I Hate You So Much Right Now

Hi Mo, nice to see you posting.

My opinion, which might be shite, is that depending on your currently assessed mental state and previous knowledge of what you’ve been up to, I would suspect there isn’t much you could say that would cause a nurse (or maybe just me?) to phone the police, really believing you were likely to act on what was said.

Would you prefer a less general response, answering each point?

Hey Mo, Hope you`re not doing too badly. It really is fantastic to have you back.

Well as the site`s resident raving, right wing Royalist I have to say that if anyone threatened to kill Her Majesty the Queen in my presence I would run them through with a bayonet.

I have some other points to make but I`m a bit nackered tonight. I`ll be back.

What about an autistic with “behavioural issues”, and a lack of emotional regulation doing the same kind of thing? Well, my experience is they end up in the cells. According to UberShrink Prof. Digby Tantam, 82% of people with autism have clinically significant problems with aggression and 36% physical violence…

The concept of nurse – patient confidentiality derives from English common law and is codified in the RCN code of practice. It is based more on ethics than law and probably dates as far back as the Roman Hippocratic oath taken by Doctors which states

“Those things which are sacred are to be imparted only to sacred persons; and it is not lawful to impart them to the profane until they have been initiated into the mysteries of the science.”

In most situations a nurse would have the discretion but not the obligation to disclose information designed to prevent a planned action of a patient. But an important legal precedent has been set in the USA in Tarasoff vs Regents of the University of California, when a therapist was sued for failing to warn a third party of a patients desire to harm her. Thus for most nurses a creditable threat to harm another will trump any considerations of confidentiality.

Responsibility for ones actions when under the influence of alcohol or if acutely unwell is a matter of degree and it would be up to the nurses/doctors responsible to assess the level of personal responsibility an individual is capable of exercising before taking action. It is not uncommon for detained patients or patients under the influence of alcohol to become threatening towards others and if we reported every incident of aggressive behaviour to the police they would need an officer permanently stationed on the ward.

However that said threats to kill are always taken seriously especially when children are involved. In my experience child protection issues always trump all other concerns and are inevitably reported either to the police or to social services depending on the level of threat involved. Other threats are generally taken (rightly or wrongly) less seriously. What happens after a threat has been reported to police depends on the police and the circumstances under which the threat was made. They would probably interview the individual making the threat and then either have an informal “chat” with him or her, issue a police caution, or in extreme cases prosecute, when depending on the situation the case would either be diverted from the court by the judge and a sec 37 (Home office section) sought or it would be dealt with under the criminal justice system.

The point at which I would break confidence would depend on the level of threat I perceived the individual posed to others, and that would depend on the individual, their history, their mental state, who the threat was made against, the level of planning if any and their level of intent. As for any terrorist threat well I would hope that common sense would prevail and that a higher level of proof would be required before action is taken under this piece of legislation. If my manager did not agree with my assessment of the level of threat then I would reserve the right to take independent action and approach the police myself if I felt that to be necessary.

There are at least two defences available to third nurses when breaking patient confidentiality First, there is the rule of disclosure in the public interest. Second, there is the de mininis rule (i.e. de minimis non curat lex : the law is not concerned with trivialities), excludes “trivial tittle tattle”. In other words, if the disclosure is not substantial it will not be actionable.

Hi Mo,

These ethical scenarios are not without their dilemmas and often it comes down to a joint decision made with other members of the team as to how best proceed. However, my thinking on the subjects you raise….

1) Personal responsibility while under the influence of alcohol

Drunkeness is a transient condition and it can be perceived that, given the person would not make such threast in a sober state, the threat is only active/potential for as long as the person is drunk.
This argument also fuels my belief that ‘transient active psychoses secondary to drug misuse’ is not a mental health defences - since everyone is more or less aware of the dangers of psychoactive substances and behavioural changes.

On the contrary - it is strange that someone can be charged for drinking and driving when the reason this charge exists is because it is apparently inevitable drunk people are in less control of themselves - alcohol causes an impairment of judgment.. ergo - who can be surprised s/he made a stupid decision to drive after drinking - and can they therefore be held responsible?

2) Personal responsibility while under section

Whilst under section is an interesting one - as the subject person is considered non compus mentus and lacking capacity to self-control. The story you relate in the USA does not surprise me - but I would think it was over-reaction to the ravings of a someone not so in control - either by nature of alcohol or mental illness (I’m not sure if they send drunks to psychiatric hospital but I would hope not). I will discuss my own rationalising below on whether to report or not - but I think 5 years for these threats in any circumstance is a bit over-patriotic.

In theory - a patient who enacts harm against another person whilst under section - is the ward of the hospital and, as such, the hospital is ultimately accountable since MHA law does not “remove” the patients rights to self-determination and freedom - it displaces it to the treating team. However, it’s a grey area in as much as patients are at varying levels of ‘wellness’ and may be capable of making decisions - once this is achieved then their responsbility is ‘given back’ to them.

