The Mental Health Legislation Committee

Annual Report

Financial Year 1 April 2024 to 31 March 2025

1. Period covered by this report

This report covers the work of the Mental Health Legislation Committee for the financial year 1 April 2024 to 31 March 2025.

2. Introduction

The Mental Health Legislation Committee (“the Committee”) is a sub-committee of the Board of Directors and provides assurance to the Board on compliance with all aspects of mental health legislation. This is a huge responsibility given that at any one time the Trust has around 308 people in its inpatient services who are detained under the Mental Health Act (MHA) 1983; 208 people who are living in the community on conditional discharge or subject to a legally binding Community Treatment Order (CTO) (this means that the Trust has power to readmit them to hospital if required); and 8 people who have been assessed as lacking capacity to make decisions about their care and are detained under Deprivation of Liberty Safeguards. When the Trust considers whether or not people should be detained (or sectioned) five guiding principles have to be applied:

• Least restrictive option and maximising independence
• Empowerment and involvement
• Respect and dignity
• Purpose and effectiveness (of potential detention)
• Efficiency and equity.

In addition, the Trust’s regulator, the Care Quality Commission (CQC) inspects the way in which the Trust administers the legislation via cyclical inspections and regular “spot checks”.

The Committee receives assurance through reports, both regular and bespoke, to ensure compliance is regularly monitored. This includes a report from the Mental Health Legislation Operational Steering Group which considers the practical issues staff face and how they are being resolved, reviews feedback from service users and CQC spot checks, and maintains and reviews the risk register. The Committee also receives feedback from the Mental Health Act Managers (MHAMs) about the way in which they are carrying out their role in reviewing detentions.

Membership of the Mental Health Legislation Committee is currently made up of two Non-executive Directors (NEDs) (including the Chair of the Committee), the Medical Director, and the Director of Nursing and Professions. Whilst only two Non-executive Directors are substantive members of the Committee, the other Non-executive Directors are invited to attend on an ad-hoc basis as and when they feel it appropriate, or to ensure quoracy. Further information about the membership of the Committee can be found in section 6 below.

3. Terms of reference for the Mental Health Legislation Committee

The Terms of Reference (ToR) were reviewed by the Committee at its meeting on 5 November 2024 where it was agreed that there were no amendments required to be made. The Committee considered whether the ToR should be expanded to include the work the Committee performed in the area of improving health equity for service users, however, it was agreed at the 30 January 2025 Board of Directors meeting that assurance on the Trust’s Health Equity Plan would be reported through the Quality Committee and therefore the Committee’s ToR would not be expanded to fulfil this role.

The latest version of the Committee’s ToR was approved by the Committee on 1 November 2023 and was ratified by the Board of Directors on 30 November 2023. It has been attached as Appendix 2 of this report for additional information.

4. Effectiveness of the Mental Health Legislation Committee

The Committee carried out a review of its effectiveness in August and September 2024 where members and regular attendees were asked to complete the Committee Effectiveness Questionnaire. The results were collated and then presented to the Committee at its November 2024 meeting. It noted that the matters that the Committee considered at its meetings were very technical and required specific training and experience to be well understood. It was agreed that there was no areas of concern which it needed to bring to the attention of the Board of Directors nor were there any changes required to be made to the Committee’s ToR.

In November 2024, a representative from The Value Circle observed a Mental Health Legislation Committee meeting as part of an independent review of the Trust’s Well Led governance arrangements. It was reported that particularly good practice was observed regarding the discussion on the item on Detentions which included consideration of how the wider aspects of service delivery, for example how the use of Community Treatment Orders impact on this issue. It was also noted that there was a thoughtful discussion on inequalities which was prompted by effective challenge made by the Chair and that the meeting was generally conducted effectively and had a clear focus on improving outcomes for service users.

5. Meetings of the Mental Health Legislation Committee

In 2024/25 the Committee met formally on four occasions. All Committee meetings were held virtually. The dates on which the Committee met during this period are as follows:

• 13 June 2024
• 12 September 2024
• 5 November 2024
• 11 February 2025

6. Membership of the Mental Health Legislation Committee and attendance at meetings

The membership of the Mental Health Legislation Committee is made up of two Non-executive Directors; the Director of Nursing and Professions; and the Medical Director. In order to be quorate, at least three members of the Committee must be in attendance, and this must include at least one Non-executive Director and the Medical Director. The Committee is chaired by a Non-executive Director (NED) with the other NED member fulfilling the role of Deputy Chair of the Committee. In 2024/25, Ms Kaneez Khan was the Chair of the Committee and Ms Katy Wilburn was the Deputy Chair of the Committee.

