Staff with responsibilities under Section 17 of the Mental Health Act. Section 17, Mental Health Act, authorisation, leave, detained, patients

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1 Policy: Section 17 Mental Health Act - Authorisation of Leave (Detained Patients) Executive or Associate Director lead Policy author/ lead Feedback on implementation to Clive Clarke, Executive Director of Operations Sobhi Girgis, Consultant Catherine Dixon, Mental Health Act Administrator Document type Policy Document status Final Date of initial draft October 2016 Date of consultation October 2016 Date of verification 8 November 2016 Date of ratification 16 November 2016 Ratified by Executive Directors Group Date of issue 17 November 2016 Date for review 31 October 2019 Target audience Keywords Staff with responsibilities under Section 17 of the Mental Health Act Section 17, Mental Health Act, authorisation, leave, detained, patients Policy Version and advice on document history, availability and storage This is version 3. This version replaces the previous version 2 (issued June 2012). This version was reviewed and updated as part of an on-going policy document review process. This policy will be available to all staff via the Sheffield Health & Social Care NHS Foundation Trust Intranet and on the Trust s website. The previous version will be removed from the Intranet and Trust website and archived. Word and pdf copies of the current and the previous version of this policy are available via the Director of Corporate Governance. Any printed copies of the previous version (V2) should be destroyed and if a hard copy is required, it should be replaced with this version. 1 P a g e

2 Contents Section Page 1 Introduction 3 2 Scope 3 3 Definitions 3 4 Purpose 4 5 Duties 4 6 Process i.e. Specific details of processes to be followed Purpose of Section 17 leave When is Section 17 leave necessary? Who may grant leave? Planning leave Assessment and review of leave Recording of leave Conditions Leave to reside in another hospital Role of nursing staff Review of leave Cancellation of leave Recall to hospital Absent without leave - AWOL 11 7 Dissemination, storage and archiving 11 8 Training and other resource implications 11 9 Audit, monitoring and review Implementation plan Links to other policies, standards and legislation (associated 13 documents) 12 Contact details References 13 Appendices Appendix A Version Control and Amendment Log 14 Appendix B Dissemination Record 15 Appendix C Equality Impact Assessment Form 16 Appendix D - Human Rights Act Assessment Checklist 17 Appendix E Development, Consultation and Verification Record 19 Appendix F Policy Checklist 20 Appendix G Authorisation of Section 17 Leave Form 22 Appendix H Guidance for Patients not Legally Detained 23 (Operational Duty) 2 P a g e

3 1. Introduction The Mental Health Act 2007 amends the Mental Health Act This policy is reviewed and amended in line with the amendments to the Mental Health Act. Section 17 Mental Health Act 1983 makes provision for certain patients who are detained in hospital under the Mental Health Act 1983 to be granted leave of absence. It provides the only lawful authority for a detained patient to be absent from the hospital. This policy is needed to ensure the Trust complies with the Mental Health Act 1983 and meets the requirements set out in the Code of Practice to the Mental Health Act. 2. Scope This policy applies to all who are involved in the care and treatment of those detained in hospital under the Mental Health Act 1983 and those who are not detained but to whom the operational duty applies this particularly relates to patients / service users who are not legally detained. 3. Definitions The Act Refers to the Mental Health Act 1983 as amended by the Mental Health Act 2007 Patient For the terms of this policy a patient is someone who is liable to be detained under Part II of the Mental Health Act 1983, following an application by an Approved Mental Health Professional or by the patient s nearest relative. Any application must be supported by medical recommendations completed by appropriately qualified medical practitioners. Patients detained under Part III of the Act, being patients concerned in criminal proceedings or under sentence of the courts, have different conditions. Approved Clinician A person approved by The Secretary of State to act as an approved clinician for the purposes of this Act. Responsible Clinician The Responsible Clinician (RC) is the Approved Clinician with overall responsibility for the patient s case. The role is not delegable but temporary cover is permitted. Cover arrangements must be clear in order to avoid unlawful granting of leave Part 2 MHA Compulsory admission to hospital. Part 2 Patient For the purposes of Section 17 leave, patients who became subject to compulsion under the Act by an application for detention by a nearest relative or an approved mental health professional i.e. someone detained under section 2 or section 3. Part 3 MHA: Patients Concerned in Criminal Proceedings or Under Sentence Unrestricted Part 3 Patient A patient who is liable to be detained in hospital on the basis of a Hospital Order (section 37) or Hospital Direction (section 45A) who never was or is no longer subject to Ministry of Justice (MoJ) restrictions or limitations (sections 41 and 49 respectively). Restricted Part 3 Patient 3 P a g e

