VISIT AND MONITORING REPORT

VISIT AND MONITORING REPORT

Suspension of Detention Monitoring Visits (May - December 2014) July 2015 1

THE MENTAL WELFARE COMMISSION FOR SCOTLAND What we do We protect and promote the human rights of people with mental health problems, learning disabilities, dementia and related conditions. We do this by Checking if individual care and treatment is lawful and in line with good practice. Empowering individuals and their carers through advice, guidance and information. Promoting best practice in applying mental health and incapacity law. Influencing legislation, policy and service development. BACKGROUND TO SUSPENSION OF DETENTION A guiding principle of the Mental Health (Care and Treatment) (Scotland) Act 2003 (2003 Act) is that care and treatment should be delivered in a way that is least restrictive of the individual s freedom. Suspension of detention (SUS) is a key provision that helps to achieve this for individuals who are detained in hospital under the 2003 Act. It enables the Responsible Medical Officer (RMO) to suspend a person s detention, to allow greater freedom and a better quality of life, while still providing the care and treatment he or she needs. Generally, suspension of detention must be authorised by the (RMO) for any time a detained patient spends outside the hospital grounds. We believe that the appropriate use of suspension of detention is of benefit to the individual. We are, however, also aware that the provisions that authorise suspension of detention are complex and sometimes hard to understand; they have also been cumbersome to operate. The Mental Welfare Commission has produced a guidance document 1 relating to Suspension of Detention to help practitioners. This report is primarily intended for those directly working with individuals (in a professional capacity) with mental illness, learning disability and related conditions who are subject to suspension of their detention from hospital. WHY WE CARRIED OUT THESE VISITS The process of transfer from in-patient to community care is often gradual, especially for people with severe and enduring mental illness. In general, suspension is initially used for short periods then with gradually lengthening spells to assist rehabilitation and recovery. 1 Guidance on best practice when suspending compulsory treatment http://www.mwcscot.org.uk/media/51870/suspension%20of%20detention.pdf 2

Suspension of detention should be used up to the point when the person appears able to live in the community with any appropriate support. Consideration should be given, in particular, to the principle of ensuring the minimum restriction on the freedom of the patient that is necessary in the circumstances. When suspending measures that authorise detention the RMO can (under Section 127 of the 2003 Act 2 ), grant a certificate suspending that detention for up to six months. Sub-section 127(2) places a limit on the maximum amount of time for which a RMO may grant a suspension certificate for; this limits suspension to no more than nine months in any 12 month period. Concerns have been raised that the application of the nine month limit for allowing periods of suspension is arbitrary, complicated and difficult to operate in practice. In January 2008, the Minister for Public Health announced the establishment of a group, chaired by Professor Jim McManus, set up to undertake a limited review of the Mental Health (Care and Treatment) (Scotland) Act 2003. The arrangements for suspension of detention were considered in this review under medical matters issues that were causing difficulty to medical professionals in their use of the 2003 Act. Many medical professionals felt that the arrangements for suspension of detention, although well intentioned, are inflexible and difficult to manage and have resulted in the development of excessively bureaucratic systems to count up the number of days a patient has had their detention requirement suspended. In the initial response to the review, it appeared that the Scottish Government was proposing to remove the time limit on suspension of detention altogether. The Mental Welfare Commission expressed significant concerns in response to this proposal, as Section 127(6) of the 2003 Act allows the RMO attach potentially quite restrictive conditions to suspension of detention. The Commission highlighted the fact that the time limit for suspension of detention was recommended by Millan for a good reason to avoid a person in the community being made subject for very long periods of time to conditions imposed at the discretion of the responsible medical officer, without scrutiny by the Mental Health Tribunal. Following consideration of these concerns, amendments have been made to the Mental Health Bill; current proposals are: - That a RMO can authorise the suspension of detention for a period of no more than 200 days (incorporating an overnight element) in any 12 month period. The RMO will be able to authorise up to a further 100 additional overnight periods of 2 Mental Health (Care and Treatment) (Scotland) Act 2003 3

