Supervised Community Treatment and Community Treatment Orders (S17(a)) Policy

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1 Supervised Community Treatment and Community Treatment Orders (S17(a)) Policy

2 SUPERVISED COMMUNITY TREATMENT AND COMMUNITY TREATMENT ORDERS (S17(A)) POLICY Document Type Policy Unique Identifier CL-010 Document Purpose This policy provides assurance that mental health professionals have up to date guidance and paperwork to support the use of the Mental Health Act 1983 (amended 2007) in order to deliver the best possible high quality patient care Document Author Helen Reynolds, Mental Health Act/Patient Records Manager Target Audience Worcestershire Health and Care NHS Trust staff working with sectioned patients Responsible Group Hospital Managers Mental Health Act Monitoring Group Date Ratified 24 August 2011 (NHS Worcestershire) Expiry Date 24 August 2014 Equality Impact Assessment: 12 July 2011 This validity of this policy is only assured when viewed via the Worcestershire Health and Care NHS Trust website (hacw.nhs.uk.) or via the NHS Worcestershire website (worcestershire.nhs.uk). If this document is printed into hard copy or saved to another location, its validity must be checked against the unique identifier number on the internet version. The internet version is the definitive version. If you would like this document in other languages or formats (i.e. large print), please contact the Communications Team on or Policy on Supervised Community Treatment & Community Treatment Orders v01 Page 1 of 14

3 Version History Version Circulation Date Job Title of Person/Name of Group circulated to Brief Summary of Change Quality & Safety Committee none Worcestershire Health and Care NHS Trust holds a contract with Applied Language Solutions to handle all interpreting and translation needs. This service is available to all staff in the Trust via a free-phone number ( ). Interpreters and translators are available for over 150 languages. From this number staff can arrange: Face to face interpreting; Instant telephone interpreting; Document translation, via the Communications Manager and British Sign Language interpreting. Please note that where the visit or consultation is likely to be less than 40 minutes in duration telephone interpreting should be the preferred option. Where a lengthy consultation is expected a pre booked face-to-face interpreter would be more appropriate. Policy on Supervised Community Treatment & Community Treatment Orders v01 Page 2 of 14

4 SUPERVISED COMMUNITY TREATMENT & COMMUNITY TREATMENT ORDERS (S17A) Contents 1. What is, and what is the purpose of, Supervised Community Treatment? Guiding Principles of the Mental Health Act Criteria for a CTO Who can be considered for a CTO? Who cannot be considered for a CTO? The criteria for a CTO Age limits for a CTO The Statutory Forms Rectification of statutory forms Functionalisation who is the Responsible Clinician (RC)? Adult Early Intervention and Assertive Outreach services Making a CTO Roles of the Professionals Making a CTO statutory form CTO Conditions to be attached to the CTO Statutory conditions Individual conditions Varying the conditions Temporary suspension of conditions Medical treatment under CTO CTO patients in the community (part 4a) Emergency treatment whilst on a CTO The SOAD Treatment for physical disorders Informal admission to hospital for CTO patients Recall to hospital Conveying to hospital following recall Requirements on nursing staff following recall Recalled patients accepted from other Trusts/Hospital Managers Release from Recall Revoking a CTO The effect of revocation Roles of the professionals: Extending the CTO Procedure for extending the CTO Roles of the professionals: CTOs and hospitals not managed by Worcestershire Health and Care NHS Trust Transferring a CTO patient to different hospital managers Accepting recalled patients from hospitals under different hospital managers Recalling to a hospital under different hospital managers Hearings Discharging the CTO Useful reading: Policy on Supervised Community Treatment & Community Treatment Orders v01 Page 3 of 14

