Section 19 Mental Health Act 1983 Regulations as to the transfer of patients

Document level: Trustwide (TW) Code: MH9 Issue number: 4 Section 19 Mental Health Act 1983 Regulations as to the transfer of patients Lead executive Authors details Type of document Target audience Document purpose Medical Director Mental Health Act Team Manager Policy All inpatient staff To assist staff in their duty to work within the Mental Health Act 1983 when involved in arrangements for the formal transfer of patients. Approving meeting Patient Safety and Effectiveness Sub Committee 18-Apr-13 Implementation date Jun -15 followed by an annual compliance review CWP documents to be read in conjunction with HR6 Mandatory Employee Learning (MEL) policy CP1 Admission and discharge from hospital policy GR1 Incident reporting and management policy Document change history Further guidance on transfer of restricted patients, to and from Guardianship, What is different? and Cross Border transfers. Policy in line with Code of Practice 2015. Appendices / electronic forms What is the impact of change? One appendix has been added Checklist for receiving transfers Will this new document change the way we do things currently Training requirements Financial resource implications No - Training requirements for this policy are in accordance with the CWP Training Needs Analysis (TNA) with Learning and Development (L&D) No External references 1. Mental Health Act as amended by the Mental Health Act 2007 2. Mental Health Act: Code of Practice 2015 3. Mental Health Act Manual 17th Edition, Richard Jones, 2014 4. Reference Guide to Mental Health Act 1983, Department of Health, 2015 Equality Impact Assessment (EIA) - Initial assessment Yes/No Comments Does this document affect one group less or more favourably than another on the basis of: - Race No - Ethnic origins (including gypsies and travellers) No - Nationality No - Gender No - Culture No Page 1 of 13 Do not retain a paper version of this document, always view policy / guidance documents from the desktop icon on your computer

Equality Impact Assessment (EIA) - Initial assessment Yes/No Comments - Religion or belief No - Sexual orientation including lesbian, gay and bisexual people No - Age No - Disability - learning disabilities, physical disability, sensory impairment and mental health problems No Is there any evidence that some groups are affected differently? No If you have identified potential discrimination, are there any exceptions valid, legal and/or justifiable? Is the impact of the document likely to be negative? No - If so can the impact be avoided? N/A - What alternatives are there to achieving the document without N/A the impact? - Can we reduce the impact by taking different action? N/A Where an adverse or negative impact on equality group(s) has been identified during the initial screening process a full EIA assessment should be conducted. If you have identified a potential discriminatory impact of this procedural document, please refer it to the human resource department together with any suggestions as to the action required to avoid / reduce this impact. For advice in respect of answering the above questions, please contact the human resource department. Was a full impact assessment required? No What is the level of impact? Low Page 2 of 13 Do not retain a paper version of this document, always view policy / guidance documents from the desktop icon on your computer

Content Quick reference flowchart 1. Introduction... 5 2. Definition of section 19... 5 2.1 Section 19(1)... 5 2.2 Section 19(3)... 5 3. Policy and procedure... 5 3.1 Section 19(1) - transfers from one hospital trust to another... 5 3.1.1 Transfers out of the Trust... 6 3.1.2 Emergency off-site treatment for a physical disorder... 6 3.1.3 Transfers into the Trust... 6 3.2 Section 19(3) - Transfer of patients between hospitals of the same Trust... 7 4. Patient Involvement in the transfer process... 7 5. Additional factors to consider when deciding whether to transfer a patient... 7 6. The Effect of a Transfer... 8 7. Section 19A Transfer of responsibility of patients subject to Community Treatment... 8 7.1 Transfer of responsibility into the Trust... 8 7.2 Transfer of responsibility out of the Trust... 8 8. Transfer to/from Guardianship... 8 8.1 Patients detained under Section 3 may be transferred to Section 7.... 8 8.2 Patients subject to Guardianship may be transferred to hospital.... 9 9. Transfer of Restricted Patients between hospitals, both within and outside the Trust... 9 10. Transfer of Patients between Jurisdictions... 9 10.1 Cross Border transfer from Scotland, Northern Ireland, Isle of Man/Channel Islands to... 9 England (and Wales)... 9 10.2 Authority to Transfer... 10 10.3 Arrangements for Transfer... 10 10.4 Cross Border Transfers from England and Wales to Scotland, Northern Ireland, Isle of... 10 Man/Channel Islands.... 10 11. Repatriation of Foreign Patients... 10 11.1 Return to England of Patients Detained outside the UK, Scotland, Northern Ireland, Isle... 11 of Man/Channel Islands.... 11 12. Statutory documents... 11 Appendix 1 Checklist for receiving formal transfers under Section 19... 12 Page 3 of 13 Do not retain a paper version of this document, always view policy / guidance documents from the desktop icon on your computer