suspended detention within the original 12 month period following application to the Tribunal. The Commission believes that 200 days is a reasonable compromise, but raised concerns during the passage of the Bill about the proposal to allow a further 100 day extension of the suspension order with the authorisation of the Tribunal. We believe if a patient has been in the community for over six months, and it is felt that he or she should remain in the community but subject to compulsion, the appropriate next step should be to apply to the Tribunal to vary the order to a community-based compulsory treatment order. Given the imminent changes to legislation, we wanted to find out how suspension of detention is currently working; this will help to understand the effect of potential changes to the Act. We wanted to meet specifically with individuals who would be directly affected by any changes in legislation. We wanted to ask them to share their views and experiences of being subject to suspension of detention. Our aim was to see 50 individuals across Scotland who are subject to suspension of detention and had been living out of hospital for more than three months. HOW WE CARRIED OUT THE VISITS In April 2014 we wrote to the chief executives of each health board informing them of our intention to visit people who had been out of hospital for between three and six months, on suspension from measures that authorise their detention in hospital (SUS). Between May 2014 and December 2014 we visited 49 individuals. Our visits covered all health board areas apart from NHS Dumfries and Galloway and the island health boards, where (at the time of our visits) nobody fell into the criteria group. Visits were often difficult to arrange as there are in fact not a large number of patients subject to suspension of their detention from hospital for more than three months in the community at any one time. A number of individuals also chose not to speak with us. Prior to our visits we: - Contacted medical records of the hospital in which the SUS was granted, to confirm the patient s current address and ask for the name, address and phone number of the community psychiatric nurse (CPN) and the RMO. - CPNs were contacted to inform them we would be visiting the patient, and to gain any important background information, (primarily safety issues). - A letter was sent to the patient in relation to our visit. - A letter was also sent to the patient s RMO. There were approximately 1700 people subject to long term compulsory powers of detention in hospital at the time of our visits. On any one day, around 300 of these would have been subject to suspension of their detention from hospital [based on our prevalence data 1 Oct 2014]. The 49 individuals we visited represent nearly 40% of 4

the 123 people who had been out of hospital for more than three months during our visiting period. OUR INTERVIEWS The main purpose of these visits was to hear individuals experiences of being subject to suspension of detention. We used a standard questionnaire format to capture information from the people we visited, with a particular focus on the support they were receiving and the effect that being on suspension of their detention was having on their lives. We also asked them if they were happy for us to speak to their named person if they had one. (Anyone receiving treatment under the Act can choose someone to help protect their interests. This person is called a named person). There were also questions we asked of the CPN, and some details gained from patient notes. In addition we had a number of specific questions for named persons, and wanted the opportunity to hear their observations. In any cases where we became aware of issues of concern these were followed up with the appropriate people. WHAT WE EXAMINED There has been much discussion regarding the complexities and bureaucracy of suspension of detention, but very little in relation to capturing the views and experiences of individuals who have their detention suspended. We looked at Some general factors relating to the profile of this group of individuals: Age Detention details Health board And more specific factors: - Conditions imposed in relation to suspension - CPN / Staff input - Care planning and review - Patient experience of suspension of their detention - Named persons - Details from the suspension of detention form (SUS 1A form) We also asked these individuals about the care and treatment they were receiving and about plans for their future care. 5

KEY MESSAGES Key Message 1 Though most patients had an allocated community psychiatric nurse (CPN) in many cases we found their main role was reported to be to administer medication and to monitor mental health. This is an important part of their role but there needs to be a greater focus on promoting recovery and engagement with other services. Recommendations: To address this - NHS Boards should: Ensure adequate resourcing to make sure CPN input is not just about administering medication. Ensure greater focus on promoting recovery and helping engagement with other services in the community. Ensure individuals have a more formal and regularly reviewed 'staying well' plan. Promote the use of Wellness Recovery Action Planning (WRAP). Examine ways that staff can improve the understanding and promote the use of advance statements. Key Message 2 Care planning and review appears to be most effective when a more structured case management approach is used such as Care Programme Approach (CPA). Such approaches also provided the best examples of multidisciplinary intervention. Recommendations: To address this - NHS Boards should: Ensure individuals on suspension of their detention from hospital have appropriate care plans, encouraging multi disciplinary working and a focus on recovery. Ensure individuals know when their situation will be reviewed, and are included in planning discussions. Key Message 3 The majority of people we spoke to had a basic understanding of their situation. Most understood that they were required to take medication and keep appointments, but few had any understanding of any specific conditions related to their suspension of detention from hospital, or how long this situation could last for. 6

Recommendation: To address this - NHS Boards should: Ensure more accessible information is provided for individuals to help them understand more about their situation with regard to their suspension of detention from hospital, be clear about the conditions of this suspension, how long the situation could last and potential future actions. Key Message 4 Having been out of hospital for at least three months just over half of the individuals felt they had too much support and found the situation intrusive; they just wanted to get on with their own lives. Recommendations: To address this - NHS Boards should: Ensure patients who are on suspension of their detention from hospital have their need for compulsory treatment kept under review. Less restrictive options should be considered e.g. variation to a community based Compulsory Treatment Order or removing the order completely. Encourage individuals to be more involved in their support planning. Key Message 5 There was a general lack of recovery based activity, and of promoting engagement with other services in the community. Recommendation: To address this - NHS Boards and service providers should: Strive to become more recovery focused, using tools such as SRI 2 to evidence their progress. Key Message 6 Named persons are not always being appropriately notified about suspension of detention decisions, and many are not involved in care planning discussions. Recommendations: To address this - NHS Boards should: Ensure RMOs clearly evidence compliance with the notification of named persons as required under section 127 of the 2003 Act. 7

