Set aside the decision to detain DND for assessment with recommendations made to the Secretary of the Department of Health and the Chief Psychiatrist as to provision of educational training and resources to medical practitioners, approved medical practitioners, and legal order co-ordinators as per the Tribunal's order.

The urgent circumstances treatment on 21 December 2025 was invalid.

Protective Division - Mental Health Stream - application for treatment order - treatment criteria met - recommendations for provision of education, training and resources made - Treatment order made for 6 months

Review of Detaining for Assessment - decision to detain for assessment set aside - patient detailed without authority - patient treated without authority recommendations made for provision of education, training and resources

Review of Urgent Circumstances Treatment - failure to properly complete form - failure to comply with statutory requirements - urgent circumstances treatment invalid - no authority to administer medications

Mental Health Act 2013, ss 4, 6, 7, 12, 15, 15A, 17, 19, 32, 37, 39, 40, 53, 55, 179, 186, 193, 194, Sch 1 and Sch 4;

Tasmania Civil and Administrative Act 2020, s 10.

B v Mental Health Tribunal [2020] TASSC 10);

CMB v Mental Health Tribunal [2021] TASFC 4;

Re IC, AN and LZ (Review of Assessment Orders) [2024] TASCAT 30;

SBC (Review of Assessment Order) [2024] TASCAT 53;

EDT v State of Tasmania (Review Proceedings - Own Motion) [2024] TASCAT 190.

The decision has been anonymised for the purpose of publication.

1. DND is a 47-year-old female living in Tasmania with an extensive and complex history of mental illness. DND has diagnoses of severe borderline personality disorder and major depressive disorder, on a background of 'significant developmental trauma' and comorbid borderline low IQ. DND has a history of multiple admissions to hospital as an adolescent and adult, with serious suicide attempts and 'parasuicidal behaviour'. Since 2022, she has been subject to numerous orders under the Mental Health Act 2013 (the Act) authorising treatment of mental illness. In 2025, DND had 13 admissions to approved facilities.
2. On 24 December 2025, the Tribunal received an application for the making of a treatment order for DND pursuant to s 37(3) of the Act by Dr KLL dated 22 December 2025 (the application). In addition to the application the Tribunal received copies of:
   1. Detaining for Assessment made by Dr TC on 19 December 2025 at 16:00.
   2. Urgent Circumstances Treatment authorised by Dr BD on 21 December 2025 at 16:00 (UCT).
   3. Assessment Order made by Dr BD on 21 December 2025 at 16:00 and part B Affirmation of Assessment Order made by Dr KLL made 22 December 2025 at 09:50 with an expiration date of 25 December 2025 at 09:50.
   4. Complex Care Panel Meeting.
   5. Order appointing guardian for DND for decisions relating to where she lives and provision of care services.
3. In the application, Dr KLL sought the making of an interim treatment order prior to the hearing of the application for treatment order. On 24 December 2025 at 2:02pm, Senior Member Chaperon made an interim treatment order. That interim treatment order was to expire on 3 January 2025. The terms of the interim treatment order were:

This Treatment Order: > > (A) is authority for the patient to be admitted to and if necessary detained in an approved facility for the purposes of receiving treatment; > > (B) authorises a combination of treatment settings and the admission or readmission of the patient to those settings, including treatment in the community; and > > (C) authorises the following:

4. The patient is to take the following medication (depending on clinical indication):

1. Antipsychotic medication 2. Mood stabiliser medication 3. Antidepressant medication

Medications may be administered orally and/or by intra-muscular injection and/or by depot injection as prescribed by a treating psychiatrist within clinical guidelines, with dosages adjusted according to clinical response and tolerability.

