First-tier Tribunal (Mental Health) hearings: protecting the therapeutic relationship
Intended for healthcare professionals
CPD    

First-tier Tribunal (Mental Health) hearings: protecting the therapeutic relationship

Helen Rees Field lead mental health nursing, Nottingham Trent University, Nottingham, England

Why you should read this article:
  • To enhance your understanding of the First-tier Tribunal (Mental Health) process

  • To consider how you can support patients through the process and protect the therapeutic relationship

  • To contribute towards revalidation as part of your 35 hours of CPD (UK readers)

  • To contribute towards your professional development and local registration renewal requirements (non-UK readers)

The First-tier Tribunal (Mental Health) is an independent judicial body that hears applications from people who have had their freedom restricted under the Mental Health Act 1983 (amended 2007). Mental health nurses may be required to provide its panel with written and/or oral evidence. It can be challenging for nurses to protect the therapeutic relationship with the patient while fulfilling their duty to provide evidence to the panel. This article gives an overview of the legal process and details the evidence nurses may be required to provide. The article also discusses ways in which nurses can support patients throughout the process and attempt to protect the therapeutic relationship.

Mental Health Practice. doi: 10.7748/mhp.2023.e1664

Peer review

This article has been subject to external double-blind peer review and checked for plagiarism using automated software

@lavellerees

Correspondence

Helen.rees@ntu.ac.uk

Conflict of interest

None declared

Rees H (2023) First-tier Tribunal (Mental Health) hearings: protecting the therapeutic relationship. Mental Health Practice. doi: 10.7748/mhp.2023.e1664

Published online: 10 October 2023

Aims and intended learning outcomes

The aims of this article are to enhance mental health nurses’ understanding of the First-tier Tribunal (Mental Health) process and of the written and oral evidence they may have to provide the tribunal panel, and to explore ways in which nurses can support patients throughout the process and protect the therapeutic relationship.

After reading this article and completing the time out activities you should be able to:

  • Explain the purpose and process of the First-tier Tribunal (Mental Health).

  • List the information that needs to be included in the written nursing report submitted to the panel before the hearing.

  • Discuss patients’ legal rights in relation to the process.

  • Describe ways in which you can support patients throughout the process.

  • Describe ways in which you can attempt to protect the therapeutic relationship while fulfilling your duty to provide evidence to the panel.

Introduction

The First-tier Tribunal (Mental Health) (referred to throughout this article as ‘the tribunal’) is a judicial body that hears applications from people detained or restricted under the provisions of the Mental Health Act 1983 (amended 2007) (referred to throughout this article as ‘the act’). It was previously called the Mental Health Tribunal.

The tribunal serves as a legal safeguard within the act (which applies only to England and Wales) and requires clinicians, on behalf of the detaining authority, to demonstrate how a patient detained or restricted under the act meets the legal criteria for being detained or restricted (Zigmond and Brindle 2022). Mental health nurses who work with patients detained or restricted under the act have a statutory duty to provide written evidence to the panel and/or to give oral evidence at the hearing if requested to do so (Department of Health and Social Care (DHSC) 2015).

Hearings at the tribunal can demonstrate respect for patients who have been detained under the act by involving them in the legal processes surrounding their detention (Jones 2022). However, some patients find participation in the hearing stressful and challenging (Macgregor et al 2019). Furthermore, hearings have been criticised for favouring the medical model, excluding the patient voice and endangering the therapeutic relationship between the patient and the professionals presenting evidence about them (Akther et al 2019).

Key points

  • The First-tier Tribunal (Mental Health) hears applications from people detained or restricted under the Mental Health Act 1983 (amended 2007)

  • Nurses who work with patients detained or restricted under the act may be requested to provide evidence to the tribunal

  • Nurses may have to write a report containing a recommendation regarding the ongoing use of, or discharge from, detention or restriction

  • It can be challenging for nurses to protect the therapeutic relationship with the patient while providing evidence to the tribunal

  • Nurses can attempt to protect the therapeutic relationship by displaying transparency and acting as the patient’s advocate throughout the process

The ability to develop and maintain therapeutic and recovery-oriented relationships with patients is a core competency of mental health nurses (Health Education England 2020). The enforced or restrictive treatment of patients can negatively affect the therapeutic relationship. It is therefore important for nurses to be able to minimise the risk of damage to the therapeutic relationship while fulfilling their duty towards the tribunal.

