Some specialist units have developed for personality disordered patients, learning disabled patients, women, and adolescents. The State hospital, Carstairs, and the central mental ho spital, Dundrum, admit many patients who would be admitted to medium-security units in Engl and and 17_Semple_Chap17.indd 694 12/7/2012 3:49:47 PM SECURE HOSPITALS AND UNITS 695 Wales due to the under-development of local secure forensic provision in Scotland, NI, and the RoI. Low-security units Low-security units and wards have locked doors but do not usually have a secure perimeter. Some regional forensic services have a combination of low- and medium-se curity wards; in areas of Scotland and NI there are low-security forensic wards without med ium-security units. Intensive Psychiatric Care Units (IPCUs) are low-security short-stay wa rds pri- marily for the care of acutely disturbed general psychiatry patients. In a few are as they also take patients from courts, prisons, and more secure units, but they are not we ll-suited to providing longer-term assessment or treatment. Referring a patient to secure forensic services \200 A comprehensive assessment should be made and details of this should be sent with the refer ral. Particular attention should be given to the risk the person poses (b p. 692) and why t his risk cannot adequately be managed in less secure services. Patients should meet the cri teria for compulsory detention in hospital under relevant legislation. 1 Kennedy HG (2002) Therapeutic uses of security: mapping forensic mental health services b y stratifying risk. Adv Psychiat Treat 8: 433 \200\22343. 17_Semple_Chap17.indd 695 12/7/2012 3:49:47 PM CHAPTER 17 Forensic psychiatry 696 Police liaison 1 Prevalence of psychiatric disorder 2 \200\2235% of people held in custody by the police suffer from mental disorder. About 1 \200\2232% suffer from severe mental ill ness. Liaison and diversion \200 Diversion of people with mental disorders from the criminal justice system to health care c an operate at any stage of the criminal justice process. The term is often used to refer to early diversion, the transfer of mentally disordered people from police custody or at thei r \201 rst court hearing. Diversion schemes is provided to the police and/or courts to he lp identify and divert mentally disordered individuals. These schemes may also be known as police or court liaison schemes. Police or court liaison health services provide assessment and/or diversion for people with mental disorder at an early stage of the criminal justice process. In some areas there are formal diversion schemes, but from area to area there are differences. operate in some areas whereby a speci \201 c service is the process or system by which mental In many cases where a person is diverted, the police, prosecutor, or court will discontinue the criminal justice process. This will be particu- larly appropriate in most cases where individuals with mental disorder will have committed relatively minor offenses. However, di version does not necessitate this, and where appropriate, particularly where more serious o ffenses have been committed, a prosecution may be pursued in parallel with diversion for ca re and treatment. Powers allowing police to take a person to a place of safety (Box 17.5) \200 The police have powers under mental health legislation to convey a person whom they believe is suffering from mental disorder to a place of safety. (Speci \201 c powers are set out in Box 17.5.) The purpose of these powers is to allow for a psychiatric assessment. The use by the police of these powers does not oblige mental health services to admit the person. \200 Arrest and detention in custody Where an offense has been committed, a mentally disordered offender may be arrested and taken into police custody. \200 Issues to be addressed when assessing a person in police custody: \200 \200 \200 Is there evidence of mental disorder? Is treatment in hospital required? If so, how urgentl y? What is the nature of the alleged offense and is there any evidence of a serious risk to others? Is the person \201 t to remain in police custody? Is the person \201 t to be i nterviewed by the police? Do they require an appropriate adult? Would they be \201 t to p lead if they appeared in court (see \200 b p. 716)? 