CONSENT TO EXAMINATION OR TREATMENT NOVEMBER This policy supersedes all previous policies for Consent to Examination or Treatment

Transcription

1 CONSENT TO EXAMINATION OR TREATMENT NOVEMBER 2015 This policy supersedes all previous policies for Consent to Examination or Treatment

2 Policy title Consent to Examination or Treatment Policy CL06 reference Policy category Clinical Relevant to All staff who are involved in obtaining consent from patients Date published November 2015 Implementation November 2015 date Date last August 2015 reviewed Next review November 2017 date Policy lead Dominique Merlande, Mental Health Law Manager Contact details Accountable director Approved by (Group): Approved by (Committee): Document history Claire Johnston, Director of Nursing and People Mental Health Law Committee Quality Committee November 2015 Date Version Summary of amendments August Policy completely redrafted to reflect best national practice and the MHA Code of Practice (2015) changes. Membership of the policy development/ review team Zoe Fyffe, Patient Experience Lead Acosia Nyanin, Associate Director, Governance and Quality Assurance Jenny Oates, Interim Deputy Director of Nursing Simon Rowe, Clinical and Corporate Policy Manager 1

3 Consultation Paul Calaminus, Chief Operating Officer Peter Cartlidge, Associate Divisional Director (SAMH) Aisling Clifford, Associate Divisional Director (Acute) Mary Clifton, Deputy Chief Operating Officer Rachel Cockerton, Practice Development Nurse Dr Chris Curtis, Divisional Clinical Lead (Community) Dr John Dunn, Divisional Clinical Lead (SMS) Eva Ferlez, Risk and Patient Safety Manager Ian Griffiths, Divisional Clinical Lead (Acute) Dr Jeff Halperin, Head of Psychology and Psychotherapy Caroline Harris-Birtles, Deputy Director of Nursing and People Heston Hassett, MCA Lead and Deputy Mental Health Law Manager Dr Suzanne Joels, Divisional Clinical Lead (SAMH) Claire Johnston, Director or Nursing and People Karen Jones, Service manager (Acute) Ann Jumawan, Matron (Acute) Peter Kane, Associate Divisional Director (SMS) Dr Vincent Kirchner, Medical Director Keith McCoy, Associate Divisional Director (Community) Sandra McGhee, Head of Occupational & Arts Therapies Dr Ian Prenelle, Divisional Clinical Lead (R&R) Andy Stopher, Associate Divisional Director (R&R) Deborah Wright, Head of Social Work and Social Care DO NOT AMEND THIS DOCUMENT Further copies of this document can be found on the Foundation Trust intranet. 2

4 Contents 1 Trust values 5 2 Policy and governance 5 3 Policy statement 6 4 Executive summary 6 5 Duties and responsibilities 7 6 Definitions 7 7 Key Principles of Consent 8 8 The Mental Health Act 1983 Capacity and Consent 10 9 Community Treatment Orders Consent and Mental Capacity Act Advance Decisions to Refuse Medical Treatment Lasting Powers of Attorney and Court Appointed Deputies Court of Protection Treatment for Physical Disorder Best Interests and Protection from Liability Deprivation of Liberty Provision of Information Provision for Patients whose First Language is not English Clinical Photography and Conventional or Digital Video or Audio Recordings Training Dissemination and Implementation Arrangements Monitoring and Audit Arrangements Review of the Policy References Associated Documents 22 3

5 26 Appendices 23 Appendix 1: Equality Impact Assessment Tool Appendix 2: Twelve Key Points on Consent: the Law in England Appendix 3:Current consent forms in use within the Trust Appendix 4: Seeking consent: remembering the patient s perspective Appendix 5: Flowchart: Part 4 MHA Consent to Treatment (Inpatients) Appendix 6: Flowchart: Part 4 MHA Consent to Treatment (CTOs) 4

6 1. Trust values Camden and Islington NHS Foundation Trust developed its set of six values with more than 500 service users and members of staff. Our values are important to us. They are our promise to patients as well as to each other that we will behave in a certain way, no matter what our job title is or how under pressure we feel. Our commitment to our values makes us who we are. It gives our service users confidence that they will be treated in the most compassionate way possible as they go through their journey to recovery. It also gives us pride in the knowledge we are providing the best care. Our values show that we are welcoming, respectful and kind. Professional in our approach. Positive in our outlook. Working as a team, we are your partner in care and improvement. These values are part of a wider campaign, Changing Lives which is helping to drive up the standards of care across the Trust. In simple terms our values assure our service users that: They will receive a warm welcome throughout the journey to recovery; They, their dignity and their privacy will always be respected; Their care will be founded on compassion and kindness; They will receive high quality, safe care from a highly trained team of professionals; We work together as a team to ensure they feel involved and offer solutions and choices no decision about you, without you ; We are positive so they can feel hopeful and begin their journey of recovery knowing we will do our very best. Trust value They will receive a warm welcome throughout the journey to recovery They, their dignity and their privacy will always be respected; Their care will be founded on compassion and kindness They will receive high quality, safe care from a highly trained team of professionals We work together as a team to ensure they feel involved and offer solutions and choices no decision about you, without you We are positive so they can feel hopeful and begin their journey of recovery knowing we will do our very best. Yes/No Yes Yes Yes Yes Yes Yes 2. Policy and governance A policy is an organisational statement of rules and standards which govern performance and actions required to be followed by those in employment by the Trust. A policy provides a framework for the Trust to work within and should specify actions which are required. A policy may include detailed procedures which supply standardised methods of performing clinical or non-clinical tasks by providing a series of actions to be conducted in a certain order to achieve a safe and effective outcome in a consistent method by all concerned. 5