The 2024/25 meetings of the Mental Health Legislation Committee were attended on a regular basis by the Associate Medical Director, members of the Mental Health Legislation Team, the Associate Director for Corporate Governance, the Chair of the Mental Health Legislation Operational Steering Group (Ms Janet Smith), and the Deputy Chair of the Mental Health Act Managers Forum (Ms Viv Uttley from April – August 2024 and Mr Noel Devine from August 2024 – March 2025). Invitations were extended to members of the executive team and senior managers who attended meetings to present papers and make assurances as required.

The Trust also invites governors to observe Board sub-committee meetings. This opportunity allows governors to observe the work of the Committee, rather than to be part of its work as they are not part of the formal membership of the Committee. Governors observe Board sub-committee meetings in order to get a better understanding of the work of the Trust and to observe Non-executive directors appropriately challenging the executive directors for the operation performance of the Trust.

The tables below demonstrate the attendance of the substantive members, formal attendees, and governors who observed meetings of the Committee for the period 1 April 2024 to 31 March 2025.

Attendance at Mental Health Legislation Committee meetings by substantive members

Attendance at Mental Health Legislation Committee meetings by formal attendees

Attendance at Mental Health Legislation Committee meetings by governors

Note that no governors attended to observe any of the Mental Health Legislation Committee meetings in 2024-25.

7. Reports made to the Board of Directors

The Chair of the Mental Health Legislation Committee makes an assurance, escalation, and advisory report regarding the most recent meeting of the Committee to the next possible Board of Directors’ meeting. The report seeks to assure the Board on the main items discussed by the Committee, and should it be necessary, to escalate to the Board any matters of concern or urgent business which the Committee is unable to conclude. The Board may then decide to give direction to the Committee as to how the matter should be taken forward or it may agree that the Board deals with the matter itself.

Where the Board wants greater assurance on any matters that are within the remit of the Terms of Reference of the Committee, the Board may ask for these to be looked at in greater detail by the Committee. The table below outlines the dates that the assurance and escalation reports were presented by the Chair of the Mental Health Legislation Committee to the Board of Directors meetings.

In addition to the assurance and escalation reports described above, the Mental Health Legislation Committee’s Annual Report is also received by the Board of Directors. The Committee’s Annual Report for 2023/24 was presented to the Board of Directors at its extraordinary meeting on 20 June 2024.

8. The work of the Mental Health Legislation Committee during 2024/25

For 2024/25 the Chair and members of the Mental Health Legislation Committee confirm that the Committee has fulfilled its role as providing assurance to the Trust’s Board of Directors regarding compliance with all aspects of the Mental Health Act (1983) and subsequent amendments, and on compliance with all aspects of mental health legislation including, but not limited to the Mental Capacity Act (2005), and the Deprivation of Liberty Safeguards / Liberty Protection Safeguards. This was done in accordance with its Terms of Reference which are attached as Appendix 2 for information.

In 2024/25, the Committee:

• Received assurance that the Trust had administered legislation appropriately:
  • The Committee received quarterly Mental Health Legislation Activity Reports at each of its meetings and was assured that the plans in place were sufficient to ensure ongoing compliance with all mental health legislation. It made recommendations on ways in which these quarterly reports could be further improved and noted that plans to include more patient demographic information and data trend information in these reports would be explored going forward.
  • At its June 2024 meeting the Committee received assurance that all service users who had been detained following a remote Mental Health Act Hearing which was subsequently discovered to be unlawful had been discharged, and that a duty of candour process had followed this so that all affected service users received a letter of apology.
  • At its September 2024 meeting the Committee received assurance that the Trust had a sufficient number of Section 12 Approved Doctors to operate effectively. It was noted that a more thorough review in this area would be conducted to explore why there was a historical lack of availability of doctors to conduct Section 12 assessments and whether this issue still persisted.
  • At its September 2024 meeting the Committee was assured that following a full audit of mental health legislation casework that all the procedures and processes which had been implemented at the Trust were working as intended.
  • At its November 2024 meeting the Committee discussed the results of the Mental Capacity Act internal audit which had been received with the overall opinion of limited assurance. The Committee was assured on the management responses and actions to the recommendations made in the report and noted it would monitor the implementation of these recommendations going forward.
  • At its February 2025 meeting the Committee received the Restrictive Interventions Annual Report which it receives alongside the Quality Committee and was assured by the content of the report that the Trust was compliant with legislation in this area and was administering restrictive interventions appropriately.