4 A patient who is subject to Ministry of Justice (MoJ) restrictions or limitations. (Sections 41 and 49 respectively). Leave cannot be granted by the RC without the written permission of the Minister of State for Justice Hospital Under the Mental Health Act 1983, hospital has the meaning given to it by the National Health Service Act 2006 (MHA manual, 14 th ed), that is any institution for the reception and treatment of persons suffering from illness. However now those hospitals may be divided into units and may not be coterminous with managers, a hospital, for the purpose of section 17, leave can be defined as only those buildings on a particular site that are adjacent to each other and have the same NHS Managers. It is the responsibility of each site to ensure it has a working definition of its boundaries. 4. Purpose This policy provides guidance for nursing, medical staff and other staff who are involved in the care and treatment of patients detained under the Mental Health Act 1983 and those who are not detained but to whom the operational duty applies. It describes who may grant leave, management of the process of the leave, systems for recording and the role of the staff within this. The purpose of this policy is to ensure that those who implement the provisions of the Act work within its boundaries and are aware of the scope of these boundaries. 5. Duties Responsible Clinician: The Responsible Clinician is responsible for: Authorising Section 17 leave requests (see 6.3, 6.8) Ensuring that he/ she is informed of any child protection, child welfare issues, adult protection or domestic abuse issues (see 6.4) Recording the decision to grant / refuse leave and rationale in the patient / service user s notes and on the relevant Mental Health Act Documentation (Authorisation for leave form) Considering the benefits and any risks to the patient s health and safety of granting or Refusing leave Considering the benefits of granting leave for facilitating the patient s recovery balance these benefits against any risks that the leave may pose for the protection of other people (either generally or particular people) Considering any conditions which should be attached to the leave, e.g. requiring the patient not to visit particular places or persons Taking account of the patient s wishes, and those of carers, friends and others who may be involved in any planned leave of absence Considering what support the patient would require during their leave of absence and whether it can be provided Ensuring that any community services which will need to provide support for the patient during the leave are involved in the planning of the leave, and that they know the leave dates and times and any conditions placed on the patient during their leave Ensuring that the patient is aware of any contingency plans put in place for their support, including what they should do if they think they need to return to hospital early Liaising with any relevant agencies, e.g. the sex offender management unit (SOMU) Undertaking a risk assessment and put in place any necessary safeguards, and (in the case of part 3 patients see chapters 22 and 40 Mental Health Act 1983 Code of Practice (2015)) consider whether there are any issues relating to victims which impact on whether leave should be granted and the conditions to which it should be subject. Ensuring that a care plan, incorporating a contingency plan is written (see 6.7) Ensuring that the duty to provide aftercare under Section 117 (for those eligible) includes patients / service users who are on leave has been met. 4 P a g e

5 Recalling a patient / service user on leave when it is necessary in the interest of the patient / service user s health or safety or necessary for the protection of others (see 6.11). Ward Manager: The Ward Manager is responsible for: Ensuring that all staff (within remit) comply with this policy Ensuring that Section 17 leave forms are completed before any applicable period of leave and that decisions and rationales for leave requests are recorded in the patient s notes and on Section 17 leave request forms, checking compliance on at least a weekly basis (see 6.6). Nursing staff: Nursing staff are responsible for (see also 6.9): Contributing to the granting, planning and facilitation of leave Ensuring that Section 17 leave forms have been completed and that these are recorded in the patient s record, with a copy given to the patient Assess the patient s clinical state and conduct a risk assessment prior to each period of leave (see 6.9) Withholding leave if required Ensuring that appropriate escort and support arrangements are in place Meeting the information needs of patients, relatives and carers. Recording details and outcomes of each period of leave Ensuring that an up to date description of the patient and a photograph (see 6.6, 6.9) are recoded in the notes. All Staff: All staff implementing the provisions of the Mental Health Act must be aware of their duties and responsibilities under the Mental Health Act and the guidance of the Code of Practice; and must comply with this policy. 6. Process 6.1 The purpose of Section 17 leave Section 17 makes provisions for certain patients / service users who are detained in hospital under the Mental Health Act 1983 to be granted leave of absence for any reason. It provides the only lawful authority for a detained patient / service user to be absent from the hospital. Section 17 leave applies to patients / service users detained under sections 2, 3, 37 and notional 37. Section 17 applies technically to sections 47 and 48 if unrestricted, but in practice such transferred prisoners will normally be subject to restrictions. Section 17 applies to those patients / service users detained and restricted or subject to limitations under Sections 37/41 and 45A; however approval must first be sought from the Secretary of State for Justice. It does not apply to those patients / service users detained under Sections 4 or 5 or to those patients / service users who have been remanded in hospital under Sections 35 & 36 or who are subject to interim hospital orders under Section When is formally authorised Section 17 leave necessary? Whenever a detained patient / service user has official leave from the hospital site Section 17 leave is necessary, this applies to short leave (e.g. to the local shops), longer leave, escorted leave, unescorted leave and periods of stay in another hospital where transfer under Section 19 would not be appropriate (e.g. general hospital) 5 P a g e