17_Semple_Chap17.indd 696 12/7/2012 3:49:47 PM POLICE LIAISON 1 697 Options following assessment if person appears to be mentally disordered: \200 \200 \200 \200 Admission to hospital informally or under mental health legislation. Treatment in the commu nity. Recommend admission on remand following \201 rst court appearance. Recommend furthe r assessment on remand in custody or on bail following \201 rst court appearance. Fitness to remain in police custody There are no legal criteria to determine whether a person is \200\230 \201 t to remain in police custody \200\231. A person may be un \201 t to remain in police custody due to physical illness or mental disorder. Where a person is mentally d isordered such that there would be a serious immediate risk to their own health if they rem ained in the police cells, then they would be un \201 t to remain in police custody, and s hould usually be admitted to hospital. Box 17.5 Powers allowing the police to take a mentally disordered person to a place of safe ty England and Wales Section 136 MHA 1983 allows the police to appre- hend a person who appear s to be mentally disordered found in a public place, and convey them to a place of safety w here they may be detained for up to 72hrs. The place of safety should be a mental health se tting, but often a police station is used. The purpose of section 136 is to allow for the p erson to be assessed by mental health services. Following the assessment the person may be diverted to mental health services (infor- mally or under compulsion), arrested and taken i nto police custody, or released. Scotland Section 297 MH(CT)(S)A 2003 allows similar provis ions in Scotland, but detention may only be for up to 24hrs. NI Article 130 MH(NI)O 1986 al lows similar provisions in NI, but deten- tion may only be for up to 48hrs. RoI Under secti on 12 MHA 2001, if a garda has reasonable grounds for believing that a person is suffering from a mental disorder and that, because of the disorder, there is a serious likelihood of the person caus- ing harm to himself/herself or another person, the garda may take the pers on into custody. If necessary, the garda may use force to enter the premises where it is be lieved that the person is. The garda must then go through the normal application procedure for involuntary detention in an approved center. If the garda \200\231s application is refu sed, the person must be released immediately. If the application is granted, the garda must remove the person to the approved center. Note: in England and Wales, Scotland, and NI the se powers do not allow the police to enter premises if they want to remove a person who app ears to be suffering from mental disorder. Under these circum- stances powers are available under s135 MHA 1983, s293 MH(CT)(S)A 2003, and article 129 MH(NI)O 1986. 17_Semple_Chap17.indd 697 12/7/2012 3:49:47 PM CHAPTER 17 Forensic psychiatry 698 Police liaison 21,2,3 Police interviews: \201 tness, false confessions, and appropriate a dults Mental disorder may affect a police interview by: impairing the ability of a person t o communicate; leading to the person giving unreliable evidence; or making a person vulnera ble to becoming distressed. In some cases men- tal disorder may be so severe that a person is un \201 t to be interviewed. \200 \201 tness to be interviewed, but the following There is no legal basis for issues may be relevant: \200 Does the detainee understand the police caution after it has been fully explained to him or her? Is the detainee fully orientated in time, place, and person and does he or she recogn ize the key persons present during the police interview? Is the detainee likely to give ans wers which can be seriously misconstrued by the court? Where a person is mentally disordered and \201 t to be interviewed, an appropriate adult should be present during the police interview. Appropriate adult schemes operate differentl y in the different jurisdictions of the British Isles (see Appropriate adults). False confe ssions miscarriages of justice. Three types are recognized: \200 have been at the heart of some notorious Voluntary (the person voluntarily presents and confesses to a crime he has not committed). Coerced compliant (persuasive interrogation leads to a person confessing to an offense he k nows he has not committed). Coerced internalized (amnesia or subtle manipulation by the int errogator leads to the person believing he has committed a crime which he has not). Appropriate adults \200 England and Wales (PACE) 1984 and its Codes of Practice provide a statutory basis for appropriate adults. Appropriate adults should be requested by the poli ce where a detained person is under 16 or is deemed to be \200\230vulnerable \200\231 (per haps due to mental disorder). The appropriate adult may be a relative or carer. Scotland op erate to provide appropriate adults, who should not be a relative or carer, and who should be requested by the police when they are interviewing any mentally disordered person. These schemes do not cover children. NI RoI The Police and Criminal Evidence Act No statutory basis for appropriate adult schemes. Schemes \200 Similar statutory basis as England and Wales. No speci \201 c provisions. 1 Gudjonnson GH (1993) The psychology of interrogations, confessions and testimony. Chiches ter: Wiley. 2 Birmingham L (2001) Diversion from custody. Adv Psychiat Treat 7: 198 \200\223207. 3 Pear se J and Gudjonnsen G (1996) How appropriate are appropriate adults? J Forens Psychiat 7: 570 \200\22380. 