. arrangements for identification of dangerous severely personality disordered
people and assessment of risk based on agreed national protocols;
. acasemanagement system for those who have been assessed;
. conditions for managing people in detention that protect the public and are
safe for staff and those who are subject to detention; programmes for the
management of dangerous severely personality disordered people, in
detention and following discharge from detention, based on best practice
including risk assessment.. .'
While it is true to say that these provisions will affect a very small minority of
individuals ± assessed at around 2000 in the discussion document since it is
necessary for the individual not only to have a personality disorder but for it to be
both dangerous and serious ± the impact is certainly wider. The ability to detain to
prevent offending, and where offending need never have occurred in the past, is
harsh, albeit for the aims of protection of the public and is the area that is likely to
cause the greatest moral and ethical debate. Detention in this situation would be
via the civil law, and would result in the dangerous person being kept in facilities
run by the health service `whether or not they were likely to benefit from treatment
in hospital' [58], with an expectation that the facilities would be separate from
other mental health units. If the individual has offended, the criminal courts would
have the power to give a variety of different disposals, which all look towards
assessment of risk and detention in specialist units, albeit that the specialist units
may be jointly run by the health and prison services.
The method of implementation of any or all of these proposals will be either by
minor modifications to the existing legal regime, or by introducing new powers for
the civil and criminal courts. Regardless of the means to introduce the powers,
unless accompanied by rigorous assessment procedures, they represent a possible
retrograde step in the way in which society sees the mentally disordered person.
9.8 Treatment in the community
The context of the above discussion has been on treatment and care of the mentally
disordered patient within the hospital or nursing home. However, many mentally
ill people are perfectly able to live in the community and receive treatment with
only out-patient visits or short in-patient stays. For these individuals, treatment will
be with their consent since the treatment provisions in the MHA only permit
compulsory treatment when the patient is in hospital or when they are on leave of
absence under section 17 MHA. While on leave of absence the patient may be
recalled at any time if necessary in their interests or the interests of others. In
addition, if the detention section is to be renewed, the patient must be recalled to
hospital, with the intention that the patient then remains in hospital.
Hence, there has been a long running debate on the need for community
treatment orders, and incidents involving mentally ill people in the community,
such as Ben Silcock, have served to continue the discussion. Following the Silcock
incident, where Silcock, who suffered from schizophrenia, was mauled by a lion at
London Zoo after entering its enclosure, the Department of Health examined the
178 Nursing Law and Ethics