6 For part 2 & unrestricted part 3 patients Section 17 leave is not required for the patient / service user to leave the ward and remain within the hospital grounds, however if two or more hospitals are located within the same ground but managed by different Trusts, leave must be given to move from the detaining hospital to another. Section 17 leave authorisation is required for the patient / service user to attend a different site belonging to the same Trust. If this includes an overnight stay the patient / service user should be transferred. Where the courts or the Secretary of State have decided that restricted patients are to be detained in a particular unit of a hospital. Those patients require leave of absence to go to any other part of that hospital as well as outside the hospital. For part 2 & unrestricted part 3 patients / service users longer term leave may granted but when considering authorising a period of leave which would be more than 7 consecutive days the Responsible Clinician must first consider whether a Community Treatment Order would be the better option. If, after consideration, the Responsible Clinician still feels that longer term leave is the better option, the Responsible Clinician will need to show that both options have been considered. The decision and reasons should be recorded in the care records, which should include a record of the MDT discussion. Community Treatment Orders (CTO) cannot be considered for patients / service users detained under restriction orders. CTO does not apply to restricted patients / service users. The conditions on CTOs were designed to emulate the conditions that persist under Section 41 when restricted patients are granted conditional discharge by the Secretary of State/Ministry of Justice or Tribunal. If a patient / service user who is detained under one section is granted leave but subsequently becomes detained under another section a new authorisation of leave should be completed. 6.3 Who may grant leave? Part 2 patients & unrestricted part 3 patients Only the patient / service user s Responsible Clinician may authorise Section 17 leave. This role may not be transferred or delegated to another doctor. In the absence of the Responsible Clinician (by illness or leave or out of hours), leave may only be granted by the Approved Clinician who is for the time being acting as the patient / service user s responsible Clinician. In the absence of the RC in the out of hours period and during weekends and bank holidays, the duty consultant would take over the over the role RC. Additional information is available in the Allocation of a Responsible Clinician Policy. Restricted patients / service users Leave may be granted to patients / service users detained under a restriction order but authorisation must first be sought form the Secretary of State for Justice by the Responsible Clinician (only the Responsible Clinician can make this request). The Secretary of State should be given as much notice as possible, together with full details of the proposed leave. 6.4 Planning leave Leave should only be granted after careful planning and risk assessment. The decision for leave to be granted should be discussed and agreed in the MDT available at the time and should involve the patient / service user, family, carers and the CMHT / other community services where appropriate. The benefits of granting leave need to be balanced against any risks that leave may pose to the protection of the patient / service user and others. The Responsible Clinician must also be aware of any child protection, child welfare issues, adult protection or domestic abuse issues. Consideration must also be given to what support the patient / service user would require and whether this can be reasonably provided. The 6 P a g e

7 decision to grant leave and rationale should be recorded in the patient / service user s notes and on the relevant Mental Health Act Documentation (Authorisation for leave form). At this point consideration should be given as to the taking of photographs as per local procedure of appropriate. The patient / service user should be involved in the decision to grant leave and should be asked to consent to any consultation with others that is thought necessary. It is the Responsible Clinician s responsibility to undertake any appropriate consultation. If a carer or relative is involved in or affected by the leave they should be consulted and if they are taking the service user out under their care/accompany them then their responsibilities should be explained and this conversation then documented in the patient / service user s notes. Risk assessment should also take place immediately prior to the patient / service user going out on the planned leave (as it may be a few days since the leave was discussed and agreed) i.e. prior to each episode of leave. The shift co-ordinator (RMN) and contact nurse with input from the ward team and the Consultant, if required, should ensure that the leave remains appropriate and safe to do so based on the current health of the patient / service user. Prior to every episode of leave a record should be made of what the patient / service user is wearing particularly if there is an increased risk of AWOL. The RC retains overall responsibility for granting or refusing leave. Leave of absence can be an important part of a detained patient s care plan, but can also be a time of risk. When considering and planning leave of absence, responsible clinicians should: Consider the benefits and any risks to the patient s health and safety of granting or Refusing leave Consider the benefits of granting leave for facilitating the patient s recovery balance these benefits against any risks that the leave may pose for the protection of other people (either generally or particular people) Consider any conditions which should be attached to the leave, e.g. requiring the patient not to visit particular places or persons Be aware of any child protection and child welfare issues in granting leave Take account of the patient s wishes, and those of carers, friends and others who may be involved in any planned leave of absence Consider what support the patient would require during their leave of absence and whether it can be provided Ensure that any community services which will need to provide support for the patient during the leave are involved in the planning of the leave, and that they know the leave dates and times and any conditions placed on the patient during their leave Ensure that the patient is aware of any contingency plans put in place for their support, including what they should do if they think they need to return to hospital early Liaise with any relevant agencies, e.g. SOMU (Sex Offender Management Unit) and MAPPA (Multi-Agency Public Protection Arrangements) Undertake a risk assessment and put in place any necessary safeguards, and (in the case of part 3 patients see chapters 22 and 40 Mental Health Act 1983 Code of Practice (2015)) consider whether there are any issues relating to victims which impact on whether leave should be granted and the conditions to which it should be subject. Paragraph 27.10, Mental Health Act 1983 Code of Practice (2015) 6.5 Assessment/Review of Leave Every period of leave must be recorded in the nursing notes. This should include dates and time of departure and return. The outcome of each period of leave along with an assessment of its relative success should also be recorded. Patients / service users should be encouraged to contribute by giving their views and particular note should be made of any benefits or concerns raised by the patient / service user or any escorting staff, relatives or friends. 7 P a g e