17_Semple_Chap17.indd 698 12/7/2012 3:49:47 PM COURT LIAISON 699 Court liaison Broadly covers all aspects of psychiatric assessments for courts, but here is used narrowly to refer to psychiatric assessment at an early (usually the \201 rst) cour t appearance. The terms \200\230liaison \200\231 and \200\230diversion \200\231 in relati on to police and courts are described on b p. 696. Preparation of court reports and giving evidence in court are covered on b p. 708. Some areas have court liaison or diversion schemes, aimed at identifying people with mental disorders at an early stage of the court process and diverting them to appropriate mental health services where necessary. Some screen all detainees, but most rely on referrals from criminal justice staff when mental disorder is suspected. In many schemes the \201 rst a ssess- ment is by a CPN who then refers the person on if necessary. Back-up from psychiatri sts is necessary for those cases where admission, particu- larly under compulsion, may be n ecessary. Features of successful court liaison schemes \200 \200\230Owned \200\231 by ma instream general or forensic services. \200 Staffed by senior psychiatrists. \200 Nurse -led and closely linked to local psychiatric services. \200 Good working relationships wi th courts and prosecution. \200 Good methods for obtaining health, social services, and c riminal record information. Access to suitable interview facilities. Use of structured scre ening assessments. Direct access to hospital beds. Ready access to secure beds. Access to s pecialized community facilities. Integrated with police and prison liaison schemes. \200 \200 \200 \200 \200 In many areas there are no dedicated schemes. Under these circumstances it is important tha t it is clear to the police, courts, social services, and health services how an urgent ass essment may be obtained if necessary. Issues to be addressed when assessing a person at an early court appearance \200 \200 \200 \200 Is there evidence of mental disorder? Is assessment and/or treatment in hospital required? If so, how urgently? What is the nature of the alleged offense and is there any evidence of a serious risk to others? Is the person \201 t to plead (see b p. 716)? Options following assessment if person appears to be mentally disordered \200 \200 \200 \200 Admission to hospital informally or under mental health legislation. Treatment in the commu nity. Recommend admission on remand (see Recommend further assessment on remand in custody or on bail. b p. 712). In many cases it will be appropriate for the criminal justice process to be discontinued. H owever, where serious offenses are alleged it would usually be appropriate, if diversion is necessary, for the person to be remanded in hospital (see b p. 712). 17_Semple_Chap17.indd 699 12/7/2012 3:49:47 PM CHAPTER 17 Forensic psychiatry 700 Prison psychiatry 1: overview Introduction The average daily population of prisons in the U K is 775 000 (7140 per 100 000 population). This places the UK \200\230mid-table \200\231 in a list of incarcera- tion rates by country, but is high for Western Europe and historica lly high for the UK. Prisons in the UK are either local prisons (accommodating remand priso ners and prisoners serving sentences of less than 2yrs) or training prisons (taking prisone rs serving sentences of more than 2yrs). In practice a number of prisons perform both funct ions. Security varies depending on the categories of prisoners held. All prisoners are cate go- rized solely on security considerations: \200\230A \200\231 (the highest category requ iring maximum security) to \200\230D \200\231 (the lowest category, suitable for open cond i- tions). Most female prisoners are kept in separate prisons. The prison remand A person accused of committing an offense may be held on remand in prison whilst awaiting trial and/or sentence. Courts should not remand a person in custody unless there is a good reason not to grant bail. Mentally disordered offenders are more likely to be remanded in custody than other offenders perhaps because: they are more likely to be ho meless; they are considered less likely to comply with bail; they are perceived as more dan gerous because of their mental disorder; there are a number of statutory objections to bail for mentally disordered defendants even where the offense is not punishable by imprisonmen t; and even though remands in custody for reports are discouraged there is a lack of hospit al or specialist bail facilities. The prison sentence A prison sentence is imposed on an offender by a judge. He will conside r a number of factors, including any mitigating or aggravating circumstances. The sentence may serve one or more of the following functions: punish- ment, deterrence, reparation, inc apacitation, rehabilitation. In certain cir- cumstances there may be a mandatory prison sen tence (e.g. a life sentence