Version: 1.0. Mental Health Act 1983 Policy (as amended in 2007) Name of Policy: Effective From: 08/08/2012

Full text

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Policy No: MH28

Version: 1.0

Name of Policy:

Mental Health Act 1983 Policy

(as amended in 2007)

Effective From:

08/08/2012

Date Ratified

27/07/2012

Ratified

Mental Health Act Committee

Review Date

01/07/2014

Sponsor

Director of Transformation and Compliance

Expiry Date

26/07/2015

Withdrawn Date

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Version Control

Version Release Author/Reviewer Ratified by/Authorised

by

Date Changes

(Please identify page no.)

1.0

08/08/2012 Claire

Downes Mental

Health

Act Committee

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CONTENTS

Page No

1 Introduction ... 4

2 Policy

Scope ... 4

3 Aim

of

Policy ... 4

4

Duties, Roles and Responsibilities ... 4

5 Definition

of Terms ... 6

6

Structures of the Mental Health Act 1983 (as amended in 2007) ... 6

6.1

Guiding

Principles ... 8

6.2

Using

the

Principles ... 8

6.3

Applications for Detention ... 9

6.4

Appropriated

Medical Treatment ... 9

6.5

Use of the Act in General Hospitals ... 9

6.6

Alternatives to use of the Mental Health Act ... 10

7 Training ... 10

8

Equality and Diversity ... 10

9

Process for monitoring compliance with the Policy ... 11

10

Consultation and review of this policy ... 11

11 Implementation

of this policy ... 11

12 References ... 11

13 Associated

Documents ... 11

Appendix 1 Definition of Terms

Appendix 2 Processes for Applying the Mental Health Act

Appendix 3 Procedure for Receipt and Scrutiny of Mental Health Act Documentation

Appendix 4 Section 135 Protocol

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1.

Introduction

The Mental Health Act 1983 (MHA) provides a framework for the compulsory

admission to hospital and subsequent treatment of patients with a mental disorder.

All health professionals who are considering a course of action under the MHA must

ensure they proceed in accordance with the guiding principles set out in the Code of

Practice.

This Policy and Procedure Guidance outlines the management of the MHA across

Gateshead Health NHS Foundation Trust and aims to highlight the key principles

within the Code of Practice and provide guidance on those cases where it might be

more appropriate to use the Mental Capacity Act 2005 (MCA) as alternative

legislation.

2.

Policy scope

This policy applies to all frontline staff, locums, bank staff and voluntary workers

involved in delivery of care of patients who are detained, or liable to be detained,

under the MHA.

3.

Aim of policy

The aim of this policy is to protect users and the public, provide staff with guidance

to ensure compliance with the provisions of the MHA and to protect staff and the

Trust from litigation.

The policy includes procedural guidelines (as appendices) which must be adhered

to. These are based on the MHA (as amended by the 2007 Act), the Code of

Practice, the MHA Regulations, DOH circulars and established best practice.

However, these are a simplified guideline only and do not constitute a guide to the

law.

4.

Duties – Roles and responsibilities

Trust Board

The Trust Board is responsible for implementing a robust system of corporate

governance within the organisation. This includes having a systematic process for

the development, management and authorisation of policies.

Chief Executive

The Chief Executive is ultimately responsible for ensuring effective corporate

governance within the organisation and therefore supports the Trust-wide

implementation of this policy.

Hospital Managers

The Hospital Managers are responsible for the correct implementation of the MHA

as delegated by the Trust Board. To receive applications for admission under the

act, hold review panels when a patient’s detention is renewed, hold appeal hearings

when a patient appeals against their detention, refer patients to the Mental Health

Review Tribunal where appropriate and ratify the policy.

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Mental Health Act Managers’ Committee

The Mental Health Act Managers’ Committee monitor the responsibilities of hospital

managers under the MHA, ratify policy and review Trust compliance within the legal

framework of the MHA.

Mental Health Act Administration Team (MHA Admin Team)

The MHA Admin Team are responsible for the scrutiny of legal paperwork on behalf

of the Hospital Managers and ensure rectification of errors. The team will provide

written information to patients and their nearest relative. The Team has delegated

responsibility to co-ordinate Hospital Managers Hearings and Mental Health Review

Tribunals. Capture and present Mental Health Act data, audit compliance with the

legislation, inform CQC of the death of a detained patient, a detained patient who is

Absent Without Leave (AWOL) and any other functions delegated to them by the

Hospital Managers.

Divisional Managers

The Divisional Managers are responsible for ensuring staff are aware of and adhere

to this policy and that their actions comply with the MHA.

Approved Clinicians (AC)

AC’s are personally accountable for discharging their duties under the MHA and

must abide by any applicable professional code of conduct. Apply s5 (2) where

appropriate.

Responsible Clinicians (RC)

RC’s are personally accountable for discharging their duties under the MHA and

must abide by any applicable professional code of conduct

Ensure all staff are aware who the nominated deputy is and how to contact them for

times when they are unavailable. Responsible for the maintenance of the section

including renewal, discharge and granting leave.

2

nd

Professionals

Staff taking on 2

nd

professional responsibility are responsible for providing a second

opinion at renewal of section.

Admitting Nurse

The admitting Nurse is responsible to accepting the detained patient on behalf of

the Hospital Managers. The admitting nurse is responsible for completing Forms

H3, H3A and H3B, the initial checking of all detention paperwork and ensure

paperwork is delivered to the MHA Admin Team promptly.

Named Nurse

The named nurse will continue to inform the patient of their rights and document on

Form H3B. Where appropriate ensure referral to Independent Mental Health

Advocate (IMHA).

All Clinical Staff

All clinical staff will adhere to this policy when assessing or providing care and

treatment (directly or indirectly) to individuals suffering from a mental illness.

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5.

Definition of Terms of the Act

Terms used under the MHA are described in Appendix 1

6.

