Social Circumstances Reports for First-Tier Tribunals in a Secure

Psychiatric Service: An Audit

Abstract

Social workers play a critical role in assisting Mental Health Tribunal Panels to decide

whether or not people detained as psychiatric inpatient could be discharged from their

detention. The content of Tribunal reports is laid down in Practice Directions, the most

recent of which was published in October 2013. The study aims were to audit the

quality of Social Circumstances Reports prepared for service users at a secure

psychiatric hospital before and after the introduction of this Practice Direction and to

see if an in-house report-writing template improved report quality. Eighty reports were

audited in 2013 and a further 80 in 2014 against 28 key items derived from the Practice

Direction. Reports prepared in 2013 contained on average 13.1 of 28 key items

increasing to 19.1 in 2014. The template was used for 60% of reports in 2014 and

resulted in better quality reports. In the repeat audit more reports contained

recommendations, mostly advising the service user’s continued detention, though a few

recommended discharge to a less restrictive placement. Such professional judgements

take place at the juxtaposition of the Mental Health Act (1983) and the Human Rights

Act (1998), in which risk management and risk taking are key to decision-making.

Keywords: social circumstances report; tribunal, risk, audit, psychiatry, inpatient

1

Introduction

In England and Wales, one of the many duties of social workers working with people

who are detained in psychiatric hospitals is the provision of oral and written information

about their social circumstances to First-tier Tribunals. The service user’s consultant

psychiatrist (Responsible Clinician) and a nurse are also required to produce reports and

give oral evidence. For many years, little guidance was provided to health and social

care professionals about the content of their written reports but in the last few years

increasingly detailed requirements have been issued culminating in the most recent

Practice Direction published by the Tribunals Service in October 2013. Adherence to

the current Practice Direction and respective timescales for the completion of reports is

mandatory, and delays in providing reports can potentially lead to sanctions and fines of

the detaining authority, and the individual named professional.

In England there have been a number of studies by psychiatrists addressing the quality

of Medical Tribunal Reports. In general these have found considerable room for

improvement and have suggested a range of interventions to rectify shortcomings,

including local guidelines or checklists (Davidson and Perez de Albeniz, 1997; Egleston

and Hunter, 2002) or performance management of those producing poor quality reports

(Murphy and Basu, 2012). A single study has assessed the quality of Social

Circumstances Reports (Lewis, 2006). This audit was conducted in a secure inpatient

service and examined the quality of reports written on service users detained on

Restriction Orders before and after the issuing of the 2002 guidelines on report-writing

for Mental Health Review Tribunals (Department of Health, 2002). Some improvement

was seen in most items audited at follow-up, although a number of issues including

personal history, accommodation, opportunities for employment, finances and aftercare

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remained infrequently commented upon. The sample was relatively small – 30 reports

before and 30 after the new guidance was published. Curran and Golightley (2009) in an

article on Social Circumstances report-writing skills state that the most common fault in

reports is simply that the writer is unaware of the required contents of reports, an

observation previously made by Eldergill (1997).

The 2013 Practice Direction is much more prescriptive about the types of information

that should be included in Social Circumstances Reports than previous instructions.

There is now a requirement to comment upon a wide range of issues, such as factors

that might affect the service user’s ability to cope with the hearing and any adjustments

that the Tribunal Panel should consider making, details of any index offence and

forensic history, previous involvement with the mental health services and the service

user’s previous response to community treatment, the service user’s current progress,

behaviour, compliance and insight and any involvement with the Multi-Agency Public

Protection Agency (MAPPA). There is a requirement for the report-writer to provide an

opinion as to whether detention in hospital for medical treatment is justified in the

interests of the service user’s health, or safety or for the protection of others and the

social worker is also invited to make recommendations to the Tribunal with reasons.

With the introduction of this new Practice Direction it seemed timely to study the

quality of tribunal reports written by all three disciplines (social workers, psychiatrists

and nurses). This paper will focus on Social Circumstances Reports. Separate papers

have been prepared on the quality of Medical and Nursing Tribunal Reports using

comparable methodology (Haw, in press; Haw, submitted).

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The aims of the study were firstly to complete a survey of the quality of Social

Circumstances Tribunal Reports at baseline immediately prior to the introduction of the

2013 Practice Directions and then to repeat the audit at a later date. A further aim was to

see if report-writing could be improved by use of an in-house report-writing template.

Method

Setting

The study was conducted at a charitable tertiary referral service providing a range of

different services to people experiencing mental distress, many of whom have complex

needs and require secure levels of care. Almost all are referred and funded by the NHS.