7 Policies should take account of existing good quality evidence. The Whittington Health Library provides a library service to the Foundation Trust and can assist with literature searches and finding evidence to inform policy and practice. For more information please contact: Richard Peacock Librarian Whittington Health Library richardpeacock@nhs.net Good governance lies at the heart of all successful organisations. Good governance helps protect the Trust, its staff and service users from poor decisions and exposure to risks. All Trust policies must be compliant with the relevant statutory legislation, e.g.: the Mental Health Act 1983 (which was amended in 2007) and national expectations, e.g.: the NHS Litigation Authority Risk Management Standards A policy which has not been scrutinised and approved by the appropriate Trust committee but is being used by staff could lead to poor practice being delivered which could potentially harm service users and have consequences for staff. It is therefore essential that in either developing or revising a policy, managers ensure that the proper governance procedures have been followed. By following the correct governance procedures, we all help to reduce risk and assure safe and effective care is delivered to service users. 3. Policy statement This policy sets out the standards and procedures for all health and social care professionals employed by, or on behalf of, Camden and Islington NHS Foundation Trust who are required to obtain consent to examination or treatment from patients. While this document is primarily concerned with healthcare, social care colleagues should also be aware of their obligations to obtain consent before providing certain forms of social care, such as those that involve touching the patient or client. This policy has been revised following the publication of the second edition of Reference guide to consent for examination or treatment (Department of Health, 2009) which provides an update on legislation relating to obtaining valid consent, e.g.: the Human Tissue Act 2004, the Mental Capacity Act 2005 and recent legal cases. This policy also reflects the requirements of the new Code of Practice to the Mental Health Act (Department of Health, 2015). 4. Executive summary The principle of consent to examination and/or treatment is a fundamental principle of medical ethics and human rights law that a patient must give their permission before they receive any type of examination or treatment. This policy takes account of developments in common law, new legislation and guidance relevant to capacity and consent and clarification in the interpretation of Part IV of the MHA

8 The two key pieces of legislation are the Mental Health Act 1983 (as amended) and the Mental Capacity Act Whilst both of these Acts will apply to those under the age of 18 years, the Children Act 1989 and the Family Law Reform Act 1969 are also key pieces of legislation when dealing with the treatment of children. 5. Duties and responsibilities The Chief Executive has ultimate responsibility for ensuring that mechanisms are in place for the overall implementation, monitoring and revision of policy. The Director of Nursing and People is the executive director responsible for this policy, but will delegate authority for the operational implementation and ongoing management of the policy to the Mental Health Law Manager. The Mental Health Law Manager is responsible for reviewing this policy every two years. The Associate Director, Governance and Quality Assurance, via the Clinical and Corporate Policy Manager, is responsible for ensuring: Dissemination and implementation of the policy Identification of any resource implications to enable compliance Training and monitoring systems are in place Regular review of the policy takes place. Associate Divisional Directors are responsible for implementation of the policy within their own spheres of management and must ensure that: All new and existing staff have access to and are informed of the policy Ensure that local written procedures support and comply with the policy Ensure the policy is reviewed regularly Staff training needs are identified and met to enable implementation of the policy. Each registered healthcare professional is accountable for his/her own practice and will be aware of their legal and professional responsibilities relating to their competence and work with the Code of Practice of their professional body. All Trust staff are responsible for ensuring that they: Are familiar with the content of the relevant policy and follow its requirements Work within, and do not exceed, their own sphere of competence. 6. Definitions 7

9 Advance Decision or AD is a statement made by a person with capacity stating their wish to refuse future treatment. The statement only becomes effective if the person, at a later date, lacks capacity to make a decision regarding the treatment in question. Approved Clinician or AC is a professional (registered medical practitioner, chartered psychologist, social worker, mental health/learning disability nurse or registered occupational therapist) who has undertaken specific training, meets specific competencies and has been approved by the strategic health authority to provide certificates to authorise treatment under Part 4 of the Mental Health Act 1983 (amongst other powers and duties). Consent is a patient s agreement for a qualified health professional or other member of Trust staff to undertake an examination or provide care. Valid consent is consent that is given voluntarily by an appropriately informed person who has the capacity to consent to the intervention in question (this will be the patient or someone with parental responsibility for a patient under the age of 18, someone authorised to do so under a Lasting Power of Attorney or someone who has the authority to make treatment decisions as a court appointed deputy). Acquiescence where the person does not know what the intervention entails is not valid consent. Consent to treatment is the voluntary and continuing permission of a patient to be given a particular treatment, based on a sufficient knowledge of the purpose, nature, likely effects and risks of that treatment, including the likelihood of its success and any alternatives to it. Permission given under any unfair or undue pressure is not consent. "Capacity" means the ability to understand, retain, use the information to make a decision, and communicate any decision made. It is based on a person s ability to make a specific decision at the time it needs to be made, not their ability to make decisions in general. Common law (also known as case law or legal precedent ) is law developed by judges through decisions of courts deciding individual cases. This is in contrast to Acts of Parliament which are statutes adopted through the legislative process. Emergency treatment can only be administered under the Mental Health Act if the treatment is immediately necessary to: Save the patient s life; Prevent a serious deterioration of the patient s condition, and the treatment does not have unfavourable physical or psychological consequences which cannot be reversed; Alleviate serious suffering by the patient and the treatment does not have unfavourable physical or psychological consequences which cannot be reversed and does not entail significant physical hazard; or Prevent the patient behaving violently or being a danger to themselves or others and the treatment represents the minimum interference necessary for that purpose, does not have unfavourable physical or psychological consequences which cannot be reversed and does not entail significant physical hazard. For the administration of ECT in an emergency, only the first two categories apply. Lasting Power of Attorney or LPA is granted by an individual (the donor) when they have capacity, giving another person (the done or attorney) authority to make decisions on their behalf if they lack capacity to do so themselves. 8

10 Responsible Clinician or RC is the Approved Clinician with overall responsibility for the patient s care. 7. Key principles of consent 7.1 Whilst the general principles of consent are not enshrined in English statute, common law has established that touching/treating someone without permission could be considered assault or battery under criminal law and civil law. Where valid consent has not been obtained a case can be brought for battery. In actions for battery it is not necessary to prove that injury has followed as a result so an action can succeed even where the treatment has been of benefit to the patient. 7.2 Consent is a patient s agreement for a qualified health professional, or other member of Trust staff, to undertake an examination or provide treatment and pre-supposes that the person has the capacity to understand what they are consenting to. A person who lacks capacity to consent does not consent to treatment, even if they co-operate with the treatment or actively seek it. Nobody can consent on behalf of a person who has the capacity to consent for him or herself. 7.3 It is a general legal and ethical principle and part of good medical and nursing practice that valid consent must be obtained from a patient before undertaking an examination or providing treatment to that patient. The Department of Health s Reference guide to consent for examination or treatment (second edition, 2009) states that: A healthcare professional (or other healthcare staff) who does not respect this principle may be liable both to legal action by the patient and to action by their professional body. Employing bodies may also be liable for the actions of their staff Consent must be sought and the outcome recorded before the first administration of medication. This also applies to patients subject to the Mental Health Act 1983 (para CoP). 7.4 Patients may indicate consent either orally, in writing or non-verbally (e.g.: by presenting their arm for their pulse to be taken). For the consent to be valid, the patient must: have capacity to take the particular decision; and have received sufficient information about the purpose, nature, likely effects and risks of the treatment, including the likelihood of its success and alternatives to it; and not be acting under any unfair or undue pressure. 7.5 Consent is often wrongly equated with a patient s signature on a consent form. A signature on a form is evidence that the patient has given consent, but is not proof of valid consent. If a patient is rushed into signing a form, on the basis of too little information, the consent may not be valid, despite the signature. Similarly, if a patient has given valid verbal consent, the fact that they are physically unable to sign the form is no bar to treatment. Patients may, if they wish, withdraw consent after they have signed a form: the signature is evidence of the process of consent-giving, not a binding contract. 7.6 Patients should be told that their consent can be withdrawn at any time. If an adult with capacity makes a voluntary and appropriately informed decision to refuse or withdraw 9

