The Newcastle upon Tyne Hospitals NHS Foundation Trust Exclusion from Treatment of Violent or Abusive Patients Version No.: 4.1 Effective From: 11 October 2016 Expiry Date: 11 October 2019 Date Ratified: 27 September 2016 Ratified By: Clinical Policy Group 1 Introduction The Newcastle upon Tyne Hospitals NHS Foundation Trust has a duty to provide a safe and secure environment for patients, staff and visitors. Violent or abusive behaviour will not be tolerated and decisive action will be taken to protect staff, patients and visitors. This policy is seen as an important step in improving the Trust s ability to tackle incidents involving violence and abuse. The Trust has a responsibility to ensure the safety of staff, patients and visitors. The Placing a Risk of Violence Alert on Patient Records policy provides an early warning to Trust staff of a particular individual or situation that represents a risk to themselves, colleagues, patients or other members of the public. 2 Scope The use of this policy applies to violent or abusive patients aged 16 or over, including their parents, guardians or visitors. (In applying this policy, it should be borne in mind that, legally, individuals under the age of 18 are minors, and that referrals to Social Services may be made in respect to individuals aged up to 18 years.) In situations where the parents or guardians of a minor are the perpetrators of such behaviour, the overriding principle should be that treatment, in the child s best interests, should be continued. The policy outlines measures to protect staff, and applies to patients, parents, guardians, friend or relatives in Trust premises, community premises and private residences visited by community staff. 3 Aims The aim of this policy is to outline behaviours which are unacceptable and the sanctions available to deal with them. These sanctions include a process whereby patients, parents, guardians or visitors who are extreme or persistent in their unacceptable behaviour can, as a last resort, be excluded from treatment. Page 1 of 13
4 Duties (roles and responsibilities) 4.1 Chief Executive The Chief Executive has overall responsibility for the strategic direction and operational management of the Trust and takes overall responsibility for policy. 4.2 Trust Board The Trust Board has a role in driving quality assurance and ensuring compliance with Trust policy. 4.3 Directorate Managers Directorate Management Teams are responsible for ensuring that policies are implemented within their individual Directorates / departments. 4.4 Patient Services Manager and Patient Services Matron The Patient Services Manager and Patient Services Matron are responsible for ensuring that operational aspects of the policy are implemented out of hours. For community patients, the on call manager will be contacted out of hours. 5 Definitions 5.1 Non-Physical abuse The use of inappropriate words, or behaviour, causing distress and/or constituting harassment to others (i.e., patients, staff or the general public). It is difficult to provide a comprehensive list of types of incident that are covered under this definition; however, some examples are provided below: 5.2 Physical abuse The intentional application of force to someone without lawful justification resulting in physical injury or discomfort. It is difficult to provide a comprehensive list of types of incident that are covered under this definition; however, some examples are provided below: 5.3 Verbal Warning Patients who display any of the behaviour described in Section 7 will be asked to desist and offered the opportunity to discuss and explain their behaviour and actions. 5.4 Formal Warning ( Yellow Card ) A written warning letter will be issued (Appendix 1). Page 2 of 13
5.5 Exclusion from Treatment ( Red Card ) If the patient breaches the expected standards of behaviour, despite a formal warning ( yellow card ), a decision to withdraw treatment will be made and a Red Card issued (Appendix 2). 6 Main Body of the Policy The following patients are exempted from the application of this policy: 1. Patients who, in the expert judgment of the relevant clinician, are not competent to take responsibility for their actions (e.g., an individual who becomes abusive as a result of illness or injury). Patients who are mentally ill or do not have mental capacity are also excluded. 2. Patients who because of condition or disability which impacts on ability to control behaviour, may manifest physical or non-physical behaviour that would normally be deemed as unacceptable. 3. Patients who, in the expert judgment of a relevant clinician, require urgent emergency treatment. 4. Other than in exceptional circumstances, any patient under the age of 16. (Advice should be sought initially from a consultant paediatrician and, if necessary, also from the on-call member of the Medical Director s team before withdrawing treatment from any patient under the age of 16.) 5. Patients who because of a medical condition may exhibit behaviour that can be perceived by some to be inappropriate (e.g. Tourette s) and therefore need those behaviours to be accommodated on an individual basis. 