Review of Consent to Treatment Documentation in University Hospital Wishaw Inpatient Psychiatry

AIMS: To establish if the Mental Health Act Code of Practice was being followed in the mental health inpatient ward population in Wishaw General Hospital. Specifically, those who were subject to detention with a Compulsory Treatment Order (CTO) under the Mental Health Act and whether or not documentation of consent to treatment was being kept. METHODS: Over the course of one week beginning on (1s)t December 2022, we reviewed the inpatient population within acute psychiatric wards (Wards 1-3) at Wishaw General Hospital to determine the nature of patient admissions, informal or under detention, specifically Short Term Detention Certificate (STDC) or Compulsory Treatment Order(CTO). A total of 57 inpatient notes were evaluated, including those of 10 patients with STDC and 14 with CTO. From these 14 patients, we determined whether T2b(240) or T3b(240) forms were clearly documented in both paper and electronic records (MORSE). RESULTS: One of the three patients on Ward 1 who were subject to CTO had both electronic and physical documentation of the T3B form. In the physical notes of two patients, the T2B or T3B form, as well as the reason and specific treatment, were adequately described. Seven of the eight patients subject to CTO in Ward 2 had adequate documentation of the cause and particular treatment, as well as clear documentation of the T2B or T3B form in their physical notes. None of these patient’' electronic notes contained any documentation. As the last patient was less than two months into CTO, they did not fit the criteria for the T2B or T3B consent forms. All three patients subject to CTO from Ward 3 had clear documentation of T3B forms in their physical notes, as well as appropriate documentation of their cause and treatment. There was no documentation on these patient’' electronic notes. CONCLUSION: Overall, the clinical documentation was accurate with strict adherence to mental health act code of practice. 100% of patients requiring consent to treatment documentation either via T2B or T3B form were completed and available for review in the paper notes. Of note however, only 1 patient had CTO documentation and consent to treatment documentation available on electronic records (MORSE) which would allow remote viewing. We propose the practice to upload detention certificates and consent to treatment forms to Electronic data (MORSE within the “files” tab). This information will be shared with ward staff to encourage copy and filing of documentation within this section on MORSE (electronic records).