8 6.6 Recording of leave The decision to grant leave must be recorded in the patient / service user s care records together with details and condition of leave. A section 17 leave form must be used for this purpose (Appendix G). The date and time that a patient / service user goes on Section 17 leave the must be documented. The date and time of the patient / service user s return to the ward must also be documented. A qualified member of staff should record this information. A ward manager or deputy should check compliance with this on a daily basis when possible or weekly as a minimum standard. As part of the regular monitoring of records the documentation relating to Section 17 leave and correlation with the patient / service user s care record must be checked. The information must be clearly detailed e.g. whether the patient / service user is to be escorted and by whom, how often the patient / service user may leave the hospital. Day leave must state the times during which leave can be taken and the maximum time which may be spent away from the hospital. Overnight leave should state the time and date leave can commence and the date and time leave ends. Phrases such as as per care plan are insufficient. Nursing staff may be given the authority to negotiate actual times when leave is taken. This must be recorded as part of the MDT decision making and planning. The Inpatient Care Plan should be used to support the leave granting, planning and risk assessment. Hospital managers should establish a standardised system by which responsible clinicians can record the leave they authorise and specify the conditions attached to it. Copies of the authorisation should be given to the patient and to any carers, professionals and other people in the community who need to know. A copy should also be kept in the patient s notes. In case they fail to return from leave, an up-to-date description of the patient should be available in their notes. A photograph of the patient should also be included in their notes, if necessary with the patient s consent (or if the patient lacks capacity to decide whether to consent, a photograph is taken in accordance with the Mental Capacity Act (MCA)). Paragraph 27.22, Mental Health Act 1983 Code of Practice (2015) 6.7 Conditions/Role of the Responsible Clinician The Responsible Clinician may place any condition upon the granting of leave considered to be in the interest of the patient / service user or for the protection of others. The conditions of leave should be clearly given and recorded, including escort details. It may be appropriate to authorise leave subject to the condition that a patient / service user is accompanied by a friend or relative. If that is so the Responsible Clinician should specify that the patient / service user is to be escorted/accompanied by the friend or relative only if it is appropriate for that person to be legally responsible for the patient / service user and that person understands and accepts the consequent responsibility. Escort by hospital staff should include consideration as to who is best placed/qualified to do this and whether this is within their scope of practice and job description. This should be discussed and recorded at both the planning MDT and as part of the arrangements for each episode of leave. This will also be reflected in the immediate/prior to each episode risk assessment. A care plan for leave should be drawn up and this should incorporate a contingency plan including contact numbers. 8 P a g e