7 Key Principles 1. The Patient s clinical care should not be compromised in any way. 2. The Trust recognises the diversity of its patients and people who access treatment. It is important to provide communication support where this is required to prevent misunderstandings escalating into aggression. 3. The Trust has a range of processes and support to meet individuals needs, including Patient Advice and Liaison Service (PALS), Interpreter Services, Learning Disability Liaison Nurse, Chaplaincy Team, and Mental Capacity Advocacy. 4. Where substance abuse has been identified, appropriate assistance and referral will be provided by the Lead Clinician responsible for the patient s care. 5. A record of the action/decision will be held centrally in the Patient Relations Department and a copy will also be kept in the patient s notes and on the Page 3 of 13
patient s electronic record for a period of 12 months. 6. The Trust will fully investigate all valid concerns raised by the patient. 7. Patients will be given appropriate warning before a decision to withdraw treatment is made. 8. There must be clear documentary evidence of the process followed in the patient s records. 9. The decision must be clearly communicated to the patient and their GP in a format that is clear and in a language that they can understand. There may be an occasion (e.g., visual impairment) when it is deemed necessary to meet the patient in a safe environment to advise of the Trust s decision. 10. Failure by the patient, visitor, parent or guardian to comply with the policy will, at the request of the relevant Directorate Manager and the Clinical Director (or their nominated deputies), result in exclusion from treatment (a Red Card ). 11. Any patient, visitor, parent or guardian behaving unlawfully will be reported to the Police and the Trust will seek the application of the maximum penalties available in law. The Trust will prosecute all perpetrators of crime on or against Trust property, assets, and staff. 12. The following are examples of behaviour not acceptable on Trust premises, or directed to Trust employees, whether on or off the premises. 7.1 Non-Physical abuse The use of inappropriate words, or behaviour, causing distress and/or constituting harassment to others (i.e., patients, staff or the general public). It is difficult to provide a comprehensive list of types of incident that are covered under this definition; however, some examples are provided below: - Offensive language, verbal abuse and swearing - Discriminatory language that constitutes hate crime - Loud and intrusive conversation - Unwanted or abusive remarks - Negative, malicious or stereotypical comments - Invasion of personal space - Brandishing of objects or weapons - Near misses (e.g., unsuccessful physical assaults) - Offensive gestures - Threats or risk of serious injury to NHS staff - Intimidation - Stalking - Alcohol- or drug-fuelled abuse - Incitement of others and/or disruptive behaviour - Unreasonable behaviour and non-cooperation such as repeated disregard of hospital policies Page 4 of 13
- Any of the above linked to destruction of or damage to property - Any breach of Trust policies 7.2 Physical abuse The intentional application of force to someone without lawful justification resulting in physical injury or discomfort. It is difficult to provide a comprehensive list of types of incident that are covered under this definition; however, some examples are provided below: - Spitting on/at staff - Pushing - Shoving - Poking or jabbing - Scratching and pinching - Throwing objects, substances or liquids onto, or at, a person - Punching and kicking - Hitting and slapping - Sexual assault - Incidents where reckless behaviour results in physical harm to others - Incidents where attempts are made to cause physical harm to others and fail. 7.3 Sanctions There is a range of sanctions which can be taken against those who abuse Trust staff or property. Whilst these sanctions are described as a sequential process, the policy can be initiated at any stage if, in the judgment of the staff involved, the severity of the behaviour warrants that level of intervention. In situations where parents or guardians of a minor are the perpetrators of such behaviour, the overriding principle should be that treatment, in the child s best interest, should be continued. It may be appropriate to seek advice from the named or designated doctor for safeguarding children to facilitate this, particularly in the situation of an acute presentation. In an outpatient or community setting, parents or guardians of children behaving in a violent or abusive fashion should be advised that such behaviour is not acceptable. If this behaviour continues, despite such warning, they should be advised that the Trust will offer treatment to their child but that they will potentially be excluded. Should parents or guardians continue to behave in a violent or abusive fashion despite this, they should be handled in accordance with the procedures for adult patients outlined below in (section 7.4 of this policy). Should they indicate their intention to leave and to remove their child, thereby depriving the child of what the Trust considers to be necessary medical treatment, they should be advised that the Trust will regard this as a Safeguarding Children issue and will inform Social Services of their behaviour. Page 5 of 13
