General Practice: Mental health, safeguarding, certification and the law

🩺 Mental health, safeguarding, certification and the law in primary care. About a third of GP consultations involve a mental health component, and GPs are often the first to hear about abuse, neglect or risk to others. This chapter covers common mental health presentations in primary care, safeguarding duties, fitness to work and drive, death certification and the legal and ethical framework that the UKMLA tests directly.
Your four questions: Is this person safe - from themselves, from others, and are others safe from them? Do they have capacity for this decision? Do I need to share information, and on what basis? Have I documented my reasoning?

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Depression and Anxiety

• Screening questions: "During the last month have you often been bothered by feeling down, depressed or hopeless?" and "…by having little interest or pleasure in doing things?" - if yes, assess fully (PHQ-9 for severity; GAD-7 for anxiety).
• NICE NG222 (2022): categorises less severe (PHQ-9 <16) and more severe (PHQ-9 ≥16) depression.
• Less severe: guided self-help, group CBT or behavioural activation, exercise groups, individual CBT; antidepressants are not routinely first line unless the patient prefers them.
• More severe: combination of individual CBT and an antidepressant (SSRI usually first choice), or either alone.
• Antidepressants: review at 2–4 weeks (1 week if under 25 or at increased suicide risk), effect in 4–6 weeks, continue for at least 6 months after remission; withdraw gradually.
• Generalised anxiety disorder (NICE CG113): stepped care - education and monitoring → low-intensity psychological interventions → CBT or applied relaxation, or SSRI (sertraline first line); avoid benzodiazepines except short-term in crisis.
• NHS Talking Therapies (formerly IAPT) - patients can self-refer.
• Postnatal depression - Whooley questions at contacts; consider puerperal psychosis (urgent - same day) if confusion, mania or psychotic symptoms after birth.

Suicide and Self-harm Risk

• Ask directly about suicidal thoughts - asking does not increase risk.
• NICE NG225 (2022): do not use risk assessment tools or scales to predict future suicide or to decide who to treat or discharge; focus on a needs-based, collaborative safety plan.
• Factors associated with higher risk: previous self-harm, male sex, middle age, living alone, unemployment, recent loss, chronic pain or illness, alcohol/drug misuse, psychiatric illness (especially recent discharge), access to means, hopelessness, plans and preparations.
• Self-harm: every person who self-harms should have a psychosocial assessment; consider medical risk (paracetamol overdose - emergency department regardless of apparent wellness).
• Safety planning: warning signs, coping strategies, people and places for distraction, people to ask for help, professional contacts (crisis team, 111 option 2 in England, Samaritans 116 123), making the environment safe (means restriction - limit quantities of prescribed medicines).
• Urgent referral to the crisis/home treatment team if high immediate risk; emergency (999) if attempt in progress.

Severe Mental Illness and Physical Health

• People with schizophrenia or bipolar disorder die 15–20 years earlier, mostly from cardiovascular disease, respiratory disease and cancer.
• Annual physical health check: BMI, BP, lipids, HbA1c, smoking, alcohol and substance use; cervical, breast and bowel screening uptake; medication side effects.
• Antipsychotic monitoring: weight, glucose, lipids, prolactin (symptoms), ECG for QT-prolonging drugs; clozapine - FBC monitoring (neutropenia), constipation (can be fatal), myocarditis, and smoking cessation increases clozapine levels.
• Lithium toxicity: tremor (coarse), ataxia, vomiting, diarrhoea, confusion - stop and check levels; triggers include dehydration, NSAIDs, ACE inhibitors and thiazides.
• First episode psychosis - refer to Early Intervention in Psychosis service (2-week target).

Alcohol and Drug Misuse

• AUDIT-C for screening; full AUDIT if positive (score ≥8 = hazardous; ≥20 = possible dependence).
• Brief intervention (5–10 minutes, FRAMES: Feedback, Responsibility, Advice, Menu, Empathy, Self-efficacy) reduces consumption.
• Alcohol withdrawal - risk of seizures and delirium tremens 2–3 days after stopping; community detox only if suitable (no history of seizures/DTs, supportive environment, not severely dependent) with chlordiazepoxide reducing regimen and thiamine; otherwise admit.
• Relapse prevention: acamprosate, naltrexone, disulfiram (specialist).
• Opioid dependence: refer to substance misuse service for opioid substitution (methadone, buprenorphine); naloxone supply to people at risk of overdose and their families.
• Wernicke's encephalopathy - confusion, ataxia, ophthalmoplegia - IV Pabrinex (parenteral thiamine) urgently.

