I will discuss a number of issues concerning the topic of the nominated person, one of the Bill’s key reforms. I will first address clause 24 and schedule 2, which seek to replace the current nearest relative provisions with the nominated person, chosen by the patient, who can protect their rights when they are detained. The independent review found the nearest relative provision to be outdated and inappropriate. It allocates someone based on a hierarchical list, which does not reflect modern families and could result in someone unfamiliar or potentially risky to the patient being given the role.
We have ensured that appropriate safeguards are in place to protect patients as well as to enable choice. A health or social care professional or an advocate must witness the nomination and confirm in writing that the nominee meets the criteria and that no undue pressure has been put on the patient. Children and young people with the relevant capacity or competence can choose their own nominated person. We expect this will be their parent or guardian, but sometimes a step-parent or other relative over 18, without parental responsibility, may be more suitable to protect a patient’s rights. Safeguards will be put in place to support children in making this choice.
If a patient of any age lacks capacity or competence to make a nomination, an approved mental health professional will appoint a nominated person on their behalf. For children under 16, this will be someone with parental responsibility, including the local authority if the child is subject to a care order. This appointment is temporary until the patient has capacity or competence to make their own appointment.
For all patients, the responsible clinician or approved mental health professional can temporarily overrule the use of a particular nominated person’s power, for example to discharge the patient, if the patient is likely to act in a manner that is dangerous to themselves or others. A nominated person can be removed by the county court if deemed unsuitable—for example, if they misuse their powers or neglect the patient’s welfare or the public interest. Anyone with an interest in the patient’s welfare, such as their parents, can apply to the court. The Bill extends the nominated person safeguard to some restricted part III patients, but their nominated person’s powers will be limited, as appropriate, in the interests of public safety and criminal justice.
Amendments 54 and 55 would require nominated persons for patients under 16 to have parental responsibility for the child, whether chosen by the child or appointed for them. The Bill currently requires this if the child lacks competence to appoint their own nominated person. However, where a child has competence to decide, we think it is right that they can choose the person to represent their interests. That view was supported by the majority of respondents to the White Paper consultation on reform of the Mental Health Act, and it is in keeping with the principles of choice, autonomy and treating the person as an individual.
Like the current “nearest relative” provision, which the nominated person will replace, the amendments do not take into account the greater diversity of modern family structures—for example, where a step-parent may play a vital role in a young person’s life but does not have formal parental responsibility. Our engagement with children and young people during the development of the Bill suggests that the vast majority will appoint a parent as their nominated person. However, we think having choice is important to prevent children from having to have a nominated person who may not engage with the role or act in accordance with their best interests, just because they have formal parental responsibility.
Where children have competence to choose their own nominated person, a health or social care professional, or advocate, will be required to witness the nomination and confirm in writing that the nominated person is over 18 and suitable to take up the position. Regardless of nominated person status, parents should be involved in a child’s care and treatment, and they will retain their legal rights under parental responsibility. Safeguards are in place to allow for the overruling and displacement of the nominated person if they are behaving in a way that is not in the child or young person’s best interests.
Government amendments 40 and 41 will remove paragraph 11(3) to 11(5) of schedule 2 from the Bill, as it is unnecessary to specify in legislation which person with parental responsibility the approved mental health professional must appoint as nominated person for an under 16-year-old. A prescriptive list of who an approved mental health professional must appoint for a child under 16 may prevent a more suitable adult from being chosen as the nominated person. The Bill states that for under-16-year-olds lacking competence, an approved mental health professional must appoint a parent, or whoever has parental responsibility, to be the child’s nominated person. This would include consideration of special guardians and child arrangement orders.
The Government do not agree that a person with residual parental responsibility should always be blocked from being a nominated person, as the child arrangement order or special guardianship may be in place for reasons other than the parent being a risk to the child. For example, the parent might struggle with their own health issues, but that does not necessarily mean that they would not be an effective nominated person. The situation is different in the case of a care order because the local authority is being given lead parental responsibility. We have engaged with the Children’s Commissioner on that point.
If there is no suitable person with parental responsibility willing to act, the approved mental health professional must take into account the patient’s past and present wishes and feelings, so far as reasonably ascertainable, when deciding who to appoint. We will establish an expert taskforce to support the development of the statutory code of practice to provide clear guidance for professionals involved in the nominated person appointment process for children and young people.
Clause 25 will require the approved mental health professional to consult the nominated person before they make an application for admission for treatment or guardianship. This is an existing right for the nearest relative. However, currently if the nearest relative exercises one of their powers, such as the ability to block admission, but the professional believes their objection is unreasonable, the only means of overruling them is to remove or displace them as the nearest relative. This can leave patients without someone to represent their interests during detention.
Clause 25 will allow the approved mental health professional to make use of the existing barring order to temporarily overrule the nominated person, if the patient would be likely to act in a manner dangerous to other persons or themselves if their admission was blocked. This is a well-established process. Although the nominated person can continue to represent the patient in other ways, they can still be displaced by the court from the role entirely if their actions indicate they are unsuitable for the role—for example, if they are repeatedly objecting to admission without considering the welfare of the patient or the interests of the public. Approved mental health professionals can continue to use that process.
Clause 26 will transfer the nearest relative provisions relating to the power to order discharge of a patient to the new nominated person role. The power can be temporarily overruled by a responsible clinician if they think that the patient’s discharge would result in danger to themselves or others. It is a well-established process that allows for clinical discretion, but means that the nominated person can continue to represent the patient’s rights in other ways. Clause 26 also reduces from six months to three months the time period during which the nominated person cannot make another order for discharge. That reflects the changes in detention periods under clause 29.
Clause 27 will give the nominated person a new power to object to the use of a community treatment order. We also recognise, however, the importance of protecting patients and the public, so if the responsible clinician is concerned that without a community treatment order, there would be a risk of danger to the patient or others, they can overrule the nominated person’s objection. Those changes will help both to reduce the number of inappropriate community treatment orders and to ensure that safeguards are in place for patient safety and public protection.
Finally, clause 28 provides that before deciding to transfer a patient, the person responsible for taking that decision must consult the patient’s nominated person, unless consultation is not reasonably practicable or would involve unreasonable delay. The nominated person will not be able to object to a transfer, because there may be good reasons for transferring a patient—for example, if a different trust can provide better care, such as a specialist eating disorder unit. Consulting the nominated person, however, means that they are aware of the reasons for transfer and how it will benefit the patient. That will help the nominated person to remain actively involved in protecting patients’ rights and kept informed about a patient’s care and treatment.