Approved Medical Practitioners - Mental Health (Care and Treatment) (Scotland) Act, 2003 Training Manual

Section 13. Appendix 3 - Psychiatric report to the Court

Suggested structure/contents of a psychiatric report to the Court

A good psychiatric report to the Court uses plain English, and explains medical jargon. It will also be sufficiently comprehensive to preclude where possible a requirement for oral evidence.

Key heading areas in the report

Preliminary information

• At whose request the assessment was undertaken, circumstances of assessment (place, time, any constraints on assessment such as inadequate time to complete assessment due to prison routine)

• Sources of information used (interview with the person, interviews with others, documents examined)

• The person's capacity to take part or refuse to take part, and understanding of the limits of confidentiality

• If any important sources of information could not be used, there should be a statement explaining why this was the case.

Background history

• Family history

• Personal history

• Medical history

• Psychiatric history

• Recent social circumstances

• Personality

• Forensic history

Circumstances of offence or alleged offence

Progress since offence or alleged offence

Current mental state

Opinion

Would cover all or some of the following matters:

• Fitness to plead

• Presence of mental disorder currently and whether the criteria for the relevant order are met

• Presence of mental disorder at the time of the offence:

• the relationship between any mental disorder and the offence (this is still relevant even if - the person has been convicted, as it may affect the choice of disposal)
• whether the person was insane at the time of the offence
• in murder cases, whether there are grounds for diminished responsibility
• Assessment of risk:
• the risk of harm to self or others
• the risk of re-offending
• the relationship between this risk and any mental disorder present
• does the person require to be managed in a secure setting, and if so, should this be at a state hospital?
• What assessment or treatment does the person require?
• does the person need further assessment?
• where? Does the person need a period of in-patient assessment and at what level of security?
• why? What issues remain to be clarified?
• Does the person require treatment for a mental disorder or condition?
• what treatment do they need, and where?
• State any matters that are currently uncertain and the reasons they remain uncertain.

Recommendation

• Should the Court consider using any particular order?

• If so, what arrangements have been made for the person to be received in hospital or elsewhere under this order?

• Whose care will the person be under?

• Consider whether an alternative order may be appropriate if circumstances change so that the order recommended above cannot be acted on. For example:

• if the person is or is not found to be insane
• if the person is or is not convicted.

Medical practitioner's details

• Name

• Current post

• Current employer

• Qualifications

• Registration status with the General Medical Council

• Approved under Section 22 of the 2003 Act and with which NHS Board

• A statement that the report is given on 'soul and conscience'

• A statement as to whether the medical practitioner is related to the person

• A statement as to whether the medical practitioner has any pecuniary interest in the person's admission to hospital or placement on any community-based order

• The medical practitioner should sign the report.