COMMUNITY TREATMENT ORDER (SECTION 17A MENTAL HEALTH ACT 1983) August 2017

Transcription

1 COMMUNITY TREATMENT ORDER (SECTION 17A MENTAL HEALTH ACT 1983) August 2017 This policy supersedes the previous policies for Supervised Community Treatment (Nov 2009) and for Community Treatment Order Recall (Nov 2009)

2 Policy title Community Treatment Order (Section 17A Mental Health Act 1983) Policy MHA09 reference Policy category Mental Health Act Relevant to Staff working in Trust Inpatient and Community Teams Date published January 2016 Implementation January 2016 date Date last August 2017 reviewed Next review February 2018 date Policy lead Dominique Merlande, Mental Health Law Manager Contact details Telephone: Accountable director Approved by (Group): Approved by (Committee): Document history Membership of the policy development/ review team Claire Johnston, Director of Nursing and People Mental Health Law Committee Quality Committee January 2016 Date Version Summary of amendments May Reviewed and updated Nov Policy redrafted to reflect the MHA 2007 Policy redrafted to reflect the MHA Code of Practice Jan (2015) changes Clarity on handling CTO3 Form and need to upload Aug form to Carenotes (Section 12.7) Dr Stefania Bonaccorso, Consultant Psychiatrist Acute Division Dr Sergi Costafreda, Consultant Psychiatrist SAMH Division Ian Griffiths, Clinical Divisional Lead Acute Division Heston Hassett, Deputy Mental Health Law Manager/Mental Capacity Act Lead Dominique Merlande, Mental Health Law Manager Simon Rowe, Corporate and Clinical Policy Manager Deborah Wright, Head of Social Work and Social Care 1

3 Consultation Margaret Adedeji, Matron (Acute) Paul Calaminus, Chief Operating Officer Peter Cartlidge, Associate Divisional Director (SAMH) Aisling Clifford, Associate Divisional Director (Acute) Rachel Cockerton, Practice Development Nurse Cath Gilchrist, Mental Health Act Officer Sital Gorasia, Mental Health Law Officer Elaine Greer, Associate Divisional Director (R&R) Debra Hall, Mental Health Law Coordinator Dr Suzanne Joels, Divisional Clinical Lead (SAMH) Claire Johnston, Director or Nursing and People Karen Jones, Service manager (Acute) Ann Jumawan, Matron (Acute) Dr Vincent Kirchner, Medical Director Dr Koye Odutoye, Deputy Medical Director Sophie Philipou, Practice Development Nurse Dr Ian Prenelle, Divisional Clinical Lead (R&R) Stanley Riseborough, Deputy Director of Nursing and People Andy Stopher, Deputy Chief Operating Officer DO NOT AMEND THIS DOCUMENT Further copies of this document can be found on the Foundation Trust intranet. 2

4 Contents Page 1 Trust Values 4 2 Policy and Governance 4 3 Policy Statement 5 4 Executive Summary 5 5 Duties and Responsibilities 5 6 Definitions 6 7 Community Treatment Orders Criteria 7 8 Considering a Community Treatment Order 7 9 Initiating a Community Treatment Order 7 10 Treatment Duration and Extension of Community Treatment Orders Recall and revocation Effect of Section 136 and Other Admissions Missing and AWOL Patients Transfers Discharge Custodial Detention Training Dissemination and Implementation Arrangements Monitoring and Audit Arrangements Review of the policy References Associated documents 26 Appendix 1: Equality Impact Assessment Tool 27 3

5 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 organizational 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 standardized 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. 4

6 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 organizations. 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, eg: 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 scrutinized 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 acting on behalf of Camden and Islington NHS Foundation Trust who are involved in the operation of Community Treatment Orders (CTOs) under section 17A of the MHA This policy reflects the requirements of the Mental Health Act 2008 as well as the 2015 Code of Practice to the Mental Health Act. 4. Executive summary An in-patient subject to a treatment section (without a restriction) i.e. Sections 3, 37, 47 or 48 can be placed on a Community Treatment Order (CTO) under section 17A of the Mental Health Act A CTO allows the patient to be discharged from hospital under conditions agreed to ensure they receive medical treatment for mental disorder, prevent a risk of harm to their health or safety and/or protect other people. Patients cannot be treated against their will in the community, except when they lack capacity in emergencies. Medical treatment in the community has to be authorised by the patient s consent or, if they lack capacity to consent to treatment, there must be no conflict with an advance decision, attorney or deputy and no use of force (see Trust policy on Consent to Examination and Care 9.7). Either way treatment certificates requirements must be met before treatment can be administered. CTO patients can be recalled to hospital for up to 72 hours if they need to be assessed or to receive treatment for a mental disorder in hospital and there would be risk of harm to themselves or others or if this is considered the appropriate response to breaking one of the mandatory conditions. 5