This article gives an overview of the tribunal process and of the evidence nurses may be required to provide. It also discusses ways in which nurses can support patients and attempt to protect the therapeutic relationship throughout the process.

Time Out 1

Recall a time when you prepared written evidence for, and/or gave oral evidence to, the First-tier Tribunal (Mental Health). How did you feel when you were asked to do this? How did you feel when you attended the hearing? Did you feel confident in carrying out this statutory duty? If so, what supported you to feel confident? If not, what might have helped you to feel confident?

First-tier Tribunal (Mental Health)

The purpose of the tribunal is ‘to review the cases of detained and conditionally discharged patients and patients subject to community treatment orders (CTOs) under the act […] and to direct the discharge of any patients where it thinks it appropriate’ (DHSC 2015) – in other words, when it considers that the legal criteria are not met. For patients subject to a community treatment order – which requires the person to have supervised treatment in the community when they leave hospital – the tribunal considers the availability of appropriate treatment in the community and the necessity of the power of recall (DHSC 2015).

The tribunal panel is independent of the detaining authority and scrutinises written and oral evidence justifying the patient’s detention to determine whether the legal criteria established by the act have been accurately and fairly applied. If it judges that this is not the case, the panel can end the detention.

The panel consists of (DHSC 2015, Royal College of Psychiatrists (RCPsych) 2019, Courts and Tribunals Judiciary 2023):

  • A person who is legally qualified, referred to as the tribunal judge, who chairs the hearing.

  • A person with mental health expertise, referred to as the specialist member.

  • A consultant psychiatrist, referred to as the medical member or tribunal doctor.

The tribunal process is supported by the Mental Health Act office of the relevant local authority, which ensures that legislation associated with the act is adhered to, supports mental health services and manages the administrative aspects (DHSC 2015).

Preparing the evidence

Before the hearing, the tribunal panel will usually request three written reports (Care Quality Commission 2018):

  • A medical report from the patient’s responsible clinician.

  • A nursing report from a member of the inpatient nursing team (for patients who are detained under the act).

  • A social circumstances report. If the patient has an allocated care coordinator (who may be a mental health nurse or a social worker), that person will usually prepare the social report. If the patient does not have an allocated care coordinator, the social report can be prepared by a duty worker (usually a social worker) or an approved mental health professional (that is, a mental health professional approved by the local social services to carry out duties under the act).

Contents of the nursing report

To ensure that the panel is presented with robust evidence, it is important that the nurse who is writing the nursing report (referred to from hereon as ‘the report’) understands the legal criteria underpinning the patient’s detention or community treatment order and is knowledgeable about the person. The report should be written and submitted as soon as possible after it has been requested, since a delay in submitting evidence can result in the adjournment of the hearing, which can increase the patient’s stress or anxiety and reduce their engagement in the process.

To be liable to detention under the act, patients must have a mental disorder, defined for the purposes of the act as ‘any disorder or disability of the mind’ (DHSC 2015). If the patient has received a definitive, specific diagnosis, it is important to refer to that diagnosis consistently in the report.

The report should contain a clear description of the patient’s symptoms observed by the nursing team since the patient has been detained, including their chronology and severity, and the patient’s symptoms and mental state at the time of writing the report. The report should also describe the ‘nature’ and ‘degree’ of the patient’s mental disorder. The act defines ‘nature’ and ‘degree’ as follows (DHSC 2015): ‘Nature refers to the particular mental disorder from which the patient is suffering, its chronicity, its prognosis, and the patient’s previous response to receiving treatment for the disorder. Degree refers to the current manifestation of the patient’s disorder.’

Examples of the type of evidence that may help the nurse writing the report to describe the nature and degree of the patient’s mental health condition, based on the author’s experience, are shown in Table 1.

Table 1.

