Mental Capacity Act 2005 — Clinical Assessment Tool

Mental

Capacity Act

Mental Capacity Act 2005 · England & Wales · Clinical Assessment Tool

⚖️ This tool guides structured assessment. It does not replace clinical and legal judgement. Document everything contemporaneously and thoroughly.

⚠️ Capacity is DECISION-SPECIFIC and TIME-SPECIFIC. A person may have capacity for one decision but not another, and may regain or lose capacity over time.

🚨 The MCA does NOT generally authorise deprivation of liberty. Only s4B permits this in life-threatening emergencies. If the primary issue is mental disorder — consider MHA, not MCA.

What type of situation are you dealing with?

The Five Statutory Principles — s1 MCA 2005

These principles apply to EVERY capacity-related decision. They are mandatory, not optional.

Principle 1 — s1(2)

Presumption of Capacity

A person must be assumed to have capacity unless it is established that they lack it. You start from the position of capacity — the burden is on you to establish lack of capacity, not on the patient to prove they have it.

Prehospital implication: Even a person who appears confused, distressed or is refusing treatment is PRESUMED to have capacity until the two-stage test establishes otherwise.

Principle 2 — s1(3)

Support Before Concluding Lack of Capacity

A person is not to be treated as unable to make a decision unless all practicable steps to help them to do so have been taken without success. Have you simplified the information? Removed distractions? Given more time? Used an interpreter?

Prehospital implication: Asking once and moving on is not sufficient. Document what steps you took to support decision-making.

Principle 3 — s1(4)

Unwise Decisions Do Not Equal Lack of Capacity

A person is not to be treated as unable to make a decision merely because they make an unwise decision. This is one of the most important and most misapplied principles. A person can make a decision you consider foolish, dangerous or irrational and still have capacity.

Critical: Disagreeing with a decision is NOT grounds to override it. The question is HOW they reached the decision, not WHETHER you agree with it.

Principle 4 — s1(5)

Best Interests

An act done or decision made for or on behalf of a person who lacks capacity must be done or made in their best interests. Best interests is not solely clinical — it includes the person's wishes, feelings, beliefs and values where ascertainable.

s4 sets out a checklist for best interests decisions. It is not the same as "what the clinician thinks is best" — it is a structured process.

Principle 5 — s1(6)

Least Restrictive Option

Before any act is done, regard must be had to whether the purpose for which it is needed can be as effectively achieved in a way that is less restrictive of the person's rights and freedoms of action.

Prehospital implication: Can you treat on scene? Treat at the door? Gain verbal agreement for partial treatment? Only if all less restrictive options fail does restraint and conveyance become justified.

Stage 1 — Diagnostic Threshold Test (s2 MCA)

Stage 1 of 2

Does the person have an impairment of, or disturbance in the functioning of, the mind or brain?

This must be established BEFORE the functional test. Without it, the MCA does not apply regardless of how the person is behaving. The impairment can be permanent or temporary.

Stage 1 can be satisfied by a very wide range of conditions. It is NOT limited to mental illness.

Possible causes of impairment — tap all that may apply

Dementia

Delirium / Acute confusion

Head injury

Stroke / CVA

Hypoglycaemia

Hypoxia

Alcohol intoxication

Drug intoxication / overdose

Psychosis / Schizophrenia

Bipolar disorder (acute episode)

Severe depression

Learning disability

Sepsis / Infection affecting cognition

Severe pain affecting cognition

Shock / haemodynamic compromise

Post-ictal state

Alcohol — A Critical Edge Case

Intoxication CAN satisfy Stage 1 if it has produced an impairment of mind or brain functioning. However:

The degree of intoxication matters — mild intoxication alone does not automatically satisfy Stage 1
A person may be drunk AND capacitous — they may understand, retain, weigh and communicate
Alcohol combined with head injury, overdose or psychiatric illness significantly lowers the threshold
Document EXACTLY what features of impairment you observed — slurred speech alone is insufficient

⚠️ "They're just drunk" is not a capacity assessment. Document the specific functional impairments observed.

Stage 1 conclusion

Stage 2 — The Functional Test (s3 MCA)

Stage 2 must be linked to Stage 1 by the CAUSATIVE NEXUS. The inability to do one of the four things must be BECAUSE OF the impairment — not just at the same time as it.

Stage 2 of 2

Can the person do ALL FOUR of the following?

A person lacks capacity for this decision if they CANNOT do ONE OR MORE of these four things, AND that inability is caused by the impairment identified in Stage 1.

Failing just ONE of the four parts = lacks capacity for this specific decision. But remember — the causative nexus must be established for each failure.

U

Understand the information relevant to the decision

Can the person understand the information you have given them about their condition, the proposed treatment, the risks of accepting, and the risks of refusing? You must present the information in a way they can understand — in simple terms, without jargon.