Structure of the Mental Health Act

The Act comprises of 10 parts as described below;

Part Sections Heading Deals

with

1

1

Application of the Act

Definition of mental disorder

2

2 - 34

Compulsory admission

to Hospital &

Guardianship

Detention in Hospital

Supervised Community

Treatment (SCT)

Guardianship

(including procedures for

admission, renewal, transfer and

discharge for each of the above)

Nearest relative – definition and

displacement

3

35 - 55

Patients Concerned in

Criminal Proceedings or

Under Sentence

Powers of the courts to remand

defendants to hospital while

awaiting trial or sentence

Powers of the courts to detain

convicted offenders in hospital

or make them subject to

guardianship

Transfer of patients from prison

to hospital (and their return)

Special restrictions on certain

patients (“restricted patients”)

Conditional discharge of

restricted patients by the

Secretary of State

4

56 - 64

Consent to Treatment

Treatment for mental disorder

without consent of patients

detained in (or recalled to)

hospital

Safeguards for detained (and

other) patients in respect of

particular forms of treatment

(e.g. medication,

electro-convulsive therapy)

4A

64A - 64K

Treatment of

Community Patients Not

Recalled to Hospital

Safeguards for supervised

community treatment (SCT)

patients in relation to treatment

for mental disorder while not

recalled to hospital

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Part Sections Heading Deals

with

5

65 - 79

Mental Health Review

Tribunals

The establishment of Mental

Health Review Tribunals

Right for patients (and nearest

relatives) to apply to the

Tribunal for discharge

Powers and duties of other

people to refer cases to

Tribunals

Powers of Tribunals

6

80 - 92

Removal and Return of

Patients Within the

United Kingdom

Transfer of patients between

England and Wales and

Scotland, Northern Ireland, the

isle of Man and the Channel

Islands.

Removal of patients to places

outside the UK, the Isle of Man

and the Channel Islands

Patients who go absent across

borders

8

114 – 123

Miscellaneous

Functions of Local

Authorities and the

Secretary of State

Approval of approved mental

health professionals (AMHPs)

Duty to provide after-care

services

Code of Practice

Mental Health Act Commission

9

126 – 130

Offences

Specific offences under the Act,

including ill-treatment or neglect

of patients

10

130A - 149

Miscellaneous and

Supplementary

Independent mental health

advocacy

Informal admission of patients to

hospital

Children and young people

admitted to hospital

Duties of hospital managers to

give information to patients and

nearest relatives

Patients correspondence

Warrants to enter premises

Detention in places of safety by

the police

Legal custody, conveyance and

absconding

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6.1

Guiding Principals

The MHA Code of Practice sets out five guiding principles which should be

considered when making decisions about a course of action under the Act.

Purpose principle – Decisions under the Act must be taken with a

view to minimising the undesirable effects of mental disorder, by

maximising the safety and wellbeing (mental and physical) of patients,

promoting their recovery and protecting other people from harm

Least restriction principle – People taking action without a patient’s

consent must attempt to keep to a minimum the restrictions they

impose on the patient’s liberty, having regard to the purpose for which

the restrictions are imposed

Respect principle – People taking decisions under the Act must

recognise and respect the diverse needs, values and circumstances of

each patient including their race, religion, culture, gender, age, sexual

orientation and any disability. They must consider the patient’s views,

wishes and feelings (whether expressed at the time or in advance), so

far as they are reasonably ascertainable, and follow those wishes

wherever practicable and consistent with the purpose of the decision.

There must be no unlawful discrimination.

Participation principle – Patients must be given the opportunity to be

involved, as far as is practicable in the circumstances, in planning,

developing and reviewing their own treatment and care to help ensure

that it is delivered in a way that is as appropriate and effective for them

as possible. The involvement of carers, family members and other

people who have an interest in the patient’s welfare should be

encouraged (unless there are particular reasons to the contrary) and

their views taken seriously.

Effectiveness, efficiency and equity principle – People taking

decisions under the Act must seek to use the resources available to

them and to patients in the most effective, efficient and equitable way,

to meet the needs of patients and achieve the purpose for which the

decision was taken.

6.2

Using the principles

The ways in which the principles should be applied are illustrated throughout

the Code of Practice. Healthcare Professionals should consult the detail of

the Code in the event of any doubt as it is not the purpose of this policy to

reproduce all of the Codes’ guidance. Whilst the Act does not impose a legal

duty to comply with the Code, failure to follow could give rise to legal

challenge and a court will use the Code to scrutinize any reasons for not

following it.

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6.3

Applications for Detention

Applications for detention require certain criteria to be met:

The person must be suffering from a mental disorder of a nature or degree

which warrants their detention in hospital for assessment and/or treatment

and detention and/or treatment is in the interests of the patient’s own health,

safety and protection of others.

In all cases, consideration must be given to:

The patient’s wishes and views of their own needs

The patient’s age and physical health

Any past wishes or feelings expressed by the patient

The patient’s cultural background

The patient’s social and family circumstances

The impact that any future deterioration or lack of improvement in the

patient’s condition would have on their children, other relatives or

carers, especially those living with the patient, including an

assessment of their ability and willingness to cope

The effect of the patient and those close to the patient of a decision to

admit or not to admit under the Act

6.4

Appropriate Medical Treatment

The Mental Health Act 2007 introduced a new criterion for detention and

supervised community treatment known as the Appropriate Treatment Test.

For purposes of the Act, medical treatment includes:

• Nursing

• Psychological

interventions

Specialist mental health habilitation

• Rehabilitation

• Care

Medical treatment need only have the intended purpose of alleviating or

preventing a worsening of a mental disorder or one or more of its symptoms

or manifestations. Even if particular mental disorders are likely to persist or

get worse, despite treatment, there may be a range of interventions which

would represent appropriate medical treatment and it should never be

assumed that any disorders are inherently or inevitably untreatable or that

such treatment is therefore inappropriate or unnecessary.

Appropriate medical treatment does not have to involve medication or

psychological therapy. There may be patients whose circumstances mean

that treatment may be appropriate even though it consists of nursing care or

day care under the clinical supervision of an approved clinician.

6.5

The use of the Act in General Hospitals

It may be necessary to use the MHA to admit a patient to a general hospital

where, for example, they have been assessed as requiring detention under

the Act but also needs treatment for their physical health that cannot be

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provided by mental health services. Patients detained in general hospitals

should be transferred to a mental health unit as soon as their physical health

permits.

From time to time, in-patients of general hospitals are thought to

require detention under the MHA. If so, they are assessed as shown

in Appendix 1. In an emergency, where a patient who needs to be

detained is already in hospital, the doctor in charge of their treatment

may or any “approved clinician” (defined at s145 (1) of the MHA) can

initiate a 72-hour ‘holding’ power, which will prevent the patient leaving

hospital and allow time for consideration to be given as to whether an

application should be made under the MHA. This power is know as a

Section 5(2).

General hospitals that admit a patient under the MHA should retain a

copy of the legal paperwork and follow the Procedure for Receipt and

Scrutiny of MHA Documentation as shown in Appendix 4.