5. Standard medical and/or blood, and/or urine tests and/or diagnostic radiological and medical imaging tests, as clinically indicated and as directed by the treating team.
6. Adult Community Mental Health Service (ACMHS) appointments (inclusive of home visits as arranged when being treated in the community).
7. In addition to the making of an interim treatment order [3] Senior Member Chaperon identified issues of concern relating to the UCT and the detaining for assessment. Consequently, The Tribunal sought to review those matters pursuant to ss 179(3)(b), 186 and 194 of the Act.
8. On 30 December 2025, the following matters came before a 3-member panel of the Tribunal for determination:

(a) Application for treatment order.

(b) Review of UCT; and

(c) Review of detaining for assessment.

1. At the hearing DND continued to be an inpatient at an approved facility. She attended the hearing together with Dr BD, Dr KLL, Dr OJ, SG and TX (ward sitter). Since 5 December 2025, DND had been an inpatient at an approved facility.
2. In making its determinations, we considered the entirety of the evidence before us. As we delivered our determination, DND left the hearing.
3. On 30 December 2025 at 10.58am, we made a treatment order for a period of 6 months with an expiry of 26 June 2026 at 10:58am. We were satisfied that it was appropriate to make recommendations regarding education, training and resources. The terms of the treatment order being:

This Treatment Order: > > (A) is authority for the patient to be admitted to and if necessary detained in an approved facility for the purposes of receiving treatment; > > (B) authorises a combination of treatment settings and the admission or readmission of the patient to those settings, including treatment in the community; and > > (C) authorises the following:

4. The patient is to take the following medication (depending on clinical indication):
   1. Antipsychotic medication
   2. Mood stabiliser medication
   3. Antidepressant medication
5. Medications may be administered orally and/or by intra-muscular injection and/or by depot injection as prescribed by a treating psychiatrist within clinical guidelines, with dosages adjusted according to clinical response and tolerability.
6. Standard medical and/or blood, and/or urine tests and/or diagnostic radiological and medical imaging tests, as clinically indicated and as directed by the treating team.
7. Adult Community Mental Health Service (ACMHS) appointments (inclusive of home visits as arranged when being treated in the community).

We makes [sic] the following recommendations pursuant to s 194(e) of the Mental Health Act 2013: > > 1. By the authority provided to the Tribunal pursuant to s 194(e) of the Mental Health Act 2013 (the Act) we recommend that educational training and resources as to the requirements for the making of a detaining for assessment, valid assessment order, valid urgent circumstances treatment, and applications for treatment orders is provided at the earliest opportunity to: > > a. Medical practitioners employed by the Tasmanian Health Service who may be required to make assessment orders and applications treatment orders, and consideration of when to use a detaining for assessment noting the 4-hour prescribed time limit; > > b. Approved medical practitioners; and > > c. Legal order co-ordinators. > > 2. Such educational training and resources should emphasise the requirements of the Act including: > > a. That prescribed time limits are strictly adhered to and the need for accuracy and completeness of prescribed documents. > > b. When and what treatment is authorised for a patient and pursuant to what legal authority. > > 3. These recommendations are directed to the following parties to the proceedings: > > a. The Secretary of the Department of Health (in capacity as both Secretary (cl 1(g) of Pt 1 in Sch 4 of the Act) and the controlling authority of the facility in which DND is accommodated (cl 1(e) of Pt 1 in Sch 4 of the Act); and > > b. The Chief Psychiatrist.

8. On 30 December 2025, we found that it was not appropriate for Dr TC to rely on s 17 to temporarily detain DND for assessment because she was already detained at an approved facility and had been for at least 14 days. In the circumstances it was not the appropriate legislative pathway to provide authority for assessment under the Act. We set aside the decision to detain DND for assessment, and issued recommendations concerning education, training and resourcing.
9. On 30 December 2025, in reviewing the UCT we found that Dr BD failed to properly complete the UCT form, that the statutory requirements of s 55 had not been complied with, and the UCT of 21 December 2025 was invalid. Consequently, the Tribunal found there was no authority for medications to be administered to DND on 21 December 2025.
10. These are our reasons for decision regarding the findings relating to the making of a treatment order for DND and review of UCT.

