Emergency mental-health assessment and disposition — formative SAQs

SAQ 1 — Structured risk assessment and disposition (10 marks)

A 15-year-old girl is brought to the emergency department by her mother after taking twelve paracetamol tablets two hours ago. She is alert and haemodynamically stable. She says her boyfriend ended their relationship that day and she 'wanted it to stop'. There are more paracetamol tablets at home. She has a history of one previous overdose six months ago and is not currently engaged with any mental-health service. [4] [6]

Questions

1. Outline the rapid safety and medical screen and the structured risk assessment you would perform, naming a validated screening instrument and the elements you would synthesise into a risk stratum. (6 marks) [1]
2. Justify the most likely disposition for this young woman and the components of the safety-net you would put in place before she leaves the department or is admitted. (4 marks) [5]

Model answer

Screen and structured assessment (6). I would first perform a rapid medical screen — vital signs, a capillary glucose, a focused examination, and a paracetamol level at the appropriate interval with treatment per the poisoning protocol — because an ingestion is a medical event as well as a psychiatric one, and I would treat any medical consequence before the psychiatric disposition. I would place her in a safe, ligature-aware, low-stimulus room at an observation level matched to the apparent risk. I would then perform the structured risk assessment: a focused risk history (the method, the intent, the expectation of death, the planning, the access to means, the precipitant, the prior history, the substance use, and an abuse and bullying screen), a mental state examination looking for hopelessness, a sense of being a burden and active intent, and a validated brief screen — the Ask Suicide-Screening Questions, a four-question instrument validated in the paediatric emergency department — supported where available by the computerised adaptive CASSY. I would take collateral from her mother on the baseline, the recent change and whether this presentation is a departure, and I would weigh the protective factors. I would then synthesise the history, the mental state, the screen, the collateral and the protective factors into a working risk stratum — not a single score — because the stratum, not the tool result, drives the level of care. [1] [2] [4]

Disposition and safety-net (4). This young woman has active intent, access to means (further tablets at home), an acute precipitant and a prior attempt, placing her at least at moderate-to-high risk; her disposition is therefore not a simple discharge but a higher level of care — most likely a brief admission or a crisis/home-treatment team providing daily contact, with inpatient psychiatry and consideration of involuntary status under local mental-health statute if the risk is judged high and she lacks capacity or refuses. Before any disposition I would build a collaborative safety plan covering warning signs, internal coping, social distraction, social support, professional contacts and means restriction; I would counsel the family to remove or secure the access to further paracetamol at home, because the acute state is time-limited and means-dependent; I would give her and her mother a crisis number; and I would confirm a follow-up contact within 24 to 72 hours, because the period immediately after a self-harm attendance carries the highest repeat risk. [7] [5]

SAQ 2 — Organic exclusion, intoxication and capacity (10 marks)

A 14-year-old boy is brought in acutely agitated and confused after attending a party where alcohol and an unknown substance were available. He fluctuates between drowsiness and agitation, his speech is slurred, and he cannot reliably describe what he took. His friends report he said he 'wanted to die' before the party. [4] [6]

Questions

1. Describe your immediate assessment and management, including how intoxication changes your approach to the risk assessment. (6 marks) [4]
2. Discuss how you would assess his capacity and approach a disposition decision if he later refuses admission once sober, citing the principle that governs involuntary care. (4 marks) [6]

Model answer

Immediate assessment and the effect of intoxication (6). I would treat this as a combined medical and psychiatric emergency and run the two phases in parallel. Medically, I would secure the airway, breathing and circulation, check observations and a capillary glucose, run a poisoning protocol including a paracetamol and salicylate level and a venous blood gas, consider an ECG for arrhythmogenic substances, and monitor his conscious level closely because intoxication can both destabilise him and mask a deteriorating medical or neurological state; I would also consider delirium, head injury and hypoglycaemia as drivers of the confusion and agitation and exclude them. I would place him in a safe, low-stimulus, observed environment and escalate to the agitated-child de-escalation pathway if behaviour escalates. Critically, because he is intoxicated I would treat any risk assessment I can perform now as provisional: intoxication invalidates a definitive assessment of intent, capacity and protective factors, so I would observe him in a safe place and repeat the structured risk assessment as he sobers, recognising that the picture may change substantially as the substance clears. [4] [6]

Capacity and disposition (4). Capacity is decision-specific and time-specific, and I would assess it formally once he is sober and able to engage: I would test whether he can understand, retain, use and weigh the information about the proposed admission and its alternatives, and communicate his decision. If he has capacity but the risk is high and unmanageable in the community, his refusal does not end the matter — the question of involuntary assessment or treatment is governed by the local mental-health statute, and I would involve the mental-health team and apply that statute rather than relying on parental consent alone or a single age threshold. If he lacks capacity — for example through ongoing psychosis or severe disturbance — I would act in his best interests, again under the relevant capacity or mental-health law, sharing the minimum necessary and keeping him and his family informed. I would document the capacity assessment, the risk synthesis, and the statutory basis for any involuntary action, and I would ensure the safety plan, means restriction and a confirmed follow-up contact are in place whatever the disposition. [6] [5]