Ensure the appropriate involvement of named persons and carers in the care planning and review process. Key Message 7 We noted many errors by Responsible Medical Officers (RMOs) in the completion of SUS 1A forms, the main issues were: Confusion regarding the authorised person condition. A lack of clarity on the form where other conditions were included. A lack of evidence in relation to the RMO contacting the required relevant parties. Issues with regard to the date of RMO signatures. Recommendations: To address this - NHS Boards should: Ensure that Responsible Medical Officers comply with the suspension of detention guidance already issued by the Mental Welfare Commission. Ensure that Responsible Medical Officers include any specific condition requirements in a patient s care plan on the SUS 1A forms. The Mental Welfare Commission should: Update good practice guidance on suspension of detention from hospital following any changes to the current 2003 Act; advice on pre-dated Suspension Certificates is also required. Review the SUS 1A form and amended it to improve ease of use. 8

FINDINGS AND RECOMMENDATIONS GENERAL PROFILE OF INDIVIDUALS WE SAW ON SUSPENSION OF DETENTION What we looked at We noted the details of some of the demographic factors in relation to the group of individuals in our sample group. We noted factors such as age, sex and the health board areas these patients were detained in. We also noted some specific details in relation to the compulsory orders these patients were subject to, and when they were made. What we expected to find As we had not selected in relation to age, sex or nature of orders, we expected a general spread across these criteria, likely to reflect the situation of general prevalence of such orders. What we found Age: We looked at the age and sex profile of the 49 individuals in our patient group. There were 30 men and 19 women in our sample, with a spread of ages across the group. There would not seem to be anything particularly significant in relation to the profile of the individuals we saw. Age Range 18-24 25-44 45-64 65-84 Total Male 0 14 16 0 30 Female 2 5 9 3 19 Total 2 19 25 3 49 Detention details: Of the 49 individuals in our grouping 46 were on suspension from Compulsory Treatment Orders (CTOs) [civil orders made by the Mental Health Tribunal] and three were on suspension from Compulsion Orders [orders made by criminal courts]. In relation to the process and management of suspension of detention, these orders are treated in the same way. Year order made 2014 2013 2012 2011 2009 2007 2006 2003 Number of orders 22 18 3 1 2 1 1 1 Over 80% of the orders had been made within the last two years, though some patients had been subject to detention measures for considerably longer; with 10% of patients having an order that started at least five years ago. All of these orders had been appropriately reviewed by the Mental Health Tribunal Service (MHTS). There were no situations where the end date of the order was before the end date of suspension. 9

Health Board: We managed to see patients from across all health boards apart from NHS Dumfries and Galloway and the island Health boards where at the time of our visits nobody from these areas fell into the criteria group [details appendix 1]. 10

COMMUNITY PSYCHIATRIC NURSE (CPN) INPUT Key Message 1 Though most patients had an allocated community psychiatric nurse (CPN, in many cases we found their main role was reported to be to administer medication and to monitor mental health. This is an important part of their role, but there needs to be a greater focus on promoting recovery and engagement with other services. When a patient is on suspension of their detention from hospital and back in the community, it is usually a CPN who is their main contact in terms of monitoring their health, administering medication and providing support. What we looked at We managed to speak by telephone to most of the CPNs involved in the care of the patients in our sample group, to ask about their involvement in the discharge planning and contact with the patients on suspension of their detention. What we expected to find In most situations we would expect that if a patient has a CPN prior to admission, they should be involved throughout the patients stay in hospital and should be involved with all aspects of their discharge on suspension of detention. If there is no CPN on admission and there is an assessed need for discharge, a CPN should be identified as soon as possible. Community nurses are often crucial in monitoring and promoting the wellbeing of individuals mental health; there should be clear plans to give support for recovery. What we found We managed to speak by telephone to most of the CPNs involved in the care of the individuals in our sample group. We found that at least 86% (42) people had a community psychiatric nurse directly involved in their care while on suspension of their detention from hospital, and that most people were seen either weekly (14 people) or fortnightly (19 people) by their CPN. It was encouraging to see that the majority of the CPNs had been involved at an early stage of the planning for the patient s return to the community, and contributed to the planning for discharge from hospital. CPN involvement varied from patient to patient. We heard of some situations where CPNs had an active involvement whilst the patient was in hospital, including attending ward meetings. These were situations where the patient already had an 11