6.6

Alternatives to Use of the Mental Health Act

The Codes of Practice to both the Mental Health Act and the Mental Capacity

Act contain guidance on the circumstances when one of the Acts mat be

used as an alternative to the other. At present, the use of the Mental

Capacity Act as an alternative to the Mental Health Act is limited to those

cases where:

The patient is found to lack the capacity to consent to admission and

treatment in hospital and

Is not objecting or considered to be objecting to admission and

treatment and

The use of force or restraint is not required and

Admission and Treatment would not amount to a Deprivation of Liberty

7

Training

Staff working within Mental Health

Wards/Departments

Update training every two years provided

in-house.

Mental Health Hospital Managers

Update training every year

8

Equality & Diversity

The Trust is committed to ensuring that, as far as is reasonably practicable, the way

we treat members of staff and patients reflects their individual needs and does not

discriminate against individuals or groups on the grounds of any protected

characteristic (Equality Act 2010). An equality analysis has been undertaken for

this policy.

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9

Monitoring compliance/effectiveness of the policy

Monitoring compliance with this policy will be the responsibility of the Mental Health

Act Hospital Managers Committee

Standard /

process / issue

Monitoring and audit

Method

By

Committee

Frequency

The principles of best practice as set out in the Mental Health Act 1983 will be

embedded into the practice of employees within the organisation who provide care and treatment for those who are detained or liable to be detained under the Act.

Regular monitoring of all Section paperwork will be routinely carried out. Mental Health Act Administration Team Mental Health Act Committee Each time a section is applied. Audit will be carried. Mental Health Act Administration Team Mental Health Act Committee Yearly

10

Consultation & Review

This policy has been reviewed against the Mental Health Act 1983, The Code of

Practice 2008 and the Reference Guide to the Mental Health Act 1983 2008 and in

discussion with the Mental Health Hospital Managers Committee and the Equality

and Diversity Officer.

11

Implementation of policy

This policy will be implemented in accordance with policy OP27 “Policy for the

development, management and authorisation of policies and procedures” and policy

training will be included in the programme of training as detailed in section 7.

12

References

The Mental Health Act 1983 (as amended by the 2007 Act)

Department of Health (2008) Mental Health Act 1983 Code of Practice

Department of Health (2008) Reference Guide to the Mental Health Act 1983

Mental Capacity Act 2005 & Deprivation of Liberty Safeguards

13

Associated Documents

Consent to Treatment Policy RW22

Patients considered to be AWOL Policy MH10

Missing Patients Procedures OP44

Conveying Detained Patients to Hospital Policy MH24

Mental Capacity Act Policy RM

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Appendix 1

Definition of terms

Absent without leave (AWOL) A patient being absent, without permission, from the place they ought to be under the Act

The Act The Mental Health Act 1983, as amended over time

Application for admission An application to the managers of a hospital for a patient to be detained there under Part 2 of the Act. As well as being a request for detention, the application becomes the legal authority on the basis of which the patient is detained.

Application for assessment An application for admission under Section 2 of the Act for the patient to be detained in hospital for up to 28 days to be assessed. An emergency application under Section 4 is also a form of application for admission for assessment.

Application for admission for treatment

An application for admission under Section 3 of the Act for a patient to be detained in hospital for medical treatment.

Approved Clinician A mental health practitioner approved for the purpose of the Act, or on behalf of, the Secretary of State in England. Certain decisions under the Act can be made only by approved clinicians. In particular, medical treatment cannot be given without a patient’s consent unless an approved clinician is in charge of it. Only approved clinicians can be responsible clinicians.

Approved Mental Health Professional (AMHP)

A social worker or other professional approved by a local social services authority (LSSA) to perform a variety of functions under the Act. Those functions include making applications for admission to hospital and guardianship applications, and agreeing that patients should become SCT patients.

Code of Practice Under Section 118 of the Act, the Secretary of State must publish a Code of Practice for the guidance of certain people who make decisions under the Act.

Detained patient A patient who is detained (or liable to be detained) in hospital against their wishes.

Discharge Under the Act this usually means discharge from being liable to be detained under the Act.

Escorted Leave Leave to be absent from hospital on condition that the patient remains in the custody of a named person whilst away from the hospital.

Emergency application An application for admission for assessment made under Section 4 of the Act where obtaining a second medical recommendation would cause undesirable delay where it is urgently necessary to admit the patient.

First-tier Tribunal An independent judicial body with the power to discharge detained patients, SCT patients and guardianship patients.

Guardianship The regime established by the Act under which patients mat become and remain subject to the guardianship of an individual or body that has certain powers, including the power to decide where the patient should live.

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Holding Powers Under Section 5(2) a doctor or AC in charge of a

patient’s treatment may detain them for up to 72 hours. Under Section 5(4) certain nurses may detain existing mental health patients for up to six hours pending the arrival of the doctor or AC who could then use Section 5(2).

Hospital Managers The individual or body responsible for a particular hospital. It generally refers to the managers of the hospital in which a patient is (or is liable to be) detained.

Independent Mental Health Advocate (IMHA)

Means the advocacy services for detained patients and is provided under Sections 130A to 130D of the Act.

Leave of absence Leave to be absent from hospital whilst under detention to a named place for designated periods.

Mental Capacity Act (MCA) Provides a legal framework for decision-making in relation to people who lack capacity to make particular decisions for themselves. The MCA does not apply to anyone under the age of 16.

Mental Disorder The Act defines mental disorder as any disorder or disability of the mind (apart from dependence on alcohol or drugs).

Nearest Relative (NR) The NR is defined in Section 26 of the Act. If often does not mean the same thing as ‘next of kin’. Under the Act nearest relatives have various rights.

Recall An enforceable order requiring a patient who was previously detained to come back to hospital.

Renewal (of detention) Authorises the continuation of the authority to detain a patient, or to keep someone subject to guardianship.

Responsible Clinician (RC) The RC is the AC in overall charge of the patient’s care.

SCT patient A patient who has been discharged from detention to supervised community treatment (SCT) by means of a community treatment order (CTO)

Section 12 approved doctor A doctor approved by a strategic health authority on behalf of the Secretary of State for Health to carry out certain functions under the Act.

Section 57 treatment Treatment for mental disorder which may not be given to ant patient except in accordance with section 57 (neurosurgery).