7 If assessment on recall concludes the patient needs to be further detained in hospital, the CTO can be revoked and the patient would be detained under their original section i.e. Sections 3, 37, 47 or 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 three 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 Care Quality Commission: The regulator established by the Health and Social Care Act 2008 of all providers of regulated health and social care. This includes care provided under the Mental Health Act Mental Health Act (MHA): The term used within this policy to refer to the Mental Health Act 1983 which is, the legislation that deals with the care and treatment of people who are mentally disordered? Code of Practice: The Code required within the MHA which defines good practice for exercising powers and functions under the MHA, and is something which all persons exercising functions under the MHA should have regard to. Approved Clinician (AC): a person approved by the Secretary of State to act as an approved clinician for the purposes of the MHA. Some decisions under the Act can only be 6

8 taken by people who are approved clinicians. All responsible clinicians must be approved clinicians. Responsible Clinician (RC): The Approved Clinician who has overall responsibility for the care and treatment of a patient subject to the MHA. Certain decisions (such as renewing a patient s detention or placing a patient on a community treatment order) can only be taken by the responsible clinician. Approved Mental Health Professional (AMHP): A role defined within the Act which includes the responsibility for making applications for detention under Part II of the MHA. Mental Capacity Act 2005: Act of Parliament that governs decision-making on behalf of people, aged 16 years and over, who lack capacity, both where they lose capacity at some point in their lives, for example as a result of dementia or brain injury, and where the incapacitating condition has been present since birth. Independent Mental Health Advocates (IMHA) provide an additional safeguard for patients who are subject to the Act. They support patients to exercise their rights and ensure they can participate in the decisions that are made about their care and treatment. They do not replace any other advocacy or support services and work in conjunction with other services. They help qualifying patients to obtain relevant information and to understand their position including their rights and aspects of their treatment. Absent Without Leave (AWOL): A patient is described as being AWOL when they are detained under the Mental Health Act and missing from hospital, including where they have not returned from leave or are absent without leave. This also applies to patients under Guardianship Orders or Community Treatment Orders who have been recalled but have not returned to hospital. Second Opinion Appointed Doctor (SOAD): An independent doctor appointed by the CQC who gives a second opinion on certain types of medical treatment for mental disorder. 7. Community Treatment Orders Criteria Community Treatment Orders can be used where: Patients are detained in hospital for treatment under section 3 of the Act or They are detained for treatment without restriction under Part 3 of the Act (i.e. patients detained under an unrestricted hospital order (section 37), an unrestricted hospital direction (section 45A) or transfer direction (sections 47 or 48) and They are suffering from a mental disorder of a nature or degree which makes it appropriate for them to receive medical treatment They need to receive such treatment for their health or safety or for the protection of others and Such treatment can be provided without the patient continuing to be detained in a hospital, subject to the patient being liable to be recalled and It is necessary that the RC should be able to exercise powers to recall the patient to hospital and Appropriate medical treatment is available for the patient 8. Considering a Community Treatment Order 8.1 A Community Treatment Order must be considered: 7