The majority of service users are detained under the Mental Health Act (1983),

amended in 2007, although some people are receiving services under authorised

Deprivation of Liberty Safeguards.

Ethical approval

Research Ethics Approval was not deemed necessary since the study was considered to

be a clinical audit. It was, however, approved by the Organisation’s Head of Clinical

Effectiveness.

Initial audit

For the initial audit, the lead author obtained a list from the Hospital’s Mental Health

Act Administration of First-tier Tribunal meetings scheduled to take place between June

and December 2013. Reports on service users who had withdrawn their applications

prior to the Tribunal were included. A structured proforma based on the items listed in

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the latest Tribunals Service Practice Direction (October 2013) was developed and

piloted on a small number of reports. The proforma was then modified in the light of the

pilot study and a final version produced. The Practice Direction for Social

Circumstances Reports is lengthy and complicated, particularly with respect to children.

A series of key items were selected that should be included in reports regardless of the

service user’s age (that is items pertaining only to young people were not included). A

total of 28 key items were identified and each was scored as being present or absent in

the reports studied. Almost all the items left no room for observer bias, for example, is

the report signed? Is the service user’s financial situation described? What are the views

of the Nearest Relative? Ten reports were randomly chosen from each of the

Organisation’s eight Registered Hospitals (Neuropsychiatry, Low Secure, Locked and

Psychiatric Intensive Care Unit Services, Men’s Medium Secure Service, Women’s

Service, Medium Secure Adolescent Services, Neuropsychiatry and three satellite

hospitals).

Implementing the requirements of the new Practice Directives

Following the publication in October 2013 of the new Practice Direction, an in-house

Word template was introduced for the completion of Social Circumstances Reports. It

was circulated by e-mail to all social workers and also made available on the

Organisation’s intranet. The template was also discussed in senior social work meetings

with the aim of cascading it to all social workers.

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Repeat audit

For the second cycle of the audit, the lead author obtained a further list of Tribunals

scheduled to take place between April and September 2014 and used the same data

collection procedure as previously. In addition, it was recorded whether or not the in-

house template had been used to complete the reports.

Data analysis

Data from both audits was entered into an SPSS database and a descriptive analysis

performed. The independent samples T-test was used to compare mean values between

groups.

Results

A total of 80 Tribunal Reports were studied in the initial audit and a further 80 in the

repeat audit. The characteristics of the included service users are summarised in Table

1. Most service users were male and approximately a quarter were detained on

restriction orders. They were suffering from a wide variety of mental disorders, most

commonly schizophrenia, personality disorders and learning disabilities and often had

multiple mental health problems.

Initial vs. re-audit

In the initial audit 75 (93.8%) reports were written by a social worker, 3 (3.8%) by a

social care assistant and 2 (2.5%) by a student social worker. In the re-audit 67 (83.8%)

reports were written by a social worker, 6 (7.5%) by a student social worker, 5 (6.3%)

by a student social worker together with a social worker, 1 (1.3%) was written by a

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social care assistant together with a social worker and for 1 (1.3%) report the status of

the author was not given.

Scores on the 28 key items for both audits are shown in Table 2. The figures in bold

type show where scores on individual items had improved in the re-audit. All but two

key items (service user’s financial situations and their views, wishes, beliefs and

opinions) showed an improved score in the repeat audit. Items where most improvement

occurred were:

(1) Use of numbered paragraphs,

(2) Information for the Tribunal about service user factors that needed to be taken into

account in order that the hearing was fair,

(3) Funding issues concerning the proposed care pathway,

(4) Details of past psychiatric history and

(5) Previous response to community support.

Items that remained not so well documented in the repeat audit were:

(1) The likely effectiveness and adequacy of the proposed care pathway,

(2) Whether or not the service user if discharged was likely to act in a dangerous

manner to themselves or others and

(3) Whether or not the service user could now be managed in the community and if

yes, how any risks could be managed.

The average number of the 28 key items present increased from a mean of 13.1 (SD 3.2)

in the initial audit to 19.1 (4.4) in the repeat audit (t=-9.81, p<0.0001). Length of reports

also increased somewhat from a mean of 7.3 (SD 3.2) pages in 2013 to 9.3 (SD 3.4)

pages in the 2014 re-audit (t=-4.01, p<0.0001).