Examples of the type of evidence that may help describe the nature and degree of the patient’s mental health condition

NatureDegree
  • A chronology of the events that have led to the patient becoming unwell

  • The patient’s engagement with treatment and/or ward-based activities in hospital and what may trigger their disengagement (if known)

  • Any untoward event since the patient has been detained, including what may have triggered it (if known)

  • The patient’s understanding of their condition and how this affects their adherence to treatment

  • The patient’s independent adherence to treatment, such as self-medication

  • The patient’s response to treatment

  • The patient’s engagement with, or disengagement from, activities of daily living, for example personal hygiene

  • The patient’s level of independence when undertaking activities of daily living

  • How often the patient needs administration of as-required medicines

The report should include details of whether or not detention needs to continue in the interests of the patient’s health and safety and/or for the protection of others (DHSC 2015). It is important that the panel knows about the patient’s historic and current risks to themselves and/or others and about their potential protective factors. Protective factors, for example having a strong support network of family and/or friends or actively seeking help, mitigate risk factors (RCPsych 2016).

Risks to self may include vulnerability (for example, behaviours related to distress that make it more likely that the patient will become a victim of crime), self-neglect (for example, neglecting personal hygiene or diet), disengagement from services, acts of self-harm and risk of completed suicide. Risks to others may include aggression, violence, carrying weapons, disinhibition and reckless or unpredictable behaviours (RCPsych 2016). Understanding those risks enables the nurse writing the report to consider what support the patient might require if they were to be discharged from detention by the tribunal and whether such support would be available. The report should account for the evolving nature of the risks.

The report should conclude with a recommendation regarding the ongoing use of, or discharge from, detention under the act and a brief summary of the evidence supporting that recommendation. Nurses can consult the Mental Health Act 1983 Code of Practice (DHSC 2015) for further information on what to include in the report.

The report is communicated to the panel and to the patient and their legal representative before the hearing (Courts and Tribunals Judiciary 2023). The nurse who has written the report has the right to request that the panel withholds, from the patient, certain information contained in the report (DHSC 2015). They will need to provide a clear and reasonable justification for this.

Time Out 2

How might you prepare written evidence for a hearing before the First-tier Tribunal (Mental Health)? Make a list of the type of information you will need to include and the potential sources of that information. Consider how you might describe the ‘nature’ and ‘degree’ of the patient’s mental health condition

Representing the nurse who has written the report at the hearing

It is best practice for the nurse who has written the report to attend the hearing so that they can respond to any questions the panel may have about the evidence provided. If this is not possible, for example if the hearing is due to take place when the nurse is on annual leave, they can be represented by another member of the nursing team. In such a situation, the representative should ensure that they are familiar with the contents of the report and up to date on the patient’s mental state, condition, symptoms and progress towards recovery. The representative should therefore consult additional sources of information before the hearing, for example the patient’s clinical record or handover notes, and/or liaise with the patient’s support network, which may include family members, supporters and advocates.

Protecting the therapeutic relationship

The therapeutic relationship in mental health nursing practice has been described as a ‘partnership that promotes safe engagement and constructive, respectful, and non-judgemental intervention’ (NHS England 2022). It requires nurses to demonstrate genuineness, humility, empathy and unconditional positive regard. It can be challenging for nurses to protect the therapeutic relationship with the patient while fulfilling their duty to provide evidence about them to the tribunal. However, they can attempt to minimise potential damage to the therapeutic relationship by displaying transparency and acting as the patient’s advocate throughout the process.

Time Out 3

Reflect on your understanding of the therapeutic relationship in mental health nursing. Thinking about a patient you have worked with, how could your duty to give evidence to the First-tier Tribunal (Mental Health) adversely affect your therapeutic relationship with that patient? What might you do to attempt to protect it?

Preparing the patient for the process

The tribunal process begins long before the hearing takes place and nurses often have a critical role in preparing the patient, notably by informing them of their legal rights, by discussing the report’s recommendation with them and by practising trauma-informed care.

Informing the patient of their legal rights

Ensuring patients are aware of their rights to apply to the tribunal and to have free legal representation is an important nursing duty underpinned by ethical, professional and legal frameworks (Beauchamp and Childress 2001, DHSC 2015, Nursing and Midwifery Council 2018). It supports patients to exercise their rights in a legal system that mental health service users often experience as disempowering (Carr et al 2022).

Free legal representation is organised by the Mental Health Act office of the detaining authority (DHSC 2015). A legal representative can advise the patient based on their specialist knowledge of the legal framework underpinning the process. Once the patient’s legal representative has been appointed, nurses can assist the patient to contact them. Supporting the patient in this way demonstrates authenticity, trustworthiness and honesty, which are essential qualities in the therapeutic relationship (Wright 2021).