Ask: "Can you tell me in your own words what I've told you about your condition?" Correct understanding, not parroting back your words.

✓ CAN UNDERSTAND

✗ CANNOT UNDERSTAND

R

Retain the information long enough to make a decision

The person only needs to retain information for long enough to make the decision — not necessarily long-term. However, if information dissolves within seconds and cannot be re-established, this part may be failed. Short-term retention difficulties (e.g. severe dementia, severe delirium) are relevant here.

This is NOT about memory generally — it is about retaining the information long enough to make this specific decision at this specific time.

✓ CAN RETAIN

✗ CANNOT RETAIN

W

Use or weigh the information as part of the decision-making process

This is the most complex and most often misapplied element. The person must be able to take the information, consider it, and use it to make a decision. Severely disordered thinking, compulsions, delusional beliefs and severe depression can all impair this element even when the first two appear intact.

⚠️ THIS IS WHERE THE CAUSATIVE NEXUS IS MOST OFTEN CONTESTED. A person can appear to weigh information logically but be doing so from a false premise — see Causative Nexus section.

✓ CAN WEIGH

✗ CANNOT WEIGH

C

Communicate the decision by any means

Communication can be verbal, written, by gesture, eye movement or any other means. A person who is unconscious or cannot communicate in ANY way cannot communicate a decision. However, this part is rarely the basis for a capacity finding alone — explore all communication methods first.

✓ CAN COMMUNICATE

✗ CANNOT COMMUNICATE

The Causative Nexus — The Critical Link

s2(1) MCA 2005: "A person lacks capacity in relation to a matter if at the material time he is unable to make a decision for himself in relation to the matter BECAUSE OF an impairment of, or a disturbance in the functioning of, the mind or brain."

What is the Causative Nexus?

The causative nexus is the BECAUSE OF link between the impairment (Stage 1) and the inability to decide (Stage 2). The two stages must be causally connected, not merely concurrent.

A person can appear to pass all four parts of the functional test while still lacking capacity — if their apparently coherent reasoning is built on a foundation that is itself a product of their impairment.

This is the most sophisticated and most legally contested aspect of the MCA. It requires you to examine not just the LOGIC of the person's reasoning, but the PREMISES on which that logic is based.

Classic Causative Nexus Failures — Tap to Expand

📹 False Beliefs — "Cameras in the Light Switches"

Patient refuses to go to hospital because "the hospital is monitoring me through cameras in the light switches and working with the government to harvest my organs." They can explain this belief clearly, logically argue from it, and articulate their refusal fluently.

🧠 Anosognosia — Denial of Neurological Deficit

Patient has had a significant stroke affecting their right side. They deny any weakness despite it being demonstrable and clearly visible. They refuse physiotherapy and hospital admission saying "there's nothing wrong with me — my arm is fine." Their speech is clear, they can hold a conversation.

🤕 Head Injury — Denial and Minimisation

Patient fell, witnessed LOC, obvious signs of head injury. They deny any loss of consciousness, minimise symptoms ("I'm fine, just a scratch"), refuse transport. They speak clearly and appear oriented to time/place. They argue coherently that they don't need hospital.

💊 Severe Depression — "I Deserve to Die"

Patient has taken an overdose and is refusing treatment. They say clearly "I understand I might die without treatment. I want to die. I've thought about it carefully and made my decision." Their reasoning appears coherent and they are not psychotic.

🍺 Intoxication — "I Know What I'm Doing"

Patient has taken a significant overdose while intoxicated. They say they are fine, refuse treatment, state clearly they know what they took and are making a free choice. They can hold a conversation and appear to understand your explanation.

👴 Dementia — Preserved Social Facade

Elderly patient with known moderate dementia is refusing hospital admission for a serious infection. They engage pleasantly, make small talk, appear to follow the conversation. They say "no thank you, I'm fine at home." Family report dramatic functional decline over 24 hours.

⚠️ The Unwise Decision — NOT a Nexus Failure

Patient with no mental impairment is refusing chemotherapy for cancer. They understand the prognosis, understand the treatment, understand the consequences of refusal, have considered it over time, and say they prefer quality of life over quantity. Family are distraught and say "they can't be thinking straight."

Causative Nexus — Self-Check Questions

Before Concluding Capacity Is Absent, Ask:

Have I identified a specific impairment of mind or brain (Stage 1)?

Have I identified which of the four functional elements is failing?

Is the failure BECAUSE OF the impairment — or is it coincidental?

Is the person's reasoning built on a false premise that is itself a product of the impairment?

Am I confusing an unwise decision with a capacity failure?

Have I taken all practicable steps to support decision-making before concluding failure?