11 consent to treatment (whether contemporaneously or in advance), this decision must be respected, except in certain circumstances as defined by the Mental Health Act If new information, relevant to the treatment to which the patient had already consented, becomes available, a professional with sufficient knowledge of the treatment being provided and the new information should inform the patient and re-establish their consent to the treatment. A brief record of the conversation should be made on the EPR. 7.8 Where a person s capacity to consent is in doubt, for example where there is uncertainty about the person s ability to sufficiently understand the treatment or care being proposed, then the lack of an objection to the treatment or care being proposed should not be seen as consent. A formal assessment of the person s capacity should be undertaken in line with the principles of the MCA. 7.9 The only authority for treating an informal patient is either their valid consent (see above) or, if the patient lacks capacity to make this decision and treatment would be in their best interests, by using the provisions of the Mental Capacity Act A summary of the information provided to a patient must be recorded in the patient s notes and include both verbal and written information. If the patient specifically requests to receive very little information related to the proposed treatment, but still consents, this should also be recorded The law now requires a doctor to take reasonable care to ensure that the patient is aware of any material risks involved in any recommended treatment, and of any reasonable alternative or variant treatments. The test of materiality is whether, in the circumstances of the particular case, a reasonable person in the patient s position would be likely to attach significance to the risk, or the doctor is or should reasonably be aware that the particular patient would be likely to attach significance to it. Whether a risk is material cannot be reduced to percentages, and instead is based on a variety of factors such as: (1) nature of the risk; (2) effect on the life of the patient; (3) the importance to the patient of the benefits of the treatment; (4) any possible alternatives; and (5) the risk of those alternatives The professional in charge of the treatment is responsible for establishing the valid authority to treat and the professional administering the treatment must be satisfied that such authority exists. 8. The Mental Health Act 1983 capacity and consent (i) Whilst the Mental Health Act 1983 permits certain medical treatment for mental disorder to be administered without consent, wherever practicable, consent should still be sought before treatment is given and a record made of that consent or refusal to consent to treatment. (ii) Neither the existence of a mental disorder nor the fact that someone is detained under the Mental Health Act should lead to an assumption of incapacity. The person s capacity must be assessed in relation to the particular decision they are being asked to make and this must be recorded in the patient notes. (iii) In circumstances where consent is withdrawn, the responsible clinician in charge of the treatment should review the treatment and consider whether to provide alternative treatment, give no further treatment or proceed with treatment in the absence of consent under the Mental Health Act (where applicable). 1 Montgomery v Lanarkshire Health Board [2015] UKSC 11 10

12 (iv) Treatment plans are essential for patients who are being given treatment for mental disorder under the Mental Health Act 1983 and the responsibility for ensuring that a treatment plan is in place rests with the Responsible Clinician (RC). This should form part of the care plan, be recorded in the patient s notes and should include both immediate and long term goals and treatment methods. The plan should be reviewed regularly in conjunction with the patient and with carers where appropriate. (v) Medical treatment is defined in section 145(1) of the Mental Health Act 1983 as including nursing, psychological intervention and specialist mental health habilitation, rehabilitation and care and means treatment for the purpose of alleviating or preventing a worsening of a patient s mental disorder or one or more of its symptoms or manifestations. Medical treatment must be appropriate and available. (Refer to the Mental Health Act Code of Practice for further guidance) 8.1 Part IV of the Mental Health Act Part IV of the Act relates to treatment for mental disorder for those patients who are liable to be detained in hospital under section 2, 3, 36, 37(or 37/41), 38, 44, 45A, 47 (or 47/49), 48(or 48/49) and to patients subject to a community treatment order who have been recalled to hospital (section 17E) and are receiving medical treatment for their mental disorder, whether or not they have capacity in relation to any specific decision Patients detained under sections 4, 5(2), 5(4), (1), 136, conditionally discharged restricted patients, patients subject to a community treatment order who have not been recalled to hospital and patients detained in a place of safety under Part III of the Act are excluded Part IV applies to all forms of treatment for mental disorder however, certain types of treatment are subject to special rules: Medication (s58) Forms T2 and T3 Psycho-surgery (s57) patient must have capacity and must consent. SOAD must be requested and complete Form T1. ECT (s58a) - Age 18+ with capacity AC completes Form T4 - Under age 18 with capacity - SOAD completes Form T5 - Lacks capacity - SOAD completes Form T6 (can t conflict with LPA or AD) Other treatment can be given without consent under Section All treatment provided under Part IV of the Act must be documented on the relevant certificate of authorisation. The original certificates must be sent to the MHA Office and copies attached to the patient s prescription chart. 8.2 Procedure Governing Part IV of the MHA Medication - section Although treatment can be administered to a patient who is subject to Part IV of the Act without consent for three months following the first administration, it is good practice for the RC to seek the consent of the patient and to assess their capacity to consent to treatment prior to the first administration of treatment. If the RC is not available and the administration of treatment cannot be delayed until they are, the seeking of consent and capacity assessment should be undertaken by the Ward Doctor or the Nurse in Charge on the ward. 11