9 Leave should not be used as an alternative to discharge, although it may be used to assess an unrestricted patient s suitability for discharge. The duty to provide aftercare under Section 117 (for those eligible) includes patients / service users who are on leave. A patient / service user granted leave under section 17 remains liable to be detained and the provisions of Part 4 of the Act, Consent to Treatment, still apply. Patients / service users on leave retain the right of appeal to the Mental Health Review Tribunal or Hospital Managers. 6.8 Leave to reside in another hospital Leave can be given to authorise the patient / service user to reside in another hospital but consideration should first be given to whether it would be more appropriate to transfer the patient / service user under section 19. When a patient / service user is given leave to reside in another hospital the overall responsibility of the patient / service user s care remains with the Responsible Clinician granting the leave. 6.9 Role of nursing staff Nursing staff have a vital role to play in the effective implementation, recording and evaluation of section 17 leave. The granting and planning of leave should include the contributions of nursing staff as part of the MDT and be clear on the role they are to play in facilitating this i.e. risk assessment prior to each episode of leave. There must be a correlation between the Section 17 leave form and the subsequent note in the daily record, risk assessment and care plan for safety and audit purposes. The nurse in charge/shift coordinator must ensure that a Section 17 leave form has been completed before the patient / service user is allowed to leave hospital. This task can be delegated to another registered nurse. This form should be accessible to staff at all times. Copies of the form are to be stored on each ward as well as be scanned onto the patient / service user record system. Replacement supplies can be ordered via Medical Records. Copies of the form should be handed to the patient / service user and copies given to any relatives, friends or carers who may require the information (subject to the patient / service user s consent). Although only the Responsible Clinician and in the case of restricted patients / service users the Secretary of State for Justice can authorise leave, it may be managed by nursing staff. Nursing staff should assess a patient / service user s clinical state and conduct a risk assessment prior to each period of leave, even if the taking of leave is not contingent upon the approval. Particular attention should be paid to the risk posed to the patient / service user or to others. There must be an awareness of any child protection, child welfare issues, adult protection or domestic abuse issues. Consideration must also be given to what support the patient / service user would require and whether this can be reasonably provided. The risk assessment should be recorded in the locally agreed format, and take into account the recent history, e.g. use of as required medication and the reason, incidents on the ward, 9 P a g e

10 events outside, bad news, anniversaries of significant events, speech incongruent with behaviour etc. Nursing staff have the discretion to withhold leave if they have any doubts about the patient / service user s fitness. Reasons for refusal should be documented in the notes Any decision to grant leave under circumstances that might be taken to reasons to refuse it (such as the clinical opinion that time away from the ward after a period of disturbed behaviour would be beneficial) must be carefully documented and the reasons for leave being deemed safe explained in the record. Consideration should be given to who should escort the patient / service user i.e. staff or relative / carer. Escort by hospital staff should include consideration as to who is best placed/qualified to do this and whether this is within their scope of practice and job description If staff are escorting the patient / service user they should have a mobile phone with them in case of emergency and be clear what action to take in case of an emergency. When relatives are taking a patient / service user on leave they should be made aware of what to do in the event of an emergency, they should be given the ward contact details and asked to alert the ward as soon as possible if any untoward issues arise. Guidance notes for relatives / carers should be given prior to the first period of leave. If a carer or relative is involved in or affected by the leave they should be consulted and if they are taking the patient / service user out under their care/accompanying them. The responsibilities of the escort (as defined in the guidance) should be explained and this conversation then documented in the service user s notes. Every period of leave must be recorded in the nursing notes and within the overall recording and safety system of the ward (which allows staff to see who is on and off the ward). This should include dates and time of departure and return. The outcome of each period of leave along with an assessment of its relative success should also be undertaken and recorded. Patients / service users should be encouraged to contribute by giving their views and particular note should be made of any benefits or concerns raised by the patient or any escorting staff, relatives or friends. An up to date description of the patient / service user should be recorded on the notes and a photograph taken (see 6.6) in order to improve the effectiveness of the missing persons procedure in the event of absconding or failure to return from leave. Any request to amend the leave plan to an alternative venue of increased length of time should be considered in light of a full risk assessment which should consider the risks to the service user and others and involve other professionals as necessary Review of leave Responsible clinicians should regularly review any short-term leave they authorise on this basis and amend it as necessary (paragraph 27.17, MHA 1983 Code of Practice, 2015). Any S17 forms that are no longer valid should be marked as such Cancellation of leave Should escorted leave have to be cancelled due to lack of staff escort an incident must be completed with rationale for the decision being provided and a record made in the patient / service user s notes. If leave is cancelled for other reasons this should be assessed as to whether this is incident reportable but at the very least a note made in the patient / service user record. 10 P a g e

11 6.12 Recall to hospital The Responsible Clinician may recall a patient / service user on leave when it is necessary in the interest of the patient / service user s health or safety or necessary for the protection of others. This must be in writing to the patient / service user and any other relevant persons (i.e. carers, escorts etc). The reasons for the recall must be explained to the patient / service user and a record of the explanation should be made in the patient / service user s notes. It is unlawful to recall a patient / service user to hospital to facilitate the renewal of the patient s detention under section 20 (see R v Hallstrom Ex p. W; R V Gardner Ex p. L[1986]2 All ER 306). However a patient s detention may be renewed whilst s/he is on leave even if the leave is for an extended period and the patient s contact with the hospital is modest (see R(on the application DR v Mersey Care Trust [2002] EWHC 1810(Admin)). A restricted patient / service user s leave may be revoked either by the Responsible Clinician or the Secretary of State for Justice. Patients may not be recalled from leave once they have ceased to be detained Absent without leave Section 18 of the Mental Health Act refers to patients being AWOL. When this occurs the Missing Person s Policy must be implemented. If a patient / service user fails to return from section 17 leave, the date and time and action taken must be recorded and the Absent Without Leave and Missing Patients Policy should be followed. 7. Dissemination, storage and archiving (Control) A copy of the policy will be placed on the SHSC intranet within seven days of ratification and the previous version removed by Quality Improvement team. An will be sent to all SHSC employees informing them of the revised policy. Managers are responsible for ensuring the hard copies of the previous versions are removed from any policy/procedure manually or files stored locally. The Corporate Governance team will hold archives of previous version(s). 8. Training and other resource implications The Trust delivers training on the Mental Health Act and the process of Section 17 leave forms part of that training. 11 P a g e