for murder). Most prisoners serving determinate sentences are r eleased before the end of their sentence and subject to a period of supervision and/or reca ll. The exact nature of this depends on the nature of the offense and the length of the sen tence imposed. Life-sentenced prison- ers have a tariff (minimum time to serve as punishmen t) set by the judge. Following the end of the tariff period the parole board may authorize the release of the prisoner on \200\230life license \200\231. They are subject to recall t o prison should they breach their parole conditions. Following legal challenge, the UK Home Secretary has lost the power to set the tariff for prisoners sentenced to life imprisonmen t, although the Attorney General has the power to petition the Court of Appeal to increase any prison terms which are seen as unduly lenient. The legality of \200\230whole-life \200 \231 tariffs (i.e. where the prisoner is sentenced to die in jail) is currently being chall enged in the European Court of Human Rights. 17_Semple_Chap17.indd 700 12/7/2012 3:49:48 PM PRISON PSYCHIATRY 1: OVERVIEW 701 Mental disorder in prisoners The prevalence of mental disorder in the prison population is high, espe- cially in remand and female populations. Psychotic disorders: 2 \200\22310%; af fective/neurotic disorders: 6 \200\22359%; alcohol-related disorder: 22 \200\22363%; drug-r elated disorder: 20 \200\22373%; personality disorder: 10 \200\22375%. It has been estimate d that 23 \200\22355% of prisoners have psychiatric treatment needs, with 2 \200\2235% requ iring transfer to psychiatric hospital. Mental health services in prison Traditionally the prison medical service has been separate from the main- stream health service. Health screening occurs on reception to prison but i s cursory and ineffective. Of \201 cially prisons should give prisoners access to the same quality and range of health care services as the general public receives from the NHS. Psy chiatrists from the health service provide ses- sions or may visit for a particular case. P risons may have mental health nurses who provide assessment, monitoring, and support for pr isoners and advice to other staff. Some prisons have multidisciplinary mental health teams. In England and Wales greater partnership between the NHS and the prison service is propose d in the provision of mental health serv- ices to prisoners. 17_Semple_Chap17.indd 701 12/7/2012 3:49:48 PM CHAPTER 17 Forensic psychiatry 702 Prison psychiatry 2: the role of the psychiatrist1,2 Psychiatrists may be asked to assess p risoners for the following reasons: \200 \200 b p. 706). To provide court reports (see To provide assessment and treatment at the request of a priso n medical of \201 cer. For statutory purposes (e.g. preparing reports for the parole board ). When arranging to see a prisoner, a psychiatrist should make an appoint- ment which will \201 t in with the prison routine. There will usually be only 2 \200\2233hrs in the morning or afternoon when there is access to prisoners. The psychiatrist will have to wait to be e scorted by prison staff. Assessment of prisoners Prisoners should be seen on their own unless prison staff or other sources indicate this would be unwise. It may be dif \201 cult to get relevant informa- ti on about the prisoner \200\231s day-to-day functioning and presentation from prison staff, although attempts should be made to do this. Ask the pris- oner for a relative \200\231s te lephone number and permission to speak to them. The prison medical \201 le may not contai n all the necessary information, and in some cases other prison records should be examined. History-taking, MSE, and information gathering should proceed as with any other psychi- at ric assessment. Options in the management of mentally disordered prisoners If a psychiatrist assesses a pri soner and \201 nds that they are mentally disor- dered he may: \200 \200 Treat the person in prison. Arrange for the person to be transferred to mental health servi ces, either by arranging direct transfer from prison (see b p. 712) or by recommending a me ntal health disposal through the courts if the prisoner has not been sentenced yet. No prison, or prison medical center, is recognized as a hospital under mental health legisl ation. Therefore compulsory treatment under the Mental Health Act cannot be given. All pris oners with severe mental ill- ness should be transferred to hospital for treatment. Legal p rovisions for transferring prisoners to hospital are set out on b p. 713. Similar pro- visi ons for remand prisoners are discussed on b p. 712 and listed on b p. 714 for each jurisdic tion. Treatment in prison \200 Medication, monitoring, and modest psychological treatment (supportive psychotherapy perhap s utilizing some cognitive \200\223 behavioral or psychodynamic techniques) may be offered to prisoners with mental disorders who do not require treatment