9 When considering section 17 leave lasting more than 7 consecutive days (or where leave is extended so the total leave granted exceeds 7 consecutive days) If a Tribunal recommends that the RC should consider a CTO (tribunals can recommend consideration of CTO when deciding on applications for discharge; they cannot place patients on CTO or instruct that RCs should do so) 8.2 It is good practice to consider CTO whenever a patient who meets the criteria is considered for discharge from hospital. 9. Initiating a Community Treatment Order ASSESSMENT AND CONSULTATION 9.1 Decisions about placing someone on CTO are the responsibility of the RC, but they require the agreement of an Approved Mental Health Professional (AMHP) and full consultation. It is important consultation starts at an early stage. There are no time limits for completing consultation and assessment, but expiry dates of current sections will be relevant. 9.2 Consultations should involve: The patient Where relevant (and subject to usual considerations of patient confidentiality) the patient s family and/or nearest relative, and any carers Any advocate or Independent Mental Health Advocate (IMHA) If the patient lacks capacity, anyone with authority under the Mental Capacity Act 2005 (MCA) to act on the patient s behalf The multi-disciplinary team involved The patient s GP (if there is one) The Community RC, if there is to be change in RC responsibility 9.3 The RC, with the assistance of the care co-ordinator and/or AMHP as appropriate should make a full clinical assessment including: Reviewing the patient s history Assessing the risk of deterioration if the patient is discharged from in-patient care Assessing any related risks of the patient refusing or neglecting to receive treatment 9.4 The RC must be satisfied that risk of harm arising from the patient s disorder is sufficiently serious to justify the power to recall a patient to hospital for treatment. 9.5 The AMHP s role is to consider the wider social context for the patient, how the patient s social and cultural background may influence the environment in which they will be living, the support available, and whether conditions proposed are necessary or appropriate. 9.6 The AMHP may be one who is already involved in the patient s care and treatment as part of the multi-disciplinary team, but can be any AMHP. The AMHP may be acting on behalf of any willing local social services authority. If no local social services authority is willing to provide an AMHP, responsibility lies with whichever authority would be responsible for providing section 117 aftercare. 9.7 Whether or not the AMHP is personally involved with the patient, it is imperative that he or she meets with the patient to explore the wider social context and any other related issues. 8

10 9.8 If the AMHP does not agree with the RC that the patient should go onto CTO, then the CTO cannot be made. It is not appropriate for the RC to approach another AMHP for an alternative view. ALLOCATION OF RC 9.10 In most cases the appropriate Responsible Clinician for a patient who is subject to a Community Treatment Order will be the Consultant Psychiatrist from the Community Team who will be providing care for the patient once discharged from hospital The inpatient Responsible Clinician who has initiated the Community Treatment Order must liaise with Approved Clinicians in the Community Team to establish who will take on the Responsible Clinician role. The community Responsible Clinician must always be established prior to Community Treatment Order being made. FORMS AND DOCUMENTATION 9.12 If the RC and AMHP agree, the CTO is made using a Form CTO1: Parts 1 and 3 are completed by the RC Part 2 is completed by the AMHP 9.13 It should be noted that Part 1 and Part 2 must be completed before the RC completes Part The RC must specify: The date and time when the CTO comes into effect. Patients are no longer liable to be detained from this date. The reasons why the patient meets the criteria The CTO conditions 9.15 It may be sensible, in some circumstances, to identify a future date to allow time for arrangements to be put in place before the patient is discharged from hospital, but any delay should be for a short period only. It is recommended this should not be longer than two weeks to avoid complications if the patients mental state or circumstances change in the period between the completion of the form and the start of CTO The CTO commences and authority to detain is suspended on the date set out on the CTO1 form. The patient can remain in hospital as a voluntary patient after that date Once the CTO1 Form has been completed and signed by both the RC and the AMHP, the RC is responsible for ensuring it is submitted to the local Receiving Officer (MHA Officer or Duty Nurse) who will receive it on behalf of the Hospital Managers. The form must be uploaded to EPR by the MHA Officer The following documents must be submitted with the completed CTO1 Form. A copy of the CPA care plan. If the fully completed care plan is not yet available a typed/hand written summary of the provisions of the care plan must be attached. The completed CPA care plan must be made available on EPR/sent to the MHA Officer within two weeks; A statement must be recorded on EPR by the inpatient RC regarding the patient s capacity to consent to treatment using the C&I Test for Capacity form; If the patient is deemed to lack capacity to consent to treatment, the inpatient RC must lodge a SOAD request with the CQC (within 48hrs of the CTO starting) There is no mechanism for amending or rectifying a defective Form CTO1 or any other CTO form once it has been completed. It is therefore trust policy that the form should be run past a Receiving Officer (Mental Health Act Officer or equivalent) before 9