Section 58 treatment Treatment for mental disorder which may not be given to a detained patient except in accordance with Section 58. This applies to medication given after an initial 3 month period.

SOAD Certificate A certificate given by a second opinion appointed doctor approving the administration of specified treatments. A SOAD certificate will always be needed for section 57 treatments and for section 58 treatments where patients cannot or do not consent to treatment.

SCT The scheme in the Act by which certain patients may be discharged from detention in hospital by their RC, subject to the possibility of recall to hospital for further medical treatment if necessary.

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SECTION 2

Patient admitted 1xForm A3 or 2xForm A4 completed by

Doctors. Form A2 completed by AMHP. Form H3, H3a &

H3b to be completed by ward staff. All section papers to be

forwarded to the MHA Admin Office

At each MDT, review the necessity for the patient to remain under section

Patient can be detained for 28 days & is subject to Part IV consent rules. RC must inform MHA Admin of the date treatment starts See consent procedure

Patient has 14 days from admission to appeal to MHRT

Can make appeal to Hospital Managers at any time

Named nurse continues to ensure patient knows their rights (including their right to an IMHA) and that Form H3b is completed

Section 17 leave may be granted (see section 17 procedure)

Section 3 assessment required

In most situations by day 21 a decision needs to be made regarding the need for section 3

Two weeks before section due to expire MHA Admin team write to RC and Ward manager requesting Form H23 if patient is to be discharged or Section 3 assessment to be arranged.

If no response, 1 week before section due to expire MHA Admin team write to RC and Ward manager requesting Form

H23 or section 3 paperwork.

If still no response notification will be sent to Link Director for Mental Health

Link Director contacts RC to request action

MHA Admin record as a lapse if section 3 paperwork or Form H23 not received.

Report to Mental Health Act Committee

RC arranges for AMHP & second medical recommendation

Forms A6 & A7/A8

completed and sent to MHA Admin Team

See Section 3

Linked Procedures:

Section 3 Section 17

Section 3 not required

Form H23 sent to MHA

Admin team

Patient informed by RC that they are an informal patient and what this means.

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SECTION 3

Patient admitted 1xForm A7 or 2xForm A8 completed by Doctors. Form A6 completed by AMHP. Form H3, H3a & H3b to be completed by ward staff. All section papers to be forwarded to the MHA Admin Office

At each MDT, review the necessity for the patient to remain under section

Patient can be detained for 6 months & is subject to Part IV consent rules. RC must inform MHA Admin of the date treatment starts See consent procedure

Named nurse continues to ensure patient knows their rights (including their right to an IMHA) and that

Form H3b is completed

Section 17 leave may be granted (see section 17 procedure)

2 months before section due to expire MDT consider whether patient still needs to be treated under section. RC examines patient. Assessment made of whether patient has capacity to object to renewal and

documented. Ward manager to identify 2nd Professional* and inform MHA Admin Team.

Eight weeks before section due to expire MHA Admin team write to RC, Ward Manager requesting Form

H23 if patient is to be

discharged or Form H5

4 weeks before section due to expire MHA Admin team send reminder to RC and Ward manager requesting Form H5 or Form H23

If no form received 1 month before renewal, further reminder sent copied to Link Director for Mental Health

MHA Admin team arrange for a hospital managers renewal panel or hospital managers hearing if a patient objects to renewal. Write to patient and NR. If patient lacks capacity to object a full hearing must be arranged

MHA Admin inform patient and NR, in writing, of Hospital Managers decision

Form H23 sent to MHA

Admin Team 2nd Professional does not agree with renewal

Patient informed by RC that they are informal patient and what that means including s117. Letter will be sent to patient and NR by MHA Admin Team

2nd Professional agrees with renewal and completes Form H5 Part 2 and returns to RC at least 2 weeks prior to expiry of the section

RC consults 2nd Professional, completes Form H5 Part 1 and sends to 2nd Professional at least 4 weeks prior to the expiry of the section

Section 3 renewal recommended (S20)

Linked Procedures:

Section 3 Section 17

Consent to treatment Hospital Managers Patient can be detained for a further 6 months at their

Form H5 Part 3 completed by RC and sent to MHA

Admin team 2nd professional must be professionally concerned with the patient’streatment and must not belong to the same

profession as the responsible clinician.

Section 3 renewal not required

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SECTION 4

Patient admitted Form A11 completed by Doctors

Form A10 completed by AMHP Form H3, H3a & H3b to be completed by ward staff. All section

papers to be forwarded to the MHA Admin Office

Patient can be detained for 72 hours. Patient is not subject to Part IV consent rules

Named nurse continues to ensure patient knows their rights and that Form H3b is completed

RC decides whether patient requires further assessment under MHA

Report to Mental Health Act Committee

A4 completed and sent to MHA

Admin Team

Form H23 sent to MHA

Admin team

Patient informed by RC that they are informal patient and what that means

RC arranges for s3 assessments to be undertaken (2 new medical recommendations & application required)

RC arranges for second medical recommendation in accordance with s2 or completes Form 4

Follow Section 3 procedure

Linked Procedures:

Section 2 Section 3

Section 3 recommended

MHA Admin record as a lapse if section 3 paperwork, Form 4 or Form H23 not received Follow Section 2 procedure

Link Director for Mental Health informed Section2 recommended Further detention not required

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SECTION 5

Message left for AC/Nominated Deputy to attend ward as a matter of urgency

Contact AC or nominated deputy (ensure every effort made to contact them) Are either immediately available?

After examination does AC/Nominated Deputy consider detention necessary?

MHA Admin team record as a lapse if section 2/3 paperwork,

Form H2 or Form H23 not received. Further section

AC completes Medical recommendation and arranges for other assessments urgently. Patient admitted under section 5(2). Patients’ rights explained to them. Form H3a completed and enter reason for use in notes. Section papers sent to MHA Admin team

Patient admitted under section 5(4). Patients’ rights explained to them. Form H3a completed. Section papers sent to MHA Admin team

If yes RMN (level 1 or 2) fills in Form H2

Named nurse continues to ensure patient knows their rights and that B Form

H3b is completed

AC or deputy completes Form H1 Send to MHA Admin

Patient is not subject to Part IV consent rules

Linked Procedures: Section 2 Section 3 Patient remains informal Nurse completes Form H2 & s5 monitoring form sends to

MHA Admin & patient becomes informal Patient can be held for 6 hours with minimum force necessary

No further section AC

completes form H23

Patient can be held for 72 hours with minimum force necessary

Is patient receiving treatment for mental disorder • Inpatient wanting to leave hospital premises

• If staff feel that the patient would be at risk to self or others if allowed to leave • Staff attempt to discuss/reason with patient

• Patient is still refusing to stay on premises

Yes No

Yes No

Attempt to make contact with AC/Nominated Deputy

Has AC/Nominated Deputy arrived within 6 hours?