5 1. What is, and what is the purpose of, Supervised Community Treatment? Supervised Community Treatment (SCT) is the part of the Mental Health Act 1983 that allows certain detained patients to leave hospital and live back in the community, whilst having an agreed treatment plan. The way that this is achieved is by a Community Treatment Order (CTO). A CTO has the effect of discharging the patient from hospital, but enabling their recall to hospital if inpatient treatment becomes necessary again. The CTO effectively suspends the originating section. Longer-term leave of absence under s17 may not be granted to a patient unless the responsible clinician first considers whether the patient should be discharged on a CTO. Longer-term leave is defined as more than seven consecutive days, or an extension which would make the total period more than seven consecutive days. The time periods for a CTO are the same as for detention under s3. It lasts initially for a maximum of six months, but can be extended for a further six months and thereafter can be extended for 12-month periods. In research conducted by the Care Quality Commission, the success of CTO s was noted to be greater when the patient had been involved with and consenting to the CTO from the outset. This policy should be read in conjunction with the Act (Section 17A-17G), the Code of Practice (chapter 25) and the Department of Health/NIMHE publication Supervised Community Treatment: A guide for practitioners. 2. Guiding Principles of the Mental Health Act The following set of principles should be considered when making decisions under the Act. They should inform decisions, not determine them. Decisions under the Act must always be lawful and informed by good professional practice; they must also be balanced by the individual needs of each patient. 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 person 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, Policy on Supervised Community Treatment & Community Treatment Orders v01 Page 4 of 14

6 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. 3. Criteria for a CTO 3.1 Who can be considered for a CTO? Patients may only become SCT patients if they are currently detained on the basis of: Section 3 application for admission for treatment Section 37 or 51 a hospital order (without a restriction order) Section 45a a hospital direction (but no longer a limitation direction) Section 47 or 48 a transfer direction (without a restriction direction) 3.2 Who cannot be considered for a CTO? SCT cannot be used for patients who are subject to restrictions imposed by the courts. It cannot be used for patients subject to sections 2 or 4 and it cannot be used on patients who are not currently detained under the Act (ie retrospectively) 3.3 The criteria for a CTO a. The patient is suffering from mental disorder of a nature or degree which makes it appropriate for the patient to receive medical treatment b. It is necessary for the patient s health or safety or for the protection of other persons that the patient should receive such treatment c. Subject to the patient being liable to be recalled, such treatment can be provided without the patient continuing to be detained in a hospital d. It is necessary that the responsible clinician should be able to exercise the power under section 17e(1) to recall the patient to hospital And e. Appropriate medical treatment is available for the patient If there are no concerns as to whether the patient would continue with the agreed treatment plan once they left hospital, then d) above would suggest that a CTO Policy on Supervised Community Treatment & Community Treatment Orders v01 Page 5 of 14

7 serves no purpose. Likewise, if the treatment is only available in hospital, then c) above also indicates that a CTO is not suitable. 3.4 Age limits for a CTO There are no age limits surrounding CTO s, however the criteria above must be met. 4. The Statutory Forms There are a series of statutory forms relating to CTO s and most steps allowed under a CTO will require a form to be completed. The forms are as follows: CTO1 CTO2 CTO3 CTO4 CTO5 CTO6 CTO7 CTO8 CTO9 CTO10 CTO11 community treatment order variation of conditions of a community treatment order community treatment order: notice of recall to hospital community treatment order: record of patient s detention in hospital after recall revocation of community treatment order authority for transfer of recalled community patient to a hospital under different managers community treatment order: report extending the community treatment period authority for extension of community treatment period after absence without leave for more than 28 days community patients transferred to England authority for assignment of responsibility for community patient to hospital under different managers certificate of appropriateness of treatment to be given to community patient (part 4a certificate) 4.1 Rectification of statutory forms CTO forms are not rectifiable. Mistakes other than those which are de minimis (of no importance) will render the forms invalid and in some cases can invalidate the section. An example of a de minimis error may be a spelling error or similar where the original meaning of the text remains clear. 5. Functionalisation who is the Responsible Clinician (RC)? Worcestershire Health and Care NHS Trust has Functional RCs, ie inpatient consultants and community consultants. With the exception of Early Intervention (adult) and Assertive Outreach patients, inpatient consultants will be the RC for all patients detained in hospital. When making a CTO, the inpatient RC must agree the treatment plan and any conditions with the RC in the community. The community RC will be assuming responsibility for the CTO from the date and time stated in part 3 of the form CTO1. These consultants should also agree the risk criteria that the patient must meet to consider being recalled to hospital. Where a Crisis Resolution Home Treatment team (CRHT) psychiatrist is also temporarily involved in the patient s care, different short term RC arrangements may apply. When recalling the patient to hospital, the community RC remains RC until the form CTO4 is completed (which is when the patient is admitted to hospital) at which time the inpatient RC assumes responsibility. Policy on Supervised Community Treatment & Community Treatment Orders v01 Page 6 of 14