13 8.2.3The RC must ensure that the patient s consent is sought and their capacity to consent to the treatment assessed and recorded once three months have elapsed since medication was first given in a continuous period of detention. The assessment and the decision must be clearly documented on the EPR system If, after three months have elapsed, the patient consents to all the treatment or the plan of treatment proposed, the RC completes Form T2, including name or category of drugs (and number within category), BNF code, route and dosage. The Form T2 will be medically scrutinised by another Approved Clinician If the patient either refuses or lacks/loses the capacity to consent or withdraws consent, a second opinion should be sought. The second opinion is provided through the Care Quality Commission (CQC), who provides a Second Opinion Appointed Doctor (SOAD) on request. The responsible Clinician will be responsible for ensuring a SOAD request is lodged with the CQC in a timely fashion. Training and guidance on how to lodge SOAD requests will be provided by Mental Health Act Officers The SOAD will attend the ward and discuss the proposed treatment with the RC, one nurse and one other professional (non-nurse/non-medic) involved in the patient s care. Statutory consultees must make an entry in the patient s records to document the SOAD consultation. If the SOAD believes the proposed treatment is appropriate, they will complete Form T Where a SOAD visit has been requested, the RC in charge of treatment must ensure that the patient receives a copy of the SOAD s report (including reasons) for authorising treatment It is possible to have concurrent Forms T2 and T3 where the patient consents to some elements of treatment but not to others The Form T2 or Form T3 should be reviewed by the RC at regular intervals and at each renewal of section or change in section status. Where the patient s capacity changes or they change their mind regarding consent a new Form T2 or Form T3 should be completed as appropriate If the treatment authorised on the treatment certificate changes or the certificate is time limited, the RC must ensure that treatment is not be given until a fresh certificate is issued or unless section 62 applies (see below) Where there is a permanent change to the RC, the new RC must review the treatment certificate at the earliest opportunity and either produce a new form T2 or request a SOAD, if there is any change needed to the existing form T3. Practitioners who administer medication to detained patients are responsible for checking the medication authorised on the certificate against the prescription chart each time the medication is given, satisfying themselves that the certificate remains applicable and raising any issues of incompatibility immediately with the RC Only the medication authorised by a Form T2 or T3 can be given to the patient, except in an emergency under the provisions of Section 62 of the Mental Health Act An emergency is defined as the necessity for urgent treatment to be given to save life, prevent a serious deterioration in the patient s condition, alleviate serious suffering or prevent the patient from behaving violently or being a danger to themselves or others When emergency treatment is necessary, the RC must record it in the patient s progress notes on the EPR system and complete the URGENT TREATMENT UNDER 12

14 SECTION 62, 64B(3)(b) or 64(g) OF THE MENTAL HEALTH ACT 1983 form, which should be attached to the front of the prescription card as legal authority for treatment. Electro convulsive therapy (ECT) section 58A The administration of ECT requires the consent of the patient or, if the patient lacks capacity to consent, a second opinion appointed doctor s certificate The RC must ensure that the patient s capacity to consent to ECT is assessed and recorded if this treatment is being considered at any time during the patient s detention. If the patient lacks capacity to consent, a SOAD must be requested. A detained patient with capacity can refuse ECT (this can be overridden in an emergency under Section 62 see ) Except where ECT is immediately necessary to save life or prevent deterioration, all patients under the age of 18 years, whether detained or not, must first be seen by a SOAD regardless of whether they have capacity or not to consent to ECT. The SOAD will complete a Form T Where the patient has the capacity and has given a valid consent to the administration of ECT, the RC must complete a form T4 for the procedure, together with medication administered as part of ECT Where the patient does not have the capacity to consent and a second opinion appointed doctor has stated that the treatment is appropriate, a Form T6 must be completed T4 and T6 certificates must be sent to the MHA office and uploaded to the EPR system. Practitioners who administer ECT must always ensure at the point of its administration that they have legal authority to do so A Form T4 or Form T6 will become invalid if it is time limited, if the patient was consenting and has withdrawn consent or has lost capacity to consent, if the patient lacked capacity to consent and has now regained capacity or if it is discovered that the incapacitated patient has made an advanced decision to refuse treatment, or that the donee of an LPA or deputy appointed by the Court of Protection makes a decision that treatment should not be given. Therefore a person can make an advance decision to refuse ECT and it would have to be respected despite the person being detained under the Mental health Act and lacking capacity to consent. However, this can be overridden if the treatment is classed as an emergency under Section 62 (see ) To authorise ECT as urgent treatment under Section 62, it must be immediately necessary to save the patient s life or treatment which (not being reversible) is immediately necessary to prevent a serious deterioration in the patient s condition. The Act defines irreversible treatment as one that has unfavourable irreversible physical or psychological consequences. Hazardous treatment is defined as one that entails significant physical hazard. 9. Community Treatment Orders 9.1 Community Treatment Order (CTO) patients who have capacity to consent to treatment and who have not been recalled to hospital, can only be treated for a mental or physical disorder in the community, with their consent. There are no exceptions to this rule, even in an emergency. Consideration should be given to recalling the patient to hospital (if the criteria are met) if compulsory treatment is necessary. 13

15 9.2 The RC making the Community Treatment Order (inpatient RC) is responsible for assessing the patient s capacity to consent to treatment at the point the CTO starts and for documenting it in the patient s records. If the patient is found to lack capacity to consent to treatment, a SOAD visit must be requested within 48 hours of the CTO starting. It is the responsibility of the RC making the Community Treatment Order to lodge the request. If the patient is found to have capacity to consent to treatment, the RC making the CTO (inpatient RC) will need to inform the new RC (community RC) of the outcome of the assessment. The new RC must issue a CTO12 certificate to confirm that the patient has capacity to understand the nature, purpose and likely effects of the treatment. It is recommended to assess capacity to consent to treatment in the pre-cto/discharge CPA meeting, in the presence of the MDT, including the inpatient RC and the community RC. 9.3 Medication can be given during the first month on CTO (or during the first three months since treatment started being administered under Part IV of the Mental Health Act, whichever is the longest) without a certificate but after this period, one must be in place (form CTO11 or CTo12) for medication to continue. 9.4 The SOAD will discuss the proposed treatment with the RC and two statutory consultees. At least one of the statutory consultees must not be a medical doctor (but need not be a nurse), and neither may be the RC. Typically a general practitioner (GP) may be consulted. Statutory consultees must make an entry in the patient s records to document the SOAD consultation. If the SOAD believes the treatment is appropriate, they will complete Form CTO11. They will also include on the form any treatment that may be provided should the patient be recalled to hospital. 9.5 A copy of form CTO11 or CTO12 must be kept in the patient s records and the original sent to the MHA Office. It is the responsibility of anyone who prescribes, dispenses or administers medication to a CTO patient after one month on CTO (or 3 months under Part IV) to ensure that all medication is recorded on the treatment certificate. It must be noted however that the certificate does not provide legal authority to treat. Only the patient s consent does. If the patient lacks capacity, treatment can be administered without their consent as long as force is not required. 9.6 In an emergency, treatment for CTO patients who have not been recalled must follow the provisions of section 64B (with capacity) or section 64G (lacking capacity). If treatment is to be provided in an emergency the URGENT TREATMENT UNDER SECTION 62, 64B(3)(b) or 64(g) OF THE MENTAL HEALTH ACT 1983 form must be completed. Treatment for patients who lack capacity may be administered in an emergency even if it goes against an advance decision or a decision made by a person authorised on the patient s behalf under the Mental Capacity Act If physical force needs to be used to administer treatment to a patient who lacks capacity, it can only be given in an emergency and only if the person administering the treatment believes that the treatment is immediately necessary and that any force used is a proportionate response to the likelihood of harm being suffered (Section 64G, MHA 1983 and MCA 2005). The patient should, if not already in hospital, be returned to hospital as soon as it is safe to do so. 9.8 Patients whose community treatment order has been revoked can be treated under Part IV of the MHA Recall to hospital When a patient on CTO is recalled to hospital or the CTO is revoked, they will become subject to Part IV consent to treatment provisions as though they had never been discharged 14