Is this decision-specific — am I applying capacity to the right decision?

Lawful Action Where Capacity Is Absent

s4A MCA: "This Act does not authorise any person to deprive another person of their liberty." — EXCEPT under s4B or a Court of Protection order.

s4B — The "Vital Act" Exception

This is the PRIMARY power available to paramedics to act against a person's expressed wishes where they lack capacity. Its conditions are strict.

s4B authorises deprivation of liberty (including restraint and conveyance) where ALL of the following are met:

There is a question about whether you are authorised to deprive P of liberty under s4A (i.e. no Court of Protection order exists)
The deprivation of liberty is wholly or partly for the purpose of: giving life-sustaining treatment, OR doing any vital act (any act to prevent serious deterioration in condition while a court decision is sought)
The deprivation is NECESSARY to give that treatment or do that vital act

⚠️ s4B is an emergency exception — not a general authority. It is not a blanket power to convey anyone who lacks capacity. The necessity test is real and must be documented.

If s4B is used: document explicitly. State what the life-sustaining treatment or vital act was, why you believed it necessary, why less restrictive options were not available, and that you believed the person lacked capacity for this specific decision.

s6 — Restraint Conditions

Restraint is only lawful under s5/s6 MCA if TWO conditions are both met:

You reasonably believe restraint is necessary to prevent HARM to the person
The restraint is a PROPORTIONATE response to the likelihood AND seriousness of that harm

Restraint = use or threat of force to secure an act P resists, OR any restriction of P's liberty of movement whether or not P resists. This includes physical holding, use of carry chair against will, and locked ambulance doors.

Document: what harm you were preventing, why you believed restraint necessary, what level of restraint was used and why it was proportionate.

s5 — General Defence (Acts in Connection with Care/Treatment)

s5 provides protection from liability for acts done in connection with the care or treatment of a person who lacks capacity, provided you:

Reasonably believe the person lacks capacity for the decision
Reasonably believe the act is in their best interests
Have taken reasonable steps to assess capacity

This is the most commonly used MCA defence prehospital — but it does NOT extend to deprivation of liberty (only s4B does that).

s44 — Wilful Neglect

A person who has care of someone who lacks capacity commits an offence if they wilfully neglect or ill-treat that person.

This creates a legal duty in BOTH directions: you can be liable for acting without proper authority, AND for failing to act when a person who lacks capacity is at serious risk and you do nothing. Inaction is not a safe default.

Best Interests — s4 Checklist

Before acting, consider all of the following:

Whether and when P might regain capacity (can this decision wait?)

P's past and present wishes and feelings, and any advance statement

P's beliefs and values that would likely influence the decision

Other factors P would consider if they could

Views of family/carers/anyone with an interest in P's welfare (if practicable)

Whether there is a valid ADRT (Advance Decision to Refuse Treatment)

Whether there is a valid Lasting Power of Attorney (Health and Welfare)

Advance Decisions to Refuse Treatment (ADRT) — s24-26 MCA

A Valid ADRT BINDS You — It Is Not Advisory

A valid and applicable ADRT refusing life-sustaining treatment is as legally binding as a contemporaneous capacitous refusal. Overriding it could constitute a criminal assault.

For an ADRT to be valid it must:

Be made by a person aged 18+ who had capacity when it was made

Specify the treatment being refused (not just a general "no treatment")

Specify the circumstances in which the refusal applies

NOT have been made under duress or undue influence

If the ADRT refuses LIFE-SUSTAINING treatment, additionally:

Must be in writing

Must be signed by the person (or by another in their presence at their direction)

Signature must be witnessed

Must state explicitly "even if life is at risk" or equivalent clear language

When Does an ADRT NOT Apply?

An ADRT does not apply if ANY of the following are present:

P has done anything clearly inconsistent with the ADRT remaining their fixed decision since making it
P has withdrawn the ADRT (verbally, even if the document is not destroyed)
A Lasting Power of Attorney was granted AFTER the ADRT that gives the attorney authority over the relevant treatment
The circumstances now present are not the circumstances specified in the ADRT

Doubt about validity: if you have reasonable doubt whether an ADRT is valid and applicable, you may provide life-sustaining treatment. Document the doubt and your reasoning thoroughly.

Lasting Power of Attorney — Health and Welfare

A Health and Welfare LPA allows a nominated person to make decisions on behalf of someone who lacks capacity. However:

The LPA must specifically state it covers life-sustaining treatment decisions to override those decisions
The attorney cannot consent to or refuse treatment in a way that is not in P's best interests
An attorney cannot authorise deprivation of liberty without a Court of Protection order

⚠️ You cannot simply take a family member's word that they have an LPA — ideally verify it. In an emergency where life is at risk and verification is impossible, document the doubt and treat in best interests.