12 9. Audit, monitoring and review Monitoring Compliance Template Minimum Requirement Policy content, including duties and process. The completion of the section 17 leave form will be audited along with other Mental Health Act requirements on a weekly basis. Process for Monitoring Review of policy Responsible Individual/ group/committee Mental Health Act Committee Frequency of Monitoring 3 yearly, or before to meet regulatory or statutory requirements. Review of Results process (e.g. who does this?) Mental Health Act Committee Audit Ward Managers Quarterly Mental Health Act Committee Responsible Individual/group/ committee for action plan development Head of Mental Health Legislation Ward Managers Responsible Individual/group/ committee for action plan monitoring and implementation Mental Health Act Committee Mental Health Act Committee Policy documents should be reviewed every three years or earlier where legislation dictates or practices change. The policy review date for this policy is October Implementation plan Action / Task Responsible Person Deadline Progress update New policy to be uploaded onto the Intranet and Trust website. A communication will be issued to all staff via the Communication Digest immediately following publication. A communication will be sent to Education, Training and Development to review training provision. Director of Corporate Governance Director of Corporate Governance Director of Corporate Governance Within 5 working days of ratification Within 5 working days of issue Within 5 working days of issue 12 P a g e

13 11. Links to other policies, standards and legislation (associated documents) Absent Without Leave and Missing Patients Policy Allocation of a Responsible Clinician Policy Guidance to Staff on Community Treatment Orders 12. Contact details Title Name Phone Mental Health Act Administration Manager Catherine Dixon Cath.Dixon@shsc.nhs.uk 13. References Mental Health Act 1983 Mental Health Act 1983 Code of Practice revised 2015 Chapter 27 Reference Guide to the Mental Health Act 1983, revised 2015 Chapter 25 Mental Health Act Manual, Richard Jones 19 th Edition 13 P a g e

14 Appendix A Version Control and Amendment Log Version No. Type of Change Date Description of change(s) V3 D0.1 Initial draft Oct 2016 Previous version mapped onto new policy template. Content reviewed and updated. V3 D0.2 Draft for consultation / verification 3.0 Review / ratification / issue Nov 2016 Nov 2016 Ratified/ finalised / issued 14 P a g e

15 Appendix B Dissemination Record Version Date on website (intranet and internet) Date of all SHSC staff 3.0 Nov 2016 Nov 2016 via Communications Digest Any other promotion/ dissemination (include dates) 15 P a g e

16 Equality Impact Assessment Process for Policies Developed Under the Policy on Policies Stage 1 Complete draft policy Appendix C Stage One Equality Impact Assessment Form Stage 2 Relevance - Is the policy potentially relevant to equality i.e. will this policy potentially impact on staff, patients or the public? If NO No further action required please sign and date the following statement. If YES proceed to stage 3 This policy does not impact on staff, patients or the public (insert name and date) Stage 3 Policy Screening - Public authorities are legally required to have due regard to eliminating discrimination, advancing equal opportunity and fostering good relations, in relation to people who share certain protected characteristics and those that do not. The following table should be used to consider this and inform changes to the policy (indicate yes/no/ don t know and note reasons). Please see the SHSC Guidance on equality impact assessment for examples and detailed advice. This is available by logging-on to the Intranet first and then following this link AGE DISABILITY GENDER REASSIGNMENT PREGNANCY AND MATERNITY RACE RELIGION OR BELIEF SEX SEXUAL ORIENTATION Does any aspect of this policy actually or potentially discriminate against this group? Can equality of opportunity for this group be improved through this policy or changes to this policy? No No No No No No No No No No No No No No No No No No No No No No No No Can this policy be amended so that it works to enhance relations between people in this group and people not in this group? Stage 4 Policy Revision - Make amendments to the policy or identify any remedial action required (action should be noted in the policy implementation plan section) Please delete as appropriate: Policy Amended / Action Identified / no changes made. Impact Assessment Completed by (insert name and date) Catherine Dixon, Mental Health Act Administration Manager (08/11/2016) 16 P a g e