Safeguarding Children

• Every doctor has a duty to act on concerns about a child (GMC: Protecting children and young people). The child's welfare is paramount (Children Act 1989).
• Categories of abuse: physical, emotional, sexual, neglect; also child sexual and criminal exploitation (county lines), FGM, radicalisation, domestic abuse exposure.
• Warning features: bruising in a non-mobile infant ("those who don't cruise rarely bruise"), bruises on soft areas (cheeks, ears, neck, buttocks, abdomen), patterned injuries, burns/scalds with clear edges, injuries inconsistent with history or development, delay in presentation, frequent attendance, faltering growth, sexualised behaviour, STI or pregnancy in a young child.
• Under 13 and sexually active → always a safeguarding referral (cannot consent in law). 13–15 - assess for exploitation.
• Action: if a child is at immediate risk → police/999; otherwise discuss with the practice safeguarding lead and refer to children's social care (MASH) the same day if significant harm is suspected; document facts, the child's words verbatim, and your actions; you do not need parental consent if seeking it would put the child at risk.
• Child protection medical - arranged by the paediatric team, not in primary care.

Safeguarding Adults and Domestic Abuse

• Care Act 2014 - safeguarding duty for adults with care and support needs who are experiencing or at risk of abuse or neglect and cannot protect themselves.
• Types: physical, sexual, psychological, financial/material, neglect and acts of omission, self-neglect, discriminatory, organisational, domestic abuse, modern slavery.
• Six principles: empowerment, prevention, proportionality, protection, partnership, accountability; Making Safeguarding Personal - ask what the person wants.
• Domestic abuse: ask routinely when there are indicators (injuries, depression, frequent attendance, pregnancy - risk increases); see the patient alone; use DASH risk assessment; high risk → MARAC referral (can be made without consent if serious risk); Independent Domestic Violence Advisers (IDVAs); IRIS programme in general practice.
• Capacity and consent - if the adult has capacity and declines action, respect this unless others (e.g. children) are at risk or a serious crime is involved; keep the door open.

FGM, Modern Slavery and Prevent

• FGM: health professionals have a mandatory duty to report to the police (101) known cases (disclosed or observed) in girls under 18 in England and Wales; FGM is a criminal offence; record in the clinical record (FGM Information Sharing system for at-risk girls).
• Modern slavery - signs include someone else speaking for the patient, no access to documents, fear, inconsistent addresses; refer via the National Referral Mechanism (consent needed for adults; children always referred).
• Prevent - part of the counter-terrorism strategy; concerns about radicalisation are discussed with the safeguarding lead and referred to Channel.

Capacity, Consent and Best Interests

• Mental Capacity Act 2005 - five principles: presume capacity; support decision-making; unwise decisions do not mean lack of capacity; best interests; least restrictive option.
• Two-stage test: is there an impairment of, or disturbance in, the functioning of the mind or brain? Does it mean the person cannot make this specific decision now - unable to understand, retain, use/weigh the information, or communicate the decision?
• Best interests - consider the person's past and present wishes, beliefs and values, consult family/carers and any attorney; an IMCA if no one appropriate to consult for serious decisions.
• Lasting power of attorney (health and welfare; property and financial), advance decisions to refuse treatment (must be written, signed and witnessed if refusing life-sustaining treatment), deputies appointed by the Court of Protection.
• Deprivation of liberty - DoLS (care homes, hospitals) and the Court of Protection elsewhere; Liberty Protection Safeguards have been delayed.
• Children: Gillick competence (under 16 can consent if sufficiently mature to understand); 16–17-year-olds are presumed to have capacity to consent (Family Law Reform Act), but refusal of life-saving treatment may be overridden by the court.

The Mental Health Act in Primary Care

• Section 2 - assessment, up to 28 days (two doctors - one section 12 approved - and an AMHP).
• Section 3 - treatment, up to 6 months, renewable.
• Section 4 - emergency, 72 hours, one doctor (when waiting for a second would cause undesirable delay).
• Section 135 - warrant for police to enter premises and remove a person to a place of safety; Section 136 - police remove a person from a public place to a place of safety (up to 24 hours).
• Section 5(2) - doctor's holding power for a hospital inpatient (72 hours); 5(4) - nurse's holding power (6 hours).
• The GP is often the doctor who knows the patient (the second, non-section-12 doctor) in a section 2 or 3 assessment. Reforms to the Mental Health Act are being introduced in stages - check current practice.