• Received assurance on the Trust’s preparations for changes to mental health legislation:
  • The Committee discussed the implications of the Hospital Discharge and Community Support Statutory Guidance which highlighted a potential gap in commissioned services regarding the discharge of homeless service users into appropriate accommodation in the community. This guidance was escalated to appropriate channels in the local authority and within the Trust.
  • The Committee monitored the development and progress of the new Mental Health Act Bill in Parliament and was assured that the implications of the changes proposed in this Bill were being considered by the Trust.

• Monitored the experiences of service users and carers using services provided by the Trust:
  • At its June 2024 meeting the Committee was alerted to an issue of some service users potentially being disadvantaged as a result of being detained in a “flex bed” in the Section 136 suite for extended periods of time. It noted that the policy underpinning this practice was being reviewed to include additional guidance to improve the experience of service users detained in a “flex bed” and that efforts to improve patient flow would decrease both the average length of detentions and the overall number of service users detained in this manner. As of November 2024, the average length of detentions of service users in a Section 136 “flex bed” were included in the quarterly Mental Health Legislation Activity Report received by the Committee for reassurance.
  • At its September 2024 meeting the Committee received the Representation at Mental Health Act Hearings report and was assured that service users were adequately informed and supported pre and post hearing by an independent advocate provider and the Trust, and that service users had access to an independent mental health advocate at these hearings when it was requested and agreed to be appropriate.

• Received regular updates from the Mental Health Act Managers Forum, including any issues which had been identified at the Forum
  • Following a request made by the Forum to the Committee, it was agreed that the Trust would remunerate Mental Health Act Managers who had their tribunal cancelled within one working day, as opposed to the previous practice of only offering remuneration within a strict 24-hour period.

• Received regular updates from the Mental Health Legislation Operational Steering Group (MHLOSG) regarding the flow of Mental Health Act inspection reports, and any issues which had been identified at the Group:
  • At its November 2024 meeting, the Committee discussed challenges which had been identified at the MHLOSG regarding safety and security arrangements of Mental Health Act hearings and tribunals, in particular for community patients due to a reduced number of staff present at such hearings. It was noted that a review of the Trust’s security arrangements would be conducted, and that this issue would be discussed further at the Clinical Environments Group.
  • The format of the report received by the Committee detailing the issues discussed by the MHLOSG in the quarter was amended to an “alert, advise, and assure” format to improve the flow of information received at the request of the Committee.

• Received assurance that colleagues had been properly trained and supported in their delivery of care so that it was compliant with mental health legislation.
  • At its June 2024 meeting, the Committee received a report which reviewed the comprehensive Human Rights Training programme which was delivered in collaboration with the British Institute of Human Rights across the Trust. It noted that feedback to this training was very positive and that following this a Human Rights Community of Practice had been set up in the Trust which would meet monthly to discuss issues regarding human rights and provide advice and training to colleagues.

• Continued to monitor the rollout of the “Right Care, Right Person” operational model employed by local police forces and potential issues faced by the Trust in its implementation.
  • The Committee noted that this issue was also being monitored by the Quality Committee as well as other groups within the Trust such as the Police Liaison Forum and the MHLOSG. It noted at its February 2025 meeting that work was ongoing to review and determine the appropriate routes of escalations for issues in this area.
  • At its September 2024 meeting it was reassured that the Trust was reviewing its policies and procedures to ensure that police forces were contacted in-line with the operational model.

• Received assurance on the continued focus and drive on work to investigate and address issues around overrepresentation of service users from ethnic minority backgrounds in crisis and detention:
  • At its November 2024 meeting the Committee received the Mental Health Detentions Report for 2023-24 and noted that it demonstrated that people from minority ethnic backgrounds were statistically more likely to be detained under the Mental Health Act. It noted that the report made several recommendations which would form part of the Trust’s priorities for the Patient Care Race Equality Framework.
  • At its November 2024 meeting the Committee discussed the potential for its Terms of Reference to be expanded so that the Committee was responsible for gaining assurance that the Trust was tackling health inequalities experienced by service users from minority ethnic backgrounds. At its February 2025 meeting it noted that it had been agreed by the Board of Director’s that the Trust’s Health Equity Plan would be reported through the Quality Committee and therefore the Committee’s Terms of Reference would not be expanded, but that the Committee would retain its current reports in this area to ensure that it was adequately sighted on areas of health equity.