Decision made as to whether patient requires assessment for s2 or s3

No Yes AC/Nominated Deputy decides whether to further detain the patient. If no, Patient informed they are informal and completed Form H2 sent to MHA Admin team If Yes, AC/Nominated Deputy completes Form H1. The

time held by the nurse counts towards the 72hr maximum.

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SECTION 17 Leave

Leave Granted?

Leave of absence conditions agreed by RC, team & patient YES

Consider use of CTO record reasons on Form H17

Is leave for more than 7 consecutive days and nights (i.e. daytime & overnight?)

Copy of leave Form H17 sent to MHA Admin team and other relevant professionals as stated on form.

NO Complete Form H17

NB In cases of emergency if the patient is in need of urgent medical treatment and needs to be moved to a general hospital for medical care the patient can be moved and the s17 form completed retrospectively by the RC at the earliest opportunity.

Any outpatient hospital appointments, or other appointments must be planned and the s17 leave form completed by RC in advance of the appointment

RC completes s17 Form H17 clearly specifying conditions. NB only RC can do this

Named Nurse ensures patient is aware of any conditions and AWOL procedures. A contingency plan agreed in case patient does not return.

Linked Procedures:

AWOL Section 2 Section 3

Nurse completes risk assessment and exercises discretion at time of leave. (If leave refused nurse documents reasons). Patient informed that if they have

any problems they should return to hospital.

Leave is documented in Nursing Notes and on 24 hr report

Patient given copy of leave Form H17 • Patient detained under MHA • Patient requests leave of absence • Reviewed by RC & Team at MDT review

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Absent Without Leave (AWOL)

To be read in conjunction with Trust Policy OP44 Missing

Patient policy

Patient is considered to be missing (AWOL) • Absent from ward without authorised S.17 leave or

• Failed to return following authorised leave or

• Failed to return following recall to hospital for CTO patient or

• Are absent without permission from a place where they are required to reside as a condition of leave under Section 17

CQC AWOL NOTIFICATION FORM (part 1) TO BE COMPLETED BY WARD MANAGER AND FAXED WITHIN ONE WORKING DAY OF THE

INCIDENT

The patient can be brought back to the hospital by: o An AMHP

o Any member of staff from the ward/unit o Any police officer

o Any person authorised by the Hospital Managers

o If the patient is on leave at another hospital, any member of that hospital’s staff or authorised person

It is the responsibility of the detaining authority to arrange for the patient to be conveyed back to the place where they are liable to be detained.

Inform Nurse in Charge of the ward and the patients RC

Inform Care-co-ordinator/ Community Nurse if involved and MHA Admin Team.

Follow Trust Policy OP44 Missing Person Policy

ON PATEINTS RETURN ALL RELEVANT INDIVIDUALS TO BE INFORMED AND CQC AWOL NOTIFICATION FORM (part 2) TO BE

COMPLETED BY WARD MANAGER AND FAXED WITHIN ONE WORKING DAY

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SUPERVISED COMMUNITY TREATMENT

RC considers CTO

Consult the patient.

Talk and listen to patient’s family, advocate and carer’s. Carry out full risk assessment.

Are SCT criteria met?

Appropriate community team becomes involved with patient’s case.

Involve family, carers and GP in care planning process

RC creates conditions for CTO, and completes Part 1 of

Form CTO1

Form CTO1 passed to AMHP who completes Part 2 of

Form. RC then completes Part 3 of Form CTO1

CPA review takes place at which a date is set for discharge. If RC is to change, this should be documented

at the CPA meeting.

Request SOAD report (Form CTO11) (If medicinal treatment required after first month)

Inform the patient.

Involve family, carers and patient’s GP in care planning process

After the first month of SCT, a SOAD certificate (part 4A certificate) is needed for

medication even if the patient has capacity and is consenting to the treatment. (CTO11 required within 1 month or till end of 3 month rule, whichever is longer)

Form CTO1 sent to MHA

Administration for scrutiny.

Must include – patient makes

self available for examination for extension of CTO and allows examination by SOAD to authorise Treatment in the community.

Care Plan Checklist

Supervision and monitoring Appropriate Accommodation OT Services

Day-time Activities Personal support

Counselling and Advocacy Carer and Family Support Welfare Rights

Financial Assistance Cultural Requirements Crisis Support

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Appendix 3

Procedure for receipt and scrutiny of Documentation relating

to the Mental Health Act 1983

1. Introduction

Patients can only be detained lawfully under the MHA if the correct documentation has

been accurately completed within the timescales permitted

and in accordance with all other legal requirements. Where there are failures

the lawfulness of the patient’s detention becomes questionable. For this reason it is

important that the procedure for the receipt and scrutiny of statutory paperwork is kept to.

2. Purpose

This procedure will ensure the lawfulness of section applications. It does not apply where

a patient feels that they do not meet the criteria for detention under the Act: in that case

they should exercise their right of appeal to the Hospital Managers or First-tier Tribunal.

However, if the issue is about whether the procedure used to detain a patient is lawful,

reference should be made to this procedure.

3. Duties & Responsibilities

Ward Staff – The receiving Nurse in Charge of a Ward admitting a detained

patient is responsible for;

• Receiving the statutory paperwork

• Carrying out initial check that all paperwork is there and appears to be in order

• Completing Form H3/H3A & H3B to signal that the patient and paperwork have

been received

Approved Mental Health Professionals (AMHP) – are responsible

for completing their own application correctly.

Consultant Psychiatrists – Collectively Consultants must nominate a

suitable doctor or rota of doctors to be responsible for the Medical scrutiny of

recommendations.

MHA Administration team – have the primary responsibility for scrutinising

section documentation. This includes responsibility for ensuring that mistakes are

corrected where possible within the legally permitted timescales.

4. General Procedure - Patients 65 years and over.

4.1. The statutory paperwork should be received on the unit by the nurse in

charge, who will accept the patient and sign Form H3 with delegated authority from the

Hospital Managers. They should check the admission papers for errors. Wherever

possible the GP/Section 12 doctor and the AMHP should remain on the ward until the

papers have been checked to avoid having to return to rectify errors.