16 onto CTO. Therefore, a certificate (Form T2, T3, T4, T5 or T6) is required to authorise treatment with only three exceptions: If it has been less that one month since the patient was discharged onto CTO (i.e. does not have Form CTO11); If the treatment is explicitly written on Form CTO11 as being authorised following recall; If the treatment was being given on CTO and the RC believes discontinuing would cause the patient suffering. If any of those three exceptions applies, the RC should fill in a Section 62A form and submit it to the MHA Office Arrangements should be made for a new certificate where necessary as the above exceptions will only apply whilst a new certificate is being obtained Treatment in an emergency must follow the provisions of section 62 the URGENT TREATMENT UNDER SECTION 62, 64B(3)(b) or 64(g) OF THE MENTAL HEALTH ACT 1983 form must be completed 9.10 Second Opinion Appointed Doctors (SOADs) The arrangements surrounding the Second Opinion Appointed Doctor s examination will be complicated by the fact that the patient is in the community, and will require careful management. It is therefore important that the Care Coordinator is nominated to take responsibility for confirming arrangements with the SOAD and the patient and for coordinating the process Other than in exceptional circumstances, SOAD examinations will be arranged in a hospital or clinical setting. If the RC agrees that it is necessary to visit a patient in any other setting, the SOAD will always be accompanied by an appropriate member of the care team, who will act as one of the statutory consultees. 10. Consent and Mental Capacity Act A person must always be presumed to have capacity unless it can be established otherwise and cannot be treated as lacking capacity on the basis of a decision that seems unwise or irrational The Mental Capacity Act (MCA) 2005, which came into effect in 2007, regulates care and treatment for those people who lack capacity (where the MHA 1983 does not apply). It generally applies to people over the age of 18 years, but some parts apply to those people aged between 16 and 18 years of age. It allows for others to make decisions on behalf of a person who lacks capacity (lasting power of attorney, deputies appointed by the Court of Protection etc) and also allows for people to make decisions in advance about treatments they do not want to receive in the event that they lose capacity in the future (advance decision to refuse medical treatment) The MCA also provides protection for those carers/professionals providing care for people who lack capacity, provided that the care is in their best interests and if restraint is used, that it is a proportionate response to the likelihood and seriousness of harm which might occur if the person was not restrained Test for Capacity: The MCA defines someone who lacks capacity as a person who is unable to make a decision for themselves because of an impairment or disturbance in the functioning of the mind or brain. It does not matter if this is a permanent or temporary 15

17 disturbance. (Refer to the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards Policy for further information on assessing capacity) 10.5 The person responsible for assessing capacity will be the person responsible for providing treatment or organising care for the patient The assessment of capacity focuses on the specific decision that needs to be made at the specific time the decision is required. It does not matter if the incapacity is temporary, or the person retains the capacity to make other decisions, or if the person s capacity fluctuates, although, if the impairment is temporary and the decision can realistically be put off until such time as the person is likely to regain capacity, then it should be deferred The test for capacity is a functional one. Professionals should carry out a proper examination and assessment of the person s capacity to make the decision. Regard should be paid to whether the person is able to: Understand the information that is given to them relevant to the decision that they are being asked to make; Retain that information for long enough to make the decision; Use or weigh up the information as part of the decision making process; and Communicate the decision - every effort must be made to assist the person to communicate in whatever mode they can 10.8 Assistance should be given to the person to help them make a decision. Where the person fails one or more parts of the test, then they do not have the relevant capacity and the entire test is failed in relation to the particular decision needing to be made When a capacity test is applied in relation to the decision that needs to be made, the reasons why capacity was in doubt and details of the assessment process, including what help was provided to enable the patient to make his or her own decision must be recorded in the patients notes In situations where a patient s capacity fluctuates, practitioners should encourage patients, when they retain capacity to provide an advance statement of treatments they would prefer should they lose capacity or an advance decision refusing specific treatments. 11. Advance decisions to refuse medical treatment 11.1 There is a distinction between an advance statement, which is a statement of treatment preference, and an advance decision, which is a refusal of treatment. The former has no statutory force but should be taken into account when determining what treatment is in the patient s best interests. The latter has statutory force and must be respected An advance decision only applies to healthcare matters and can be made by anyone with capacity to make the decisions covered by the advance decision if they are aged 18 years or over. An advance decision must be followed, if it is valid and applies to the particular circumstances Healthcare professionals must take all practical and appropriate steps to determine whether an advance decision exists A person s treatment decision can be overridden in some circumstances. For example, when a patient is detained under the MHA 1983, the contents of any advance decision relating to a refusal of treatment for mental disorder may be overridden by virtue of the provisions in Part IV of the Act. 16