11 signature. Minor errors and slips of the pen may be corrected and initialled without affecting the validity of the CTO. INFORMATION FOR PATIENT, NEAREST RELATIVES, CARERS AND OTHERS 9.20 Information must be given to the patient both orally and in writing. These are not alternatives. Those providing information to patients should ensure that all relevant information is conveyed in a way that the patient understands. It is not sufficient to repeat what is already written on an information leaflet as a way of providing information orally. 9.21The Mental Health Act Officer should send written information to the patient and the patient s nearest relative, unless the patient objects to this Information should be provided about the decision to discharge a patient onto CTO and the reasons for it, including any conditions applied and what services will be available for the patient. The Care Co-ordinator must provide the patient with details of: The provisions of the CTO patient is subject to, and the effect of those provisions The rights of their nearest relative to discharge them (and what can happen if the RC does not agree with that request) The effects of CTO, including the conditions which they are required to keep to and the circumstances in which the RC may recall them to hospital The reasons for CTO The maximum length of the current period of CTO How CTO may be ended at any time if it is no longer required or the criteria for it are no longer met How CTO will be reviewed in the two months before the end of the current period of CTO. It should be made clear that CTO will not be discharged or extended automatically and that decisions will depend on circumstances when CTO is reviewed. Any treatment they will receive on CTO and the rules about its provision Who has the power to discharge them from CTO Their rights to apply to the Tribunal and to the Associate Hospital Managers Their rights to request an IMHA 9.23 The Care Co-ordinator must also provide the patient with the relevant information leaflet at the point of placing the patient on CTO. The Care Co-ordinator must follow up and provide additional written and verbal information and clarification throughout the period of CTO recording their efforts on the Trust 132 Rights form on EPR The Trust Information for Patients, Nearest Relatives, Carers and Others Policy highlights the specific times when patients should be informed of their rights. CONDITIONS 9.25 All CTOs must include two mandatory conditions. Patients must make themselves available: For medical examination by the RC when needed for consideration of extension of CTO If a SOAD needs to examine them to consider providing a Part 4A treatment certificate. 10

12 9.26 RCs, with the agreement of the AMHP, may also set additional conditions to: Ensure that the patient receives medical treatment for mental disorder Prevent a risk of harm to the patient s health or safety Protect other people When considering additional conditions: The patient, and (subject to the usual considerations of patient confidentiality) any others with an interest, such as a relative or carer, should be consulted The patient s specific cultural needs and background should be taken into account Any conditions should: Be kept to a minimum consistent with achieving their purpose so that patients and professionals are not set up to fail Restrict the patient s liberty as little as possible, consistent with achieving their purpose Have a clear rationale, linked to one or more of the purposes above Be clearly and precisely expressed, so that the patient can understand what is expected Other than the mandatory conditions, no other conditions are directly enforceable RCs can vary or suspend the conditions. This may occasionally be necessary, for instance to reflect a temporary change in the patient s circumstances such as an informal admission or a short trip away from the area. The Act gives RCs the power to do this without consulting anyone. Trust policy is that any proposed changes should normally be discussed with the patient, any carers or advocate involved and the clinical team. If conditions have recently been agreed with an AMHP it would be good practice to discuss any proposed changes with that AMHP. Any condition no longer required should be removed. 9.31RCs should record any variations on Form CTO2 and any suspension on the CNWL form Suspension Of Conditions Of A Community Treatment Order and send it to the Mental Health Law Office. Any decision to vary or suspend conditions should be recorded in the clinical notes. 10. Treatment AUTHORITY TO TREAT 10.1 CTO patients are subject to treatment rules set out in Part 4A of the Act. These rules differ depending on whether or not the patient has capacity to consent to the treatment in question. Medication for mental disorder (as described in section 58 of the Act) can normally only be given if: There is authority to give it (for patients with capacity, authority is provided by obtaining their consent); and If treatment is to be given after the initial period on CTO, a treatment certificate has been issued Capacity to Consent to Treatment: Treatment cannot be forced on a patient who has capacity and refuses to consent. If the patient has the capacity to consent to the treatment in question, the patient s own consent provides the authority for giving it. There are no exceptions to this rule, even in emergencies. In an emergency, treatment can be given without consent only if they are formally recalled to hospital. For patients aged under 16, capacity means competence to consent. 11