8 Normal out-of-hours and cross cover arrangements for RC s apply, as agreed by the Medical Advisory Committee 5.1 Adult Early Intervention and Assertive Outreach services For patients of the EI and AO services, the RC will remain the same throughout the entire period of care. 6. Making a CTO 6.1 Roles of the Professionals Responsible Clinician (RC) The RC must consult with the patient, patient relatives or carers (unless the patient objects), the GP, the multi-disciplinary team that the patient will be caring for the patient in the community, as well as the Community RC (if applicable). The RC must indicate that the criteria for SCT are met and stipulate any conditions which are to be applied to the CTO, by completing part 1 of form CTO1. Once the AMHP has completed part 2 of the form, the RC must complete part 3. The RC must also complete a Care Quality Commission (CQC) Second Opinion Appointed Doctor (SOAD) request and send it to the MHAA with the original CTO form. Note: if the AMHP does not agree that the criteria for the CTO are met, the RC cannot simply approach another AMHP for an alternative view. Approved Mental Health Professional (AMHP) To make a CTO, the AMHP must assess the patient and once the assessment is complete, agree in writing that the patient meets the criteria for SCT, and that the proposed conditions are suitable. Once they are satisfied, they must complete part 2 of the form CTO1. If the AMHP does not agree, a CTO cannot be made and a record and reasons for the AMHP s decision must be recorded in the notes. Care Co-ordinator The care co-ordinator is an important facet of a successful CTO. They will be expected to be involved in the setting up of the CTO and to be the facilitator of the SOAD visit. They are also vital in ensuring that the patient is aware of their right of appeal against the CTO, as well as their right to an Independent Mental Health Advocate (IMHA). MHA Administrator (MHAA) the MHAAs as well as a s12(2) approved clinician unconnected to the patient, will scrutinise the form CTO1. This form cannot be rectified and if there are mistakes on the form, the MHAA will notify the RC accordingly. A copy of the AMHP assessment should also be provided to the MHAA. The MHAA will write to the patient and their nearest relative (unless there are express reasons why the nearest relative should not be informed), notifying them of the CTO, the duration, conditions attached, rights etc. A copy of the letters will be made available to the care co-ordinator. The MHAA will also ensure that the SOAD request form is submitted to the CQC. Second Opinion Appointed Doctor (SOAD) at present, the CQC are required to authorise the treatment plan and this needs to be done within a month of the start of the CTO. A SOAD will use form CTO11 to authorise both the treatment in the community and any treatment to be given in the event of a recall to hospital. If a Policy on Supervised Community Treatment & Community Treatment Orders v01 Page 7 of 14

9 SOAD does not provide the authorisation in time, s64g must be used to authorise treatment until such time as a SOAD sees the patient. 6.2 Making a CTO statutory form CTO1 CTO1 must be completed in date order, with the RC completing part 1, the AMHP completing part 2 and the RC then completing part 3. Although there are no statutory timescales around the creation of a CTO and the completion of a CTO1, the process must take place in a timely fashion. If the patient being considered for a CTO is on a section that is due to expire, it is the responsibility of the RC to ensure that the CTO paperwork can be scrutinised and accepted on behalf of the Hospital Managers prior to that expiry date and the date that the CTO is due to come into force. Incorrect paperwork can lead to the CTO not being accepted and if the original section has expired, the patient is no longer subject to the Mental Health Act The RC should allow the MHAAs at least 7 days before the CTO is to come into force, to ensure that the completion of the form is correct. 7. Conditions to be attached to the CTO When considering appropriate conditions, RC s must consider Article 8 of the Human Rights Act This Article relates to the right to respect for private and family life, home and correspondence and it prevents a public authority from intruding disproportionately into a person's private life. The code of practice to the MHA (chapter 25) contains expectations of the conditions, particularly; The number of conditions must be kept to a minimum They should restrict the patient s liberty as little as possible Have a clear rationale They should be clear so that the patient can understand what is expected 7.1 Statutory conditions Two statutory conditions are attached to each CTO, these are: (a) a condition that the patient make himself available for examination under section 20A below; and (b) a condition that, if it is proposed to give a certificate under Part 4A of this Act in his case, he make himself available for examination so as to enable the certificate to be given. The first mandatory condition relates to the extension - or renewal - of the CTO; the second to the assessment required for a SOAD certificate. These conditions are pre-printed on form CTO1. Policy on Supervised Community Treatment & Community Treatment Orders v01 Page 8 of 14