7.4 Procedure for Issuing Warnings/Excluding from Treatment in the event of inappropriate behaviour by a patient, parents, guardians or visitors- 7.4.1 Verbal Warning Inform and seek advice from the senior doctor or nurse on duty, relevant senior community manager. Ensure that the incident (whether verbal or physical) which triggered the procedure is documented and signed by the member of staff and any witnesses, and is reported via the Incident Reporting Procedure. The senior doctor or senior nurse on duty should inform the patient, parents, guardians or visitors that their behaviour is unacceptable (see section 7), ensuring that they understand expected standards of behaviour and the possible consequences of failing to comply (except in circumstances where this would put staff in direct danger or where it is vital for the safety of others to have the patient urgently removed). They will be offered the opportunity to discuss and explain their behavior and actions. This should then be documented in the patient notes as a verbal warning. Ensure that a suitable member of staff (any doctor or registered nurse) witnesses the explanation to the patient, parents, guardians or visitors and signs the incident report which is completed. 7.4.2 Formal Warning (Yellow Card) The patient (or other) should be warned at this stage by relevant senior community manager. The senior doctor or nurse on duty (Patient Services Coordinator) that a record will be made of their behaviour within the Trust and this will remain on file. The Directorate Manager will investigate the incident (See appendix 2, Placing a Risk of Violence Alert on Patients Records Policy) and confirm the appropriate warning and will issue a warning letter (Yellow Card) as per Appendix 1. If the patient re-attends the Trust and displays violent or abusive behaviour, they will receive a final warning. Should further unacceptable behaviour be demonstrated after this point, the Trust will refuse patient treatment, unless in a life-threatening situation. The yellow card will remain on file. This should be signed by the consultant or relevant senior community manager responsible for the patient s care and the Chief Executive or Nominated Deputy (i.e., the Directorate Manager or the Nursing and Patient Services Director or Medical Director) and sent to the patient and their general practitioner (GP). 7.4.3 Withdrawal of Treatment (Red Card) If the patient breaches the expected standards of behaviour, despite a formal warning ( yellow card ), a decision to withdraw treatment will be made and a Red Card issued. This will remain in place for a 12-month period (Appendix 2). A confirmation letter will be issued. Page 6 of 13
This will be signed by the Chief Executive or a nominated Executive Deputy. The decision to exclude can be taken only by both the relevant Directorate Manager and the Clinical Director (or in their absence their nominated deputies), following investigation of the incident(s) by completing a risk assessment using (See appendix 2, Placing a Risk of Violence Alert on Patients Records Policy). The decision can only be made once alternate care arrangements have been organised. The provision of such arrangements must be pursued with vigour by the relevant clinician. This does not preclude the relevant clinician discharging a patient who no longer requires inpatient care in the normal manner. The responsible consultant or relevant senior community manager must be informed and write to the patient s GP detailing the exclusion and the reasons for it. The patient (or other) must be informed that they may challenge exclusion via the established complaints procedure. The Directorate Manager will facilitate the dispatch of a written confirmation from the Chief Executive/Executive Director to the patient s home and ensure that a record is made of the warning being in place. The Trust Portering and Security Manager must also be informed. A detailed record of the rationale for exclusion, along with the risk assessment completed and of the alternate arrangements for care must be kept in the patient s medical and nursing documentation. If an excluded individual returns in any circumstances other than a medical emergency, security staff should be called immediately. The Trust will subsequently seek legal redress to prevent the individual from returning to Trust property. In the event of an excluded individual presenting at the Trust s Emergency Department for emergency treatment, that individual will be treated and stabilised with, if necessary, security staff in attendance. Where possible, they will then be transferred immediately. However, if admission is unavoidable, security staff will, if necessary, remain in attendance. The need for security attendance will be determined by an appropriate member of staff, in consultation with the Portering and Security Manager. At any stage of the process the Police may be informed and requested to attend. 7.5 Notification Once the decision to issue a warning has been made in accordance with the policy, this needs to be communicated to the patient and their GP (Appendix 1 & 2). In addition, relevant departments in the Trust must be informed to ensure an appropriate and accurate record is made. The following departments should be notified: Page 7 of 13