17 Appendix D - Human Rights Act Assessment Form and Flowchart You need to be confident that no aspect of this policy breaches a person s Human Rights. You can assume that if a policy is directly based on a law or national policy it will not therefore breach Human Rights. If the policy or any procedures in the policy, are based on a local decision which impact on individuals, then you will need to make sure their human rights are not breached. To do this, you will need to refer to the more detailed guidance that is available on the SHSC web site (Relevant sections numbers are referenced in grey boxes on diagram) and work through the flow chart on the next page. 1. Is your policy based on and in line with the current law (including case law) or policy? Yes. No further action needed. No. Work through the flow diagram over the page and then answer questions 2 and 3 below. 2. On completion of flow diagram is further action needed? No, no further action needed. Yes, go to question 3 3. Complete the table below to provide details of the actions required Action required By what date Responsible Person 17 P a g e

18 Human Rights Assessment Flow Chart Complete text answers in boxes and highlight your path through the flowchart by filling the YES/NO boxes red (do this by clicking on the YES/NO text boxes and then from the Format menu on the toolbar, choose Format Text Box and choose red from the Fill colour option). Once the flowchart is completed, return to the previous page to complete the Human Rights Act Assessment Form. 1.1 What is the policy/decision title? What is the objective of the policy/decision? Who will be affected by the policy/decision?.. 1 Will the policy/decision engage anyone s Convention rights? YES Will the policy/decision result in the restriction of a right? YES NO NO Flowchart exit There is no need to continue with this checklist. However, o Be alert to any possibility that your policy may discriminate against anyone in the exercise of a Convention right o o Legal advice may still be necessary if in any doubt, contact your lawyer Things may change, and you may need to reassess the situation Is the right an absolute right? 3.1 YES NO 4 The right is a qualified right Is the right a limited right? YES Will the right be limited only to the extent set out in the relevant Article of the Convention? NO YES 1) Is there a legal basis for the restriction? AND 2) Does the restriction have a legitimate aim? AND 3) Is the restriction necessary in a democratic society? AND 4) Are you sure you are not using a sledgehammer to crack a nut? YES NO Policy/decision is likely to be human rights compliant BUT Policy/decision is not likely to be human rights compliant please contact the Head of Patient Experience, Inclusion and Diversity. Get legal advice Regardless of the answers to these questions, once human rights are being interfered with in a restrictive manner you should obtain legal advice. You should always seek legal advice if your policy is likely to discriminate against anyone in the exercise of a convention right. Access to legal advice MUST be authorised by the relevant Executive Director or Associate Director for policies (this will usually be the Chief Nurse). For further advice on access to legal advice, please contact the Complaints and Litigation Lead. 18 P a g e

19 Appendix E Development, Consultation and Verification This policy has been updated as part of the ongoing policy development and review process. There has been no major change in S17 through the revised Code of Practice. There are minor changes: Expanded checklist for consideration when granting leave (27.10). Added to 6.4 of the policy. Clarity on requirement to document consideration of CTO for leave of more than 7 days (already in the policy) New guidance that a photograph of the patient should be available in the notes in case the patient fails to return - suggesting either on the basis of the patient's consent or MCA best interests decision (27.22). There has been agreement on doing that in the Trust. Added to 6.6 of the policy. The revised code has removed the term Supervised Treatment Order (or SCT) that was interchangeable for Community Treatment Order (or CTO). Only CTO is retained. Clarification of RC out of hours arrangements and reference to the Allocation of a Responsible Clinician Policy added. New paragraph 6.10 added re review/ expiry of S17 Duties section strengthened previously only referring to the process section. Consultation was undertaken via the Mental Health Code of Practice Group and verification was via the Mental Health Act Committee (Chairman s Action). 19 P a g e

20 Appendix F Policies Checklist Please use this as a checklist for policy completion. The style and format of policies should follow the Policy Document Template which can be downloaded on the intranet. 1. Cover sheet All policies must have a cover sheet which includes: The Trust name and logo The title of the policy (in large font size as detailed in the template) Executive or Associate Director lead for the policy The policy author and lead The implementation lead (to receive feedback on the implementation) Date of initial draft policy Date of consultation Date of verification Date of ratification Date of issue Ratifying body Date for review Target audience Document type Document status Keywords 2. Contents page Policy version and advice on availability and storage 3. Flowchart N/A 4. Introduction 5. Scope 6. Definitions 7. Purpose 8. Duties 9. Process 10. Dissemination, storage and archiving (control) 11. Training and other resource implications 12. Audit, monitoring and review This section should describe how the implementation and impact of the policy will be monitored and audited and when it will be reviewed. It should include timescales and frequency of audits. It must include the monitoring template as shown in the policy template (example below). 20 P a g e

