Case study A woman who had a dementia was admitted to a medical ward in a rural general hospital as an ‘informal’ patient. The circumstances of her admission meant that she was heavily sedated on arrival. For a 52-hour period after admission, she was actively trying to leave and was prevented from doing so by use of restraint and heavy sedation. She was then transferred to a psychiatric ward. Her welfare attorney had been consulted over her stay in hospital. The doctor treating her had taken this as a legal authority and had not considered detention under the Mental Health Act. He had not obtained the attorney’s permission to use sedation. This person was effectively being de facto detained against her will. Staff had poor understanding of relevant legislation and poor support in providing care for confused individuals. The NPM member made recommendations for better training and support for staff and Government action to ensure better dementia care in remote hospitals. Through this review of member actions, we were able to identify the responses currently provided by NPM members when they identify cases of de facto detention. Recommendations for policy and training accounted for 13 of the 33 recommendations. Assessment of capacity 30 and ensuring that individuals know their rights also featured strongly. It is of note that when making recommendations about the level of restriction of liberty, member organisations were more likely to focus on the necessity for restriction than its legality. This reflects the principle of least restriction of freedom that runs through most of the recent UK legislation on mental health and incapacity law. The evidence generated in this review has helped the NPM identify the type of practices constituting de facto detention, as well as the actions currently taken when cases are identified. As a result, the NPM has decided to continue looking into the issue, and will provide a further update to this work in its next annual report. International collaboration Many requests were received from international counterparts interested in the UK’s multi-body NPM as well as the functions of its individual members. The NPM coordination has played a role in ensuring that these requests can, as far as possible, be honoured, as well as linking up the requests with appropriate NPM members. In turn, hosting international delegations in the UK or participating in visits abroad have helped NPM members develop their expertise and understanding of OPCAT issues beyond their current remit. In April 2012, MWCS participated in a roundtable discussion with a delegation from the Norwegian government, advising on the use of mental health consultation by remote video link, especially in relation to decisions on involuntary treatment.