong. Section 31 provides for the detention of mentally ill and mentally disturbed person by an ambulance officer. That section says:
(1) An ambulance officer may detain a person being conveyed in an ambulance for up to 6 hours where the ambulance officer believes, on reasonable grounds, that the person may fulfil the criteria for involuntary admission on the grounds of mental illness or mental disturbance.
(2) When detaining a person under subsection (1), an ambulance officer may use reasonable measures, including the use of restraints, on the person:
(a) to prevent the person causing serious harm to himself or herself or to someone else; or
(b) to prevent behaviour of the person likely to cause serious harm to the person or to someone else; or
(c) to prevent further physical or mental deterioration of the person; or
(d) to relieve acute symptomatology.
(3) An ambulance officer who detains a person under subsection (1):
(a) must convey the person to the nearest approved treatment facility or, if that is not practicable, to the nearest hospital, as soon as practicable after the person is detained; and
(b) on arriving at the approved treatment facility or hospital, must complete the approved form and send it to an authorised psychiatric practitioner.
(4) For subsection (3)(b), the form may be sent by fax or email.
In the absence of any ambulance service legislation, the term ‘ambulance officer’ must be defined. For the purposes of the Mental Health and Related Services Act, ‘ambulance officer’ means any person ‘employed as an ambulance officer, or engaged as a volunteer ambulance officer, by an approved ambulance service at the level of qualified ambulance officer or above’ or a person appointed as an ambulance officer by the Chief Health Officer (ss 4 and 24).
What follows is that if an ambulance officer who believes that the person they are treating:
… has a mental illness; and
(b) as a result of the mental illness:
(i) the person requires treatment that is available at an approved treatment facility; and
(ii) without the treatment, the person is likely to:
(A) cause serious harm to himself or herself or to someone else; or
(B) suffer serious mental or physical deterioration; and
(iii) the person is not capable of giving informed consent to the treatment or has unreasonably refused to consent to the treatment; and
(c) there is no less restrictive means of ensuring that the person receives the treatment.
Then the ambulance officer can detain the person and take them ‘to the nearest approved treatment facility or, if that is not practicable, to the nearest hospital’. Equally they may be detained and transported to an approved treatment facility or hospital if the person is not suffering from a mental illness but:
… (b) the person’s behaviour is, or within the immediately preceding 48 hours has been, so irrational as to lead to the conclusion that:
(i) the person is experiencing or exhibiting a severe impairment of or deviation from his or her customary or everyday ability to reason and function in a socially acceptable and culturally appropriate manner; and
(ii) the person is behaving in an abnormally aggressive manner or is engaging in seriously irresponsible conduct that justify a determination that the person requires psychiatric assessment, treatment and care that is available at an approved treatment facility; and
(c) unless the person receives treatment and care at an approved treatment facility, he or she:
(i) is likely to cause serious harm to himself or herself or to someone else; or
(ii) will represent a substantial danger to the general community; or
(iii) is likely to suffer serious mental or physical deterioration; and
(d) the person is not capable of giving informed consent to the treatment and care or has unreasonably refused to consent to the treatment and care; and
(e) there is no less restrictive means of ensuring that the person receives the treatment and care.
If the ambulance officer does not have the appropriate authority, then a mentally ill or mentally disordered person may be detained on the authority of a treating medical or nursing practitioner (s 30) the police (s 32A). Section 32A will be most relevant where the person is not already in a health facility, that is they are in the community and police are called because of concerns about the person’s behaviour. Where
… a police officer believes, on reasonable grounds:
(a) a person may require treatment or care under this Act having regard to the appearance and behaviour of the person; and
(b) the person is likely to cause serious harm to himself or herself or to someone else unless apprehended immediately; and
(c) it is not practicable in the circumstances to seek the assistance of an authorised psychiatric practitioner, a medical practitioner or a designated mental health practitioner.
(2) The police officer may apprehend the person and bring the person to an authorised psychiatric practitioner, a medical practitioner or a designated mental health practitioner for an assessment …
With respect to the voluntary treatment of children, that is people under 18, there are some particular considerations (s 26). There are no provisions with respect to the involuntary treatment of people under 18 so the provisions, above, apply whether the person is a child or not. The difficulty will be where a child is unable to give consent due to their mental illness and their parent or guardian refuses consent. If that refusal is ‘unreasonable’ (ss 14(b)(3) or 15(b)) then the person may be detained.
My correspondent wrote ‘I’m confused only by what Paramedics can lawfully do with mental health patient treatments’ and with respect, his comments did confirm that and would also appear to confirm that paramedics in the NT have had ‘limited training or introduction to the … Mental Health Act’.
Under the current law ambulance officers who believe that the person under their care is mentally ill or disturbed, and the conditions set out in ss 14 or 15 apply, may detain the person and take them to ‘to the nearest approved treatment facility or, if that is not practicable, to the nearest hospital’ for an assessment and possible detention as an involuntary patient. They do not need to rely on the police, but it would be common experience that often police are first on scene if a person’s behaviour is causing concern or appears to be criminal.
The Act applies regardless of the age of the patient.