13 10.3 No Capacity to Consent to Treatment: If someone else is empowered under the Mental Capacity Act 2005 to consent on the patient s behalf, they would provide the necessary authority. They could be an the donee of a Lasting Power of Attorney, a Court Appointed Deputy or the Court of Protection itself In any other case, there will only be authority to treat a patient who lacks capacity to consent to treatment if the following conditions are met: The person giving the treatment has taken reasonable steps to establish whether the patient does or does not have capacity to consent to treatment and Having taken those steps, the person giving the treatment reasonably believes the patient lacks the capacity to treatment and Either the person giving the treatment has no reason to believe that the patient objects to the treatment, or the person giving the treatment does have reason to believe that the patient objects, but it is not necessary to use any force against the patient in order to give the treatment and The person giving the treatment is either the approved clinician who is in charge of the treatment in question, or someone acting under that approved clinician s direction and Giving the treatment does not conflict with an advance decision made by the patient and Giving the treatment does not conflict with a decision lawfully made by an LPA donee, a Court Appointed Deputy or the Court of Protection In deciding whether a patient objects to treatment, the person concerned must consider all the reasonably ascertainable evidence. The question is simply whether the patient objects. The reasonableness (or unreasonableness) of the objection is irrelevant The 3rd, 4th, 5th and 6th conditions above do not apply if treatment is immediately necessary and: Either it is not necessary to use force against the patient; or The treatment needs to be given in order to prevent harm to the patient, and the use of force used is a proportionate response to the likelihood of the patient suffering harm and the seriousness of that harm As in Part 4, treatment is immediately necessary if it is: Immediately necessary to save the patient s life; or A treatment which is not irreversible, but which is immediately necessary to prevent a serious deterioration of the patient s condition or A treatment which is not irreversible or hazardous, but which is immediately necessary to alleviate serious suffering by the patient (not applicable to ECT); or A treatment which is not irreversible or hazardous, but which is immediately necessary to prevent the patient from behaving violently or being a danger to himself or to others, and represents the minimum interference necessary to do so (not applicable to ECT). CERTIFICATE REQUIREMENTS 10.8 For medication which would fall within section 58 of the MHA, the treatment must be reviewed and certified as appropriate by a SOAD or by the Responsible Clinician. This must take place either by the end of one month from the start date of the CTO, or if the patient is still within the three month period of treatment without consent, by the end of that three month period whichever is the later. Neither of these applies to ECT treatment When receiving the CTO1 form, the MHA Officer should: 12

14 Determine the date the certificate will be required; Ensure a capacity statement has been completed by the inpatient RC. Ensure the inpatient RC has made arrangements to request a SOAD visit immediately (and at the very latest 48 hours after CTO starts, in line with CQC guidance), if the patient is deemed to lack capacity If the patient is deemed to have capacity and consents to treatment, the community RC will complete a CTO12 form, certifying that the patient has capacity and consents to treatment. The CTO12 form must be completed either during the CPA meeting when the CTO is made or before the end of the period of treatment without treatment certificate The CTO12 form can only be completed by the RC who is responsible for the patient after the CTO commences. If the role of RC changes from in-patient to community, this will be the responsibility of the community RC The CTO12 form will need to be reviewed, with a new form completed, every time there is a change of RC The RC must ensure the following information is recorded on the CTO12 Form before submitting it to the Mental Health Act Office: i the patient s name and address is correctly spelt, iii all the relevant drugs are listed, including medication given as required (PRN). iv the route through which each treatment should be given is recorded (e.g. oral, intra-muscular ( I / M ), or intravenous ( I / V ), v the BNF category of each drug/preparation is given, vi the dose limits of each treatment is given (e.g. within BNF limits), vii the number of preparations in each BNF category are given A CTO patient who has consented may at any time withdraw that consent or lose the capacity to consent. If they lose capacity, a SOAD request will need to be lodged with the CQC by the RC. If they withdraw consent, treatment can no longer be lawfully administered in the community If the patient lacks capacity to consent to treatment, a SOAD certificate is required. The RC who places the patient on CTO must lodge a SOAD request with the CQC Arrangements for the SOAD visit should be planned in advance. Consideration should be given to the most appropriate venue for the SOAD to examine the patient, which may well be a community venue: The mandatory conditions require that patients attend hospital for examination. However the definition of a hospital under the MHA 1983 is quite wide and covers CMHTs as well as outpatient clinics. The choice of venue should reflect the fact that people on CTO are community patients and it may not be convenient or therapeutic for them to see a SOAD in hospital. The treatment proposed and notes of any relevant multi-disciplinary discussion must be given to the SOAD at the time of the visit or before. SOADs may also wish to access other records. If the visit takes place at the local Community Team, it will be the responsibility of the care coordinator to make those records available to the SOAD. SOADs are not expected to visit patients home addresses. 13