1. Section 39 sets out the Tribunal's authority to make a treatment order, which may be exercised only when all statutory prerequisites have been satisfied. This includes an application by an approved medical practitioner, compliance with s 37, confirmation that the person meets the treatment criteria, and the preparation of a treatment plan that meets the s 53 requirements.
2. Accordingly, we needed to be satisfied DND met the treatment criteria provided under s 40 which provides:

40. Treatment criteria > > The treatment criteria in relation to a person are - > > (a) the person has a mental illness; and > > (b) without treatment, the mental illness will, or is likely to, seriously harm - > > (i) the person's health or safety; or > > (ii) the safety of other persons; and > > (c) the treatment will be appropriate and effective in terms of the outcomes referred to in section 6(1); and > > (d) the treatment cannot be adequately given except under a treatment order; and > > (e) the person does not have decision-making capacity.

3. In deciding whether to exercise jurisdiction to issue a treatment order under s 39, well considered and applied the s 12 objectives.
4. We had regard to DND's rights as a patient receiving assessment and treatment under the Act as outlined in s 15A. DND has the right to dignity, minimal restriction, respect for her decision‑making, and clear information about her rights, diagnosis and treatment. Furthermore, DND's rights in an approved facility, including appropriate detention conditions, access to information, communication, legal advice, health care, religious practice, adequate living conditions, and reasonable assistance to exercise the rights.
5. In exercising our responsibilities under the Act, we had regard to the mental health service delivery principles set out in Schedule 1 of the Act (s 15: see _B v Mental Health Tribuna_l [2020] TASSC 10 at [39] and CMB v Mental Health Tribunal [2021] TASFC 4 at [31]).
6. We had regard to and observed the main objectives of the Tribunal as outlined in s 10 of the Tasmanian Civil and Administrative Tribunal Act 2020 (TASCAT Act).
7. Section 55 of the Act sets out the requirements for the authorisation of UCT. It requires that:

...an involuntary patient may only be given treatment (urgent circumstances treatment) without informed consent or Tribunal authorisation if an approved medical practitioner authorises the treatment as being urgently needed in respect of the patient'.

...(2): - An approved medical practitioner may only authorise urgent circumstances treatment in respect of a patient if the approved medical practitioner is satisfied, as a result of an assessment of the patient, that -

(b) waiting for the treatment to be authorised by the Tribunal (or by a member thereof on an interim basis) would compromise -

(i) the outcomes of the treatment, as specified in section 6(1) , for the patient; or

(ii) the effectiveness of the treatment, for the patient, in meeting the outcomes of treatment as specified in section 6(1) .

1. Section 186 empowers the Tribunal to review UCT, even after the treatment has ceased, and to make a range of recommendations or decisions, including seeking further information, setting aside authorisations, or recommending reassessment.
2. The power for the Tribunal to review DND's detaining for assessment is found in s 194. It provides

The following provisions govern the conduct of any review:

(a) the Tribunal may combine a mandatory review with a discretionary review;

(b) [Section 194 Amended by No. 4 of 2023, s. 158, Applied:25 Sep 2023] the Tribunal may refer any matter concerning the review to the Chief Psychiatrist for possible intervention;

(c) the Tribunal, in making a determination, may issue any related or incidental directions it considers appropriate and, without limiting this, may -

(i) [Section 194 Amended by No. 4 of 2023, s. 158, Applied:25 Sep 2023] direct that the patient be examined, assessed or given specified health care; and

(ii) direct a specified person to provide the Tribunal or another person with a specified report at or by a specified time; and

(iii) direct that a specified action be taken or not taken in respect of the patient; and

(iv) give directions to ensure and monitor compliance with its determination; and

(v) direct that the patient or another person be given a statement of rights;

(d) the Tribunal may give a copy of its determination to any health professional or other person who, to its knowledge, is directly involved with the patient's treatment or care;

(e) the Tribunal may issue such recommendations to such persons as it considers appropriate.

