Section 4 of the Mental Health Act: emergency admission

What is section 4?

Section 4 is an emergency application for admission for assessment, founded on one medical recommendation instead of two (s4(1), (3)). It's for urgent necessity, when waiting for a second doctor would cause undesirable delay. It holds the patient for up to 72 hours.

Think of it as the start of a s2. When a valid second recommendation arrives in time, the patient is treated as admitted on an ordinary s2. The Act doesn't call that conversion, though it's often called that (Reference Guide 8.52).

Section 4 criteria

All three must apply (Code 15.2):

• The s2 criteria are met.
• Urgent necessity. The patient needs to be admitted and detained as a matter of urgency.
• Undesirable delay. Getting a second recommendation would involve undesirable delay. The application must say so, and the doctor must verify it (s4(2), (3)).

The Code expects evidence of an immediate and significant risk of mental or physical harm to the patient or others (Code 15.8). A danger of serious harm to property, or a need for restrictive interventions, also counts. It should never be used for administrative convenience (Code 15.7).

How to make a section 4 application

1. An AMHP applies on Form A10, or the nearest relative on A9. The applicant must have seen the patient personally within the previous 24 hours (s4(5), Code 15.3).
2. One doctor examines the patient and recommends on A11. They needn't be s12 approved, but should know the patient if practicable (s4(3)).
3. The AMHP should tell the nearest relative at the same time or soon after (Code 15.4).
4. The patient must be admitted within 24 hours of the doctor's examination or the application, whichever was earlier (s6(1)(b)).
5. The hospital records the admission on Part 1 of Form H3, and the second recommendation's arrival on Part 2 (reg 4(4), (5)).

Everything else about the assessment is as for s2, except that there's one doctor (Code 15.5). See making an application.

How long does section 4 last?

Up to 72 hours from admission. If the patient was already in hospital, the 72 hours run from when the application reaches the managers (Reference Guide 8.51).

If the managers receive a second recommendation within the 72 hours, and the two together meet the s12 rules, the patient is treated as admitted under section 2. The 28 days count from the original admission, not from the end of the 72 hours (s4(4), Reference Guide 8.52). If the first doctor wasn't s12 approved, the second must be (Code 15.13).

If no second recommendation arrives, the authority to detain ends, and they must be allowed to leave if they want to (Reference Guide 8.53).

Can you treat someone on section 4?

Not under the Act. Part 4's power to treat without consent doesn't apply until the second recommendation is received (s56(3)(a)). Until then, a patient with capacity is in the same position as an informal patient and can refuse treatment (Code 15.14).

If they lack capacity, treatment may be given under the MCA if it's in their best interests and within its scope (Code 15.14). That's one more reason to get the second doctor in fast. More on consent to treatment under Part 4.

Rights on section 4

• Information. The managers must take practicable steps to help them understand the section, its effect and their tribunal rights, orally and in writing (s132).
• The tribunal. A s4 patient can apply, as a s2 patient can (s66(1)(a), Reference Guide figure 14).
• No IMHA yet. They don't qualify for an IMHA until the second recommendation arrives (s130C(2)(a), Code 6.9).
• Discharge. The RC, the hospital managers or the nearest relative can discharge them (s23).
• Absconding. If they go missing, they can't be retaken once the 72 hours have passed (s18(5)).

Section 4 vs section 5(2)

A nurse's holding power under s5(4) lasts up to 6 hours, for an inpatient already being treated for mental disorder. More on holding powers.

Section 4 isn't Part 4, or section 4 of the MCA

• Part 4 of the MHA (ss56 to 64) covers consent to treatment. Its power to treat without consent doesn't apply to a s4 patient until the second recommendation arrives, though s57 and, for under-18s, s58A always do.
• Section 5(4) of the MHA is a nurse's holding power, for up to 6 hours.
• Section 4 of the MCA sets out how to decide what's in the best interests of someone who lacks capacity. See best interests.
• Section 42 of the MHA gives the Secretary of State powers over restricted patients. See restricted patients.

Common mistakes with section 4

• Using it for convenience. For example, because the second doctor would rather examine in hospital than at home (Code 15.7).
• A slow second doctor. The second examination should happen as soon as possible after admission (Code 15.13).
• Moving straight to s3. You can apply for s3 during a s4, but it needs two new recommendations (Code 15.15).
• Ignoring a CTO. If they're known to be on a CTO, recall them instead of making an application (Code 15.17).
• Fixing errors too late. A faulty s4 can't be corrected after the 72 hours unless the second recommendation has arrived (s15(4), Reference Guide 31.25).

If you're using s4 because no second doctor could be found, the AMHP should report it to the local authority. Hospital managers and councils should monitor how s4 is used (Code 15.10, 15.11).

A worked example

Section 4 fits. There's an immediate and significant risk, and waiting would mean undesirable delay (Code 15.8). The AMHP applies on A10 with the GP's A11, and she must reach hospital within 24 hours. The second recommendation must come from a s12 doctor, as soon as possible (Code 15.13). If it's received within 72 hours, she's on a s2 counted from her admission.