15 Recall procedures can be used to require patients to attend for SOAD examination, but this should be a last resort SOADs should normally have the opportunity to interview the patient in private, but others may attend if the patient and the SOAD wish, or the Risk Assessment suggests the SOAD may be at significant risk of physical harm from the patient, and the SOAD agrees SOADs are required to consult two persons who have been professionally concerned with the patient s medical treatment. At least one of the statutory consultees must not be a medical doctor (but need not be a nurse), and neither may be the clinician in charge of the proposed treatment or the responsible clinician. Teams should identify appropriate consultees, who should normally include the patient s care co-ordinator, and should ensure they are available for consultation The patients care co-ordinator will be responsible for co-ordinating the SOAD visit if it should take place at the local Community Team. This will include booking a room for the SOAD to examine the patient, making relevant records available and ensuring statutory consultees have been contacted and are available to discuss the patient s case with the SOAD If the SOAD reviews the patient and decides not to issue a certificate, treatment must end immediately The Part 4A certificate is no longer valid if: The patient stops (even if only temporarily) being an CTO patient The SOAD specifies a time limit for a course of treatment, and the time limit has been reached The certificate was given on the basis that the patient consented, but the patient no longer consents or has lost the capacity to consent The certificate was given on the basis that the patient lacked capacity to consent, but the patient now has that capacity There has been a change in medication. EMERGENCY TREATMENT FOR PATIENTS LACKING CAPACITY OR COMPETENCE Medication can be given as emergency treatment if it meets one of the following conditions: a) To save the patient s life; b) To prevent a serious deterioration of the patient s condition, and the treatment does not have unfavourable physical or psychological consequences which cannot be reversed; c) To 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; d) To 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. However, if it is necessary to use force against the patient to give the treatment: Treatment must be needed to prevent harm to the patient Such force must be a proportionate response to the likelihood of the patient suffering harm and to the seriousness of that harm. 14

16 10.23 Any decision to give treatment in these circumstances should be clearly recorded on the Trust Urgent Treatment form. This form must be uploaded to EPR by the MHA Officer. A copy of this form must also be sent to the local MHL Office. The provisions above do not dispense with the need for a SOAD certificate and they should only be used pending the visit of a SOAD The RC must ensure the following information is recorded on the Trust Urgent Treatment form: i the patient s name is correctly spelt, iii all the relevant drugs are listed, including medication given as required (PRN). iv the route through which each treatment should be given is recorded (e.g. oral, intra-muscular ( I / M ), or intravenous ( I / V ), v the BNF category of each drug/preparation is given, vi the dose limits of each treatment is given (e.g. within BNF limits), vii the number of preparations in each BNF category are given. 11. Duration and Extension of CTO 11.1 A CTO lasts for an initial period of six months. It can be extended for a further six months and then for a year at a time During the final two months of the CTO, the RC must examine the patient in order to decide whether the patient meets the criteria for CTO extension. The RC may recall the patient to hospital for this purpose. Being available for this examination is one of the mandatory conditions The criteria for extension are the same as those for making a CTO. If the RC considers the conditions are met, they must: Consult one or more other people who have been professionally concerned with the patient s medical treatment and Arrange for an AMHP to consider the extension The AMHP who is asked to consider the extension cannot also be the consultee. If the AMHP is already involved in the patient s treatment (e.g. as care coordinator) they cannot fulfil both of these roles: at least one additional professional must be consulted If the AMHP does not agree to an extension, the CTO would not automatically end until the date it is due to expire. The RC should consider whether the patient should be discharged from CTO and an alternative care plan devised If extension is agreed, a Report Extending Community Treatment Period, Form CTO7, is submitted to the MHA Officer acting on behalf of the managers of the responsible hospital: The RC completes Parts 1 and 3 The AMHP completes Part 2 The MHA Officer completes Part 4 on behalf of the managers of the responsible hospital. It should be noted that Part 1 should be completed before Part 2 and Part 2 before Part The furnishing of the RC s report gives authority for the extension. A report is considered furnished to the Hospital Managers at the moment it is handed to an officer 15