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An additional item, whether or not the report was accompanied by a copy of the Police

National Computer Record, was not included in the key items as a significant minority

of service users had no previous convictions. In the initial audit there were 50 service

users with previous convictions. Of these only 6/50 (12.0%) had a copy of their Police

Record submitted with their Social Circumstances Report. In the re-audit there were 51

service users with previous convictions but in only 8 (15.7%) instances was the Social

Circumstances Report accompanied by a copy of their Police Record. Another variable,

whether or not the service user was known to MAPPA and at what level, was relevant

for 40 (50.0%) service users in both audits. In the initial audit mention of MAPPA

status was made for just 13/50 (26.0%) service users but in the re-audit there was

recording of MAPPA status for 29 (58.0%) service users.

In 48 (60.0%) instances the report writer had used the in-house template. Reports

written using the template had a higher mean number of key items present than those

that did not (template used, mean number of key items = 21.0 (SD 3.5) vs. no template,

mean number of key items = 15.3 (SD 4.2), t=-5.83, p<0.0001). Where the template was

used the length of the report was not significantly longer than when it was not used

(template used, mean report length = 9.6 (SD 3.4) pages vs. no template used, mean

report length = 8.3 (SD3.3) pages, t=-1.5, p=0.14).

In the first audit there were 40 (50.0%) reports where the report writer made a

recommendation to the Tribunal. In 38 out of these 40 reports the recommendation was

for continued detention, while in one case a recommendation was made for continued

psychological treatment and in another for discharge on a Community Treatment Order

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(CTO). In the repeat audit a greater number of recommendations were made (63;

78.8%). Of these 50 were for continued detention, four for continued psychological

treatment, two for transfer to a hospital nearer to the service user’s home, two for a

move to a step-down facility, two for discharge to a residential home, with the

remaining three recommending unescorted leave, self-medication and eventual

discharge on a CTO.

Overall, social workers used the in-house template for 60.0% of reports. This compares

with 31.3% of psychiatrists and 27.2% of nursing staff.

Discussion

It was pleasing that Social Circumstances Report quality, as judged by the number of

key items present, improved substantially in the repeat audit. However, there was still

room for improvement, particularly in the areas of justifying the service user’s

continuing detention, the likely effect of immediate discharge from section, MAPPA

status and inclusion of a copy of the Police National Computer Record with the report.

The Practice Direction for reports on children is particularly lengthy and so reports

written on young people deserve a separate tailor-made audit. A further point is that

some of the details listed in the Practice Direction are not readily applicable to mentally

disordered service users who have been hospitalised for many years and for whom no

discharge plans have been formulated. Such items include accommodation available to

the service user if discharged and the likely effect of immediate discharge. Another

issue is the potential duplication of information between Medical and Social

Circumstances Reports for inpatients, since both types of report are required to contain

9

details of any index offence and forensic history, the service user’s previous

involvement with the mental health services, any incidents of violence to self, others or

property or threats made and a summary of the service user’s current progress,

behaviour, compliance and insight. One of our social workers commented upon this

issue as follows, ‘It seems unnecessary that in our Social Circumstances report under

“psychiatric history” we are asked to give “a chronology listing the patient’s previous

involvement with mental health services including any admissions to, discharge from

and recall to hospital” which is no doubt substantially  covered  in the RC’s report’.

Use of the Word report-writing template improved compliance with the new Practice

Direction in the re-audit. Another of our social workers commented ‘They (the

templates) are a very easy to use and a helpful aide memoire.’ Compared to

psychiatrists and nursing staff, social workers more often used the new template (60%

of Social Circumstances Reports used the template), though the quality of their reports

at re-audit (an average of 68.2% of key items were present in reports) was intermediate

between those prepared by psychiatrists (73.6%) and nursing staff (51.3%). One of our

Mental Health Act administrators said that following the issuing of the template, ‘In

terms of quality and compliance I have seen overall a marked improvement with regards

to quality and compliance (deadlines being met)’.

It used to be that the main purpose of the Social Circumstances Report was to provide

the Tribunal with hard evidence of the service user’s circumstances if discharged from

hospital, in particular what professional support would be available in the community

(Curran et al, 2010). However, the role of the Social Circumstances Report has now

been broadened to include the social worker’s knowledge of the service user’s past

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behaviour in relation to psychiatric services and the law, as well as their current risks

and needs.