4.2 .When checking papers, the receiving nurse in charge should accept in good faith and

at face value the information in them. Minor errors that can be rectified should not prevent

the section being accepted.

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4.3. If the receiving nurse in charge believes there are major or fundamental errors, which

cannot be rectified, the section cannot be accepted. They should consider holding the

patient under Section 5 powers until a new assessment under the Act can be arranged. In

the first instance, where possible, staff should contact the MHA Admin team for advice

before any decisions are reached. Ext. 6341 or via Medical Secretaries on Ext.3836.

4.4. All papers must undergo administrative and medical scrutiny to ensure that they are

technically correct and that the clinical reasons given are sufficient for detaining the patient

under the Act. The MHA Admin team will carry out the administrative scrutiny and a

consultant psychiatrist who is not involved with the patient concerned will do the medical

scrutiny.

4.5. Once scrutinised and corrected the original papers will be stamped as such by the

MHA Admin team and kept in the MHA Admin Office, QEH. A duplicate will be sent to the

ward and should be kept in the medical notes. Any earlier copies (which may still show

uncorrected errors) should be destroyed.

5. Procedure for patients under the age of 65 years

The Procedures remain the same as stated above with the exception of 4.5.

First confirm that the patient is not currently being cared for by one of the Consultant Old

Age Psychiatrists (Gateshead Health NHS Foundation Trust provides a service for patients

under the age of 65 years who have a dementia illness).

If the patient is not receiving psychiatric care from Gateshead Health NHS Foundation

Trust then their psychiatric care will be undertaken by Northumberland, Tyne and Wear

Foundation Trust and all administrative work is carried out by the Mental Health Act

Administrators at Cherry Knowle Hospital, Ryhope

,

Sunderland SR2 0NB. Telephone No.

0191 5699534. This will also be the case for patients transferred in from the Tranwell Unit

on a Section 17, (leave section), for medical treatment of a physical illness/condition. In

this instance notify the MHA Admin team at QEH that a detained patient is currently being

cared for on the ward and send them a copy of the H17 leave form.

6. Faults which can be rectified

When detention papers are incorrectly completed, most errors can be corrected under

Section 15 of the Act within 14 days of formal admission and the patient can continue to be

legally detained for this period.

The following errors may be rectified within 14 days – unless the documents have been

issued by a court.

• The leaving of blank spaces on the form other than the signature

• Failure to delete one or more alternatives

• A patient’s forename, surname or address not being fully completed or being

inaccurately stated or not being identical on all forms

• Spelling

mistakes

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• A medical recommendation for Section 3 which contains insufficient clinical

description of grounds for detention may have further clinical descriptions added by

the same doctor or it may be disregarded and replaced by a fresh recommendation

within the 14 day specified period.

The person who signed the form must rectify any errors and initial and date the correction,

within the specified timescale.

7. Faults which cannot be rectified

• The application is not accompanied by the correct number of medical

recommendations or

• The application or recommendation is not signed at all, or is signed by someone not

qualified to do so or

• The application does not specify the correct hospital or

• If the time limits of each section are not complied with ( i.e. medical

recommendations must not be more than 5 clear days apart, AMHP application is

completed within 14 days of seeing patient and after both medical

recommendations have been completed and admission to hospital is no later than

14 days after completion of the later of the medical recommendations)

If any of the above errors are identified and the patient has been admitted to

Hospital it may be possible to detain them under Section 5(2) or Section 5(4).

8. Applications for Community Treatment Orders (CTO)

Applications for placing a patient on a CTO should also be sent directly to the Mental

Health Act Manager for scrutiny.

9. Hospital Orders

Section 15 (allowing the correction of errors in statutory documentation) does not apply to

Hospital Orders or other documents issued by the Court. Unlike civil sections, Hospital

Orders are not ‘accepted’ by the Hospital Managers and paperwork is not corrected. Any

serious errors should be raised by the Mental Health Act Manager with the Clerk of the

Court, but should not be thought to invalidate a section unless there is direction to this

effect from the Court.

10. Consent to Treatment Documentation

Sections 57, 58 and 58A of the Act set out types of medical treatment for mental disorder

to which special rules and procedures apply, including the need for a certificate from a

second opinion appointed doctor (SOAD) approving the treatment. Section 57 covers

Neurosurgery for mental disorder and surgical implantation of hormones to reduce male

sex drive. Section 58 covers medication (after an initial three-month period) – except

medication administered as part of electro-convulsive therapy (ECT). Section 58A covers

ECT and medication administered as part of ECT. The Act uses statutory forms to

authorise treatment.

• Section 57 is covered by Form T1

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• Section 58A is covered by Form T4, Form T5 and Form T6

After the first month of SCT, a SOAD certificate (part 4A certificate) is needed for

medication even if the patient has capacity and is consenting to the treatment (Form

CTO11).

10.1 Medication or ECT which is not covered by a correct statutory form may not be

lawfully administered.

10.2 It is the responsibility of the RC to ensure the correct forms are completed and that a

Second Opinion is sought where applicable.

10.3 Where a Second Opinion is sought it is the responsibility of the 2

nd

Professional

consultees to complete Forms T3(1) and T3(2) and send

copies to the MHA

Administrators.

10.4 It is the responsibility of the nurse administering medication or arranging for ECT to

ensure they are covered by the appropriate statutory Form.

10.5 The MHA Admin team will notify the appropriate RC when consent to treatment is

due.

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Northumberland, Tyne and Wear

NHS Foundation Trust

Northumberland, Tyne & Wear

Place of Safety Protocol / Memorandum of

Understanding

(Multi Agency Response to Those Arrested Under

Section

135(1) & 135(2)

Mental Health Act 1983)

Assistance with Pre-Planned Mental Health Assessments

This Protocol has been agreed across the following agencies:

Northumberland, Tyne & Wear NHS Foundation Trust

Newcastle Hospital Trust

Northumbria Health Care

South Tyneside Foundation Trust Hospital

Gateshead Foundation NHS Trust

Sunderland City Hospitals

Northumbria Police

North East Ambulance Service

North Tyneside Local Authority

Newcastle Local Authority

Northumberland County Council

Sunderland City Council

Gateshead Council

South Tyneside Council

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Northumberland, Tyneside and Wearside Place of Safety Protocol

Contents

Page Introduction ……… 3

Executive Summary of Intentions ……… 3

Abbreviations………. 4

Oversight ……… 5

Section 135(1) & 135(2) Warrants Explained ……… 6

Execution of a Section 135(1) Warrant ………. 6

When to apply for a Section 135(2) Warrant………. 7

Required Documentation..……….. 8

AWOL……….……….. 8

Powers for Police Attendance without a Warrant ………. 9

Advice when Entry Required to a Hostel or Hotel Room ……… 9

Appendix A - Red Flag Criteria……… 11

Appendix B - Police Support within the Place of Safety……… 12

Appendix C - Contact Numbers……… 13

Appendix D - Procedural Flowchart……… 14

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Introduction

The following organisations are working together to improve provision to patients in contact with the criminal justice system. This document forms part of the wider plan to improve partnership arrangements between the police and NHS organisations across the region.