NB: A next of kin has NO automatic legal authority to consent to or refuse treatment on behalf of an adult lacking capacity. Next of kin status does not create legal authority under English law.

Fluctuating Capacity

Capacity can change during a single incident:

A patient may have capacity on arrival but lose it en-route (hypoglycaemia, deteriorating head injury, sepsis)
A patient may lack capacity initially and regain it (intoxication resolving, hypoglycaemia treated)
Document the time and basis of EACH capacity assessment made
If capacity is regained, the patient's refusal at that point must be respected

If capacity is in genuine doubt and the situation is life-threatening — err on the side of intervention and document why. The MCA Code of Practice supports this position.

Police Powers — When and Why

Police and paramedics have the SAME authority under the MCA — neither has more power than the other. What police have that paramedics do not is specific statutory powers to enter premises, detain under MHA, and use force in criminal contexts.

🚨 Violence or Immediate Risk to Crew

Patient is physically resisting or threatening staff. MCA restraint alone insufficient.

Call police immediately. Your safety takes priority over treatment delivery.

Police can use reasonable force to prevent crime (assault, ABH). This is a PACE / common law power, not an MCA power.

Police can restrain to prevent crime — not to convey for medical treatment
The MCA decision remains yours — police facilitate, they do not make the capacity decision
Ensure police understand WHY you have concluded the person lacks capacity so force used is lawful in context

Document: that police assistance was required, what violence or risk was present, that the clinical decision was yours and the police role was facilitative.

🏠 Private Premises — Being Ordered Out

Patient or another person in the property is ordering you to leave.

You MUST comply with a lawful instruction to leave private premises unless you have specific legal authority to remain.

Possible authority to remain:

MCA s4B: If you have assessed that the person lacks capacity and life-sustaining treatment is necessary — you may remain and act. BUT you must have a genuine basis for the capacity assessment, and police assistance is strongly advisable
s135(1) MHA warrant: Police can enter with an AMHP and doctor to assess someone believed to have a mental disorder. Paramedics have no independent power of entry
s17 PACE: Police can enter to save life or limb — this is a police power only, not a paramedic power. But police can facilitate your entry

⚠️ The Sessay case (2011): The court confirmed that the MCA CANNOT be used as a workaround where the real reason for intervention is mental disorder rather than medical treatment. If the primary issue is psychiatric — MHA is the appropriate route, not MCA.

If ordered out and uncertain: leave, call police, seek AMHP involvement if MH is the primary issue, document the circumstances fully.

👮 Section 136 MHA — Police Detention in Public

Patient is in a public place, appears to have a mental disorder, and is in immediate need of care or control.

s136(1) MHA 1983 (as amended 2017): A constable may remove a person to a place of safety if the person appears to be suffering from mental disorder and to be in immediate need of care or control, if the constable thinks it necessary to do so in the interests of that person or for the protection of others.

Key points for paramedics:

s136 can only be used in a public place — it cannot be used in a private dwelling
The place of safety is usually a designated health-based place of safety (HBPoS) — NOT a police cell where possible
Maximum duration: 24 hours (extendable to 36 with medical approval)
Purpose: to enable assessment under MHA, not treatment per se
Paramedics may be asked to convey a person detained under s136 — this is lawful
A person on s136 may still have capacity to refuse treatment for a separate physical condition — s136 does not override MCA

⚠️ Since 2017 amendments: s136 now includes places to which the public have access (e.g. shopping centres, transport hubs). It cannot be used in private dwellings or gardens.

MCA and s136 can co-exist: police detain for MHA assessment (s136); paramedics may act under MCA s4B if there is also a physical emergency requiring life-sustaining treatment.

🔑 Section 135(1) MHA — Warrant for Private Premises

Patient is in their own home and needs MHA assessment but is refusing access.

s135(1) MHA: A magistrate may issue a warrant authorising any constable to enter premises where there is reasonable cause to suspect a person with mental disorder is living and is being ill-treated, neglected, or kept otherwise than under proper control, or unable to care for themselves, and may remove them to a place of safety.

Process:

Must be applied for by an AMHP (Approved Mental Health Professional)
Magistrate issues the warrant
Police can then enter, with an AMHP and a doctor, to conduct an assessment
Paramedics may be present to provide clinical support and conveyance

⚠️ This takes TIME. If the situation is immediately life-threatening and the MCA s4B criteria are met, that is a faster route. s135 is appropriate when the issue is primarily mental disorder and risk is not immediately life-threatening.

Key distinction: s135(1) is for MHA assessment purposes. s135(2) is for returning a patient who is AWOL from a section. Different powers, different purposes.