18 12. Lasting powers of attorney and court appointed deputies 12.1 The MCA allows a person with capacity to appoint someone to make their health and welfare decisions at any point in the future when they lose capacity under a lasting power of attorney(lpa). The donee (attorney) for a personal welfare lasting power of attorney can make healthcare decisions which would be as valid as if the person had made the decision themselves To be valid an LPA must be registered with the Office of the Public Guardian (OPG). An unregistered LPA will not give the attorney any legal powers to make a decision for the donor of the LPA Deputies are those people appointed by the Court of Protection to make decisions on behalf of the incapacitated person. The powers of a court appointed deputy may be limited in scope so it is important to ascertain what decision making powers this person has With the exception of ECT, donees and deputies may not give or refuse consent to treatment on a patient s behalf if that treatment is covered by Part IV of the MHA 1983, although they could, under Part IVA, for a patient on a community treatment order who lacked capacity. They may not take a decision which would conflict with decisions that a Guardian (for a person under a MHA Guardianship Order) has a lawful right to make. 13. Court of protection The MCA 2005 established the Court of Protection which deals with decision-making for adults lacking capacity. It deals with serious decisions affecting personal welfare matters, including healthcare, which were previously dealt with in the High Court. It has the same rights, powers, privileges and authorities as the High court does. 14. Treatment for physical disorder 14.1 It is possible, in some circumstances, to use powers contained in the MHA 1983 to treat detained patients without their consent for physical conditions related to their mental disorder. The conditions that can be treated include, for example, the effects of an overdose of drugs and the effects of not eating or hydrating. In all cases a clear link must be established between the mental disorder and the physical condition being treated. In the examples given above, case law has firmly established the links between these physical states and the underlying mental disorder Conditions that are not linked to the underlying mental disorder cannot be treated without the patient s consent. Where responsible clinicians wish to treat a detained patient s physical condition (other than the above examples) where the patient has capacity but refuses the treatment, and they believe the condition is linked to the patient s mental disorder, they must obtain legal advice before doing so Detained patients who lack capacity can be treated for a physical disorder under powers contained in the MCA 2005 if it is in the patient s best interests and would not conflict with an advance decision to refuse medical treatment or a decision by an attorney or a Court of Protection or a deputy. The MCA 2005 applies to persons detained under the MHA 1983 in relation to physical disorders, just as it does to informal patients. 15. Best interests and protection from liability 15.1 Section 5 of the MCA states that, as long as acts or decisions are made in the best interests of the person who lacks capacity, the decision maker or carer will be protected from liability. The Act does not give a definition as to what best interests means as it encompasses a wide range of decisions and care acts but Section 4 sets out a checklist and 17

19 states that the care giver/decision maker must take into account all the relevant circumstances when coming to a decision. This will include, where possible, determining the person s views before they lost capacity Personal care, healthcare and treatment of patients who lack capacity may be carried out if it is in their best interests and this may extend to the use of restraint. However, this will only be lawful if the person taking the action believes the restraint is necessary to prevent harm to the person and if the amount or the type of restraint and the length of time of restraint is a proportionate response to the likelihood and seriousness of the harm, i.e. the minimum force for the shortest possible time. 16. Deprivation of liberty 16.1 If a person who lacks capacity is being cared for in a manner which amounts to a deprivation of their liberty, authorisation for this must be obtained from the supervisory body (i.e. local authority). This does not apply to people detained in hospital under the MHA An authorisation to deprive someone of their liberty does NOT automatically allow treatment to be given to that person. Treatment that is proposed following a deprivation of liberty authorisation may only be given with the person s consent (if they have the capacity to make that decision) or in accordance with the Mental Capacity Act Provision of information 17.1 The provision of information is central to the consent process. Before patients can come to a decision about treatment, they need comprehensible information about their condition and about possible treatments/investigations and their risks and benefits (including the risks/benefits of doing nothing). They also need to know whether additional procedures are likely to be necessary as part of the procedure, for example a blood transfusion, or the removal of particular tissue. Once a decision to have a particular treatment/investigation has been made, patients need information about what will happen: where to go, how long they will be in hospital, how they will feel afterwards and so on Patients and those close to them will vary in how much information they want: from those who want as much detail as possible, including details of rare risks, to those who ask health professionals to make decisions for them. There will always be an element of clinical judgement in determining what information should be given. However, the presumption must be that the patient wishes to be well informed about the risks and benefits of the various options. Where the patient makes clear (verbally or non-verbally) that they do not wish to be given this level of information, this should be documented The following sources of patient information are available in the Trust: Mental disorders. Clinical teams can provide a range of independently produced leaflets relating to relevant mental disorders. Care Programme Approach. A Trust-wide leaflet is available detailing the provisions of the Care Programme Approach. Treatment of patients detained under the Mental Health Act. All detained patients are provided with the relevant Department of Health rights leaflets. Patients with learning difficulties. Specialist leaflets designed for people with learning disabilities about commonly used psychotropic medications and commonly used medical investigations are available from the Trust's Learning 18

20 Disability Teams. Specialist advice is also available on seeking consent from this group. Medications. Information leaflets about medications are available on public folders and the Care Trust intranet. For assistance with accessing these, please contact the Pharmacy department (see Appendix C). For inpatients, additional information about medications can be obtained directly from ward pharmacists, patients' named nurses, or their doctors. Patients being treated in the community can obtain additional information from any member of their care team or from a local pharmacist (chemist). (See also above, re patients with learning difficulties). ECT. All patients for whom ECT is proposed are provided with a copy of the Royal College of Psychiatry information leaflet on ECT. Psychology, Occupational Therapy, Arts therapies. All specialist therapies provide their own information leaflets, which are routinely given to patients for whom these treatments are proposed. Additionally, information about specialist therapies is available on the Care Trust Intranet, and can be provided by the patient's named nurse or care co-ordinator. Advocacy. Advocates are available to all patients (see Appendix C). Patients with interpreting needs or sensory impairment. Wherever necessary, the Care Trust will meet the needs of patients requiring information in other languages or in alternative media. For information on medicines in a range of local languages, contact the Pharmacy Department (see Appendix C) Patients may sometimes request more detailed information about their condition or about a proposed treatment than that provided in general leaflets. The Trust has made the following arrangements to assist patients to obtain such information: Advocacy services have access to the internet, including NHS Direct Online and the National Electronic Library for Health and can access these to seek additional information at patients' request (see Appendix C for contact details). All clinical teams have access to the OVID database, which gives access to a wide range of academic and clinical sources. Where specifically requested by patients, additional information can be obtained by clinical staff, using internet or library resources. If patients wish to discuss materials which they have identified themselves, clinical staff will be happy to accommodate this. Additional information about the provisions for consent to treatment under the Mental Health Act can be obtained from the patient's named nurses or Responsible Clinicians, or from the local Mental Health Act Administrator (see Appendix C). Detained patients can also be assisted by their named nurse or the Mental Health Act Administrator in obtaining the services of an independent solicitor if more specialist advice is required. 18. Provision for patients whose first language is not English The Trust is committed to ensuring that patients whose first language is not English receive the information they need and are able to communicate appropriately with healthcare staff. It is not appropriate to use children to interpret for family members who do not speak English. Interpreters are normally accessed by the patient's named nurse or care co-ordinator. 19