• Northumberland, Tyne & Wear NHS Foundation Trust • Newcastle Hospital Trust

• Northumbria Health Care

• South Tyneside Foundation Trust Hospital • Gateshead Foundation NHS Trust

• Sunderland City Hospitals • Northumbria Police

• North East Ambulance Service • North Tyneside Local Authority • Newcastle Local Authority

• Northumberland County Council • Sunderland City Council

• Gateshead Council • South Tyneside Council

This document provides an outline operational protocol for the management of Section 135 Mental Health Act 1983 (MHA) warrants. All organisations are aware that there are a multitude of existing agreements, service level agreements and protocols across England & Wales. This document brings together the best of those existing agreements, into a concise single document.

The protocol will support the provision of multi-agency services to individuals who are likely to be patients under Section 135 of the Mental Health Act 1983. Use of this protocol will ensure

compliance with relevant legislation, national guidance and other sources of standards for the NHS, LA, Police and partner agencies.

Executive Summary of Intentions

• To ensure efficient, effective and dignified assessment arrangements under Section 135 for all people who may require an assessment using Section 135.

• To ensure an effective and co-ordinated approach in dealing with Section 135(1) and Section 135(2) Warrants;

• To ensure the use of Police Stations as a place of safety is used only in exceptional circumstances and where it is medically safe to do so.

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Abbreviations and Definition of Terms

ABD Acute Behavioural Disturbance

AC Approved Clinician (Approved by Secretary of State for the purposes of the MHA 1983. An AC may be a medical registered practitioner, chartered psychologist, nurse, occupational therapist or social worker)

AHP Approved Healthcare Professional (defined by PACE)

AMHP Approved Mental Health Professional (defined by MHA) (Approved by local social service authorities. An AMHP may be a social worker, nurse, occupational therapist or psychologist but not a doctor)

AWA Adults of Working Age

AWOL Absent with out leave

CAMHS Child and Adolescent Mental Health Services (Specialist mental health services for children and adolescents, they are mainly composed of a multi disciplinary workforce with specialist training in child and adolescent mental health)

CoP Code of Practice, (either to MHA or PACE, as specified).

D&A Drugs and Alcohol

DPA Data Protection Act 1998

ECT Emergency Care Team

ED Emergency Department

EOC Emergency Operations Centre

FME Forensic Medical Examiner (also known as police surgeon)

IIS Instruction Information System (use by Northumbria Police)

IMHA Independent Mental Health Advocate

LA Local Authority

LD Learning Disability

MAG Multi Agency Group (who have oversight of this protocol)

MHA Mental Health Act 1983

NoK Next of Kin

PACE Police and Criminal Evidence Act 1984

PCT Primary Care Trust

PoS Place of Safety

PS Police Station

RC Responsible Clinician

RLOC Reduced Level of Consciousness

RMP Registered Medical Practitioner

Section 12 Doctor approved by the Secretary of State under Sec 136 MHA as having

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1. Oversight

1.1 This protocol relates to individuals who are found or are identified as being on private premises where concern is expressed in relation to their mental health or access is believed to be denied. This scenario dictates that Section 135 Mental Health Act (MHA) 1983 must be used in order to remove the individual to a Place of Safety (PoS)

1.2 Where assessment of an individual occurs on private premises it is only being conducted under Section 135 of the Mental Health Act where there is a warrant in force, this must have been issued by a Magistrate. Where an assessment occurs without warrant, there are no powers to remove an individual to a Place of Safety and this protocol does not apply. Hospital admissions following the necessary application should occur directly from the assessment location.

1.3 Careful planning should be undertaken by the AMHP responsible for co-ordinating an assessment on private premises, especially where there is a possible risk of resistance or aggression. There is often confusion amongst professionals about the powers available to act and a lack of clear communication. The number of professionals and agencies involved dictates that effective planning and good communication is essential.

1.4 In order to manage risks, the police are able to attend a Mental Health Act assessment with or without a warrant under Section 135 MHA 1983. But only with a warrant will police have powers to enter a ‘private premises’, restrict the movement of those inside the premises or remove the individual to a place of safety for seventy two hours and assess them at that place instead of their own home.

1.5 Police attendance may be required to promote co-operation, this will be in situations where previous experience suggests the person will be significantly more co-operative if a police officer is present.

1.6 In most circumstances, entering private premises without consent or without a warrant is trespass. Entry to private premises is only legal if consent is granted by the individual or co-occupier or a Section 135 MHA warrant has been granted.

1.7 Under the provisions of Section 135(3A) a patient can be moved from one place of safety to one or more other places of safety during the 72 hour period. They can be moved by a police constable or the Ambulance service which is the preferred method of transportation, an AMHP or another person authorised by a police constable or AMHP.

1.8 Sec 135(1) are subject to local arrangements in Local Authorities and follow the principals of this document. There is an important interface between the NHS Foundation Trust and Local Authority staff when managing the care of a person subject to Sec 135(1) which must be sensitively managed.

1.9 Section 135(2) can be used to retake a patient already subject of provisions under the MHA where they have failed to return to their PoS (AWOL). With Section 135(2) there is a need to prove that admission to the individual’s premises has been refused.

1.10 NTW Trust staff should follow the Mental Health Act Policy – Practice Guidance Note ‘Section 135 – Removal of a Patient from a Private/Locked Residence to a Place of Safety (MHA-PGN-12, part of NTW(C) 55 – MHA policy).

1.11 Police Officers should refer to IIS document - Place of Safety under Section 136 Mental Health Act 1983 procedure which follows the principle of this document.

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2.