There are different eligibility periods for applications to the tribunal according to the section of the act under which the patient has been detained (DHSC 2015), examples of which are shown in Box 1. Some patients detained under section 3 (‘detained for treatment’) of the act may be automatically referred to the tribunal if they do not apply themselves (gov.uk 2023).

Box 1.

Examples of eligibility periods for applications to the First-tier Tribunal (Mental Health)

Patients can apply to the tribunal:

  • Within the first 14 days of being detained under section 2 (‘detained for assessment’) of the Mental Health Act 1983 (amended 2007)

  • At any time within the first six months of being detained under section 3 (‘detained for treatment’) of the act

  • Between six and 12 months from the date of the order made by the court if the person has been detained under section 37 (‘detained by a court order’) of the act

  • Between six and 12 months from the date of the hospital order made by the court if the person is a restricted patient detained under section 37 and section 41 (‘hospital order with restrictions’) of the act

(gov.uk 2023)

The legal aspects of applying to the tribunal are complex, so it is important that nurses provide clear, jargon-free information in plain English to patients about their rights and the process. This type of information provision has been shown to foster inclusion and respect and has been reported to be valued by patients (Murphy et al 2017). Nurses can also signpost patients to user-friendly resources – see the ‘Further resources’ section of this article – and prompt them to seek advice from their legal representative.

The information may need to be discussed with the patient several times – if they are experiencing periods of distress, they may find it challenging to process or retain information – and should be discussed with the patient’s nearest relatives, supporters or advocates, if the patient has given permission for this.

Patients are entitled to request a pre-hearing examination with the medical member of the panel. For patients detained under section 2 (‘detained for assessment’) of the act, a pre-hearing examination is automatically requested (DHSC 2015). The charity Mind (2018) emphasised that the pre-hearing examination is an opportunity for the patient to discuss their application. The pre-hearing examination also allows the medical member of the panel to make an independent assessment of the patient’s mental state.

A pre-hearing examination is an important way of ensuring that the patient’s voice is represented at the tribunal, so facilitating it is a way for nurses to advocate for patients. Facilitating a pre-hearing examination may include ensuring the appointment is recorded in the ward diary; that a private room, laptop and internet connection are available on the day; and that the patient is aware and reminded of the date and time of the appointment.

Time Out 4

Reflect on the case of a patient you have helped to prepare for a hearing before the First-tier Tribunal (Mental Health) – or imagine you have been asked to do so. What do you think are the most important aspects of preparation? What resources might you use to ensure you provide the patient with accurate and accessible information?

Discussing the report’s recommendation with the patient

It is important that nurses are honest with the patient about the report’s recommendation and supporting evidence. Communicating these to the patient is an important component of preparation and may help mitigate potential damage to the therapeutic relationship. However, broaching the subject can be challenging. One way of instigating a conversation on the subject is by talking honestly and openly to the patient about the potential advantages and disadvantages of a hearing before the tribunal. Table 2 lists some potential advantages and disadvantages, based on the author’s experience. These will vary from one patient to another so the conversation needs to be tailored to the person’s situation and needs.

Table 2.

Potential advantages and disadvantages of a hearing before the First-tier Tribunal (Mental Health)

Potential advantagesPotential disadvantages
A hearing before the tribunal could be beneficial because it will:
  • Provide the patient with an opportunity to realise their wish to be discharged from detention or released from a community treatment order

  • Offer independent scrutiny of the rationale given for continuing the patient’s detention or community treatment order

  • Give the patient a voice in their care and help them to feel that their interests are being represented

  • Improve the patient’s knowledge and awareness of the clinical decision-making process relating to their detention or community treatment order

A hearing before the tribunal could be challenging because:
  • The evidence presented may include details of the patient’s condition or history that they find distressing and/or had forgotten about

  • The recommendation and/or the panel’s decision may not be what the patient had hoped for

  • Patients can only apply to the tribunal within the time frames set out in the Mental Health Act 1983 (amended 2007) and there is a limit on the number of times patients can apply within a given period (gov.uk 2023). Therefore, in some circumstances, applying to the tribunal may prevent a future application at a point in time when the patient may be more likely to achieve their desired outcome

If the patient disagrees with the report’s recommendation and/or the supporting evidence, it is important to acknowledge this and document the patient’s view in the report to minimise the power imbalance. If the patient has not yet been informed of their diagnosis, it is important to do so, since they will have an opportunity to challenge their diagnosis during the pre-hearing examination and the hearing.