Quick reference flowchart Decision is made to transfer a patient Within the Trust Outside the Trust Transfer of patient subject to CTO Transfer from Section 3 to Guardianship Ensure copies of MHA paperwork are sent with the patient and MHA Team is informed Ensure bed availability. Document reasons for transfer. Inform MHA Team. Ensure receiving hospital provide written acceptance of transfer. Inform MHA Team Local Authority to agree to transfer and specify date. Form G6 completed by LA Restricted Patients Complete Part 1 of Form H4. If possible send original paperwork with patient. MHA Team to completed Form CTO10 and send all original documentation to receiving Trust MHA Team informed and given copy of Form G6. Transfer may only take place with the relevant authority from the Secretary of State for Justice Ensure receiving hospital sign part 2 of Form 14 to accept transfer. Send copy of completed Form 14 to MHA Team. MHA Team to send all original detention papers to the local authority NB in all cases the reasons for the decision to transfer must be fully documented on Carenotes. Page 4 of 13

1. Introduction Section 19 of the Mental Health Act 1983 regulates the transfer between trusts and hospitals of those patients who are detained for assessment or treatment, as well as the transfer between detention and Guardianship. Section 19A regulates the assignment of responsibility of patients in receipt of a Community Treatment Order (CTO) from one trust to another. Patients subject to restriction orders cannot be transferred without the permission of the Ministry of Justice. Patients detained under the following sections cannot be transferred under the provisions of section 19 as they are only either short term holding powers, remands to hospital or interim order from court: Section 5(4) nurse s holding power; Section 5(2) doctor s or approved clinician s holding power; Section 35 remand to hospital for assessment; Section 36 remand to hospital for treatment; Section 38 interim hospital order. CWP has delegated the responsibilities of transfer to various employees (refer to the scheme of delegation). Patients should only be transferred for good reason and their best interests must be taken into account when transfer is being considered. Staff must also ensure that the patient, and where applicable, the patient s nearest relative, is kept informed of the plans and arrangements for transfer. 2. Definition of section 19 2.1 Section 19(1) a) Is the formal transfer of a detained patient to another hospital under the care of a different hospital Trust or the formal transfer from hospital to Guardianship? b) Is the formal transfer of a patient under Guardianship to a different social services authority or person or transfer to hospital under section 3. 2.2 Section 19(3) Is the removal of a detained patient between hospitals within the same Trust. 3. Policy and procedure This procedure re-iterates some of the key points of the Mental Health Act. It is essential that this procedure is read in conjunction with the Mental Health Act Code of Practice 2015 (and where necessary the Mental Health Act itself) as it is statutory guidance and provides detail not contained in this document. 3.1 Section 19(1) - transfers from one hospital trust to another The hospital managers do not have the power to insist that another hospital accepts a patient. Formal transfer under section 19(1) to another Trust is usually planned in advance. Staff should ensure there are good reasons for transfer and that the needs and interests of the patient have been considered. Transfers are potentially an interference with a patient s right to respect for privacy and family life under Article 8 of the European Convention of Human Rights (ECHR). However, in some cases transfers may be unavoidable as the care a patient needs can no longer be offered by the hospital. Page 5 of 13

Taking the above into account, the reasons for transfer should be fully documented in the patients records. 3.1.1 Transfers out of the Trust During office hours Once arrangements have been confirmed for the transfer the MHA Team must be informed as soon as possible so that arrangements can be made for the original paperwork to go with the patient. The nurse in charge must complete part 1 of the H4 transfer form, which provides authority for the transfer to take place. Form H4 and the original section documents should be sent with the patient on the day of the transfer, and a copy kept in the patient s case notes. The nurse accompanying the patient must ensure that, on arrival at the new hospital, part 2 of the form H4 is completed by an officer of the receiving Trust, as this confirms that the patient is no longer under the care of CWP. A photocopy of the completed form H4 must be brought back to the ward for case notes and a copy faxed to the Mental Health Act Team. As the original section papers are kept centrally by the Mental Health Act Team, IF it is not possible to send the originals with the patient on transfer, the Mental Health Act Team will make arrangements, with the agreement of the receiving hospital, for the papers to be sent by recorded delivery. Outside of office hours Most formal transfers to hospitals in another trust are planned in advance and dealt with in liaison between the nurse in charge and the Mental Health Act Team. Such transfers do not normally take place out of hours. Should the situation occur, the nurse in charge of the ward must complete part 1 of the form H4 which formally authorises the transfer. As the originals are kept centrally at the Mental Health Act Team base, and not on the ward, the nurse in charge must ensure that copies of the section papers are sent with the transfer form, as long as the receiving hospital are in agreement. A message must be left for the Mental Health Act Team (by email or phone) regarding the transfer, so that arrangements can be made for the original documents to be sent (by recorded delivery) without delay, to the MHA Administrator of the new trust. 3.1.2 Emergency off-site treatment for a physical disorder Section 19 is not applicable to detained patients who require off-site emergency assessment / treatment for a physical disorder in a hospital at different Trust. It is not necessary for section 17 leave authorisation to be obtained for urgent emergency medical treatment at another hospital or trust. There should be no delay in ensuring that the patient is conveyed to the general acute hospital for the necessary medical treatment. Treatment of a physical disorder unrelated to a mental disorder can be provided under common law if the patient is over 16 years old and is capable and consenting; or under the provisions of the Mental Capacity Act in the patient s best interests, if the patient is incapable at the time of the need for treatment (refer to the Mental Capacity Act Code of Practice, Chapter 6). 3.1.3 Transfers into the Trust During office hours The nurse in charge must: Check that the original current section papers have been sent with the patient as well as the form H4 (authority to transfer); Page 6 of 13