7.5.1 Patient Relations Department The Patient Relations Department will hold details of the patients who have been formally warned about their behaviour or excluded from treatment. This information will be held on a secure database, with the database held in the Patient Relations Department. 7.5.2 The Trust s Medical Records Manager The Trust s Medical Records Manager is responsible for ensuring that an alert sticker is applied to the front cover of the patient s medical record, in accordance with the policy and a note entered onto the front sheet as follows: This patient is subject to a warning about their behaviour during a previous hospital visit. Please contact the Patient Services Co-coordinator for further details. Safeguarding. System 1 entries will be maintained by the relevant senior community manager. 7.5.3 Alert on Patient erecord/systm one This notification should be made by copying the letter being sent to the patient and their GP, to the Trust s Patient Relations Department and the Trust s Medical Records Manager For Action. Should the patient s GP contact the Trust to express concern about the impact of the decision on their patient and their ongoing wellbeing, this will be referred to the consultant responsible for the patient s care, who will decide in collaboration with the Medical Director the course of action. 7.5.4 Disabling the alert The Trust s Medical Records Manager is responsible for ensuring that these alerts are disabled after 12 months, on expiry of the warning. System 1 entries will be maintained by the relevant senior community manager. 8 Training The Trust will ensure that staff have the skills and knowledge to comply with this policy. 9 Equality and Diversity The Trust is committed to ensuring that, as far as is reasonably practicable, the way we provide services to the public and the way we treat our staff reflects their individual needs and does not discriminate against individuals or groups on any grounds. This document has been appropriately assessed. Page 8 of 13
10 Monitoring Compliance Standard / process / issue Ensure appropriate records are being kept and processes followed. Monitoring and audit Method By Committee Frequency Records will be scrutinized by the Trust Equality and Diversity and Human Rights Group to ensure there is no apparent unfavourable impact on any particular group. The records being considered will include: Trust Equality and Diversity Lead Trust Equality and Diversity and Human Rights Group Annual Details on the database regarding those Patients who are Red Carded. Sample of violent/abusive incidents recorded on Datix to be reviewed by Matron Patient Services to ensure they have been dealt with in accordance with the Policy. Matron Patient Services/ Violent Patient Panel Clinical Risk group Annual 11 Consultation and Review of this Policy When reviewing the policy all appropriate guidance has been taken into account. In addition to relevant subject specific guidance, the legal requirements have also been taken into account. 12 Implementation of the Policy (including raising awareness) A summary of the key changes will be notified to managers following implementation. Further advice and guidance will be available from the Human Resources Department. 13 Associated Documents The Policy should be read in conjunction with the following Trust documents. Concerns and Complaints Policy Dignity and Respect at Work Policy Drug and Alcohol Policy Equal Opportunity and Diversity Policy Management of Violence and Aggression at Work Policy Placing a Risk of Violence Alert on Patient Records Policy Security Policy Page 9 of 13
Appendix 1 Patient s Name Patient s Address Dear Re: Formal Warning Yellow Card This is to formally confirm that, as a consequence of your behaviour on date at time, in the department, you are now subject to the conditions outlined in The Newcastle upon Tyne Hospitals NHS Foundation Trust Policy for the Exclusion from Treatment of Violent or Abusive patients. A copy of the policy is included for your information and you are being formally warned about your behaviour. This warning will stay in place for a period of 12 months, should you on any occasion, fail to comply with the standards of behaviour explained to you and outlined in the policy in your possession during this period, you may be excluded from the Trust s Services. You do need to appreciate that you may not receive care and your General Practitioner would need to advise you about alternative Trusts where you may receive treatment. If emergency treatment is required, we will not refuse you treatment; however, should admission to hospital be required, arrangements may be made for your continued treatment in another establishment. Your medical record will hold an alert to inform the relevant parties that this warning is in place for 12 months. Should you wish to challenge the warning, you should do so via the established Complaints Procedure and contact the Patient Relations Department. Your Grievance will be investigated and you will receive a written response. Yours sincerely Authorised Signatory cc. GP Patient Relations Manager Medical Records Manager (For Action) Page 10 of 13