21 Monitoring Compliance Template Minimum Requirement Process for Monitoring Responsible Individual/ group/ committee Frequency of Monitoring Review of Results process (e.g. who does this?) Responsible Individual/group/ committee for action plan development Responsible Individual/group/ committee for action plan monitoring and implementation A) Describe which aspect this is monitoring? e.g. Review, audit e.g. Education & Training Steering Group e.g. Annual e.g. Quality Assurance Committee e.g. Education & Training Steering Group e.g. Quality Assurance Committee 13. Implementation plan 14. Links to other policies (associated documents) 15. Contact details 16. References 17. Version control and amendment log (Appendix A) 18. Dissemination Record (Appendix B) 19. Equality Impact Assessment Form (Appendix C) 20. Human Rights Act Assessment Checklist (Appendix D) 21. Policy development and consultation process (Appendix E) 22. Policy Checklist (Appendix F) 21 P a g e

22 Appendix G - Authorisation of Leave under Section 17, MHA 1983 Form I, the undersigned RC hereby grant leave of absence for the patient named below, under section 17 Mental Health Act Patient s Name... Insight No D.O.B MHA Section RC:. Hospital...Ward: Type of Leave Short Term Local Leave (i) Purpose/destination (ii) For a period of Hours Repeatable Yes/No - If Yes state timeframe.. Day Leave (i) Purpose/destination. (ii) Between the hours of.am/pm and...am/pm (iii) For the period of Hours..Days Repeatable Yes/No - If Yes state timeframe.. Overnight Leave (i) Purpose/destination. (ii) From: Date. Time: (iii) To: Date.. Time: (iv) Total Number of nights... Repeatable Yes/No- If Yes state timeframe.. Extended Leave (i) From:.. To: (If the leave is for more that 7 days document in the notes whether a Community Treatment Order has been considered) Address of Leave... Conditions of leave, if any are, as follows: Is an escort required yes / no. If so please indicate: Family / friend / carer escort (Please record name or relationship to the patient).. Formal staff escort (please indicate role of staff i.e. RMN or Support Worker) Other conditions of leave e.g. is the leave restricted to a specific area or are there areas the patient may or may not reside / go... Risk assessment: The following leave is granted on the basis of a recorded risk assessment. An assessment of risk should also be carried out immediately prior to leave by the allocated nurse and a record made of this. Signed by: Date and Time Copies to: Patient yes / no GP yes / no Carer / relative yes / no Other professionals please specify yes / no 22 P a g e

23 Appendix H - Guidance for patients / service users not legally detained (Duty of Care) Patients / service users who are not legally detained in hospital have the right to leave at any time. They cannot be required to ask permission to do so, but may be asked to inform staff when they wish to leave the ward. (Code of Practice). However In the case of voluntary or informal patients / service users where there is a real and immediate risk of suicide, the Supreme Court has ruled (February 2012) that the NHS has a positive duty (the operational duty) to protect life under Article 2 of the European Convention on Human Rights. In effect, this ruling requires leave for informal or voluntary patients / service users at risk of suicide to be managed as is if they were detained. Detention under the MHA must be considered in these circumstances which include Section 5(4) nurses holding power and Section 5 (2). For all other patients / service users in an acute inpatient setting, by the very nature of that setting must be seen as having risks, being vulnerable which need to be considered. Many of the process and considerations applied to patients / service users legally detained should be considered for those who are informal or voluntary. If a patient / service user wishes to leave the ward careful planning and risk assessment should take place. This should be discussed and agreed in the MDT, where appropriate and should involve the patient, carers and the CMHT / other community services where appropriate. This should be balanced against any risks that leave may pose to the protection of themselves and others. Consideration must also be given to what support the patient would require and whether it can be provided. Any discussion and decision should be recorded in the patient / service user s notes and as part of care planning. If a carer or relative is involved in or affected by the leave they should be consulted and this conversation then documented in the patient / service user s notes. Risk assessment should also take place immediately prior to the patient / service user going out. The shift co-ordinator (RMN) and contact nurse with input from the ward team and the Consultant, if required, should ensure that the leave is appropriate and safe to do so based on the current health of the patient / service user. Prior to every episode of leave a record should be made of what the patient / service user is wearing particularly if there is an increased risk of AWOL. Every period of leave must be recorded in the care record. This should include dates and time of departure and return. The outcome of each period of leave along with an assessment of its relative success should also be recorded. Patients / service users should be encouraged to contribute by giving their views and particular note should be made of any benefits or concerns raised by the patient / service user or any escorting staff, relatives or friends. Nursing staff may be given the authority to negotiate actual times when leave is taken. This must be recorded as part of the MDT decision making and planning. The Inpatient Care Plan should be used to support the leave, planning and risk assessment. 23 P a g e