10 7.2 Individual conditions The RC (with the agreement of the AMHP) can make other conditions if they believe that they are necessary and appropriate to ensure that the patient receives medical treatment, and/or prevents the risk of harm to the patient s health or safety or for the protection of other people. These conditions must be clearly stated on the CTO1. These conditions will depend on the individual. They may include matters such as when and where the patient receives treatment, avoidance of known risk factors, etc. 7.3 Varying the conditions The RC can vary the conditions of a CTO, or to suspend them for a period. Form CTO2 is used to record any variation in conditions. Once complete, this must be sent to the MHAA, who will notify the patient and their nearest relative of the variation. An AMHP is not required to approve the variation, but it is good practice to involve the care team in this type of decision. 7.4 Temporary suspension of conditions If the conditions are to be temporarily suspended, for instance if the patient is going on holiday, the RC does not have to complete any statutory paperwork, however it is recommended that the suspension and expected duration is recorded in the patient record. 8. Medical treatment under CTO 8.1 CTO patients in the community (part 4a) Prior to going onto a CTO, patients will normally have their treatment authorised by a form T2 (capacitous and consenting) or T3 (non-consenting or incapacitous). For those patients going onto SCT who are within the three months treatment allowed under s58, treatment under the CTO does not need further authorisation until the three months is up. The consent of the patient to the treatment plan is important when assessing the likelihood of success of the CTO. SCT does not authorise treatment without consent in the community and mere failure of the patient to take the treatment does not, in itself, warrant recall. Part 4a rules recognise aspects of the Mental Capacity Act 2005, including advance decisions and persons appointed to make decisions under lasting powers of attorney or court appointed deputies. At present, the CQC require that the treatment regime for a CTO patient be authorised by a SOAD within one month of the CTO starting, using form CTO11. This certificate will also cover any treatment to be provided if the patient is recalled to hospital. 8.2 Emergency treatment whilst on a CTO Treatment can only be given to a capable patient where they have consented to it and there is a SOAD certificate authorising it. There are no exceptions to this rule, even in emergencies. The effect is that treatment can only be given without a patient s consent if they are recalled to hospital. Policy on Supervised Community Treatment & Community Treatment Orders v01 Page 9 of 14

11 If there is a delay in gaining the SOAD certificate, s62 may be used to authorise treatment to a consenting patient. 8.3 The SOAD The SOAD will expect to meet the patient at a community building, they will not go to the patient s home. They will consult with both the RC and another statutory consultee. Please refer to the Trust policy Consent to Treatment under the MHA for further guidance. 8.4 Treatment for physical disorders As with all other sections, treatment for physical disorders cannot be authorised under the MHA, unless they result from a manifestation of the mental disorder. 8.5 Informal admission to hospital for CTO patients Patients subject to CTO can choose to be admitted to hospital informally. If, during that admission, there are concerns about their mental health, the recall notice can be served at that point. If a patient subject to a CTO is a voluntary inpatient, should they then choose to leave, holding powers s5(4) and s5(2) cannot be used by staff. Staff may consider using common law to restrict the movement and maintain the safety of a patient whilst awaiting the completion of a CTO3, if they deem this step a reasonable response to protect others from an immediate risk of significant harm 1. The reasons for doing this must be clearly recorded in the records. If the patient lacks capacity, the Mental Capacity Act 2005 may be used to authorise a restriction of movement, again this must be a proportionate response to the level of risk posed and can only be used whilst a CTO3 is being prepared by the RC. 9. Recall to hospital If the patient breaches either of the statutory conditions, they can be recalled. Merely failing to meet one or more of the non-statutory conditions of the CTO does not in itself warrant recall to hospital. It is only at the point where the RC believes that the patient needs medical treatment for their mental disorder in hospital - and that if they were not recalled there could be a risk to their health or safety, or that of others that the criteria for recall is met. Conversely, if deterioration in the patient s mental state is occurring despite adherence with the care plan, recall is permissible if this cannot be managed in a less restrictive fashion. Form CTO3 is the written notice of recall. The form CTO3 can be served on the patient in three different ways, these are: (a) Handing the patient the recall notice once it is given to the patient, notice has been served. (b) Delivering the notice to the last known address notice is considered to be served at the start of the following day (00.01am) 1 R (Munjaz) v Ashworth Hospital Authority (2005) UKHL 58 Policy on Supervised Community Treatment & Community Treatment Orders v01 Page 10 of 14