identified CPN prior to admission. More generally, CPNs were involved in discharge planning meetings about two weeks prior to discharge. We asked community nurses what their understanding of their role was, and what their specific nursing input was. Most identified that their main role was to administer a depot injection 3, to which some also added to monitor mental health. Responses included: Mainly to monitor her mental health and check she is taking her medication. She manages her own medication and has this in a dosset box. General monitoring of condition and medication. Monitor medication compliance especially during transition from depot. Psycho-social education; Illness education; promoting recovery and engagement with other services, and monitor mental state. Although it was only a small sample size, it was disappointing to hear that some nurses only saw their role as administering a depot injection. Administering medication and monitoring mental health is an important part of the CPN role, but we would expect a greater focus on promoting recovery and engagement in the community. We would expect the CPN to help the individual to be more aware of how to manage their illness and get help if required. We believe that in general, patients would benefit from a more formal and regularly reviewed plan for staying well. Such a recovery focused plan is likely to focus attention on a more comprehensive approach to care than simply administering medication and monitoring mental health. It is also likely in terms of review to encourage planning to focus beyond the current suspension period. We would also consider it good practice to encourage individuals to engage in the process of managing their own mental health. The use of a structured approach such as Wellness Recovery Action Planning (WRAP) can help an individual maintain wellness and recovery while working to anticipate and reflect on crisis. We asked the CPNs what plans were in place if they were concerned about the individual. Most said they would contact the RMO, and reported good access to the consultant if required. Where patients were in supported accommodation or had support workers, they generally were the first people to report concerns to the CPN. In other cases, family members would alert concerns to the CPN. 3 Depot injection - Is a special preparation of medication, which is given by injection. The medication is slowly released into the body over a number of weeks. 12

Advance statements: We looked into whether people had made advance statements 4 in relation to how they would prefer to be treated (or not treated) if they were to become unwell in the future. We found that only eight (16%) of those interviewed were known to have made advance statements. Some CPNs seemed unclear as to whether there was an advance statement in place for some patients; others said they would raise the issue following our discussion with them. We had some comments from CPNs saying they had tried to support individuals to make an advance statement but they had not wanted to. There were also comments from patients such as: I do not want any medication and I don t need to write that down. There also seemed to be a view amongst some patients that having an advance statement would not make any difference to their situation. Recommendations: NHS Boards should: Ensure adequate resourcing to make sure CPN input is not just about administering medication. Ensure greater focus on promoting recovery and helping engagement with other services in the community. Ensure individuals have a more formal and regularly reviewed 'staying well' plan. Promote the use of Wellness Recovery Action Planning (WRAP). Examine ways that staff can improve the understanding and promote the use of advance statements. 4 http://www.mwcscot.org.uk/media/128044/advance_statement_final_version_jan_2014.pdf 13

CARE PLANNING AND REVIEW Key Message 2 Care planning and review appears to be most effective when a more structured case management approach is used such as Care Programme Approach (CPA). Such approaches also provided the best examples of multidisciplinary intervention. What we looked at We reviewed patient files for each person in relation to this episode of detention. We wanted to ensure that patients treatment was lawful and that adequate care planning and support was available. What we expected to find Care plans are required to be completed by the responsible medical officer (RMO) under section 76 of the Mental Health (Care and Treatment) (Scotland) Act 2003. The Act states that the RMO shall prepare a care plan which is included in the patient s medical records and that this will set out the medical treatment which it is proposed to give and which is being given. When a suspension of detention is granted for more than 28 days, this care plan requires to be amended 5. We expected to see a comprehensive multi disciplinary care plan which evidences participation by the individual in their care. What we found Having examining the care plans of the people in our sample and having spoken to them about their care; the situation of recording an individual experience of feeling involved in their care was very mixed. The way patients were managed and reviewed varied considerably. Some patients were managed in the community using the Care Programme Approach (CPA), and in such cases there were generally good multidisciplinary links and clearly identified roles, particularly in crisis situations. Several CPNs made reference to operating a traffic light system, with crisis plans and risk management plans. These more intensive systems often involved patients where risks were judged to be higher. There were 17 patients who identified having a formal crisis plan. This level of formal planning was confirmed in our discussions with CPNs. In most cases, arrangements were not formally specified and documented. We saw some very good examples of multi disciplinary working where good care plans were in evidence, and the individual was involved and clear about their care. We heard some positive responses such as: 5 The Mental Health (Content and amendment of care plans) (Scotland) Regulations 2005 14