Appendix 2 R ef D at e Patient s Name Patient s Address Dear Re: Withdrawal of Treatment Red Card This is to formally confirm that as a consequence of your behavior on date at time in the department, you are now subject to the conditions outlined in The Newcastle upon Tyne Hospitals NHS Foundation Trusts Policy for dealing with Violent or Abusive Patients. A copy of the policy is included for your information. Please note that you are being excluded from Treatment,, this may include community premises or private residences, and you may be excluded from any Trust property by our security staff/police. You do need to appreciate that you will not receive care and your General Practitioner will need to advise you on alternative Trusts where you may receive treatment. If emergency treatment is required, we will not refuse you treatment; however, should admission to hospital be required, arrangements will be made for your continued treatment in another establishment. Your medical record will hold an alert to inform the relevant parties that this warning is in place for 12 months. Should you wish to challenge the warning, you should do so via the established Complaints Procedure and contact the Patient Relations Department. Your Grievance will be investigated and you will receive a written response. Yours sincerely Sir Leonard Fenwick CBE Chief Executive OR Nominated Executive Director Page 11 of 13
cc. GP Patient Relations Manager Medical Records Manager (For Action) Page 12 of 13
Appendix 3 WITHDRAWAL OF TREATMENT FROM VIOLENT OR ABUSIVE ADULT PATIENTS Individual becomes violent or exhibits other unwanted behaviour Is she/he a patient or visitor? Visitor Patient Verbal request to modify behaviour Verbal request to modify behaviour Behaviour acceptable No further action Involve senior clinicians to assess treatment plan Continues with unacceptable behaviour Behaviour acceptable No further action Continues with unacceptable behaviour Contact security and/or police and have individual removed from estate Clinician determines has Contact security / Consider use of least restrictive restraint under the MCA 2005 patient got mental capacity and other factors that may influence behaviour No Yes community staff withdraw form situation, contact DM Involve DM or Consultant Give patient formal warning - Yellow Card. Send out letter Poor behaviour continues Resolved DM and Consultant to escalate to Executive Director/Chief Executive and complete risk assessment Includes patients details on secure database for 12 months Patient Relations / On call manager (comm) Exclusion Red Card Patient informed Consultant Extreme violence consider non-multi Agency Public Protection Agency Informs GP Patient has right to appeal via Complaints Procedure Page 13 of 13
The Newcastle upon Tyne Hospitals NHS Foundation Trust Equality Analysis Form A This form must be completed and attached to any procedural document when submitted to the appropriate committee for consideration and approval. PART 1 1. Assessment Date: 2. Name of policy / strategy / service: Policy for the Exclusion from Treatment of Violent or Abusive Patients Policy 3. Name and designation of Author: Emergency Care Facilitator 4. Names & Designations of those involved in the impact analysis screening process: Tina Devlin; Emergency Care Facilitator, Lucy Hall; Equality and Diversity Lead 5. Is this a: Policy x Strategy Service Is this: New Revised x Who is affected: Employees x Service Users x Wider Community x 6. What are the main aims, objectives of the policy, strategy, or service and the intended outcomes? (These can be cut and pasted from your policy) The aim of the policy is to detail the behaviours, which are unacceptable, and the sanctions available to deal with such behaviour, including a mechanism whereby patients who are extreme or persistent in their unacceptable behaviour can, as a last resort, be excluded from the Trust. Exclusion from treatment - EA Page 1 of 5 Dec 2013
7. Does this policy, strategy, or service have any equality implications? Yes X No These have been taken into account in the final policy document If No, state reasons and the information used to make this decision, please refer to paragraph 2.3 of the Equality Analysis Guidance before providing reasons: 8. Summary of evidence related to protected characteristics Protected Characteristic Evidence i.e. What evidence do you have that the Trust is meeting the needs of people in various protected Groups related to this policy/service/strategy please refer to the Equality Evidence (available via the intranet Click A-Z; E for Equality and Diversity. Summary on front page and more detailed information in resources section) Does evidence/engagement highlight areas of direct or indirect discrimination? If yes describe steps to be taken to address (by whom, completion date and review date) Does the evidence highlight any areas to advance