Section 135(1) and 135(2) Warrants Explained

2.1 Section 135(1) Warrant

A Section 135(1) warrant grants the power to remove an individual from a ‘private premises’ if they are reasonably suspected of suffering from a mental disorder and has been, or is being, ill treated, neglected or kept otherwise than under proper control; being unable to care for himself, is living alone in any such place. This part of the Act should only be used when all other reasonable courses of action have been made.

The requirements are:

• Application by an Approved Mental Health Professional to a Magistrate for a warrant to be executed by a police officer to enter specified premises (if need be by force);

• Where there is ‘reasonable cause to suspect’ a person may be suffering from ‘mental disorder’

• That the individual has been or is being ill treated, neglected or kept otherwise than under proper control or ‘being unable to care for him/her self whilst living alone’; • A police officer must be accompanied by an AMHP and a medical practitioner 2.2 Section 135(2) Warrant

To access a private premises to remove a patient who is already liable to be detained. The requirements are:

• Application to a magistrate, by persons authorised to take or retake a detained or liable to be detained patient (i.e. hospital staff, Police Officer, Approved Mental Health

Professional) for a warrant to enable a constable to enter premises specified (by force if necessary)

• When a detained patient has left hospital (or residence under Guardianship Order) without leave or is liable to be detained but has not yet been conveyed to hospital • There is reasonable cause to believe that the patient is to be found on the premises; • That admission to the premises has been refused or that a refusal of such admission is

anticipated

• A police officer may be accompanied by an AMPH, Doctor or any other authorised person.

2.3 Warrants are usually only valid for a period of 3 calendar months

2.4 Warrants can only be executed on one occasion therefore it is essential that sufficient evidence exists that the individual is at the residence.

3.

Execution of a Section 135(1) Warrant

3.1 A warrant under Section 135(1) allows a police officer to enter private premises to remove someone believed to be at risk due to mental illness, by force if necessary.

3.2 An AMHP will be in attendance and will already have identified the relevant place of safety and necessary transportation (usually ambulance)

3.3 Whilst executing the removal and transportation efforts should be made to maintain the patient’s dignity and ensure trained staff are in attendance at all times.

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3.4 The patient should be searched under Section 32 PACE. Any items which are considered to pose a risk of harm to others may be seized and they should be retained by the police officers until handed to the PoS staff.

3.5 If an extreme high risk situation develops and the decision is made to transport the individual to a Police Station items should be handed to the custody sergeant.

3.6 NHS staff should note that this search is limited to a physical ‘pat down’ and to searches of pocket and bags. The individual can only be requested to remove their hat, outer coat and / or gloves – it will not be a strip or intimate search, as defined by PACE.

S32 (1) PACE.

3.7 Police officers bear legal responsibility for the health and safety of their detainees until handover to NHS staff.

3.8 Where police officers take a decision to expedite conveyance themselves, this should only be in cases of some urgency or where it is necessary in order to safely manage an extreme risk of violence. This MUST be balanced against whether or not a patient is presenting with a RED FLAG trigger condition (See Appendix A)in which case an ambulance MUST be used.

MHA CoP; para 10.17.

3.9 If it is necessary to use a police vehicle for conveyance, due to extreme violence, an ambulance should follow at a safe distance.

3.10 If the detainee continues to be violent it may be necessary for a police officer to remain at the place of safety (See Appendix B for guidance)

3.11 If it is necessary to remove an individual to a police station advance notification must be given via the Communications Centre and a relevant custody suite will be identified. 3.12 Information Gathering and Sharing

In order to facilitate a safe and comprehensive assessment on each person as much background information as possible will be sought before the assessment by all relevant parties and subsequently exchanged. This will include all information regarding risk to self or others.

4.

When to Apply for a Section 135(2) Warrant

4.1 A warrant under Section 135(2) should be sought where:

• The individual is already liable to be detained under the Act,

and

• the individual needs to be taken or taken to the place of safety or in breach of a re-call under a CTO or in breach of a Department of Justice re-re-call

and

• there is reason to believe that the patient can be found at a specific address

and

• access to that address has been denied

or

• Is likely to be denied to those seeking to take or retake the patient (any person on the staff of the hospital being legally authorised to do so)

4.2 Application for warrant under 135(2) can be made by a number of parties – ordinarily the person responsible for requesting the patients return to hospital.

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4.3 Police assistance may be sought to encourage the co-operation of the person to be

assessed. This must be in circumstances where previous experience suggests the person will be significantly more co-operative if a police officer is present. However, this is not necessarily sufficient reason for the police to attend. Other factors should be explored prior to requesting police attendance such as assessment of entry via consent, information sharing, any local protocols in place and availability of police officers

5. Required

Documentation

5.1 Under Section 135(2) NHS Foundation staff are required to obtain the below documentation –

• An ‘Information’ or Witness Statement • Good quality copy of Section Papers

• Good quality copy of Completed Section 17 Leave Form (where applicable) • Good quality copy of RCs letter recalling patient from leave (where applicable) • Section 135(2) Warrant

• Staff identification badge

5.2 Police Officers will need sight of the 135(2) warrant prior to execution.

5.3 A Police Officer executing the warrant will need to endorse the warrant once executed 5.4 A copy of the warrant is either given to the occupier of the premises (which may be the

patient) or, if the premises are empty, left at the address which was entered. 5.5 A copy of the warrant is retained by police

5.6 A copy is retained in the patient’s health records

5.7 Once executed the original warrant is to be returned to the designated officer for the local justice area concerned. If it has not been executed within the time it is valid it should be returned with an explanatory covering letter.

6.

Absent Without Leave (AWOL)

(Section 135(2) Warrant)

6.1 A patient is AWOL if they:

• Have left hospital in which they are detained without their absence being agreed (under Section 17 of the Act) by their Responsible Clinician (RC)

• Have failed to return to the hospital at the time required by conditions of leave under Section 17

• Are absent without permission from a place where they are required to reside as a condition of leave under Section 17

• Have failed to return to the hospital when their leave under Section 17 has been revoked

• Are a conditionally discharged restricted patient whom the Secretary of State for Justice has recalled to hospital

• Patients subject to Section 7 Guardianship are regarded as AWOL if they have

absconded from a place they are required to reside. Section 135(2) warrants may also be requested in these circumstances, in which case Community Mental Health Team (CMHT) staff and social services would normally take the lead in applying for a warrant and arranging for it to be executed. The general advice set out in this policy will apply. • Patients subject to Supervised Community Treatment (SCT) under Section 17a are also

Figure

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References

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