in hospital. Various treatm ent programs to address offending behavior have been developed in prisons. These are run by the prison service and do not involve mental health services. Programs are available for a reas 17_Semple_Chap17.indd 702 12/7/2012 3:49:48 PM PRISON PSYCHIATRY 2: THE ROLE OF THE PSYCHIATRIST 703 such as sexual offending, anger management, alcohol and substance misuse, problem-solving. Some prisons specialize in treating certain mentally disordered prisoners \200\224e.g. HMP Grendon in England offers therapeutic community treatment for personality disordered prison ers who volunteer to be transferred there; there is a 17-bed psychiatric unit at HMP Maghab erry in NI. Suicide in prison Suicide is the most common mode of death in prisons. The rate is approxi- mately 9 times that in the general population. The most common means is by hanging. Remand prisoners, young offenders, and those with histories of substance misuse and violent offen ses are at particular risk. Many factors probably contribute to the increased rate of suicide in prisons, including: \200 \200 \200 \200 histories of psychiatric disorder; previous self-harm; alcohol and substance misuse; social isolation. These are compounded by: \200 \200 \200 \200 uncertainty; powerlessness; bullying; isolation. The task of identifying prisoners who are at risk is extremely dif \201 cult as those who kill themselves share the same vulnerabilities and stresses with many other prisoners who d o not. A major factor that may reduce suicide rates is improvement in prison conditions. Is olation of prisoners at risk in strip cells still occurs, although it is becoming less freq uent and is against of \201 cial guidance. 1 Birmingham L (2003) The mental health of prisoners. Adv Psychiat Treat 9: 191 \200\223201 . 2 Chiswick D and Dooley E (1995) Psychiatry in prisons. In Chiswick D and Cope R (eds), S eminars in practical forensic psychiatry. London: Gaskell. 17_Semple_Chap17.indd 703 12/7/2012 3:49:48 PM CHAPTER 17 Forensic psychiatry 704 Legal provisions for transfer of prisoners to hospital Sentenced prisoners England and Wale s Section 47 MHA 1983 allows for the transfer of a mentally disordered sentenced prisoner t o hospital. There must be reports from two regis- tered medical practitioners addressing wh at category of mental disorder the person suffers from and whether this is of a nature or d egree to war- rant hospital detention. The reports are submitted to the Secretary of State who decides whether or not to grant a \200\230transfer direction \200\231. Section 49 MHA 1983 allows the Secretary of State to add a \200\230restriction direction \200\231 to a transfer direction, which has the same effect as a restriction order under se ction 41 and may last as long as the sentence the person was serving. In practice, section 47 is rarely made without section 49. Scotland Section 136 MH(CT)(S)A 2003 sets out similar provisions for Scotland. There must b e reports from two medical practitioners (one approved) addressing whether the prisoner has a mental disorder, that the mental disorder is \200\230treatable \200\231, that the perso n would be at risk or pose a risk to others, and that the transfer is necessary. The report s are submitted to the Scottish Ministers who decide whether or not to grant a \200\230tra nsfer for treatment direction \200\231. All transferred prisoners are treated as restricted patients for the duration of the prison sentence that they are serving. NI Article 53 MH(NI)O 1986 sets out similar provisions for NI. Two medi- cal practitioners (one appointed for the purposes of part II by the Mental Health Commission) must submit rep orts to the Secretary of State. The issues are similar to England and Wales, except the men tal disorder must be mental illness or severe mental impairment. The order is called a \200\230trans- fer direction \200\231. Article 55 allows the addition of a \200\230restric tion direction \200\231 as in England and Wales. RoI Section 15 Criminal Law (Insanity) Bill 2002 allows for transfer of a prisoner sufferin g from mental disorder to a designated center for the pur- pose of receiving appropriate ca re and treatment. Transfer is authorized by the prison governor on the recommendation of on e approved medical of \201 cer (if the prisoner agrees to the transfer) or of two approved medical of \201 cers (if the prisoner is unable or is unwilling to agree to the transfer) . Prisoners awaiting trial or sentence England and Wales Section 48 MHA 1983 is similar to se ction 47 but provides for transfer of unsentenced prisoners. Other differences from section 47: the person must have mental illness or severe mental impairment (cannot be used for ps ychopathic disorder or mental impairment) and there must be urgent 17_Semple_Chap17.indd 704 12/7/2012 3:49:48 PM LEGAL PROVISIONS FOR TRANSFER OF PRISONERS TO HOSPITAL 705 need for treatment. This