About This Tool
Two things live here: (1) a structured way to recognise and describe how severe a mental health presentation is — organised around the standard Mental State Examination (MSE) domains, with the correct terminology for each — and (2) a working aid for the Mental Capacity Act 2005 functional test, with a particular focus on the "use or weigh" element and the causative nexus, which is where assessments most often go wrong.
There's no single validated "depth of crisis" scale used across UK ambulance services — this organises common presentations by domain and severity so you can describe what you're seeing precisely, using correct terminology, rather than a vague overall impression. Tap the tier that best matches current presentation in each domain; the descriptor is recorded for the summary. Domains with nothing selected are simply omitted from the documentation.
Correct Terminology — Say This, Not That
Reference only. Precise, non-judgemental, person-first language reduces stigma, is more clinically useful to the next clinician, and stands up better if the record is ever reviewed.
Terminology / MSE Notes
Stage 1 — Diagnostic Test
MCA 2005, s.2(1): does the person have "an impairment of, or a disturbance in the functioning of, the mind or brain"? This can be permanent or temporary. A diagnosis or impairment alone is not enough — it only opens the door to Stage 2. Plenty of people with a mental health diagnosis, dementia, or learning disability retain capacity for most decisions, most of the time.
Stage 2 — Functional Test
MCA 2005, s.3(1): a person is unable to make the decision if they cannot do ANY ONE of the four things below — but only where that inability is caused by the Stage 1 impairment (checked on the next screen). All practicable steps to help the person decide for themselves must be taken first (accessible information, calmer environment, familiar person present, right time of day) — s.1(3).
1 — Understand
Can they understand the information relevant to this decision, explained in a way appropriate to them?
Prompt: "Tell me in your own words what this is about and what the options are."
2 — Retain
Can they retain that information for long enough to use it? (Does not need to be long-term — brief retention is sufficient, and short-term memory aids/repetition count as support.)
Prompt: revisit the same information a few minutes later — can they still recall the key points?
3 — Use or Weigh (the one most often got wrong)
Can they actually use the information as part of the process of making the decision — weighing it up, factoring in consequences — not just repeat it back?
Prompt: "What matters most to you about this? What do you think might happen if you do/don't do X? How does this fit with what's important to you?"
Common Pitfalls When Assessing "Weigh" — Self-Audit
4 — Communicate
Can they communicate their decision, by any means — talking, sign, writing, blinking, squeezing a hand?
Every practicable means of communication must be tried before concluding they cannot.
Weighing / Functional Test Notes
Causative Nexus
The step most often skipped. It is not enough that (1) an impairment exists and (2) a functional element failed — you must show the impairment is the cause of the failure. If someone fails to weigh information for a reason unconnected to the Stage 1 impairment (different values, fear, stubbornness, an unwise-but-competent choice), they still have capacity.
Select an option above.
Common Pitfalls — Self-Audit
Outcome
Complete Stage 1, Stage 2 and the Nexus check to see a suggested outcome.
This is a suggested outcome based on what's been tapped above — always apply your own clinical judgement and document your actual reasoning, not just the tool's output.
If Capacity Is Lacking — Best Interests (s.4 MCA)
Only relevant if the outcome above is "lacks capacity". A best interests decision must still consider: