A health authority has no power to require psychiatrists to act in a way that conflicts with their conscientious professional judgment, the House of Lords ruled last week
The law lords made their ruling in a case brought by a patient in Rampton Hospital whose conditional discharge was ordered by a mental health review tribunal but who remained in hospital because psychiatrists refused to supervise his treatment in the community.
The patient, named only as IH, argued that his continued detention between the tribunal's ruling and a decision by a new tribunal two years later that he should go on being detained breached his right to liberty under article 5 of the European convention on human rights.
IH, who was diagnosed with paranoid psychosis, was found not guilty of causing grievous bodily harm by reason of insanity in 1995 after severely mutilating his 3 year old son. He was detained at Rampton, but the responsible medical officer (RMO) there told a mental health review tribunal in 1999 that he was free of symptoms and that his mental illness was in a state of natural remission. A psychiatrist briefed for IH recommended that the tribunal give him a conditional discharge.
The tribunal provisionally ordered discharge on condition that IH lived in a hostel staffed 24 hours a day, was supervised by a named social worker and a named forensic psychiatrist, and remained subject to recall to hospital. It adjourned the hearing for a care plan to be drawn up.
Meanwhile, a new RMO had been appointed who did not support the conditional discharge. Enfield and Haringey in north London, the health authority responsible for IH, made "extensive efforts" to find a forensic psychiatrist to supervise his treatment in the community, but without success.
The local consultant forensic psychiatrist and his colleagues believed that discharge into the community was "clinically inappropriate and unsafe," said Lord Bingham, the senior law lord.
The tribunal reconvened and decided in 2000 that IH's discharge should be deferred until satisfactory arrangements had been made. A new tribunal in 2002 found that he "was and always had been suffering from his current mental illness and it was appropriate for him to be detained in hospital."
IH argued that his right to liberty was breached because the tribunal lacked coercive powers, failed to discharge him absolutely within a reasonable time, and had been unable to reopen and consider the case after the health authority's failure. He also said that a breach had occurred because the psychiatrists, as "hybrid public authorities," had failed to provide supervision and treatment.
The law lords ruled that tribunals could reopen their decisions if conditions were not met, overturning a ruling in an earlier case preventing them from doing so.
That previous limitation on tribunals' ability to reconsider their decisions was the only respect in which IH's rights to liberty had been violated, the law lords ruled. Health authorities were not under an absolute duty to comply with tribunal conditions, but only to use their best endeavours, and they had no power to require psychiatrists to act in a way that conflicted with their conscientious professional judgment.
The Royal College of Psychiatrists, which intervened in the case (the BMA providing £10 000 ($16 900; €14 400) of its £40 000 legal costs), was disappointed that the law lords decided it was unnecessary to rule on whether psychiatrists were a hybrid public authority in terms of the human rights act. But Tony Zigmond, a college vice president, said: "I think this is a really significant judgment for all doctors, not just psychiatrists."