⚖️ PACE s17 — Police Power of Entry to Save Life or Limb

Police can enter private premises without a warrant to save life or limb. Paramedics cannot.

s17(1)(e) PACE 1984: A constable may enter and search any premises for the purpose of saving life or limb or preventing serious damage to property.

Relevant to paramedics because:

Police can use s17 PACE to enter premises where they believe there is an immediate risk to life, even without MHA involvement
Once inside under s17, police can facilitate your assessment and treatment
The MCA assessment and treatment decision remains YOURS — police are providing access, not making clinical decisions
If you arrive first and are refused entry to a patient you believe is at life-threatening risk — police called under s17 can enter and allow you access

⚠️ s17 PACE is a police power to ENTER — it does not automatically authorise deprivation of liberty or medical treatment. Once inside, the MCA framework applies to any treatment decision.

Practical: if a patient is known to be in immediate danger inside a locked premises, police should be called for s17 entry while you prepare to treat under MCA s4B / s5.

⚡ Breach of the Peace — Common Law

Patient's behaviour constitutes or is likely to constitute a breach of the peace.

A breach of the peace occurs when harm is done or is likely to be done to a person, or in their presence to their property, OR a person is in fear of being harmed. It is a common law power available to both police and any citizen.

Relevant to paramedics:

Police can detain a person to prevent a breach of the peace — including self-harm in some circumstances if it was likely to provoke others
However — self-harm alone is generally NOT a breach of the peace (R v Howell 1982) unless it causes others to fear immediate violence
Do not rely on breach of the peace as a blanket justification for restraint in self-harm situations — it is narrower than often assumed
If police invoke breach of the peace — the MCA is still the clinical framework for any treatment given

The Sessay case confirmed: police cannot use breach of the peace (or MCA) as a substitute for MHA where the patient needs psychiatric assessment. The right legal framework must be used.

🔪 Crime in Progress — Weapons / Threat to Others

Patient has a weapon or is posing a criminal threat to themselves or others.

🚨 This is primarily a police matter. Do NOT attempt to disarm or physically engage with an armed person. Withdraw to a safe distance and call police.

Legal framework:

Threatening with a weapon is a criminal offence — police can arrest under PACE powers
Once the person is safe and disarmed, MCA assessment can proceed if required
A patient who self-harms with a blade in your presence — your duty is to provide treatment if they lack capacity, but personal safety must be secured first
Document: that you withdrew for safety, when police arrived, what assessment was conducted once the scene was safe

⚠️ Even where a person lacks capacity, you cannot lawfully treat while they are actively threatening you with a weapon. Safety first — treatment follows once the scene is controlled.

🧑‍⚖️ PACE Code C — Appropriate Adult & Custody

Patient is to be interviewed by police or taken into police custody and appears to have a mental disorder or impairment.

PACE Code C para 1.4: If a person appears to be suffering from a mental disorder, or has a mental health condition or learning disability, an appropriate adult must be called to any interview.

Relevance to paramedics:

If police are arresting a patient you have assessed as lacking capacity or having a mental disorder — advise police of your clinical findings
Police MUST arrange an appropriate adult before any substantive interview
A person lacking capacity may still be arrested — capacity is not a defence to arrest. But it affects how they are processed
If a patient needs medical treatment AND is under arrest — treatment takes priority. Police custody should be delayed if treatment is urgent
Document your clinical assessment clearly and offer this to police for their records

Your clinical assessment of mental disorder or incapacity is important clinical information for police. Share it — it protects both the patient and the police from procedural errors.

Scenario-Based Decision Pathways

These are common real-world presentations. Tap to expand each.

Scenario A — Elderly patient refusing hospital, possible sepsis, family present

Stage 1: Sepsis / acute infection affecting cognition — MET if confusion present. Stage 2: Assess URWC. Best interests: family views relevant but not determinative. s4B if life-sustaining treatment necessary. Document family input. Least restrictive: can GP attend? Can antibiotics be given at home? Police not usually required unless violence or access issue.

Scenario B — Known psychotic patient with knife to own throat in their home

Safety first — withdraw. Call police. Stage 1: psychosis likely MET. Stage 2: WEIGH almost certainly failed — delusional framework driving self-harm. s4B applicable if life-sustaining treatment necessary once scene safe. Police: s17 PACE entry if locked in, potential s136 if public, s135(1) if private and time permits. Once safe: treat under s4B / s5 MCA. Document capacity assessment, police involvement, each intervention.

Scenario C — Intoxicated patient post-overdose refusing treatment, "I want to die"

Stage 1: Intoxication + possible acute mental illness — likely MET. Stage 2: WEIGH — assess whether reasoning is built on impaired cognition or genuine autonomous wish. Intoxication alone impairs reliable capacity assessment — default to treatment in life-threatening situation and re-assess when sober. Police: call if violence risk, may support MCA action. If possibly capacitous: senior clinical advice essential. ADRT: check if any exists. Document: all reasoning, clinical observations of intoxication's effect on cognition, that a contemporaneous decision under acute intoxication may not be stable or autonomous.