John was able to tell me that there was a plan to apply for a community compulsory treatment order. There was clear evidence of good multi agency and multi disciplinary working and communication around John s care. He told me that he feels well supported and involved in decisions. He said that he was going to have an increase in Occupational Therapy involvement, with a view to getting back in to work in the future. However, we also found situations where care plans were very sparse, with poor documentation and little evidence of reviews. Jenny told me that there have been no review meetings, she has seen her RMO and CPN once since discharge from hospital. Jenny said that she did not really want to work with them so it is a bit difficult, but there was no evidence of efforts made to engage her. Given the small size of our sample of patients, and the often small numbers of patients from individual heath boards, it has not been possible to draw any conclusions about practice in specific areas. It was evident, however, that in situations where there was a more structured approach to case management (such as CPA), planning and regular review were more apparent. Good practice example In Fife, all individuals care is managed under the auspices of the Care Programme Approach (CPA). This is a good example of clear multi-disciplinary working, which includes a section 76 care plan, involvement of the individual and their named person where appropriate. This practice has regular reviews and is properly documented. There are other areas throughout Scotland which also manage individuals care in this way; it may not always be named as the Care Programme Approach. All individuals had valid T2 (21) or T3 (28) forms [the form authorising treatment under part 16 of the 2003 Act]. We did find two situations where medication was not appropriately authorised, which were addressed with the RMO, and the patient advised accordingly. Recommendations: NHS Boards should: Ensure individuals on suspension of their detention from hospital have appropriate care plans, encouraging multi disciplinary working and a focus on recovery. Ensure individuals know when their situation will be reviewed and are included in planning discussions. 15

PATIENT EXPERIENCE OF SUSPENSION OF DETENTION Key Message 3 The majority of people we spoke to had a basic understanding of their situation. Most understood that they were required to take medication and keep appointments, but few had any understanding of any specific conditions related to their suspension of detention from hospital, or how long this situation could last for. What we looked at We spoke to patients who were on suspension of their detention and we asked them about their understanding of their situation; the support they were receiving; access to advocacy and what they would do if they were concerned about becoming unwell. We also asked about their accommodation, daily activity and any concerns they had about being on suspension of their detention. What we expected to find We expected patients would understand their situation; the conditions expected of them and to see good evidence of support and patient involvement. We also expected to see a focus on care planning, crisis plans to be in place, good access to advocacy and recovery based activity. We were able to engage 42 (86%) of the people selected about their experience of being out of hospital on suspension of their detention. We asked if they understood what being on suspension of detention means. We also asked them about their support, accommodation, activity and any concerns they might have. What we found Understanding of Suspension of Detention (SUS): The process of suspension of detention can be difficult for a patient to understand. The ability to move on from hospital is an important part of the recovery process, but it is also a particularly vulnerable and often difficult time. We asked the people we interviewed if anyone had explained to them what having their detention suspended actually meant. We tried to establish their understanding of their situation, and the conditions of their detention. Twenty eight (57%) said they did understand what being on suspension of detention means. The others seemed much less clear about their situation. Some patients gave positive comments, such as: - The psychiatrist spent time explaining the situation to me. - It means I can live at home to see how I can manage. 16

- The CPN explained that I could be taken back into hospital if I was ill or not complying with my treatment plan. It was to give me a try out in the community. - I m out of hospital to see how it goes. One patient with a learning disability was able to show us a clear and simple letter from their RMO explaining suspension of detention. Many patients, even though saying they understood their situation, seemed to have only had a very basic understanding of their situation. - Said she was not really clear but knew she needed to take her medication and keep appointments or risk going back to hospital. - Out of hospital for a trial in my new house. - He knew he was out from hospital to stay in the community but certainly did not understand the technicalities of suspension of detention. - I don t really know much about suspension of detention. I know I need to take my injection to keep me well; I don t really like it but have agreed to it. A small number of patients (four) were clearly unhappy with the situation of compulsion. Comments included: - He seemed fairly clear about what suspension of detention involved but was resentful of the situation. - Joan was aggrieved that she has to stay in specified accommodation wanted to go to her own home. - Patient said its criminal, the level of power that psychiatrists have in keeping people in hospital and making them take medication. - I am anxious about being on SUS as I feel my actions are under scrutiny. For most of the patients it seemed: - There had been some discussion with their doctor prior to their detention being suspended. - They had an understanding that they no longer needed to be in hospital. - They understood that they were required to take their medication and attend for appointments or risk being brought back into hospital. Only 37% (18 patients) seemed to be aware when their suspension of detention would be reviewed, and only about 25% of patients (12 people) reported having had discussions about how long the order would last. Even patients who reported that their doctors had explained about suspension of detention and the conditions of suspension were generally unclear about how long the situation could last for, or potential future actions; they felt their lives were very much in limbo. 17

We had comments such as: - He had a general understanding of the fact he has to comply with medication and could be returned to hospital but is not aware how long this can last for. - She was unsure how long SUS would last. - Nothing has been mentioned about how long SUS will last. - He knew he was leaving hospital, but was not clear about dates or length of time. We spoke to two patients who had recently had applications made to vary their CTO to a community CTO. They seemed much clearer about their situation. Recommendation: NHS Boards should: Ensure more accessible information is provided for individuals to help them understand more about their situation with regard to their suspension of detention from hospital, be clear about the conditions of this suspension, how long the situation could last and potential future actions. SUPPORT Key Message 4 Having been out of hospital for at least three months, just over half of the individuals felt they had too much support and found the situation intrusive; they just wanted to get on with their own lives. We asked the people interviewed about the support they were receiving now they were out of hospital, and had been so for over three months. It seems, as we expected, that all of these people had ongoing contact with their psychiatrist, and nearly all seemed to have contact with a CPN; most were also in contact with their GP. Just over half mentioned contact with a social worker / MHO but this seemed to be in relation to their order rather than direct support. We would expect the MHO to be a fully involved member of the multidisciplinary team promoting the need to vary the order (if still required) to a community based CTO at the earliest opportunity. The MHO is also likely to have knowledge of community based resources in relation to community engagement. Just over half (27) of the 49 individuals had support workers, either in their supported accommodation or in their own home. These workers were generally from specialist metal health agencies. 18