Time Out 5

Think about a patient who will be attending a hearing before the First-tier Tribunal (Mental Health) in the near future. Using the examples in Table 2 as a starting point, how might you talk to the patient about the recommendation and supporting evidence contained in the nursing report in a way that will help to protect the therapeutic relationship?

Practising trauma-informed care

Acknowledging that the patient may experience distress during the hearing is a way of recognising that many mental health service users have experienced traumatic life events, which may have negatively affected their trust in services and the way they engage with them (Office for Health Improvement and Disparities 2022). It is part of working in a trauma-informed way, or practising trauma-informed care. In the author’s experience, as well as protecting the therapeutic relationship, practising trauma-informed care can reduce the risk of iatrogenic harm. Cocreating an individualised support plan with the patient while preparing for the hearing may help minimise their distress and reduce the risk of their distress worsening. It is important to determine what the patient finds supportive when they experience distress and incorporate this in their support plan.

Supporting the patient to attend the hearing

The hearing before the tribunal can be held face to face or remotely, depending on the patient’s preference and circumstances. Face-to-face and remote hearings are usually held in a private room in the detaining hospital – or, for patients subject to a community treatment order, in a suitable venue at the supervising hospital. The nursing team caring for the patient is usually responsible for ensuring the patient can attend the hearing (Courts and Tribunals Judiciary 2023).

To reduce the stress associated with attending the hearing, patients should be involved in planning the support they may need during and immediately after the hearing. That support may include reasonable adjustments, which will be specific to the person’s needs but may include requesting in advance that the person is allowed to take time out during the hearing and/or to have one-to-one support before, during and/or after the hearing. Such requests are usually made to the tribunal judge and can be made by anyone involved in the person’s care.

If the patient is attending a face-to-face hearing, it may be helpful for them to visit the venue that will be used for the hearing beforehand and if possible to visualise where everyone will be sitting. The RCPsych’s (2019) guide for trainees attending a tribunal hearing includes a seating plan, which nurses can share with patients. If the patient is attending a remote hearing, they should be supported to access the online platform and join the video call.

The patient should be encouraged to attend the hearing alongside their legal representative, and an interpreter if required. They should be introduced to the other people present at the hearing, whether it is held face to face or remotely. It is important that patients understand that the hearing will be held in private in a place where the evidence presented cannot be overheard. Making video or audio recordings of the hearing is not permitted and may be considered contempt of court under the Contempt of Court Act 1981.

The patient’s nearest relatives, supporters or advocates can attend the hearing at the discretion of the panel. Where possible, additional attendees should be discussed with the patient’s legal representative and details sent to the panel beforehand. Permission from the panel is usually required for other healthcare professionals to attend, for example nursing students or trainee psychiatrists who wish to observe the process.

Advocating for the patient before, during and after the hearing

There are various ways in which nurses can advocate for patients before, during and after the hearing. Hearings before the tribunal have been criticised for adopting a predominantly medical model and excluding the patient voice (Akther et al 2019). In the author’s opinion, nurses can ensure that the patient’s voice is represented and that a holistic approach is used to present evidence to the panel.

One way of doing this is for the nurse who is providing evidence to read the other professionals’ evidence and discuss any discrepancies with these other professionals ahead of the hearing. If the nursing evidence differs from the medical evidence, for example, the two parties should discuss, and try to resolve, the discrepancies. If this is not possible, the contents of their discussion can be documented and presented by the two parties at the hearing.

During the hearing, the nurse who is providing evidence can highlight the patient’s protective factors and their progress towards recovery. Whether or not the panel’s decision is what the patient had hoped for, including such evidence demonstrates that the nursing team has hope for the person’s future outcomes, maintaining hope being an important part of working within a recovery-oriented model of care (Leamy et al 2011).

Following the hearing, an important way of advocating for patients who have not been discharged is to consider the factors that may have affected the panel’s decision. If the panel’s decision not to discharge the patient was due to a lack of opportunity to assess the feasibility of a less restrictive environment – for example, if the patient had not had unescorted leave or had not been assessed for supported accommodation – the nursing team should try to rectify that as soon as it is safe to do so.