equal opportunities or foster good relations. If yes what steps will be taken? (by whom, completion date and review date) Race / Ethnic origin (including gypsies and travellers) Provision of Interpreting service Mental Health Community Development Worker post for BME communities Equality training which promotes inclusive approaches to patients. Lack of communication and cultural understanding can contribute misunderstanding and fear escalating to aggression. Action Ensure communication support is considered in the policy 4.1 change racist language to language that constitutes hate crime 8a Add ----in a format that the patient can understand Appendix 3 add consideration of communication support required- e.g. spoken language Sex (male/ female) Male and female practitioners are No Exclusion from treatment - EA Page 2 of 5 Dec 2013
Religion and Belief Sexual orientation including lesbian, gay and bisexual people Age Disability learning difficulties, physical disability, sensory impairment and mental health. Consider the needs of carers in this section available Chaplaincy service provided with links to leaders of major faiths. Equality training which promotes inclusive approaches to patients. Equality training which promotes inclusive approaches to patients. Dementia friendly practises in place. The policy only applies to those over 18 years of age. Safeguarding considered in the policy Equality training which promotes inclusive approaches to patients. Provision of BSL Signers and Deaf Blind Guides LD Liaison Nurse Links to Psychological and Mental Health Services The policy refers to people who are not competent to take responsibility for their actions and who because of condition or disability, which impacts on ability to control behaviour, may manifest physical or non-physical behaviour that would normally be deemed as unacceptable. Equality training which promotes inclusive approaches to patients. 6.iii add --Learning Disability Liaison Nurse, Chaplaincy Team and Mental Capacity Advocacy here No People living with Dementia and Alzheimer s may have challenging behavior if they are not receiving appropriate care and communication support. Children and young people may be at risk if parents and carers are abusive These issues are considered in the policy People living with autism and learning disability may have challenging behavior if they are not receiving appropriate care and communication support. When referring to parents in the document also add carers Parents and Carers-Section 5 para 3 -add a sentence about providing an opportunity to listen to parents. 6.ii This sounds like some people behave badly because of their diversity. I think it would be better to say ' It is important to provide communication support where this is required to prevent misunderstandings escalating into aggression. 6.iii add --Learning Disability Liaison Nurse, Chaplaincy Team and Mental Capacity Advocacy here Exclusion from treatment - EA Page 3 of 5 Dec 2013
Gender Reassignment Equality training which promotes inclusive approaches to patients. 8a Add ----in a format that the patient can understand Appendix 3 add consideration of communication support required- e.g. someone who is Deaf or has a learning disability No Marriage and Civil Partnership Equality training which promotes inclusive approaches to patients. No Maternity / Pregnancy Women s Health and Maternity Services provided by the Trust and available for advice. The policy refers to taking into account conditions which may affect patients behaviour. Some conditions such as post natal depression and pre- eclampsia may affect pregnant women and nursing mothers behaviour. This is taken into account in the policy 9. Are there any gaps in the evidence outlined above. If yes how will these be rectified? No 10. Engagement has taken place with people who have protected characteristics and will continue through the Equality Delivery System and the Equality Diversity and Human Rights Group. Please note you may require further engagement in respect of any significant changes to policies, new developments and or changes to service delivery. In such circumstances please contact the Equality and Diversity Lead or the Involvement and Equalities Officer. Do you require further engagement No 11. Could the policy, strategy or service have a negative impact on human rights? (E.g. the right to respect for private and family life, the right to a fair hearing and the right to education? Exclusion from treatment - EA Page 4 of 5 Dec 2013
Yes if treatment is withdrawn the right to life needs to be taken into account. 6.1 states The Patient s clinical care should not be compromised in any way- Need to consider if this is realistic if treatment is withdrawn. Scrutiny should be by the Health Equality and Well- being Steering Group PART 2 Signature of Author Print name Tina Devlin Date of completion 20/02/2016 (If any reader of this procedural document identifies a potential discriminatory impact that has not been identified, please refer to the Policy Author identified above, together with any suggestions for action required to avoid/reduce the impact.) Exclusion from treatment - EA Page 5 of 5 Dec 2013