Views on support We were able to get the views of 32 individuals in relation to their support. Just over half (17) felt they were now getting too much support; support they did not need. They regarded their support as intrusive and stopping them getting on with their own lives. Comments on Support: - I manage everything myself now, it was good at first to let me get settled but I don t really need them. - I can manage myself now - Support is more than enough I just want to get on with my life. - I don t want any input from mental health services. - it s a bit like being under surveillance. - The support is too much I do not need any help, I m fine. - I need to be left alone to do my own thing. - I want a bit less of people coming into my home. - I like my privacy I can manage with less input especially in the afternoon. - There are too many people involved in my life. It is acknowledged that many of the patients we interviewed had long histories of mental ill health, and many had become unwell due to not taking their medication. Even if subject to a community based CTO there is likely to be resentment to a compulsion to take medication. It does seem however that after several months of having been out of hospital, people become frustrated with being in limbo between hospital and community. Regular reviews and clear recovery based care plans can help alleviate this frustration, and progression to a community based order can be seen as a part of the recovery process. There is the potential for patients out of sight of the hospital simply to be left on suspension of their detention until it runs out, with the risk of it not being actively reviewed. Others (34%) seemed very happy with their care and with the level of support, but generally just wanted to get on with their lives or get home. Only two people indicated that they would have liked more support, and this was in relation to getting out and about in the community. We also had two comments regarding lack of flexibility in support, with it not always being at suitable times. Encouraging people to be more involved in their support planning is likely to improve their engagement with services and help those services work towards more personalised objectives for the individual. 19

Recommendations: To address this - NHS Boards should: Ensure patients who are on suspension of their detention from hospital have their need for compulsory treatment kept under review. Less restrictive options should be considered e.g. variation to a community based Compulsory Treatment Order or removing the order completely. Encourage individuals to be more involved in their support planning. Support from Family and Friends: We asked about support from friends and family; about three quarters of the group said they did have a degree of support from family and friends, but the extent of this support varied considerably. The fact that this support was informal, and something which the individual had some control over, made this very different from support provided as part of a compulsory order. Most of the support mentioned was from immediate family, mainly parents and siblings. A few people had support from their partners and children. The level of support provided by family and friends was often considerable and highly valued. It is important to acknowledge the level of this informal support as an important factor in recovery, and to acknowledge the need to effectively engage with family and carers. This informal support should be included in care plans, and family, friends and other carers consulted appropriately. Advocacy: Well over half of the people we spoke to either had an advocacy worker or had used advocacy in the past; most were aware of advocacy services. Many also spoke of their lawyers and appeals against their detention. No one we spoke to seemed unclear about being able to get support and advice regarding their rights regarding their detention. Most individuals spoke positively about support from advocacy; seven people spoke of ongoing contact with advocacy at their reviews and tribunals, many others felt they no longer needed advocacy now they were out of hospital, but knew how to get back in contact. Crisis planning: Only 17 (35%) of the individuals in our sample said they had a written crisis plan, though 36 (73%) said they would have contact details for help in the event of a crisis. 20

We asked people what they would do, or had done, if they felt they were becoming ill. Twenty four patients responded, with 19 of these stating they would contact support staff or their CPN. Five said they would or had contacted a family member or friend in a crisis. Those in supported accommodation generally had more direct access to crisis support. Only 12 people we spoke to stated that they had actually needed crisis support. Nature of Accommodation: We looked at the nature of the accommodation of this group of people. Nature of accommodation Care home 3 Own Home 32 Supported accommodation 11 Not Specified 3 Grand Total 49 Most of the people (about 65%) we interviewed were living in their own homes, some with visiting support. About 30% were living in supported accommodation or care home accommodation. There was no particular difference in the nature of the comments from those in supported accommodation to those in their own home. Both groups generally made comments about wanting to get on with their lives and wanting their privacy. The patients in a care home setting were mainly an older group of patients and spoke mainly of wanting to get back to their own homes. Accommodation is a vital factor in relation to an individual s recovery, particularly after a long stay in hospital. Good links with housing agencies are essential. ACTIVITY Key Message 5 There was a general lack of recovery based activity and of promoting engagement with other services in the community. In terms of recovery, we wanted to know what support people were getting in relation to daily structure and activity. We gained information in relation to 44 of the individuals in our sample. Only three of the 49 patients were in employment (working part time) and two others mentioned education classes. Four cited going to groups that were focused on 21