If the panel’s decision is to discharge the patient from detention so that they can be transferred to a less restrictive environment, this should not be delayed or prevented by, for example, staff shortages or inadequately resourced community mental health teams. To avoid such delays, the author recommends that the inpatient nursing team starts planning the patient’s discharge from the start of the care episode and ensures that the community mental health team is regularly updated on, or involved in, ward reviews and multidisciplinary team meetings. As part of the process of planning discharge, the inpatient nursing team should explore options for accommodation and the associated funding applications, keep the patient’s care plan up to date, liaise regularly with the patient’s support network and begin relapse prevention work.

Time Out 6

If you have never attended a hearing before the First-tier Tribunal (Mental Health), you can arrange to observe one by contacting your local Mental Health Act office. Even if you have previously attended a hearing, an observation visit may be useful, for example if you are planning to complete a training needs analysis or develop resources for colleagues. The local Mental Health Act office and your healthcare organisation’s legal team may be able to support you and your colleagues with your training needs

Conclusion

The First-tier Tribunal (Mental Health) is an important legal safeguard in the Mental Health Act 1983 (amended 2007). Mental health nurses may be required to provide written and/or oral evidence to the panel, so it is important that they know what type of evidence to include. Participating in hearings can be stressful and challenging for patients, but nurses can help them prepare for the hearing by providing information and practical support. Giving evidence that conflicts with the patient’s understanding of their condition or desire for release from detention implies a risk of damage to the therapeutic relationship. Nurses can attempt to protect that relationship by displaying transparency and advocating for the patient throughout the process.

Time Out 7

Identify how protecting the therapeutic relationship while fulfilling your duty to provide evidence to the First-tier Tribunal (Mental Health) applies to your practice and the requirements of your regulatory body

Time Out 8

Now that you have completed the article, reflect on your practice in this area and consider writing a reflective account. See: rcni.com/reflective-account

References

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  7. gov.uk (2023) Apply to the Mental Health Tribunal. http://www.gov.uk/mental-health-tribunal (Last accessed: 14 June 2023.)
  8. Health Education England (2020) Mental Health Nursing: Competence and Career Framework. http://www.hee.nhs.uk/sites/default/files/documents/HEE%20Mental%20Health%20Nursing%20Career%20and%20Competence%20Framework.pdf (Last accessed: 14 June 2023.)
  9. Jones RM (2022) Mental Health Act Manual. 25. Sweet and Maxwell, London.
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  11. Macgregor A, Brown M, Stavert J (2019) Are mental health tribunals operating in accordance with international human rights standards? A systematic review of the international literature. Health and Social Care in the Community. 27, 4, e494-e513. doi: 10.1111/hsc.12749
  12. Mind (2018) Mind’s Submission to the Mental Health Act Review. http://www.mind.org.uk/media-a/5135/mind-mhar-submission-final.pdf (Last accessed: 14 June 2023.)
  13. Murphy K, McGuinness D, Bainbridge E et al (2017) Service users’ experiences of mental health tribunals in Ireland: a qualitative analysis. Irish Journal of Psychological Medicine. 34, 4, 233-242. doi: 10.1017/ipm.2017.11
  14. NHS England (2022) The Mental Health Nurse’s Handbook. https://www.england.nhs.uk/publication/the-mental-health-nurses-handbook/ (Last accessed: 14 June 2023.)
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  16. Office for Health Improvement and Disparities (2022) Working Definition of Trauma-Informed Practice. http://www.gov.uk/government/publications/working-definition-of-trauma-informed-practice/working-definition-of-trauma-informed-practice (Last accessed: 14 June 2023.)
  17. Royal College of Psychiatrists (2016) Assessment and Management of Risk to Others. http://www.rcpsych.ac.uk/docs/default-source/members/supporting-you/managing-and-assessing-risk/assessmentandmanagementrisktoothers.pdf (Last accessed 14 June 2023.)
  18. Royal College of Psychiatrists (2019) A Guide for Trainees: Attending A Mental Health Tribunal Hearing. http://www.rcpsych.ac.uk/docs/default-source/training/curricula-and-guidance/a-guide-for-trainees-observing-tribunals-updated-sept-2019.pdf (Last accessed: 14 June 2023.)
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  20. Zigmond T, Brindle N (2022) A Clinician’s Brief Guide to the Mental Health Act. 5. Cambridge University Press, Cambridge.

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