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
- 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.
- Family history
- Personal history
- Medical history
- Psychiatric history
- Recent social circumstances
- Forensic history
Circumstances of offence or alleged offence
Progress since offence or alleged offence
Current mental state
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.
- 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
- Current post
- Current employer
- 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.