As well as the above additions to reports, social workers have to take account of other

UK legislation including the Human Rights Act (1998) and the Mental Capacity Act

(2005). For example, under the Human Rights Act (1998) people have a right to liberty,

to freedom from inhuman and degrading treatment and there should be respect for their

private and family life. These are all rights that potentially conflict with service users

being subjected to compulsory inpatient psychiatric treatment. Although the findings of

the second audit identified that there was an overall increase in social workers making

recommendations at the end of their reports, and an increase in recommendations for

alternatives to inpatient detention, this still seems to be an area which is challenging

social workers in forming judgements and making decisions. Social workers have to

balance the human rights of service users against their need for psychiatric treatment to

improve health and reduce the risk to self and others. Making a judgement about the

safety of the service user and the safety of the public should the social worker

recommend that the person is discharged, is described by Taylor (2013) as a

safeguarding decision using predictive risk factors alongside an ethical dimension. The

judgement is based on the social worker using criteria to consider risk and safety and

how far the law is a protective factor for the individual and/or the public. These ‘legal

rules’ (Preston-Shoot, 2014) on one hand reflect the principles of autonomy, self-

determination, the right to liberty and family life, yet on the other hand the principles of

protection and promotion of a person’s welfare could potentially be achieved only with

the imposition of professional power. Taylor (2013) argues that there is a paradox

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between needing to take positive risks to promote recovery and the risk of ‘being

blamed if an undesirable outcome ensues’ (p.109).

The Mental Capacity Act (2005) is particularly relevant to patients with impaired

cognitive function through dementia, traumatic brain injury or those with learning

disabilities. Anecdotal evidence from colleagues indicates that recent Tribunals have

questioning social workers as to whether service users could be managed under the

Deprivation of Liberty Safeguards (DOLS) legislation of the Mental Capacity Act

(2005), which can be perceived to be less restrictive than the provisions of the Mental

Health Act (1983, amended in 2007). Providing information to Tribunals about these

issues is likely to lead to lengthier Social Circumstances Reports. However, Tribunals

can currently only rule on whether the criteria for detention under the Mental Health Act

(1983) are met.

This study has several limitations. First, the findings may lack generalisability to the

wider NHS since the audit was conducted in an independent sector organisation.

However, the tribunal process is the same regardless of organisational setting. The

service users whose Social Circumstances Reports were audited had specialist and

complex mental health needs and, therefore reports for people in acute inpatient

psychiatric settings may be qualitatively different. However, the key items audited

would be applicable to other settings, since they are required by English Tribunals

regardless of the care provider. Secondly, as already mentioned, the audit focused on

items needed for reports on adults and we did not audit the Practice Direction for

children. Thirdly, we judged the quality of reports by the presence or absence of a series

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of items derived from the Practice Direction. Other factors, such as grammatical quality,

the amount of detail provided and its relevance were not studied.

In the light of the findings of this study, our Mental Health Act Office now attaches the

in-house template to every electronic request for a Social Circumstances Report. Further

training in report-writing for psychiatrists, social workers and nurses has been organised

and delivered on a regular basis and a repeat audit is planned for 2016. Other services

may wish to monitor the quality of their Tribunal Reports using our system of key

items. Service users deserve to have objective and comprehensive reports written with

or on behalf of them so that Tribunal members can come to fair and balanced decisions

about their detention in hospital.

Acknowledgement

Our thanks to the Mental Health Act Office with help in locating reports.

Disclosure statement

The study received no funding. We declare that we have no conflict of interest.

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References

Curran, C. and Golightley, M. 2009. “Social circumstances reports for mental health

review tribunals under 2008 Practice Direction, Section E”. Openmind, 156: 24-

25.

Curran, C., Golightley, M. and Fennell, P. 2010. “Social circumstances reports for

mental health tribunals – Part 1”. Legal Action, 30: 30-32.

Davidson, P. and Perez de Albeniz, A. 1997. “Reports prepared for Mental Health

Review Tribunals and Manager’s Reviews”, Psychiatric Bulletin, 21 (6): 364-6.

Department of Health. 2002. “Social Circumstances Report by Social Workers for

Mental Health Review Tribunals”. Accessed May 23, 2015.

http://webarchive.nationalarchives.gov.uk/+/www.dh.gov.uk/en/Publicationsandst

atistics/Publications/PublicationsPolicyAndGuidance/DH_4015462.

Egleston, P. and Hunter, M.D. 2002. “Improving the quality of medical; reports to

mental health review tribunals”. Psychiatric Bulletin, 26(6): 215-218.

Eldergill, A. 1997. Mental Health Review Tribunals: Law and Practice. London:

Thompson, Sweet and Maxwell.