Confidentiality and Information Sharing

• GMC Confidentiality (2017): disclosure is justified with consent, when required by law (e.g. notifiable diseases, court order, FGM in girls, terrorism information, DVLA in some circumstances, Road Traffic Act on police request for driver identity), or in the public interest (risk of death or serious harm, serious crime).
• Caldicott principles - justify the purpose, use only when necessary, minimum necessary, need-to-know access, everyone understands their responsibilities, comply with the law, the duty to share information can be as important as the duty to protect confidentiality, inform patients about how their information is used.
• After death - confidentiality continues; access to records of the deceased under the Access to Health Records Act 1990 (personal representatives and those with a claim).
• Subject access requests (UK GDPR) - respond within 1 month, normally free; third-party and seriously harmful information can be withheld.

Fit Notes and Fitness to Work

• Self-certification for the first 7 calendar days of sickness (SC2 form for employers).
• Fit note (Statement of Fitness for Work) after 7 days: "not fit for work" or "may be fit for work" with advice on phased return, altered hours, amended duties or workplace adaptations. The latter is encouraged - good work is generally good for health.
• Since July 2022, fit notes can be issued by doctors, nurses, pharmacists, occupational therapists and physiotherapists; they can be signed digitally.
• Fit notes are issued for up to 3 months in the first 6 months of a condition.
• Occupational health referral and the employer's duty to make reasonable adjustments (Equality Act 2010).

Fitness to Drive (DVLA)

• The licence holder is legally responsible for informing the DVLA of a relevant condition; the doctor must advise them to do so and record the advice.
• GMC guidance: if a patient continues to drive when not fit and cannot be persuaded to stop, the doctor should tell the patient they are going to inform the DVLA, and then do so promptly (disclosure in the public interest).
• Selected Group 1 (car) rules - check the current "Assessing fitness to drive" guide:

Condition	Group 1 car licence (summary)
First unprovoked seizure	6 months off driving if no relevant abnormality on imaging and EEG (12 months if there is)
Epilepsy	12 months seizure-free (or seizures only in sleep / without loss of consciousness, under specific rules)
TIA or single stroke	1 month off driving; may resume if no residual deficit (DVLA need not be told unless deficits persist after 1 month)
ACS treated with successful PCI	1 week off if LVEF ≥40% and no other disqualifying condition; otherwise 4 weeks
CABG	4 weeks
Pacemaker	1 week
ICD for ventricular arrhythmia	6 months after implantation (secondary prevention)
Insulin-treated diabetes	Must meet hypoglycaemia awareness and glucose monitoring requirements; no more than one episode of severe hypoglycaemia (needing another person's help) while awake in 12 months
Visual acuity	Must read a number plate at 20 m; acuity at least 6/12 (Snellen) with both eyes, with glasses if needed; adequate visual field
Alcohol dependence	Licence revoked for at least 1 year after detox, with abstinence

• Group 2 (lorry/bus) standards are stricter (e.g. 5 years seizure-free off medication).

Death Verification and Certification

• Verification of death (confirming death has occurred) can be performed by a doctor or trained registered nurse/paramedic; record findings and time.
• Medical Certificate of Cause of Death (MCCD): since 9 September 2024 in England and Wales, any registered medical practitioner who attended the deceased during their lifetime may complete the MCCD (the previous 28-day rule no longer limits who can certify).
• Medical examiners independently scrutinise all deaths not referred to the coroner, review the records, speak to the bereaved, and then the MCCD goes to the registrar.
• Refer to the coroner if the cause of death is unknown; the death was violent or unnatural (accident, suicide, homicide, poisoning, neglect, industrial disease); the death occurred in custody or state detention (including detention under the Mental Health Act - deaths under a DoLS authorisation have not been automatically referred since 2017); the death was related to medical treatment or surgery; or there is no attending practitioner able to certify.
• Cremation forms are now part of the medical examiner process for non-coroner deaths.
• Expected deaths at home - plan ahead (ReSPECT/DNACPR form, anticipatory medicines, informing out-of-hours services) so that families are not left without support.

