Stanislav Mucha

Dear Ms Kearsley, Thank you for your letter of 4 August 2022 about the death of Stanislav Mucha. I am replying as Minister with responsibility for Mental Health and thank you for the additional time allowed. Firstly, I would like to say how saddened I was to read of the circumstances of Mr Mucha’s death and I offer my sincere condolences to his family and loved ones. The circumstances your report describes are very concerning and I am grateful to you for bringing these matters to my attention. In preparing this response, Departmental officials have made enquiries with NHS England and the Care Quality Commission. I understand that at the time of the incident there was no shared electronic record common to all practitioners. Community teams used PARIS (electronic system) whilst inpatient services used a paper-based system. Pennine Care Foundation Trust now have a shared electronic system across services, except for Improving Access to Psychological Services (IAPT) who conform to the National Recording Keeping Requirements. In addition, The Trust has recommended the uploading of Mental Health Act documentation into patient records so that outcome and action plans are clear and explicit. This will ensure a common record accessible to all with clear plans and goals to minimise the risk of confusion. The Mental Health Act 1983 Code of Practice explicitly places the duty to record the outcome of an assessment on the Approved Mental Health Professional (AMHP). If the AMHP believed that an assessment had taken place, this should have been recorded and communicated to the Section 12 doctors. Relevant sections of the Code of Practice are below:
a. 14:41 … AMHPs who assess patients for possible detention under the Act have overall responsibility for co-ordinating the process of assessment
b. 14.100 Having decided whether or not to make an application for admission, AMHPs should inform the patient, giving their reasons. Subject to the normal considerations of patient confidentiality, AMHPs should also give their decision and the reasons for it to:
• the patient’s nearest relative
• the doctors involved in the assessment
• the patient’s care co-ordinator (if they have one), and A5

• the patient’s GP, if they were not one of the doctors involved in the assessment.
c.
14.104 Where AMHPs decide not to apply for a patient’s detention they should record the reasons for their decision
b. 14.107 Arrangements should be made to ensure that information about assessments and their outcome is passed to professional colleagues where appropriate In addition, Section 14.75 of the Code of Practice places a responsibility on Section 12 doctors to record their decisions if an assessment has taken place. However, the Code of Practice is not explicit on how these notes should be recorded. We note that there was some dispute about whether an assessment had taken place. In cases where there is a dispute, the Code then sets out the steps which should be taken with regard to the patient:
d. 14.110 Where there is an unresolved dispute about an application for detention, it is essential that the professionals do not abandon the patient. Instead, they should explore and agree an alternative plan – if necessary on a temporary basis. Such a plan should include a risk assessment and identification of the arrangements for managing the risks. The alternative plan should be recorded in writing, as should the arrangements for reviewing it. Copies should be made available to all those who need it (subject to the normal considerations of patient confidentiality). The Code of Practice does not state the timeframes in which notes of any assessment should be produced and made available. As you may be aware, work is currently in train to reform the Mental Health Act and subsequently its Code of Practice. As part of these reforms we will consider whether the revised Code of Practice should include a specific time period during which notes of any assessment should be produced. I am therefore very grateful that you have brought this matter to my attention. I hope this response is helpful. Thank you again for bringing these concerns to my attention. MARIA CAULFIELD MP A6

Dear Ms Kearsley, Re: Stanislav Mucha (Regulation 28: Report to Prevent Future Deaths). On behalf of the Royal College of Psychiatrists, I am most grateful for the opportunity to comment upon this report, apologies for the delay in responding. I would like to extend my deepest sympathies to Stanislav Mucha’s family and loved ones. The Royal College of Psychiatrists (RCPsych) is the professional medical body responsible for supporting psychiatrists. The College sets standards and promotes excellence in psychiatry; leads, represents and supports psychiatrists; improves the scientific understanding of mental illness; works with and advocates for patients, carers and their organisations. The College does not work on the care of individuals and I am not able to comment on the specific circumstances surrounding the case of the death of Stanislav Mucha. However, I have considered your findings, and have the following comments to make in relation the two concerns that you raise: Facilities to make notes in relation to an assessment. The College is very clear that it is good practice to document all clinical contacts, and this is a routine expectation of healthcare professionals across a spectrum of practice. While we are happy to use appropriate communication mechanisms to remind our members of this, in this case the Section 12 doctor seems to assert that there was no facility for them to do so. This being the case, it would seem to be an issue that needs to be addressed as an operational issue in the specific area so that there are the opportunities in place for the details of the interaction to be recorded. Outcome of the Assessment Our initial thoughts on this are that the way the system is designed means that there should not be a lack of clarity or ability to come to a clear outcome. Outcomes of MHA assessments are decided by any one of the 3 assessors (1st rec doctor, S12 doctor, AMHP) not recommending compulsory powers and then the AMHP having a final veto on the application. A3

The MHA works by generating outcomes where there may be disagreements between the assessors. That’s a key objective of the system and is an intended safeguard. We would be happy to comment further on this aspect if there is more detail to be provided in relation to this aspect of the Report. Actions to be taken by RCPsych RCPsych will use communication opportunities to:  Remind them of the need for consistent and comprehensive recording of all clinical contacts, including those which emerge through the Mental Health Act. Please do not hesitate to contact me if I can be of any further assistance.