section also enables the transfer of civil prisoners and people de tained under immigration legislation. Scotland Section 52 CP(S)A 1995 provisions ( \200\230assessment orders \200\231 and \200 \230treatment orders \200\231), as described on b p. 714, may be used for prisoners awaitin g trial or sentence. The necessary medical recommendations are made to the Scottish Ministe rs who then apply to a court for the person to be admitted to hospital, in the same way as for a hospital remand made at any court appearance. NI Article 54 sets out similar provisions for NI as section 48 MHA 1983 for England and Wal es. Again, one of the two doctors must be approved under part II by the Commission. The pri soner may not be transferred to the State hospital, as it is in another jurisdiction and th e court process has not been completed. RoI Provisions are as set out here (see b p. 704) for sentenced prisoners. 17_Semple_Chap17.indd 705 12/7/2012 3:49:48 PM CHAPTER 17 Forensic psychiatry 706 Court reports and giving evidence 1 A psychiatrist may be required to provide reports and g ive evidence in criminal and civil proceedings: the following deals with reports in crimina l proceedings. Reports may be requested by the prosecution, the court, or by a solicitor. T he assessment should be objective and professional, and should not be in \202 uenced by wh ich \200\230side \200\231 has made the request. The clinical issues The clinical issues wi ll involve those that psychia- trists usually assess: diagnosis, treatment needs, prognosis , etc. However, speci \201 c attention needs to be given to how these clinical issues inte ract with the legal issues in question. What is the relationship between any psychiatric di sorder and past, present, and future offending? How might treatment or the natural course o f the disorder impact on the likelihood of further offending? What impact might the current mental state have on the person \200\231s ability to participate in the court process? The legal issues The request for psychiatric assessment should indicate the legal issues towar ds which the psychiatrist should direct the assess- ment. However, in many cases the instru ctions are not speci \201 c. The main issues to consider are usually: \200 \200 \200 b p. 716). Fitness to plead (see Responsibility (see The presence of mental disorder and whether asses sment and/or treatment under compulsion (or otherwise) is required (see b p. 689) The risk the person poses (may be relevant in whether a restriction order is imposed, in determining if disposal should be to a secure unit or special hospital, or perhaps in determining the nature of the sentence imposed; see b p. 692). b p. 720). Before the interview \200 Comprehensive background information should usually be provided by those requesting the rep ort. Unfortunately this is often lacking. Ideally one should have the opportunity to examin e: document specifying the charges, police summary, witness statements, records of intervie ws with the accused, records of previous offenses, other reports. Sometimes tape recordings of interviews, photographic or video evidence may be available. Arrangements should be mad e to interview the person in prison (if they have been remanded in custody), as an outpatie nt (if they have been remanded on bail), or in hospital (if they have been admitted to hosp ital). The psychiatrist should be given reasonable time to complete the assessment and prod uce a considered report. If there is insuf \201 cient time then this should be stated in t he report and any opinion given should be quali \201 ed. The interview \200 Check the person \200\231s correct name and details. Introduce yourself and state who has r equested the report. Make it clear that the interview is not con \201 dential and that the information in the report will be seen by others. 17_Semple_Chap17.indd 706 12/7/2012 3:49:48 PM COURT REPORTS AND GIVING EVIDENCE 1 707 Clarify that the person has understood this, and seek their consent to prepare the report. If the person refuses to be interviewed then this should be respected and reported to the p erson requesting the report. Ask the person \200\231s permission to contact a relative and/ or their GP for further information. Follow the usual format for a psychiatric assessment. Enquiry about the circumstances of the offense and the person \200\231s understanding of th e court process will need to be made in addition. More than one session may be necessary in some cases. Physical examination and investigations should be performed if indicated. \200 \200 After the interview Further information may be gathered from the following sources: \200 Interviews with relatives or staff (health care, prison, or social services): Health (psych iatric or general practice), prison, social work, or educational records. In some cases spe ci \201 c psychometric testing by a psychologist may be necessary (e.g. where a person app ears to be learning disabled). 