supporting their mental health. We had hoped to see a greater focus on promoting recovery activity and promoting engagement with other services in the community. Seventeen of the individuals said they went out with their support workers mainly shopping, for walks and for meals or coffee. These people also generally had help with managing at home. Eighteen of the individuals cited no specific groups or activities they generally spent time in the house, out shopping, or seeing friends and family. There were a number of comments from support workers that they struggled to motivate some of the people they were trying to support. This also raised the issue of what is actually being offered to achieve motivation. There needs to be a much clearer focus on factors known to protect mental health, improving self-esteem, empowerment and improving coping skills as well as looking to improve aspects of a healthy lifestyle such as nutrition and physical activity. We would encourage services to focus more on recovery by using service development tools such as the Scottish Recovery Network s service development tool SRI 2 6 Recommendation: NHS Boards and service providers should: Strive to become more recovery focused, using tools such as SRI 2 to evidence their progress. Concerns about being on suspension of detention: Most of the people we spoke to did not express any concerns about being on suspension of their detention from hospital, and were simply glad to be back in the community. On the whole, most people seemed fairly happy with their support, though several commented they would rather not be on an order. Nine of those interviewed expressed concerns. The main issues raised were: Support being too intrusive (too much / too many people in their lives) Worries about recall: - Being dragged back to hospital - I don t like that a doctor can control my life Problems caused by being in hospital: - Difficulty sorting out benefits 6 Home - SRI 2 22

- Problems as own business failed due to my illness - Employment issues There were some comments about changes of doctors and CPNs not being helpful. Some patients had changes to their doctor and CPN as their support changed from hospital to community teams. We asked Does being on SUS stop you doing things? Most of the people on suspension of detention did not really feel it stopped them leading the life they wanted in the community. One person said to be honest I forget I am on it. However: Six people (12%) raised the issue of not being able to go on holiday (especially foreign travel). Six people (12%) raised the issue of restrictions - Having to wait in for support workers and CPNs - Restrictions on smoking - Feeling under surveillance Two people (4%) raised issues of feeling affected by their medication (feeling tired). NAMED PERSONS Key Message 6 Named persons are not always being appropriately notified about suspension of detention decisions, and many are not involved in any care planning discussions. What we looked at Named persons are one of the parties that require to be notified under section 127 of the 2003 Act when an RMO suspends the detention authorised by a compulsory treatment order or compulsion order for more than 28 days. What we expected to find We expected to find that the requirements of the 2003 Act would be complied with, and that named persons would be fully included in care planning, as they have an important role. What we found Currently a person over the age of 16, subject to treatment under the 2003 Act, can nominate a named person to help protect their interests. If a person does not choose a named person, then a carer or their nearest relative may become a named person by default. 23

The situation of having a named person by default, without a person having actively selected someone they wanted to protect their interest, has caused ongoing difficulties with the current 2003 Act. The current Mental Health Bill seeks to amend the provisions in the 2003 Act, so that an individual would only have a named person if they choose to have one. We found that 36 of the 49 patients in our group had identified named persons, of which at least half had been nominated by default. Thirteen people had either decided that they did not want a named person, or there was no one who could act in this capacity. Susan did not want one her grandparents are her closest relatives but she did not want them to have to take on any stresses. About half of the people on suspension of detention seemed to know that their named person would be informed about their discharge from hospital,l but many seemed unsure about the situation. We had various comments: Some patients did not want their named persons contacted as they did not want to worry them as they were elderly. Others did not want things said behind their backs. Several people thought that their named person usually sides with the doctor, and did not want us to speak to them. The named person has an important role to fulfil, and the default position is not always the best person to carry out this role. We asked patients about contacting their named persons. Only 12 (about a quarter) of the patients indicated that they were happy for us to contact their named person. For most patients it seemed that now they were out of hospital, they wanted to be in control of their own lives. Named persons we spoke to generally seemed supportive of the care provided on suspension of detention from hospital but said there had been little in the way of discussion about possible future options. Two said they had not been contacted by the RMO about the suspension of detention and were not involved in any care planning discussions. This was too small a sample of named persons on which to draw any firm conclusions, but it does raise issues as to whether named persons are being appropriately notified as required under section 127 of the 2003 Act. 24

Recommendations: NHS Boards should: Ensure RMOs clearly evidence compliance with the notification of named persons as required under section 127 of the 2003 Act. Ensure the appropriate involvement of named persons and carers in the care planning and review process. 25