21 Information on medicines in a range of local languages can be obtained through the Pharmacy Department. Leaflets relating to patients detained under the Mental Health Act are available in a range of local languages from Mental Health Act Officers. 19. Clinical photography and conventional or digital video or audio recordings 19.1 Photographic and video or audio recordings made for clinical purposes form part of a patient s record. Although consent to certain recordings, such as X-rays, is implicit in the patient s consent to the procedure, health professionals should always ensure that they make clear in advance if any photographic or video recording will result from that procedure Photographic and video or audio recordings which are made for treating or assessing a patient must not be used for any purpose other than the patient s care or the audit of that care, without the express consent of the patient or a person with parental responsibility for the patient. The one exception to this principle is set out in paragraph 3 below. If you wish to use such a recording for education, publication or research purposes, you must seek consent in writing, ensuring that the person giving consent is fully aware of the possible uses of the material. In particular, the person must be made aware that you may not be able to control future use of the material once it has been placed in the public domain. If a child is not willing for a recording to be used, you must not use it, even if a person with parental responsibility consents Photographic and video or audio recordings, made for treating or assessing a patient and from which there is no possibility that the patient might be recognised, may be used within the clinical setting for education or research purposes without express consent from the patient, as long as this policy is well publicised. However, express consent must be sought for any form of publication If you wish to make a photographic or video or audio recording of a patient specifically for education, publication or research purposes, you must first seek their written consent (or where appropriate that of a person with parental responsibility) to make the recording, and then seek their consent to use it. Patients must know that they are free to stop the recording at any time and that they are entitled to view it if they wish, before deciding whether to give consent to its use. If the patient decides that they are not happy for any recording to be used, it must be destroyed. As with recordings made with therapeutic intent, patients must receive full information on the possible future uses of the recording, including the fact that it may not be possible to withdraw it once it is in the public domain. 20. Training 20.1 Training on consent to treatment is included in the basic induction of medical and nursing staff Specialist training on consent is available to all clinical staff from the Learning and Development Department Local Mental Health Act Officers provide local training sessions on request covering consent to treatment requirements under Part IV of the Mental Health Act. 20

22 20.4 Consent to treatment issues are regularly included in the Continuing Professional Development Seminars provided through the Clinical Governance Team Training on consent to treatment under the Mental Health Act 1983 is delivered by the Mental Health Law Hub. For further details of mental health law training, refer to the mental health law training plan For training requirements please refer to the Trust s Mandatory Training Policy and Learning and Development Guide For further details of available training, contact the Learning and Development Department. 21. Dissemination and implementation arrangements 21.1 The Associate Director, Governance and Quality Assurance, via the Clinical and Corporate Policy Manager, will disseminate and implement the policy For clarification or support in the implementation of the policy, contact Dominique Merlande, Mental Health Law Manager. 22. Monitoring and audit arrangements 22.1 The following aspects of this policy will be monitored and audited: - Compliance with treatment certificate requirements under Part IV of the MHA 1983; - Concordance between treatment certificates and prescription charts; - Seeking of consent and acknowledgement/assessment of capacity prior to first administration of treatment to patients subject to the MHA1983; - Communication of SOAD reasons to patients following SOAD visits; - Seeking of consent and acknowledgment/assessment of capacity to consent to treatment for physical disorder, interventions and personal care; - Compliance with consent to treatment provisions in the Community (CTO patients) The Mental Health Law Manager will be responsible for carrying out the audits The audits will be undertaken every 3 years. They will undertaken more frequently when concerns have been raised via internal or external assurance sources e.g. mental health law related incident, legal claim, complaint, CQC MHA monitoring report The results will be reported to the Mental Health Law Monitoring Group, which reports to the Mental Health Law Committee Actions from the audit will be implemented by Associate Divisional Directors and monitored by the Mental Health Law Committee Learning from the audit will be shared in the Mental Health Law Committee. 21

23 22

24 Elements to be monitored Lead How Trust will monitor compliance Frequency Reporting Acting on recommendati ons and Lead(s) Change in practice and lessons to be shared Compliance with treatment certificate requirements under Part IV of the MHA 1983 Concordance between treatment certificates and prescription charts Seeking of consent and acknowledgement/assessment of capacity prior to first administration of treatment to patients subject to the MHA1983 Communication of SOAD reasons to patients following SOAD visits Seeking of consent and acknowledgment/assessment of capacity to consent to treatment for physical disorder, interventions and personal care Compliance with consent to treatment provisions in the Community (CTO patients) Mental Health Law Manager Mental Health Law Manager Mental Health Law Manager Mental Health Law Manager Mental Capacity Act Lead Mental Health Law Manager Audit Every 2 years MHL Monitoring Group MHL Committee Audit Every 2 years MHL Monitoring Group MHL Committee Audit Every 2 years MHL Monitoring Group MHL Committee Audit Every 2 years MHL Monitoring Group MHL Committee Audit Every 2 years MHL Monitoring Group MHL Committee Audit Every 2 years MHL Monitoring Group MHL Committee Required actions will be identified and completed in a specified timeframe Required changes to practice will be identified and actioned within a specific time frame. A lead member of the team will be identified to take each change forward where appropriate. Lessons will be shared with all the relevant stakeholders

25 22

26 23. Review of the policy 23.1 The review date will be two years from the date of ratification. If the review date is earlier or later than two years, a justification for this will be provided. 24. References Mental Health Act 1983 Code of Practice to the Mental Health Act 1983 Mental Capacity Act Associated documents Trust s Mandatory Training Policy Trust s Learning and Development Guide

27 Appendix 1 Equality Impact Assessment Tool 1. Does the policy/guidance affect one group less or more favourably than another on the basis of: Race Ethnic origins (including gypsies and travellers) Nationality Gender Culture Religion or belief Sexual orientation including lesbian, gay and bisexual people Age Disability - learning disabilities, physical disability, sensory impairment and mental health problems 2. Is there any evidence that some groups are affected differently? 3. If you have identified potential discrimination, are any exceptions valid, legal and/or justifiable? 4. Is the impact of the policy/guidance likely to be negative? 5. If so can the impact be avoided? 6. What alternatives are there to achieving the policy/guidance without the impact? 7. Can we reduce the impact by taking different action? Yes/No No No No No No No No No No No N/A No N/A N/A N/A Comments The policy provides for information to be given in other languages where necessary. The policy provides for alternative media to be used to seek consent where necessary. 23