Interstingly, I had a patient who attempted to abscond and fell of the fence fracturing his arm and pelvis - he believes he has a case to sue the hospital for not making the fence safe enough to either not scale or to fall down from - I mean; it’s there to stop people getting out - so we knew he (or someone) would try to climb over - why make it so dangerous?
(I think he has a case but since the act was unlawful - ie breaching MHA detention - his case might be redundant; tho he is deemed not welll enough to keep himself or others safe…. - stranger things have happened in USA)

3) Nurses responsibility and breaching confidentiality

I have no qualms about when and why to breach confidentiality and have done on various occasions. I note that I always attempt to discuss with the patient first unless doing so would put others at (greater) risk.
Incidentally, here in Oz it is illegal to NOT disclose or report child protection issues and may result in professional repercussions.

The law of negligence simply states our responsibility to our neighbour - and defines our neighbour as anyone with whom we have a formal or informal relationship. As a nurse, if a patient discloses thoughts of harm towards another identified person - I have a responsibility to disclose that information either directly to the person or to others who will direct to that person.
I have patients disclose some fabricated and embellished stories to me in the past and have generally known them to be utter tripe. However, I have always followed thru with them in one fashion or another.
One such disclosure was made by a patient who stated a friend had recently asked him to murder a known female. I knew he was making it up and was also an in-patient with no way of carrying this out so I would simply record and report it - So when I didn’t react he embellished the story - “and when I said I wasn’t going to do it - he says he’s going to do it”
I had a 98% belief this was crap - but 2% chance - when the outcome is loss of life - is enough to cause me to act.
I discussed with my line manager and with the on call psych registrar who could not give me a good enough reason to not report to the police. They attended and took details from me - the patient was not involved at this stage - but I discussed it with him a few days later to advise I had disclosed to the police. I never found out the police outcome…. but a few months later he repeated the same story to another nurse.

If I believe there is a chance of reality to the risk and the risk is imminent and high (eg threats to kill a memeber of staff) I do not hesitate to ensure that identified target’s safety.
“I’m going to fkn kill that nurse when I see him”

At the other end of the scale tho - if a patient states : “I hate my mother and I’m going to make her pay for the things she’s done to me” - if the patient has no contact with the mother, is not due for release anytime soon, is mentally unwell at the time and mum lives in another country - the risk is far less. I would document this and bring it to the attention of the psychiatrist or include in risk assessment report.

At the ultimate end - nurses have a responsibility to everyone all of the time - not just current patients - but public aswell (in all areas of nursing). To ignore threats and not prevent someone coming to harm by not disclosing information would be negligent and considered an ‘omission’ for which Nursing Council would require some answers. In such instances it would not suffice to say ‘patient confidentiality’ and any nurse found doing so may be charged with ‘accessory before the fact’.

Breaching confidentiality is always an interesting dilemma - but I would say it is more ethically demanding in Sexual Health clinics when results come in positive for Hepatitis or HIV. Should we tell sexual partners? I’m not sure what the protocols are on that one.

4) Terrorist threat
As above - based on the known detail of the patient and the reality of those threats - if they were generalised “I’m gonna blow you all up and the Houses of Parliament too” - I’d document and report - and this might also lead me to decide perhaps today wasn’t a good time for s17 leave.

Right Mo, It`s been a while since I studied this stuff so please bear with me. Shortarse Scotsman Syndrome exacerbated by drunkenness and being ginger is not a new phenomenon. It was obviously a problem in Victorian times. Consequently, Section 4 of the Offences Against the Person Act 1861 made it a serious ( probably indictable, I can`t remember ) offence to threaten to kill another person, punishable by a stiff sentence ( I can`t remember how long, however, if you were unfortunate to be in front of an austere judge you could be banished to Oz to live next door to Mr Ian, cruel and unusual punishment by any standard ). Anyway, it was quickly realised that Sec 4 wasn`t particularly fit for purpose as it was a bit heavy handed for dealing with drunken spats outside the Victorian version of the kebab shop. As far as I know it remains on the statute books but resides on a dusty shelf to be utilised in exceptional circumstances. The problem wasn`t re-addressed until the 1980`s ( again I can`t remember exactly when ) with the introduction of the Public Order Act which created a new offence of Threatening Behaviour. As I understand it if you are convicted of Threatening Behaviour in modern Britain you will be fined a guinea payable in 21 monthly 5p instalments and threatened with an ASBO. If you employ Mr Ian as your legal representative, he will portray you as the victim, claim you were regularly beaten as a child and under the influence of cannabis ( a mere technicality rather than an offence in itself )at the time the threat was made. You will then get off scot free ( pardon the pun ).

There are 9 defences in law, I have forgotten them but drunkenness certainly isn`t one. The police respond quite well when tasked to emergency situations on psychiatric units. However, if asked to conduct a criminal investigation they put minimal effort in as they have no faith that the remainder of the criminal justice system will be supportive. Unless you commit an horrendous offence whilst under Section you have little or nothing to fear.

Anyone been to Portsmouth Dockyard ? If you`re lucky one of the Fleet`s aircraft carriers will be tied up alongside. Quite amazing pieces of engineering. The new ones will be bigger and even more state of the art, at a cost of £2,000,000,000 apiece. The NHS has managed to scupper the equivalent of six new aircraft carriers in a futile attempt to develop an IT system. Deal with a terrorist threat ?. You`re having a laugh.