17 who is authorised by the Managers to receive it, or when it is put in the hospital s internal mail system There is no mechanism under the MHA 1983 for the CTO7 form to be amended. It is therefore strongly recommended that the form is discussed with and checked by the local Receiving Officer (Mental Health Act Officer or Duty Nurse) before it is signed and furnished. Minor errors and slips of the pen may be corrected and initialled without affecting the validity of the extension The patient should be informed in person of the extension. This should normally be done by the RC. The MHA Officer must also write to the patient and the nearest relative (if the patient has no objection) explaining the extension and their rights Whenever a CTO is extended the MHA Officer will also make arrangements for the Associate Hospital Managers to review the case. 12 Recall and Revocation VOLUNTARY ADMISSION/CONSIDERING RECALL 12.1 If a CTO patient, who is in the community, wishes to come into hospital voluntarily they do not need to be recalled or have their CTO revoked. Such patients can go into hospital informally for any length of time and will remain a CTO patient throughout that time (subject to the expiry of their CTO). During that period the patient s RC will need to consider suspending or varying the conditions of the CTO particularly if there are any conditions concerning the patient's residence. The treatment of the mental disorder of such patients is still governed by Part 4A. The holding powers set out in section 5 of the MHA cannot be used in respect such patients, and recall may need to be considered where appropriate Recall is a serious step and should only be considered when other options including the involvement of the Crisis Team or informal admission have failed or are inappropriate The RC may recall a patient on CTO to hospital for treatment if: The patient needs to receive treatment for a mental disorder in hospital; and There would be risk of harm to the health or safety of the patient, or to other persons, if the patient was not recalled Patients can be recalled if the RC believes they need in-patient treatment or risks cannot be managed in any other way, even though no conditions have been breached. Any action must be proportionate to the level of risk 12.5 Patients may also be recalled if they break either of the two mandatory conditions to make themselves available for examination. However, failure to comply with a condition should not in itself be enough to justify recall unless the criteria above are also met. The first response should be to assess whether the situation can be managed without using recall powers Recall to hospital for treatment should not become a regular or normal event for any patient on CTO. If a patient is being considered for regular recalls, the RC and the team should review whether CTO is working for the patient. THE RECALL PROCESS 12.7 If it is decided that recall is necessary, the RC completes a Notice of Recall to Hospital (Form CTO3) and ensures a copy of it is sent (either by themselves, by the care 16

18 Coordinator or by another team member) to the Receiving Officer (Local Mental Health Act Officer or Duty Nurse) for the relevant hospital. The CTO3 form must also be uploaded to Carenotes. There is no mechanism under the MHA for the CTO3 form to be amended. It is therefore strongly recommended that the form is discussed with and checked by a Receiving Officer (Local Mental Health Act Officer or Duty Nurse) before it is signed and submitted. Minor errors and or slips of the pen may be corrected and initialled without effecting the validity of the recall The RC is responsible for overseeing the recall process. Practical aspects of the recall process may be allocated to other workers, subject to discussion and agreement with team managers and/or multi-disciplinary teams. On-call and Duty Consultants will take the role of RC during out-of hours The recall process requires careful planning to manage risks, minimise potential distress to the patient and anyone else involved, and maximise the chances of participation. There should be early liaison with any other agencies involved, including the ambulance service and police where necessary A Recall Notice provides authority for the patient to be detained in a specified hospital, which may be different from the responsible hospital and may include an outpatient clinic. The NHS Act 2006 defines a hospital as: Any institution for the reception and treatment of persons suffering from illness Any maternity home, and Any institution for the reception and treatment of persons during convalescence or persons requiring medical rehabilitation Decisions about the most appropriate recall unit will need to balance the best interests of the patient, including the least restrictive option in the circumstances, expected duration of recall (if this can be anticipated), and the resources available to manage a detained patient for a period which may last up to 72 hours. Patients can be transferred from one hospital to another during a recall period. Arrangements for recall and potential further admission if CTO is revoked should also take account of age and needs A patient can be recalled to a different hospital from the one where they were originally detained and place on CTO. If this happens, a copy of the recall notice must be provided to the Managers of the new hospital The Recall Notice is only effective once served on the patient. There are three ways the notice can be served: Handing it to the patient personally, which means the notice becomes effective immediately Delivering it to their usual address by hand, which means it comes into effect immediately after midnight (technically on the next day) Sending it by First Class Post to their usual address, which means it is not effective until the second business day after posting (weekends do not count as business days, so a Notice posted on a Friday, for instance, would not be effective until the following Tuesday) It is suggested the last option would increase delay and may increase risks. It is recommended that this should be avoided wherever possible Once served, the Recall Notice provides authority to take and convey the patient to hospital, if necessary. If the patient does not return voluntarily or if they abscond after they have arrived at hospital on recall they are regarded as AWOL. They can be taken into custody under section 18 of the Act and taken to hospital by any AMHP, any police 17