12 (c) Posting the notice first class to the last known address notice is served two business days after it was posted. A copy of the CTO3 must be passed to the MHAA of the hospital where the patient is to be recalled this does not have to be the same hospital as the one from which they were discharged. Patients do not have to be recalled to a hospital bed; they may be recalled to a community building, if this will allow treatment to be provided. The recall period begins (72 hours) when the patient arrives at the place to which they have been recalled and form CTO4 is completed. Patients can subsequently be transferred to different hospitals. If the patient fails to return to hospital as directed by the CTO3, they are absent without leave (AWOL) and the usual AWOL processes can be used to return the patient to hospital. 9.1 Conveying to hospital following recall Staff should refer to the Trust conveyancing policy (CP0116); recall to hospital should take place in the least restrictive manner possible. 9.2 Requirements on nursing staff following recall To activate the recall, form CTO4 must be completed to record the start of the patient s period of detention. If this is not done the recall is invalidated. In Worcestershire Health and Care NHS Trust, the form can be completed by any qualified nurse or MHAA. The recall lasts for up to 72 hours. Any patient subject to recall must be informed about their rights; leaflets are available on the trust intranet. It is always preferable that a copy of the CTO3 is made available to ward staff at the time that the patient arrives at hospital; however, if a copy of the CTO3 has not been provided to nursing staff, they are entitled to rely on the word of a professional involved in the recall to enable them to complete the form CTO4. On completion, the CTO4 must be passed to the MHAA, who will record the recall and provide a copy of the form for casenotes. If the CTO3 has not been received by the MHAA, they will make further enquiries at that stage. 9.3 Recalled patients accepted from other Trusts/Hospital Managers Where a patient is subject to a CTO made elsewhere, but is recalled and transferred to a Trust ward, ward staff must ensure that they receive a copy of the CTO3 and CTO6. If the patient had already been admitted to another hospital under this period of recall, a copy of the CTO4 (completed by that hospital) is also required. In all cases, please contact the MHA Administrator at the earliest opportunity. Policy on Supervised Community Treatment & Community Treatment Orders v01 Page 11 of 14

13 9.4 Release from Recall At any time within the 72 hours, the RC may choose to release the patient from recall. Patients must be released when the 72 hours are up, if the CTO is not revoked. The person may remain in hospital informally, though they may return to the community and the CTO continues as before. There is no form for recording this, but ward staff must advise the MHAA when this has happened. 10. Revoking a CTO 10.1 The effect of revocation A patient must be recalled (as above) before the CTO is revoked. CTO5 must be completed (in order, as per the CTO1) to revoke the CTO. The effect of CTO5 is to return the patient to day 1 of the section under which they had previously been detained, without the need for further assessment. A revocation of a CTO will automatically trigger a Tribunal Roles of the professionals: RC during the 72 hours assessment period, the RC can revoke the CTO if they believe that the patient meets the criteria for s3, but they need the written agreement of an AMHP. This does not need to be the same AMHP that was involved in the creation of the CTO. AMHP If the AMHP is in agreement that the CTO should be revoked, they must agree in writing with the RC s view that the patient meets s3 criteria, and also agree that it is appropriate for the CTO to be revoked. The AMHP must complete part 2 of the CTO5. MHAA the MHAA will refer the patient to the Tribunal, as required for the revocation of a CTO. They will also advise the RC in respect of the situation surrounding part 4 of the Act (consent to treatment) as it relates to the patient. Named nurse must notify the patient of their rights, using the leaflets available for download on the intranet. 11. Extending the CTO The CTO will expire at the end of 6 months unless it is extended. Following a second 6 month period, the extension period is one year. The criteria for extension of the CTO is the same as was originally required Procedure for extending the CTO Form CTO7 is the statutory form for extending a CTO. As per the other statutory forms, the various parts should be completed in order Roles of the professionals: RC must assess the continuing suitability of the patient for a CTO within 2 months prior to the expiry of the original order. It is one of the mandatory conditions that the patients makes themselves available for this. They must also consult with A N Other Policy on Supervised Community Treatment & Community Treatment Orders v01 Page 12 of 14

