Secretary of State for the Home Department, R (on the application of) v Mental Health Tribunal & CH

A Mental Health Review Tribunal must give adequate and comprehensive reasons when deciding whether a patient should remain liable to detention or be discharged conditionally. The statutory concepts of nature and degree are distinct, although the distinction may be elusive and need not invalidate a decision where the Tribunal addresses the real issue. In a case turning on the risk of relapse if medication is not continued, that issue may depend on the likelihood of medication compliance in the community. Where medical evidence gives substantial reasons for a serious risk, the Tribunal may reject it, but must explain why. It cannot rely on unexplained preferences for other evidence or introduce material reasons retrospectively through later statements. Failure to give adequate reasons justified quashing the decision and remitting the matter to a fresh Tribunal.

The Secretary of State sought judicial review of a Mental Health Review Tribunal decision conditionally discharging a patient detained under Mental Health Act 1983 sections 37 and 41. The Tribunal considered that the patient’s long-standing delusional beliefs, limited history of violence, apparent stability in hospital and proposed community supervision justified conditional discharge, subject to medication, supervision and accommodation conditions.

The Secretary of State challenged the adequacy of the Tribunal’s reasons, including its treatment of the statutory concepts of nature and degree and its rejection of medical evidence that the patient would not comply with medication and might pose a serious risk if discharged. The central issue was whether the Tribunal had sufficiently explained its decision.

1. The claim succeeded. The Tribunal’s decision was quashed and the matter was remitted to be heard by a fresh Tribunal. No order for costs was sought.
2. The concepts of mental illness being of a particular nature or degree under the Mental Health Act 1983 are distinct and should ordinarily be considered disjunctively. In many cases the distinction may be elusive. In this case, however, the Tribunal had addressed the substance of the issue: the seriousness of the condition, the prospects of medication compliance after discharge and the resulting risk of relapse and harm.
3. The Tribunal was entitled to determine whether the patient would take medication in the community. Expert evidence did not automatically bind it. But, where the medical evidence was consistent and gave substantial reasons for anticipating non-compliance, the Tribunal had to explain why it rejected that evidence and preferred the patient’s assurance.
4. It was insufficient merely to state or imply that one witness was preferred to another. The reasons were particularly important because the evidence concerned previous medication refusal, lack of insight, reluctance to take treatment and a serious potential risk to others.
5. The Tribunal’s reasons also had to be comprehensive. Later evidence could elucidate reasons contained in the formal decision, but could not generally supply material reasons omitted from it. The Tribunal’s later assertion that it considered the medical evidence exaggerated was neither stated in the decision nor fairly explored with the doctor. That omission was material.
6. It was unnecessary to determine the additional challenges concerning the scope of the risk assessments, generality of the risk, adequacy of community support or a possible exclusion-zone condition.

• Mental Health Review Tribunal: conditionally discharged the patient, subject to medication, supervision and accommodation conditions, with discharge deferred until arrangements were made.
• High Court (Administrative Court): quashed the Tribunal’s decision for inadequate reasons and remitted the matter to a fresh Tribunal.