Evidence and findings - application for treatment order and the treatment criteria

1. At the hearing DND did not dispute the evidence of the treating team and was content with the making of a treatment order. We were grateful to DND for attending the hearing and outlining her views.
2. We found that DND has a long history of chronic and complex mental illness within the meaning of the Act (ss 4, 40(a)). She has diagnoses of borderline personality disorder characterised by impulsivity, 'emotional dysregulation, and chronic suicidal ideation' and major depressive disorder marked by 'severe low mood, hopelessness, negative self-esteem, irritability'. At the hearing the treating team stated that DND's mental state was also characterised by 'schizophrenic type elements'.
3. We were satisfied that without treatment DND's mental illness was likely to seriously harm her health, safety and or the safety of other persons (s 40(b) and B v Mental Health Tribunal). We were satisfied that DND has a chronic and complex psychiatric history which has involved many instances of deterioration in her mental state and that amounts to serious harm. We accepted the evidence of the treating team that DND was impulsive, has difficulties with emotional regulation and 'most of the time' responds to stress or distress through 'acting out in self-harming behaviours rather than verbalising her emotions'. DND was at 'high risk of self-harm, suicide and misadventure' and loss of NDIS supports in the community. DND's self-harming has required 'surgical intervention and ICU admission due to the severity of the behaviour' and injuries. DND had suffered chronic physical injuries due to self-harming. We accepted the high lethality of those instances. DND's support workers had withdrawn their services due to safety concerns with DND and support workers arising from her behaviours. DND demonstrated a lack appreciation of the severity of the risks to her health and safety reflected by her strong desire to go home and be discharged.
4. The treatment for DND was appropriate and effective in terms of the outcomes referred to in s 6(1) and pursuant to s 40(c). The treating team detailed the treatment given to DND as an inpatient in an approved facility and anticipated upon discharge treatment in the community. The application detailed administration of regular medications including antipsychotics, mood stabilisers, antidepressants and benzodiazepines. Psychological and supportive therapy together with dialectical behaviour therapy was proposed to assist with emotional dysregulation and distress tolerance. Containment in an inpatient setting was essential together with safe discharge planning. The treatment proposed was evidence-based treatment for the nature and symptoms of DND's mental illness. It was anticipated under treatment her symptoms would improve and her management of her distress.
5. We found that the treatment could not be adequately given except under a treatment order. The application stated that DND 'strongly opposed any psychiatric treatments'. At the hearing the treating team stated DND did not dispute the treatment provided and proposed, however contrary to advice DND wished to be discharged and return home. The treating team had informed DND that there would need to be a complex care meeting with all stakeholders to ensure that her discharge was 'safe' and 'build on' the confidence of support workers 'to manage' DND in the community. We accepted the nature and severity of the risks as identified by the treating team. We were satisfied that DND did not have decision-making capacity (see below) and therefore could not voluntarily consent to treatment. Accordingly, we were satisfied s 40(d) treatment criterion was met.
6. We found that DND did not have decision-making capacity about her own assessment or treatment due to an impairment or disturbance in the functioning of the mind or brain (ss 7, 40(e)). We accepted the opinion of Dr BD that 'the amalgamation of all the various' mental health disorders DND has cause a 'continuous degree' of impairment of cognition.
7. We accepted that prior to the hearing DND had 'strongly rejected her psychiatric illness' and opposed all recommended treatments. Dr BD stated that DND does not have an understanding of her mental illness and had a 'constant' profound lack of insight as to the severity of the risks. We acknowledged that at the hearing DND was more accepting of treatment however if it was her decision despite the chronic risks she would discharge from hospital and return home. Dr OJ described DND as having 'fluctuations' in her decision-making ability, with the range of fluctuation being either 'extremely short' or lengthy in duration and was difficult to predict. Dr BD opined that even at 'baseline' there were 'doubts' about DND's decision-making capacity and there were doubts about a 'reliable baseline'. DND had a 'very high degree of unpredictability'. DND's difficulty with emotional regulation and impulsivity impair and hinder her decision-making capacity. We found that DND was unable to understand, use or weigh information relevant to the decision because she fluctuated in her recognition that she has a mental illness, was unable to comprehend the need for inpatient treatment and evidence-based treatment, and safe discharge planning. She was unable to recognise the benefits from psychiatric treatment. She was unable to weigh up the benefits and or risks of treatment or no treatment. DND continued to be accompanied by a sitter due to high degree of unpredictability and the risks of self-harm.
8. During the hearing DND's answers to questions reflected a profound lack of understanding of the nature of her mental illness, how it was characterised and the severity of the risks to herself and others. We considered that DND's low IQ may also limit her ability to understand, use, or weigh information relevant to the decision.
9. In making its decision we found the expert evidence presented by the treating team persuasive and compelling. We were satisfied the evidence addressed all the treatment criteria. The Tribunal was satisfied that the s 40 treatment criteria was met and made a treatment order in respect of DND.