Haw, C (in press). “An audit of Nursing Reports for First-tier Tribunals in a secure in-

patient service”. Journal of Psychiatric and Mental Health Nursing.

IBM Corp. 2011. IBM SPSS Statistics for Windows, Version 20.0. New York, IBM

Corp.

Lewis, K.T. 2006. “Social circumstances reports presented to mental health review

tribunals”. The British Journal of Forensic Practice, 8: 31-37.

Murphy, P. and Basu, A. 2012. “The standard of medical tribunal reports in a high

secure setting”. The Psychiatrist, 36: 463-466.

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Preston-Shoot, M. 2014 Making Good Decisions. Law for Social Work Practice.

London: Palgrave MacMillan.

Taylor, B. (2013) Professional Decision Making and Risk in Social Work. London:

Sage Publications.

Tribunals Judiciary. 2013. Practice Direction First-tier Tribunal: Health Education and

Social Care Chamber statements and reports in mental health cases. Accessed

May 23, 2015. http://www.mhla.co.uk/wp-content/uploads/FTT-PD-Statements-

in-mental-health-cases-in-HESC-wef-28-Oct-2013.pdf.

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Table 1

Demographic, legal and clinical characteristics of service users audited

Service user characteristic N (%)

Male gender 113 (70.6)

Legal status Section 3 Section 37 Restricted

98 (61.3)26 (16.3)36 (22.5)

ICD-10 clinical diagnoses* F00-09 Organic diagnosis F10 Alcohol – harmful use or dependence F11-19 Drug misuse or dependence F20-29 Schizophrenia and related-psychoses F31 Bipolar disorder F32-33 Depressive disorder F60-61 Personality disorder F70-71 Learning disabilities F84 Autistic spectrum disorder F90 Hyperkinetic disorder Other diagnoses

25 (15.6)23 (14.4)39 (24.4)74 (46.3)7 (4.4)5 (3.1)

55 (34.4)43 (26.9)39 (24.4)14 (8.8)33 (20.6)

Age in years Mean (SD) 33.5 (14.6)

*Service users could have more than one diagnosis

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Table 2: Social Circumstances Tribunal Report Audit: 2013 vs 2014 Results: Number (%) items present in reportsStandard 2013: No. Present

N (%)2014: No. present

N (%)Evidence the report is up-to-date 66 (82.5) 68 (85.0)

Report prepared specifically for Tribunal 76 (95.0) 80 (100.0)

Pages are numbered 74 (92.5) 75 (93.8)

Paragraphs are numbered 0 (0.0) 48 (60.0)

Report is signed 29 (36.3) 38 (47.5)

Sources of information are listed 42 (52.5) 69 (86.3)

Report does not recite medical records 65 (81.3) 70 (87.5)

Current mental health presentation 32 (40.0) 57 (71.3)

Service user factors the Tribunal should be aware of to

ensure the case is dealt with fairly*

2 (2.5) 32 (40.0)

Index offence (if any) and forensic history* 37 (46.3) 65 (81.3)

Past psychiatric history including admissions 32 (40.0) 61 (76.3)

Service user’s home and family circumstances 74 (92.5) 75 (93.8)

Accommodation available to service user if discharged* 30 (37.5) 53 (66.3)

Service user’s financial situation including benefits 70 (87.5) 68 (85.0)

Any available opportunities for employment* 25 (31.3) 48 (60.0)

Service user’s previous response to community support* 17 (21.3) 47 (58.8)

Service user’s care pathway and S117 aftercare* 25 (31.3) 50 (62.5)

Likely adequacy and effectiveness of proposed care plan*

7 (8.8) 29 (36.3)

Any funding issues regarding the care plan* 2 (2.5) 34 (42.5)

Positive factors / service user’s strengths 59 (73.8) 73 (91.3)

Summary of service user’s progress / behaviour 41 (51.2) 61 (76.3)

Details of violence to self/others/property/threats* 27 (33.8) 40 (50.0)

Service user’s current level of insight 20 (25.0) 32 (40.0)

Service user’s views, wishes, beliefs and opinions 77 (96.3) 72 (90.0)

Nearest Relatives views* 71 (88.8) 77 (96.3)

Treatment in hospital is justified in interests of service user’s health, safety or protection of others

18 (22.5) 36 (45.0)

If service user discharged they might act in a dangerous manner to themselves of others

16 (20.0) 24 (30.0)

Could the service user now be managed in the community and if yes how any risks could be managed

5 (6.3) 28 (35.0)

*If there are none then there is a statement to this effect

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