End-of-life Care in the Community

• Identify people in the last year of life (e.g. the "surprise question", SPICT tool) and add to the palliative care register; regular Gold Standards Framework meetings.
• Advance care planning - preferred place of care and death, ReSPECT form, LPA, advance decision to refuse treatment.
• Anticipatory ("just in case") medicines for the last days: for pain/breathlessness (e.g. subcutaneous morphine or oxycodone), nausea (levomepromazine, haloperidol or cyclizine), agitation (midazolam), respiratory secretions (hyoscine butylbromide or glycopyrronium) - with a community authorisation chart.
• Syringe drivers for continuous subcutaneous infusion when oral route is lost.
• Carers' support - carer's assessment (Care Act), respite, bereavement support; Fast Track Continuing Healthcare funding for people rapidly deteriorating towards end of life.
• Special Rules for End of Life - faster benefit claims when life expectancy is 12 months or less (SR1 form).

At a Glance

Topic	Remember
Depression (NG222)	Less vs more severe (PHQ-9 16); review antidepressant at 2–4 weeks (1 week if under 25)
Suicide risk	Ask directly; safety plan; NICE: no risk-prediction scales
Child safeguarding	Bruise in non-mobile baby; under 13 sexual activity; refer same day
FGM	Mandatory police report for girls under 18
MCA	Presume capacity; decision-specific; understand, retain, weigh, communicate
Fit note	After 7 days; "may be fit" option; many professions can issue
DVLA	Patient's duty to tell; doctor may disclose after informing patient
MCCD	Any doctor who attended in life (since Sept 2024); medical examiner scrutiny

Spot the Answer

• A 16-year-old tells you she was cut as a child in Somalia; she is now in the UK. → Mandatory report to police (101) - known FGM in a girl under 18.
• A man with epilepsy had a seizure 2 months ago and is still driving despite advice. → Tell him you will inform the DVLA, then do so; document.
• An 87-year-old with dementia refuses admission for pneumonia. → Assess capacity for this decision; if lacking, decide in best interests with family and any LPA.
• A patient asks for a fit note on day 4 of gastroenteritis. → Self-certification covers the first 7 days.
• Death in a care home of a resident subject to a DoLS authorisation. → No longer automatically a coroner referral (since 2017 changes) - certify if cause known and natural, with medical examiner review.

Exam-style Scenarios

• Scenario. A woman attends with bruises she says are from a fall. Her partner answers questions for her. You see her alone and she discloses repeated assaults; she has two young children.
  Answer: Thank her, acknowledge, assess immediate safety and the children's safety, complete a DASH risk assessment, offer IDVA and specialist support, document carefully. A high DASH score warrants MARAC referral, and the children's exposure to domestic abuse needs discussion with the safeguarding lead and a children's social care referral.
• Scenario. A 23-year-old with depression started sertraline 10 days ago and now reports suicidal thoughts without a plan.
  Answer: This is a known risk in under-25s early in treatment. Review urgently, explore intent, plans, protective factors and means, make a collaborative safety plan, consider limiting supply, involve family if consented, arrange follow-up within days and refer to the crisis team if risk escalates.
• Scenario. A daughter asks you not to tell her father, who has capacity, that his scan shows metastatic cancer.
  Answer: The father has the right to information about his health; explore the daughter's concerns, explain your duty, and ask the patient how much he wants to know and who he wants involved. Information can be withheld only if sharing would cause serious harm (not simply upset).

Key Points

• Ask directly about suicidal thoughts and make a safety plan - do not rely on risk scores.
• Safeguarding concerns must be acted on the same day; document facts and the patient's words.
• FGM in girls under 18 must be reported to the police.
• Capacity is decision-specific and presumed until shown otherwise.
• Confidentiality can be breached in the public interest - DVLA and serious harm are classic examples.
• Know the 2024 death certification changes and coroner referral criteria.

Guidelines and Further Reading

• NICE NG222: Depression in adults; NICE CG113: Generalised anxiety disorder and panic disorder; NICE NG225: Self-harm
• NICE CG100: Alcohol-use disorders - physical complications; NICE CG115: Alcohol-use disorders - harmful drinking and alcohol dependence
• HM Government: Working Together to Safeguard Children (2023); Care Act 2014 statutory guidance
• Home Office: Mandatory reporting of FGM - procedural information
• Mental Capacity Act 2005 Code of Practice; Mental Health Act 1983 Code of Practice
• GMC: Confidentiality - good practice in handling patient information; Protecting children and young people
• DVLA: Assessing fitness to drive - a guide for medical professionals (check the current edition)
• DHSC: Death certification reforms (September 2024); National Medical Examiner guidance
• DWP: Getting the most out of the fit note - guidance for healthcare professionals