Scenario D — Head injury, denying LOC, refusing transport, GCS 15

Stage 1: Traumatic brain injury — MET even with GCS 15. Stage 2: UNDERSTAND/WEIGH — consider anosognosia; can they actually understand the mechanism of injury and potential intracranial pathology? GCS 15 does not equal capacity — assess the four functional elements specifically for this decision. Causative nexus: the injury preventing self-assessment is the same injury being assessed. If capacity in doubt and risk significant: s4B applicable. Police: not usually required unless violent refusal. Document: specific cognitive observations, not just GCS.

Scenario E — Patient with apparent capacity refusing treatment citing religious beliefs

If Stage 1 NOT met — this is Principle 3 (unwise decision). A capacitous decision based on sincerely held religious or philosophical beliefs MUST be respected however unwise it appears. Ensure: genuinely free and informed (not under duress), not a fluctuating capacity situation, no ADRT contradictions. Document extensively — the decision, your capacity assessment process, your conclusion. Do NOT call police to override a capacitous refusal — that would be unlawful.

Scenario F — Patient ordered you out of the house, MH concerns, no immediate life threat

This is the Sessay situation. If the primary issue is mental disorder (not immediate medical emergency): MCA cannot be used as a substitute for MHA. You MUST leave if ordered. Call police. Seek AMHP involvement. If s135(1) warrant is needed — AMHP must apply. Document: that you were ordered out, what you observed, that you referred to appropriate services. Do NOT re-enter without lawful authority — even with genuine concern for the patient.

RAVE Criteria — Requesting Police Involvement

RAVE is a structured framework used by emergency services to communicate and justify requests for police assistance. It is not a statutory framework but is widely used in joint working protocols across UK ambulance services and police forces.

R — Risk

What is the nature and level of risk present at this incident? This includes:

Risk to the patient — self-harm, overdose, medical emergency, inability to protect themselves
Risk to crew — violence, threats, weapons, unpredictable behaviour
Risk to third parties — family, bystanders, neighbours
Risk of absconding — patient leaving the scene before treatment can be given or assessment completed

Be specific. "High risk" is not enough. State WHAT the risk is, to WHOM, and WHY you assess it as present. Vague risk descriptions do not generate police attendance.

A — Authority

What legal authority do you — or do you need police — to have in order to act? This is the most important element for joint working clarity:

Are you acting under MCA s4B / s5? State this explicitly.
Do you need police s17 PACE entry to access the patient?
Is s136 MHA applicable (public place, mental disorder, immediate need)?
Is s135(1) MHA needed (private premises, MH primary issue, AMHP required)?
Is there a criminal offence in progress (obstruction, assault, weapons)?
Do you have NO authority and need police to CREATE the authority for you to act?

⚠️ If you cannot articulate the legal authority for what you want police to help with, you need to reconsider your approach. Police cannot simply "help you" override a refusal — they need a lawful basis too.

V — Violence

Is there actual or potential violence at this incident?

Has violence already occurred — to patient, crew, or others?
Is violence being threatened?
Is the patient in possession of a weapon?
Is there a history of violence at this address or from this patient?
Is the level of agitation such that violence is reasonably anticipated?

Violence (actual or threatened) is core police business. Do NOT attempt to manage an armed or imminently violent patient alone. Withdraw to safe distance and wait for police.

Emergency Workers (Obstruction) Act 2006 s1: It is a criminal offence to obstruct or hinder a paramedic in the course of their work. If you are being obstructed or threatened — police can act on this basis independently of MCA/MHA.

E — Evidence

What evidence exists to support the request and to inform police decision-making?

Your clinical findings — what you observed, your capacity assessment, what impairment you identified
History — previous incidents, known mental health history, medication, prior MHA involvement
Third party information — from family, carer, GP, crisis team, previous crew
Environmental observations — state of the property, presence of substances, medications found
Any documents — ADRT, care plans, crisis plans, CPA documentation

The more specific and detailed the evidence you provide to police, the better their decision-making will be. A well-articulated RAVE request gets a better police response than "we need you here."

Using RAVE in Practice

When calling police, structure your request clearly. Example:

"We are at [address]. RISK: Patient has taken a significant overdose approximately 3 hours ago and is refusing treatment. Currently appears physically well but clinical deterioration is expected. AUTHORITY: We have conducted a capacity assessment — patient appears to have capacity at present but is refusing life-saving treatment. We need police presence to support safety and in case capacity deteriorates requiring s4B MCA action. VIOLENCE: Patient is not currently violent but is agitated and has made verbal threats. No weapons visible. EVIDENCE: Known history of depression and previous overdoses per patient records. GP surgery confirmed active mental health input. We have found empty paracetamol packets [X tablets missing]."