19 officer (or other constable), any officer on the staff of the hospital in question, or any person authorised in writing by the managers of that hospital If access to the patient cannot be gained, it may be necessary to apply for a warrant under section 135 of the Act. The Code suggests a warrant under section 135 (2) should be used, in which case the warrant cannot be applied for until the patient is liable to be taken into custody i.e. after the Recall Notice is deemed served A Recall Notice does not have to be executed. Arrangements should be in place for telephone communication if necessary between the RC and anyone executing the Notice so that different options can be discussed. There may be circumstances when it is more appropriate for the patient to remain in the community. Alternative options should always be explored, such as including involving the Crisis Team if appropriate. The Recall Notice is issued by the RC who retains final responsibility for deciding whether it should be executed or not If a Recall Notice is either not executed or not served for any other reason, the RC must invalidate it by drawing a line through the entire document and writing void across it, together with a date, time, printed name and signature. The voided Recall Notice should be kept on the patient s notes and a copy should be sent to the MHA Officer Once the patient arrives at hospital, the Receiving Officer must complete Form CTO4, recording the arrival time and send it to the MHA Officer. The patient can be detained on recall for up to 72 hours from the time or arrival During the recall period the patient must be assessed by the clinical team and the RC must decide whether they can continue on CTO. The RC should interview the patient personally during this period. The clinical team must consult the patient and (subject to usual confidentiality considerations) any carers, to decide what steps are appropriate. This may include variations in the conditions, changes in the care plan or further admission If the assessment is not completed during the 72-hour period the patient can leave and CTO continues. It should be noted that section 5(2) or 5(4) cannot be used to hold the patient after the 72-hour period has expired If a patient absconds while they are on recall the 72-hour period starts again once they return to the hospital voluntarily or are taken into custody, provided they are returned before the expiry of the CTO or the end of the six month period starting with the first day of the absence without leave, if that is later. TREATMENT ON RECALL: MEDICATION Part 4A does not apply to the treatment of CTO patients once they are recalled to hospital. Authority to treat a recalled patient would generally revert to Part 4 of the Act. However, there are three exceptions to the Part 4 provisions which are set out below: The first exception is that if the proposed medication would otherwise require a Certificate under Section 58 or 58A but there is a Part 4A Certificate (CTO11) specifically directing that the medication can be given on the patient s recall, then the medication can be given without the need for a Part 4 Certificate. The second exception from the need to obtain a Part 4 Certificate is where a Part 4A Certificate was not required because either one month has not passed since the commencement of the CTO, or less than three months have passed since the start of the period of treatment without consent. The third exception is where a Part 4A Certificate (Form CTO11 or CTO12) authorised a programme of treatment in the community but does not specify that the treatment can be given a recall (It should be noted that a CTO12 form does not authorise treatment on recall). In those circumstances the treatment can be 18

20 continued on recall if the Approved Clinician (AC) in charge of the treatment considers that discontinuing it would cause the patient serious suffering The RC must complete the Trust Urgent treatment form on recall and revocation form highlighting the fact that treatment is being administered under one of the above exceptions If the third exception above is relied upon it only applies pending compliance with section If none of the exceptions above apply, the authority to provide medication for a patient s mental disorder during the recall period reverts to Part 4 of the Act and can only be provided: With the patient s consent, or If applicable, under Sections 57 or 58 with the authorisation of a SOAD, or In an emergency (under section 62 (1)) Urgent treatment under section 62 (1) means medication is immediately necessary to either: Save the patient s life, or Prevent a serious deterioration of the patient s condition, and the treatment does not have unfavourable physical or psychological consequences which cannot be reversed or 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 If the patient is compulsorily treated on recall, a review of treatment will be required by the CQC. This should be done by completing a CQC Section 61 Review of Treatment Form when the CTO is next extended by the RC under S20A. TREATMENT ON RECALL: ECT As with the provision of medication on recall, Part 4A does not apply to ECT treatment provided on recall and in general terms the authority to administer ECT would revert to the provisions of Part 4 of the Act and specifically the provisions of Section 58A. However, there are a number of exceptions allowing treatment to be given without the Part 4 requirements being met, these are: Where there is a Part 4A Certificate in place (CTO11 form) which specifically authorises ECT if the patient is recalled and the patient consents to the treatment or lacks capacity to consent. Where ECT was being provided in the community to the patient under a Part 4A Certificate, but that Certificate did not specify that it could be given on recall, a treatment programme can be continued if the AC in charge of the treatment considers that discontinuing it would cause the patient serious suffering. In this situation a fresh SOAD visit should be requested It should be noted that if the second exception above is relied upon, it only applies pending the completion of a SOAD certificate under s58a If none of the exceptions above is applicable, ECT can only be given: With the patient s consent and the appropriate SOAD authorisation, or If the patient lacks capacity, with the appropriate SOAD authorisation, or 19