28 Appendix 2 TWELVE KEY POINTS ON CONSENT: THE LAW IN ENGLAND 1. When do health professionals need consent from patients? 1.1 Before you examine, treat or care for competent adult patients you must obtain their consent. 1.2 Adults are always assumed to be competent unless demonstrated otherwise. If you have doubts about their competence, the question to ask is: can this patient understand and weigh up the information needed to make this decision? Unexpected decisions do not prove the patient is incompetent, but may indicate a need for further information or explanation. 1.3 Patients may be competent to make some health care decisions, even if they are not competent to make others. 1.4 Giving and obtaining consent is usually a process, not a one-off event. Patients can change their minds and withdraw consent at any time. If there is any doubt, you should always check that the patient still consents to your caring for or treating them. 2. Can children give consent for themselves? 2.2 Before examining, treating or caring for a child, you must also seek consent. Young people aged 16 and 17 are presumed to have the competence to give consent for themselves. Younger children who understand fully what is involved in the proposed procedure can also give consent (although their parents will ideally be involved). In other cases, someone with parental responsibility must give consent on the child s behalf, unless they cannot be reached in an emergency. If a competent child consents to treatment, a parent cannot over-ride that consent. Legally, a parent can consent if a competent child refuses, but it is likely that taking such a serious step will be rare. 3. Who is the right person to seek consent? 3.1 It is always best for the person actually treating the patient to seek the patient s consent. However, you may seek consent on behalf of colleagues if you are capable of performing the procedure in question, or if you have been specially trained to seek consent for that procedure. 4. What information should be provided? 4.1 Patients need sufficient information before they can decide whether to give their consent: for example information about the benefits and risks of the proposed treatment, and alternative treatments. If the patient is not offered as much information as they reasonably need to make their decision, and in a form they can understand, their consent may not be valid. 24

29 4.1 Consent must be given voluntarily: not under any form of duress or undue influence from health professionals, family or friends. 5. Does it matter how the patient gives consent? 5.1 No: consent can be written, oral or non-verbal. A signature on a consent form does not itself prove the consent is valid the point of the form is to record the patient s decision, and also increasingly the discussions that have taken place. Your Trust or organisation may have a policy setting out when you need to obtain written consent. 6. Refusal of treatment 6.1 Competent adult patients are entitled to refuse treatment, even when it would clearly benefit their health. The only exception to this rule is where the treatment is for a mental disorder and the patient is detained under the Mental Health Act A competent pregnant woman may refuse any treatment, even if this would be detrimental to the fetus. 7. Adults who are not competent to give consent 7.1 No-one can give consent on behalf of an incompetent adult. However, you may still treat such a patient if the treatment would be in their best interests. Best interests go wider than best medical interests, to include factors such as the wishes and beliefs of the patient when competent, their current wishes, their general well-being and their spiritual and religious welfare. People close to the patient may be able to give you information on some of these factors. Where the patient has never been competent, relatives, carers and friends may be best placed to advise on the patient s needs and preferences. 7.2 If an incompetent patient has clearly indicated in the past, while competent, that they would refuse treatment in certain circumstances (an advance refusal ), and those circumstances arise, you must abide by that refusal. This summary cannot cover all situations. For more detail, consult the Reference guide to consent for examination or treatment, available from the NHS Response Line and at 25

30 Appendix 3 CURRENT CONSENT FORMS IN USE WITHIN CAMDEN & ISLINGTON NHS FOUNDATION TRUST Mental Health Act Form T1: Certificate of consent to treatment and second opinion Mental Health Act Form T2: Certificate of Consent to Treatment. Mental Health Act Form T3: Certificate of Second Opinion. Mental Health Act Form T4: Mental Health Act Form T5: Mental Health Act Form T6: Mental Health Act Form CTO11: Mental Health Act Form CTO12 Certificate of consent to treatment (patients at least 18 years old) Certificate of consent to treatment and second opinion (patients under 18) Certificate of second opinion (patients who are not capable of understanding the nature, purpose and likely effects of the treatment) Certificate of appropriateness of treatment to be given to community patient (Part 4A certificate) Certificate that community patient has capacity to consent (or if under 16 is competent to consent) to treatment and has done so (Part 4A consent certificate) The circumstances in which it is appropriate to use each of these forms are summarised in the table below. 26

31 RECORDING WHICH MUST BE MADE IN CAMDEN & ISLINGTON NHS FOUNDATION TRUST INFORMAL PATIENTS (And detained patients not covered by Part IV of the MHA e.g. S136, S5(2), S5(4)) INFORMAL PATIENTS (and detained patients not covered by part IV of the MHA) Capable and consenting Capable but not consenting Not capable and compliant Not capable and resisting Medication for physical disorder Informed consent to be recorded in EPR Other treatment for physical disorder, e.g. blood tests Informed consent to be recorded in EPR Medication for mental disorder Informed consent to be recorded in EPR ECT Informed consent to be recorded in EPR Other treatment for mental disorder, involving physical contact (e.g. blood tests) Informed consent to be recorded in EPR Unlawful to treat Unlawful to treat Unlawful to treat Unlawful to treat Unlawful to treat Best interest decision to be recorded in EPR Best interest decision to be recorded in EPR Best interest decision to be recorded in EPR Best interest decision to be recorded in EPR Best interest decision to be recorded in EPR (Not applicable: Patient should be treated under MHA) Best interest decision to be recorded in EPR (Not applicable: Patient should be treated under MHA) Best interest decision to be recorded in EPR (Not applicable: Patient should be treated under MHA) 27

32 PATIENTS SUBJECT TO THE MENTAL HEALTH ACT 1983 (If covered by Part IV of the MHA otherwise treat on same basis as informal) Patients subject under the MHA to which Part IV applies Medication for physical disorder Other treatment for physical disorder, e.g. blood tests Medication for mental disorder ECT Other treatment for mental disorder, involving physical contact (e.g. blood tests) Capable and consenting Informed consent to be recorded in EPR Informed consent to be recorded in EPR No form required during first 3 months (however informed consent to be recorded in EPR). After 3 months, T2 Form required. RC s assessment of capacity and seeking of consent must also be recorded in EPR. MHA Form T4 or T5 + RC s assessment of capacity and seeking of consent must also be recorded in EPR. Informed consent to be recorded in EPR Capable but not consenting Not capable (whether compliant or resisting) Unlawful to treat Best interest decision to be recorded in EPR Unlawful to treat Best interest decision to be recorded in EPR No form required during first three months. T3 Form required after 3 months. RC s assessment of capacity and attempt at seeking consent must also be recorded in EPR. No form required during first three months. T3 Form required after 3 months. RC s assessment of capacity must be recorded in EPR. Unlawful to treat MHA Form T6 No form required. Lawful to treat if ancillary to core mental health treatment. No form required. Lawful to treat if ancillary to core mental health treatment. Last updated, August

33 29 Appendix 4