The Paracetamol Overdose Scenario — One of the Most Clinically and Legally Complex Prehospital Presentations

Scenario G — Paracetamol Overdose with Suicidal Intent, Apparent Capacity

Presentation: Patient has taken 50 paracetamol tablets approximately 3 hours ago. They have stated suicidal intent clearly and consistently. They are currently asymptomatic — alert, orientated, conversing normally. They are refusing to go to hospital. They say "I know what I took and I want to die. I've made my decision."

📋 Clinical Reality of Paracetamol Poisoning at 3 Hours

This is the clinical trap. Paracetamol poisoning at 3 hours is almost certainly asymptomatic. Nausea may be present, hepatotoxicity begins at 24-72 hours. The patient feels well and can argue coherently. This asymptotic window is exactly where the legal and clinical complexity peaks.

⚖️ The Capacity Question — Stage 1

Does the patient have an impairment of mind or brain? They appear fully orientated, coherent, without obvious cognitive impairment. But they have taken an intentional overdose with suicidal intent. Does severe depression satisfy Stage 1?

🔬 Stage 2 — The Weigh Element Under Scrutiny

The patient says: "I understand I took 50 paracetamol. I know it will cause liver failure. I know liver failure can kill me. I want to die. I've thought about this for a long time. My decision is final." This appears to pass all four functional elements — understand, retain, weigh, communicate. So do they have capacity?

🚨 The Time Pressure Problem

The NAC (N-acetylcysteine) treatment window is time-critical. The TOXBASE guidance and NPIS (National Poisons Information Service) recommend hospital assessment within the treatment window. Every hour spent in debate about capacity is an hour of treatment window lost. What do you do?

👮 Police Involvement in This Scenario

What role can and should police play? The patient is in a private dwelling. They are not committing a criminal offence — suicide attempt is not a crime in England and Wales (Suicide Act 1961). They are not breaching the peace. They are not being violent.

The AMHP, the GP, and the Reality of Getting Help

⚠️ This section addresses the practical and legal realities of obtaining AMHP and GP involvement — including what they are actually responsible for, what they can and cannot do, and what to do when the system does not respond as it should.

What Is an AMHP and What Are They Actually Responsible For?

An Approved Mental Health Professional is a person warranted under s114 MHA to make certain legal decisions. The majority are social workers, but psychiatric nurses, occupational therapists and psychologists can also become AMHPs. They are employed by Local Authorities (usually) — NOT by the NHS.

What an AMHP CAN do

Apply to a magistrate for a s135(1) warrant to enter private premises for MHA assessment — only an AMHP can make this application
Coordinate and conduct Mental Health Act assessments (with one or two doctors)
Make the application for admission under s2, s3, or s4 MHA — this is the AMHP's decision, not the doctor's
Detain and convey a patient to hospital once an application is made — and authorise others (including police and paramedics) to do so on their behalf
Apply for s135(2) warrants to return AWOL patients
Discharge a patient from detention (in some circumstances)

What an AMHP CANNOT do

Be forced by a GP, police, or anyone else to attend and complete an assessment — the AMHP exercises independent professional judgement. They can decline to attend if they do not consider it appropriate.
Make an MHA application alone — they need a s12-approved doctor (for s2/s3) or any doctor (for s4)
Override a patient's capacitous refusal of treatment — the MHA authorises detention, not medical treatment generally
Use s136 MHA themselves — that is a police power only
Enter private premises without a warrant — same as police (unless invited)

The AMHP holds the APPLICATION power under MHA — not the doctors. Two doctors can recommend admission under s2 or s3, but without an AMHP making the application, no legal detention occurs. The doctors recommend; the AMHP decides.

The Reality — Getting AMHP Attendance

The AMHP is one of the most under-resourced professional roles in the mental health system. In many areas, out-of-hours AMHP cover is extremely limited. You may be told "there is no AMHP available."

What you should know about AMHP legal duties

Under s13(1) MHA — an AMHP must make an application for admission if they are satisfied that such an application ought to be made AND if they are of the opinion that it is necessary or proper for the application to be made by them
This creates a legal DUTY to act — not just a discretion. Where a genuine referral for MHA assessment has been made and the threshold criteria appear met, an AMHP service cannot simply refuse to engage
Local Authorities have a duty under s13(1A) MHA to ensure that an AMHP is available to consider making an application "where it appears to [them] that such an application may need to be made"

⚠️ If you are told no AMHP is available and you believe one is urgently needed: document this. Escalate within your service. This is a safeguarding issue. The patient's risk does not diminish because AMHP capacity is insufficient.