Evidence and findings on review of detaining for assessment

1. On 19 December 2025, Senior Member Winter of the Tribunal dismissed an application for treatment order for DND because the assessment order was invalid. That invalid assessment order was made on 17 December 2025 at 15:05, affirmed on 17 December 2025 at 15:30 and was to expire on 20 December 2025 at 15:29. The clinician who affirmed the assessment order omitted to write their name on the assessment order. Consequently, Senior Member Winter found the assessment order failed to comply with the statutory requirements and deemed the assessment order of 17 December 2025 invalid, ultimately finding DND had been a voluntary patient since 17 December 2025 at 3:30pm.
2. The detaining for assessment for DND of 19 December 2025 was completed by Dr TC after the approved facility was informed by the Tribunal that the assessment order of 17 December 2025 was invalid and the application for treatment order was dismissed.
3. At the hearing Dr BD stated:
   1. That Dr TC was a locum clinician who had returned to the mainland and therefore was not available to give evidence.
   2. He had tried to 'piece together' the events around the making of the detaining for assessment of 19 December 2025.
   3. On 19 December 2025, DND was already an inpatient at the approved facility.
   4. It was not until nearly 2 days later, on 21 December 2025 the issue was brought to Dr BD's attention as 'on call' psychiatrist at the approved facility. On 21 December 2025, he assessed DND following which he made an assessment order and UCT at 16:00.
   5. He had recently become aware that there was another assessment order that had been made for 48 hours as opposed to 72 hours, which may not have been provided to the Tribunal. The Tribunal did not have the assessment order to which Dr BD referred. He proceeded to show the Tribunal 2 pages from an assessment order completed by Dr TC on 19 December 2025 at 16:00 and affirmed by Dr KLL (but not signed) on 19 December 2025 at 16:00 with an expiration of 21 December 2025 at 15:59.
4. Dr BD did not furnish an explanation as to why Dr TC chose to utilise the power in s 17 to 'temporarily detain' DND.
5. We observed that the affirmation of assessment order referred to at [25e] above by Dr KLL was not signed. We found that that assessment order was invalid as it failed to comply with s 32(6) of the Act as it was not signed.
6. At the hearing it was undisputed that the temporary detaining of DND was only authorisation to detain her for assessment for a period of 4 hours (s 19(2)(c)(ii)). Therefore by 8pm on 19 December 2025 that period expired. Furthermore, it was not disputed that DND was already detained prior to 19 December 2025 and detained after that day. We accepted that it was not until nearly 2 days later, on 21 December 2025 at 16:00 that an assessment order was made providing authority under the Act for DND to be detained and assessed. Consequently, between 17 December 2025 and 21 December 2025 16:00 DND was detained without authority under the Act.
7. We informed BD that s 194 outlined the powers of the Tribunal upon a review and invited submissions on whether a direction ought to be made regarding education and training. Dr BD was generally supportive of a direction to that effect. He acknowledged there were 'limitations' in the system regarding awareness of orders and authorisation of treatment.
8. DND, Dr KLL and Dr OJ did not express any views regarding the review of the detaining for assessment.
9. On review of the detaining for assessment s 193(b) of the Act enabled us to affirm the decision or set aside the decision. Furthermore s 193(c) enabled the Tribunal to substitute its own decision for the one set aside; or remit the matter to the decision-maker, with or without directions, for redetermination.
10. We found the decision to rely on s 17 to temporarily detain DND was not appropriate as she was already detained at an approved facility and had been for at least 14 days. In the circumstances it was not the appropriate legislative pathway to provide authority for assessment under the Act. We set aside the decision of Dr TC.
11. We found there were several errors and oversights by the treating team regarding the legislative requirements. Consequently, in line with other decisions of the Tribunal of Re IC, AN and LZ (Review of Assessment Orders) [2024] TASCAT 30 and SBC (Review of Assessment Order) [2024] TASCAT 53, EDT v State of Tasmania (Review Proceedings - Own Motion) [2024] TASCAT 190 we determined that it is appropriate to make the following recommendations:

1. By the authority provided to the Tribunal pursuant to s 194(e) of the Mental Health Act 2013 (the Act) we recommend that educational training and resources as to the requirements for the making of a detaining for assessment, valid assessment order, and applications for treatment orders is provided at the earliest opportunity to: 1. Medical practitioners employed by the Tasmanian Health Service who may be required to make assessment orders and applications treatment orders, and consideration of when to use a detaining for assessment noting the 4-hour prescribed time limit; 2. Approved medical practitioners; and 3. Legal order co-ordinators. 2. Such educational training and resources should emphasise the requirements of the Act including: 1. That prescribed time limits are strictly adhered to and the need for accuracy and completeness of prescribed documents. 2. When and what treatment is authorised for a patient and pursuant to what legal authority.

1. These recommendations are directed to the following parties to the proceedings: 1. The Secretary of the Department of Health (in capacity as both Secretary (cl 1(g) of Pt 1 in Sch 4 of the Act) and the controlling authority of the facility in which DND is accommodated (cl 1(e) of Pt 1 in Sch 4 of the Act); and 2. The Chief Psychiatrist.
2. The effect of our determination was that between 17 December 2025 and 16:00 on 21 December 2025 DND was detained and treated without authority under the Act.

Evidence and findings on review of urgent circumstances treatment

1. The UCT prescribed form outlines the statutory requirements of UCT (s 55) and provides boxes for the clinician to complete. Dr BD did not complete all the questions relating to s 55(2)(b)(i) and (ii). They remained blank. At hearing Dr BD acknowledged the form had not been fully completed and there was an error. He submitted that he was 'on call' when the matter was brought to his attention and it had been a 'very terrible Sunday' on call. He apologised for the error and oversight.
2. We informed Dr BD that s 186 outlined the powers of the Tribunal upon a review. We suggested that s 186(1)(c)(iv) was an appropriate avenue because DND was already subject to an interim treatment order, had been assessed against the treatment criteria, an application for a treatment order had been made, and she was not a forensic patient. Dr BD agreed with us.
3. DND, Dr KLL and Dr OJ did not express any views regarding the review of the UCT.
4. We accepted the evidence of Dr BD and found that Dr BD failed to properly complete the UCT form, that the statutory requirements had not been satisfied, and the UCT of 21 December 2025 was invalid. Consequently, we found there was no authority to administer medications to DND on 21 December 2025.

1. The treatment order was made on 30 December 2025 at 10:58am for a period of 6 months in accordance with the terms set out in par 8. The order will expire on 29 June 2026 at 10:58am unless discharged sooner or renewed.
2. In reviewing the UCT of 21 December 2025, we found the UCT was invalid and there was no authority to administer medications to DND on 21 December 2025.
3. In reviewing the detaining for assessment, we set aside the decision to detain DND for assessment, and issued recommendations concerning education, training and resourcing in terms set out in [33].