14 person professionally concerned with the patient s treatment (usually the care coordinator) as well as an AMHP. The RC must ensure that the form CTO7 is provided to the MHAA s in a timely fashion, no less than 7 days prior to the expiry of the original CTO. As with other CTO documents, CTO7 is not rectifiable and a faulty form will invalidate the section. The RC must also complete form MHAC1, reporting the treatment plan, to the CQC. This is available from the MHAA or via the Trust consent to treatment under the MHA policy CP0125. AMHP This does not need to be the same AMHP that was originally involved with creating the CTO. Following assessment of the patient, if the AMHP agrees that the criteria for a CTO are still met, they must complete part 2 of the CTO7. Care Co-ordinator will usually be the person that the RC consults with, they should record this discussion within the notes. MHAA on receipt of the CTO7, the MHAA will scrutinise the form and send it out for independent scrutiny by an RC unconnected to the case. Once satisfied that the form is correct, the MHAA will sign CTO7, accepting the CTO on behalf of the hospital managers. They will also record the section on NCRS. The MHAA will write to the patient and nearest relative advising them of the extension of the CTO and reiterating their rights. They will also arrange hearings as appropriate. They will also ensure that the MHAC1 is completed by the RC and sent to the CQC. 12. CTOs and hospitals not managed by Worcestershire Health and Care NHS Trust 12.1 Transferring a CTO patient to different hospital managers If a patient is recalled, they can be transferred to a hospital under different managers within the 72 hours, using form CTO6. A copy of the CTO4 must be provided to the receiving hospital and a copy of the completed CTO6 must be retained and passed to the Worcestershire MHAA Accepting recalled patients from hospitals under different hospital managers If Worcestershire Health and Care NHS Trust are the hospital managers of the receiving hospital, a copy of the CTO4 and the original CTO6 must be passed to the MHAA as soon as possible. They will obtain the rest of the legal documentation from the sending hospital Recalling to a hospital under different hospital managers Patients can be recalled to a hospital under different hospital managers. In that event, the MHAA must be provided with a copy of the CTO3 and notified of the name and address of the responsible hospital in order that they can liaise with their counterparts with regard to the legal documentation. 13. Hearings Hospital Managers Patients may appeal to the hospital managers to review the CTO at any time, and more than once in each period of detention. If the CTO is extended by the RC, on receipt of the CTO7 the MHAA will arrange for a review of detention by the hospital managers to take place. The MHAA will write to the patient and ascertain whether they Policy on Supervised Community Treatment & Community Treatment Orders v01 Page 13 of 14

15 object to the extension of the CTO. If there is an objection, or it is suspected that the patient lacks capacity to make this decision, then a full hospital managers hearing will be held. If the patient does not object, the hospital managers may choose to hold a paper review, using professionals reports only. Tribunals the patient can appeal to the Tribunal once in each period of detention. If they do not appeal, the Hospital Managers are obliged to refer the case to the Tribunal once every 3 years. 14. Discharging the CTO CTOs can be discharged by the: RC Nearest Relative (unless barred by the RC) Hospital Managers First Tier Tribunal If the RC discharges the CTO, they must advise the MHAA in writing, using the section 23 forms available. The MHAA will write to the patient and their nearest relative advising them of the discharge of the CTO. 15. Useful reading: National Institute for Mental Health in England: Supervised Community Treatment: A Guide for Practitioners Code of Practice to the Mental Health Act 1983 Policy on Supervised Community Treatment & Community Treatment Orders v01 Page 14 of 14

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