17_Semple_Chap17.indd 707 12/7/2012 3:49:48 PM CHAPTER 17 Forensic psychiatry 708 Court reports and giving evidence 2 The report \200 The various strands of the assessment should be brought together in the report. The report should be clear, concise, well structured, and jargon-free. Technical terms (e.g. schizophr enia, personality disorder, delusions, hallucinations, thought disorder) should be explaine d if they are used. If a number of sources of information have been used, indicate where th e particular factual information in the report has come from, particularly when there are i nconsistencies (e.g. \200\230according to \200\231, \200\230he stated that \200\230). The main body of the report should present the information gathered; the opinion should present the conclusions concerning the relevant issues and lead to the recommendati ons. The opinion and recommendations should con \201 ne themselves to psychiatric issues. Punitive sanctions, such as imprisonment, should never be recommended. \200 There are different formats for a court report, just as there are different ways of present ing history and mental state. A suggested structure is given on b p. 710. What will happen to the report? \200 \200 The report becomes the property of whoever requested it. Defense reports may or may not be produced in evidence in a particular case; prosecution reports must be revealed to the defe nse. Copies of the report should not be sent by the psychiatrist to others (such as the pat ient \200\231s GP, another psychiatrist, or a probation of \201 cer) without the consent o f both the person examined and the person who commissioned the report. A psychiatric report may come to be included in various records (health, prison, probation), and may in the fut ure be used for reference or in further legal proceedings. Giving evidence In most cases a psychiatrist will not be required to give oral evidence. Ho wever, under some circumstances this will be the case: a report requires clari \201 cation , the court \201 nds it dif \201 cult to accept the opinion, there are con \202 icting reports, in speci \201 c circumstances where oral evi- dence is obligatory (e.g. where a r estriction order is under consideration). If you are requested to attend court: \200 \200 Clarify with the court when you should attend. Prepare in advance by examining the papers a nd re-reading your report. Consult references and anticipate questions. Present in a smart, con \201 dent, professional manner and be punctual. Counsel may request a conference befo re the court sits. Have a brief interview with the accused in the court cells if he has not been seen for some time and particularly where \201 tness to plead may be an issue. \200 \200 \200 17_Semple_Chap17.indd 708 12/7/2012 3:49:48 PM COURT REPORTS AND GIVING EVIDENCE 2 709 When called to give evidence you will be asked to take the oath, and then will be questione d by the barrister or solicitor who called you. You will then be cross-examined by the \200\230other side \200\231 before being re-examined. You may take notes with you, but ask the judge before referring to them. Speak clearly and slowly, and explain technical terms. Address the judge. If counsel \200\231s questioning is not allowing you to get the appropri ate informa- tion across, then ask the judge if you may clarify your response. A note on addressing the judge: \200 England and Wales judge \200\230Your Honor \200\231; Magistrate \200\231s Court \200\230S ir \200\231 or \200\230Madam \200\231. Scotland Lady \200\231 or \200\230Ma \200\231am \200\231. NI RoI \200\224High Court \200\230My Lord \200\231 or \200\230My Lady \200\231; local \200\224High Court and Sheriff Court \200\230My Lord \200\231 or \200\230Sir \200\231 an d \200\230My \200\224as England and Wales. \200 \200\224 \200\230Your Lordship \200\231, \200\230Ju dge \200\231, or \200\230Sir \200\231. 17_Semple_Chap17.indd 709 12/7/2012 3:49:48 PM CHAPTER 17 Forensic psychiatry 710 Suggested format for criminal court report \200 The following sets out a comprehensive list of the matters that may be set out in a report. Not all of the issues will be relevant in every case. For example: \200 Where there is little information available and the recommendation is for further assessmen t, then the report may be relatively brief, focusing on the issues of relevance to the maki ng of any relevant order. Where the person has been convicted, consideration of \201 tnes s to plead, insanity at the time of the offense, and diminished responsibility (in murder c ases) is irrelevant. Where a report is updating a previous report prepared in the same case relating to the same offense (or alleged offense) or is recommending the extension of an o rder, then the report may be relatively brief, as long as it addresses whether the person f ul \201 ls the criteria