• In 2024-25 the Committee fulfilled its governance duties as detailed in the Committee’s Terms of Reference:
  • As detailed previously at its November 2024 meeting the Committee completed its Committee Effectiveness review.
  • At present none of the Strategic Risks identified in the Trust’s Board Assurance Framework are linked to the Mental Health Legislation Committee.
  • At its February 2025 meeting the Committee reviewed its risk register and was assured that the risks associated with mental health legislation were being appropriately managed.

At its February 2025 meeting the Committee reviewed the development of the Draft Internal Audit Annual Plan for 2025-26 and confirmed that there was no specific area relevant to the work of the Committee to highlight for inclusion on this plan.

9. Conclusion

As a sub-committee of the Board of Directors, the Mental Health Legislation Committee has provided assurance to the Trust’s Board of Directors regarding compliance with all aspects of the Mental Health Act (1983) and subsequent amendments. It has also received assurance that the Trust has complied with all aspects of mental health legislation including the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards / Liberty Protection Safeguards. It carried out its work diligently; discussed issues openly and robustly; and kept the Board of Directors apprised of any possible issues or risks.

The Mental Health Legislation Committee has fulfilled its role as a Trust Board governance committee in accordance with its Terms of Reference. This enables the Trust Board to comment on the adequacy and effective operation of the organisation’s internal control systems and compliance with the law and regulations.

Despite considerable staffing and operational pressures during 2024/25, administration of the mental health legislation requirements has been continued effectively.

The Committee is extremely grateful to all those who have responded to its requests during the year and who have supported it in carrying out its duties, in particular members of the Mental Health Legislation Team for their hard work, flexibility, and commitment during this period.

This section is a conclusion to the information provided in the report and should assure the ‘parent’ group that it has fulfilled its duties, acted in accordance with its powers and Terms of Reference, and contributed to improving the quality and safety of services.

Kaneez Khan

Chair of the Mental Health Legislation Committee

April 2025

Appendix 1 – Mental Health Act Managers Annual Report: 1 April 2024 – 31 March 2025

MENTAL HEALTH ACT MANAGERS

The role and remit of the Mental Health Act Managers

Mental Health Act Managers (MHAMs) are members of the public, appointed by the Board of Directors, together with non-executive directors who are able to act in this role.  Their key responsibilities are to:

• Review the detention of service users who are either detained under the Mental Health Act or who have been placed on Community Treatment Orders (CTO)
• Discharge those service users who no longer meet the criteria to be detained or are subject to a CTO.

Providing assurance to the Mental Health Legislation Committee is the Mental Health Act Managers Forum.  The Forum is chaired by a non-executive director and/or the lead Mental Health Act Manager to ensure a direct link to the Board of Directors in accordance with the Mental Health Act Code of Practice.  This seeks to provide a forum for communication between the committee, the Mental Health Act Managers and the officers of the Trust.  It provides a mechanism for assurance on, the robustness of arrangements in place for the Trust to meet its duties in respect of the Mental Health Act 1983.

In 2024/25, the Mental Health Act Managers Forum was chaired by Kaneez Khan, Non-executive Director, Viv Uttley, Lead Mental Health Act Manager and Deputy Chair of the Forum and Noel Devine who took over as Deputy Chair of the MHAMs Forum in August 2024. The Forum met four times, on 16 April 2024, 17 July 2024, 18 October 2024 and 4 February 2025. All meetings were held remotely via MS Teams.

Mental Health Act Managers who have served in 2024/25

We currently have 36 acting Mental Health Act Managers and the table below shows those people who have acted in this capacity during 2024/25, we have five MHAMs leave the panel during 2024/24, three to end of fixed term contract, one panel member resignation and one panel member who sadly passed away.  There are sufficient panel members to meet legislative requirements.

Mental Health Act Managers during 2024/25

Leavers of the Mental Health Act Managers Panel during 2024/25

Non-executive directors acting as Mental Health Act Managers during 2024/25

We are appreciative of the time and commitment that Mental Health Act Managers acting as Mental Health Act Managers have given this year.  Once again, we wish to thank our Mental Health Act Managers for their dedication and the skill they apply when undertaking this vital role.

Kaneez Khan

Chair of the Mental Health Legislation Committee

April 2025

Appendix 2 – Terms of Reference

A link to the current Terms of Reference of the Mental Health Legislation Committee can be found here.