Practical steps when AMHP is not forthcoming

Document the time of your referral, who you spoke to, and the response given

Escalate to your clinical hub / senior clinician for advice and support

Contact the Local Authority duty AMHP service directly if different from the MH trust

If MCA criteria are met and immediate life risk exists — act under MCA s4B and document fully

Consider whether hospital ED is an appropriate interim destination pending AMHP assessment

Ensure police are aware of the situation and the AMHP non-attendance if relevant to their decision-making

Can a GP Trigger an AMHP Assessment?

Yes — a GP (or any doctor) can make a referral to an AMHP requesting a Mental Health Act assessment. Under s13(1) MHA, an AMHP must consider making an application if a medical recommendation has been made. However:

A GP referral does NOT compel the AMHP to attend — it triggers consideration, not automatic attendance
The AMHP retains independent professional judgement about whether an application is necessary
A GP can provide one of the two medical recommendations needed for a s2 or s3 — but needs a s12-approved doctor for the second
In practice, GPs often act as the "any doctor" for s4 (emergency 72-hour) applications where there is no time for two doctors

A GP attending scene can be enormously helpful — they can provide a medical recommendation, assist with clinical assessment, and formally make the referral to AMHP services that gives weight to the request. Ask for GP attendance where possible in complex MH situations.

⚠️ A GP cannot independently detain a patient. Medical recommendations are not detention — only an AMHP application creates legal detention. A GP telling you "they need to go to hospital" does not give you legal authority to convey against the patient's will.

The Gap — When No One Comes

The MentalHealthCop blog (and the research it documents) consistently identifies the same systemic problem: crisis situations where police and ambulance are on scene, the patient needs MHA assessment, AMHP is unavailable, crisis teams decline, and the two emergency services are left managing an unresolvable situation with no legal framework that fits.

This is a structural gap in the mental health system — not a failure of individual professionals. However, you need to manage within it safely and legally. Key points:

You cannot be required to stay indefinitely — but you cannot simply leave a patient at serious risk without a clear plan and handover
MCA is not a substitute for MHA where the primary issue is mental disorder (Sessay). But where life-threatening physical consequences are present — MCA s4B may still apply
Police cannot stay indefinitely either — they have no power to detain in a private dwelling without lawful authority, and the cost of maintaining a presence when no action is possible is operationally unsustainable
Document the system failure — who you contacted, when, what response was given. This protects you professionally and creates a record that may support safeguarding or complaint processes
Escalate within your service — this is a matter for senior managers and clinical leads, not just the crew on scene

If you leave a patient in circumstances where you believe they are at serious risk and no handover has been arranged — document explicitly why you left, what steps you took, and what alternative provision was made or attempted. Leaving with no plan is professionally dangerous.

Crisis Teams — What They Can and Cannot Do

Crisis teams (Crisis Resolution and Home Treatment — CRHT) are NHS services providing intensive community mental health support
They can provide clinical assessment, crisis support, medication management, and may be able to provide a face-to-face response
They CANNOT detain a patient — they have no statutory powers under MHA or MCA
They CAN support an AMHP assessment and may be able to arrange it more quickly through their established pathways
A crisis team saying "we've assessed this patient and they don't meet threshold" does NOT mean MHA or MCA cannot be engaged — that is a clinical opinion, not a legal determination

⚠️ Crisis teams are frequently the first point of contact when ambulance or police request MH support. If they decline to attend or assess, document this. Their threshold for intervention may differ from yours — and in a life-threatening situation, your clinical judgement takes precedence over their triage decision.

Article 2 ECHR — The Right to Life

Article 2 of the European Convention on Human Rights (incorporated into UK law by the Human Rights Act 1998) imposes a positive obligation on the state — including emergency services — to take reasonable steps to protect life where a real and immediate risk is known.

This means that leaving a patient in circumstances of known, immediate risk to life without taking all reasonable steps available to you can engage Article 2 liability
It also means that the system's failure to provide AMHP or crisis team support when urgently needed may itself constitute a breach of Article 2 obligations
Document your actions as Article 2-aware — you took every step available to protect this person's life, you escalated, you referred, and you documented the system's failure to respond

Your thorough, contemporaneous documentation of every referral, every response, every clinical decision is your professional protection — and may be the evidence that exposes a systemic failure that has real consequences for patient safety.

MCA

Documentation Aid

Mental Capacity Act 2005 · Contemporaneous Record

⚠️ This is a documentation aid only. It does not constitute a legal record. All clinical and legal decisions are yours. Complete your full PCR with the detail this tool has prompted you to consider.

Documentation Text — Copy to PCR

MCA 2005