DETAILS FROM THE SUSPENSION OF DETENTION FORM (SUS 1A FORM) Key Message 7 We noted many errors by Responsible Medical Officers (RMOs) in the completion of SUS 1A forms. The main issues were: Confusion regarding the authorised person condition. A lack of clarity on the form where other conditions were included. A lack of evidence in relation to the RMO contacting the required relevant parties. Issues with regard to the date of RMO signatures. What we looked at We reviewed all of the Suspension Certificates for the patients in our sample. When an RMO suspends a patient s detention for more than 28 days, this is recorded on a SUS 1A form 7, notifying the Mental Welfare Commission. The main issues we looked at from the forms were: - The period of suspension granted on the form. - The total period of suspension in the last year. - Notification of relevant parties. - The date of RMO signature. - Conditions imposed in relation to suspension. What we expected to find We expected to find that suspension certificates would be filled in correctly by RMOs; that there would be evidence that relevant parties had been informed, and that suspension periods would be within the legal requirements. We also expected any additional conditions to be clearly documented and not overly restrictive. What we found All the patients we saw had been out of hospital on suspension of their detention from between three and six months; all required and had SUS 1A forms, which we reviewed. The length of suspension granted on the form: The SUS 1A form requires the RMO to confirm that the suspension period is in line with section 127 of the 2003 Act. Of the 49 forms we reviewed, 47 had this confirmation from the RMO and two did not. This lack of confirmation triggers a check by the Mental Welfare Commission; in both these cases the suspension period was in line with section 127. 7 SUS 1 A http://www.gov.scot/resource/0040/00401100.pdf 26

In all the forms, the period of suspension was also not longer than the length of the current order. We became aware of one situation where, due to suspension granted prior to the most recent admission, the period of suspension had exceeded the conditions imposed by section 127. The certificate for this patient had also been in existence for more than three months, meaning that this patient had exceeded three months unauthorised absence. In such circumstances, the CTO expires and the person becomes a voluntary patient. The RMO was advised accordingly, and the patient advised that their CTO was invalid. Recent MWC guidance 8 following a Court of Session ruling about the nine month in twelve rule 9 was issued to clarify the position in such cases. This situation shows there are still difficulties being experienced by RMOs in the operation and calculation of suspension periods, and supports the need for changes. Additional issues from the form related to the fact we found it very difficult to see evidence in case notes that the relevant parties [patient, patient s named person, general practitioner (GP), mental health officer (MHO)] had been informed and when. Date of RMO signature: An area of concern on the SUS 1A forms was the date on which the RMO signed the form; there were a very significant number of anomalies. 35% of forms were signed by the RMO contrary to our advice regarding the post dating of forms. RMO signature date Post-dated, 17 RMO Signature Same date, 27 Pre-dated, 5 0 5 10 15 20 25 30 Number of SUS 1A forms 8 http://www.mwcscot.org.uk/media/99488/chief_executive_advice_note_6_.pdf 9 D.C. FOR JUDICIAL REVIEW OF A DECISION TO RETURN HIM TO HOSPITAL DATED ON OR ABOUT 8 DECEMBER 2009 BY DR IAN MITCHELL ND A DECISION OF THE MENTAL HEAL v., 22 November 2011, Lord Stewart 27

Our advice note 6th November 2012 10 clearly states it is not lawful to post-date a suspension certificate. The suspension on a post dated form is not correctly authorised from the date suspension period was granted until the date the form was completed. Certificates should not be completed retrospectively. Of the 17 post dated forms: Length of time post Up to 1 week 1-2 weeks 2-4 weeks 4-8 weeks dated Number of SUS 1A forms 8 1 1 7 We noted that five of the SUS 1A forms were signed by the RMO prior to the start of the date on the SUS 1A form. The pre-dated forms were generally pre-dated between a few days and two weeks before the start of the suspension period. This is not something that the Commission has issued advice on. It seems the situation of pre-dating forms had been for various reasons, such as to coincide with the end of a leave plan or perhaps an RMO being on leave. We would urge caution in pre-dating plans for any significant period of time as there could be a change in the patient s circumstances. Conditions imposed: Suspension of detention is the suspension of the CTO condition of being detained in a hospital. The other treatment and access requirements remain as per the order. For most patients detained in hospital, the additional condition authorised is generally - Giving the patient medical treatment in accordance with Part 16 of the Act. Specific conditions can be added in relation to the suspension of detention from hospital if the RMO considers they are in the person s interest, or for the protection of other people. These require to be specified on the SUS 1A certificate. There is a significant difference between the conditions that can apply to suspension of detention and those that apply when a CTO is varied to a community order (except for restricted patients). This is the basis of many of the concerns about keeping a patient on suspension of their detention for a longer period than nine months, rather than varying the order; the suspension can be more restrictive. The suspension certificate requires a patient to reside at a specific address, either their home address or another as specified on the form; it can also add additional measures. 10 http://www.mwcscot.org.uk/media/99488/chief_executive_advice_note_6_.pdf 28