for that order and why extension is necessary. Preliminary information \200 At whose request the assessment was undertaken, circumstances of assessment (place, time, a ny constraints on assessment such as inadequate time to complete assessment due to prison r outine). Sources of information used (interview with the person, interviews with others, do cuments examined). The person \200\231s capacity to take part or refuse to take part and un derstanding of the limits of con \201 dentiality. If any important sources of information could not be used, there should be a statement as to why this was the case. Background history Family history; personal history; medical his- tory; psychiatric history ; recent social circumstances; personality; forensic history. Circumstances of offense or alleged offense Progress since offense or alleged offense: part icularly where there has been a considerable period of time since the (alleged) offense. Current mental state Opinion \200 \200 Fitness to plead. Presence of mental disorder currently and whether the criteria for the re levant order are met. Presence of mental disorder at the time of the offense: \200 The relationship between any mental disorder and the offense (this is still relevant even i f the person has been convicted as it may affect the choice of disposal). Whether the perso n was insane at the time of the offense. 17_Semple_Chap17.indd 710 12/7/2012 3:49:49 PM SUGGESTED FORMAT FOR CRIMINAL COURT REPORT 711 In murder cases, whether there are grounds for diminished responsibility. Assessment of ris k: \200 \200 \200 The risk that the person might pose of reoffending. The relationship between this risk and any mental disorder present. Does the person require to be managed in a secure setting (med ium-security unit, high-security hospital)? What assessment or treatment does the person require? \200 Does the person need further assessment? (Where? Does the person need a period of inpatient assessment and at what level of security? Why? What issues remain to be clari \201 ed?) D oes the person require treatment? (What treatment do they need and where?) State any matters that are currently uncertain and the reasons they remain uncertain. Recommendation \200 Should the court consider using any particular order (and if so, what arrangements have bee n made for the person to be received in hospital or elsewhere under this order)? Whose care will the person be under? Consider whether an alternative order may be appropriate if circum- stances change so that the order recommended here cannot be acted on, e.g. \200 \200 If the person is or is not found to be insane. If the person is or is not convicted. Medical practitioner \200\231s details: name; current post; current employer; quali \201 c ations; whether fully registered with the GMC; approved under relevant mental health legisl ation; a statement that the report is given on soul and conscience (in Scotland); statement s as to whether the medical practitioner is related to the person and has any pecuniary int erest in the person \200\231s admission to hospital or placement on any community-based ord er (if a mental health disposal is being recommended); the medical practitioner should sign the report. 17_Semple_Chap17.indd 711 12/7/2012 3:49:49 PM CHAPTER 17 Forensic psychiatry 712 Overview of the pathways of mentally disordered offenders through the criminal justice and health systems The following gives an overview of the criminal justice process, and how at each stage mental disorder may lead to certain courses of action being taken. Different pro cedures are available in the four main jurisdictions of the British Isles (see Table 17.3 f or a summary of the legal provisions for each jurisdiction). The numbers appearing in super script in the following bullet points give an indication as to which procedures are not app licable in all four jurisdictions: 1: England and Wales and Scotland only; 2: Not in RoI; 3 : Scotland only. Arrest and police custody After being apprehended, an individual may be diverted to mental health services informally or under civil procedures. Police may also have speci \201 c po wers allowing them to take mentally disordered individuals for assess- ment by psychiatric services. Pre-trial \200 At a pre-trial court appearance a mentally disordered individual may be remanded to hospita l for assessment and/or treatment.2 With more minor offenses criminal proceedings may be ta ken no further and an individual may receive care from mental health services either inform ally or using compulsory measures under mental health legislation. If an individual is rema nded in prison, but appears to be mentally disordered, procedures may allow for the transfe r of that person to hospital. If an individual is remanded on bail, conditions may be attac hed so that they are required to be assessed and/or treated by psychiatric services. Trial \200 