Complete part 2 of the H4 (record of admission to hospital in CWP), if satisfied that the section papers are in order (including current detention, CTO papers if applicable, and consent to treatment forms) following scrutiny complete Trust checklist: (appendix 1); Provide a copy of the H4 for the person who has accompanied the patient to CWP; Fax a copy of the section papers and fully completed H4 to the Mental Health Act Team; Inform the Mental Health Act Team of the new transfer into the ward; Place a copy of the section papers and H4 in the patient s ward case notes; Send original papers, including H4, to the Mental Health Act Team. Outside of office hours Refer to the procedure for during office hours except that there may be a possibility that the original section papers have not arrived with the patient. In this situation copies of the section papers must be provided on admission. However the transfer form H4 must accompany the patient as this is the authority for formal transfer. The Mental Health Act Team will arrange for receipt of original papers. 3.2 Section 19(3) - Transfer of patients between hospitals of the same Trust There is no transfer form required for the movement of patients between wards within the Trust. The following procedure should be followed. During and outside of normal office hours The nurse in charge must: Ensure that copies of ALL section papers are sent with the patient to the receiving ward; Contact the Mental Health Act Team by phone / email to inform details of the transfer. If out of hours, an email should be sent to the mhateam@cwp.nhs.uk or a message left on voicemail confirming details of transfer. Ensure patients rights are re-visited as soon as possible following transfer and that this is documented on the Record of Rights form, as well as CAREnotes. Where applicable ensure the patient s nearest relative is aware of the transfer 4. Patient Involvement in the transfer process Wherever practical patients should be involved in the decision making process when considering a transfer. Staff should explain the reasons for the proposed transfer to the patient, and where appropriate, the nearest relative and carers. Only in exceptional circumstances should a patient be transferred without warning. NB If a patient does not wish their nearest relative to be informed of the transfer, managers need to consider whether doing so would interfere with their right to respect for privacy and family life under Article 8 ECHR. 5. Additional factors to consider when deciding whether to transfer a patient Would the transfer give the patient greater access to family and carers, or would it have the opposite effect? What effect would the transfer have on the patient s disorder, or their recovery? What is the availability of appropriate beds at the receiving hospital? Would the transfer enable the patient to be in a more culturally suitable or compatible environment, or would it have the opposite effect? The wishes of the detained person If the transfer is to a high secure hospital additional consideration should be made to ensure the patient and/or their representative have sufficient time to make representations to the admissions panel Code of Practice Ch 37.21 22 Page 7 of 13

6. The Effect of a Transfer When a patient is transferred to another hospital they are treated as if detained in that hospital all along, eg: consent to treatment provision, expiry, right of appeal. If a patient is firstly admitted under Section 17 leave of absence, transfer takes effect on completion of the authority for transfer Form 14. Transfer between hospital does not affect a patients rights, or that of the nearest relative to apply to the Tribunal Service. 7. Section 19A Transfer of responsibility of patients subject to Community Treatment Orders Section 19A covers the transfer of patients subject to a CTO from the care of one trust to another. This will occur when there is a change of residence. It is imperative that the receiving trust confirms in writing their agreement to the transfer before any transfer takes place. Transfer of responsibility into the Trust The receiving Responsible Clinician from the Community Mental Health Team (CMHT) within CWP, after confirming acceptance of the case in writing, will provide the Mental Health Act Team with a copy of the written acceptance, and details of the transfer, including the name of the responsible trust from where the patient is to be transferred. The Mental Health Act Team will ensure that the relevant CTO documents and previous section papers are received from the transferring trust together with the completed form CTO10 confirming transfer of responsibility to CWP. Copies of the documents will be sent to the relevant CMHT for casenotes. The Responsible Clinician will be informed of the consent to treatment status, expiry date, and of any pending hearings by the MHA Team. The Mental Health Act Team will ensure the patient s record on CareNotes is updated. 7.2 Transfer of responsibility out of the Trust The CWP care co-ordinator must ensure that agreement is obtained, in writing from the clinical team in the receiving trust prior to any arrangements made for transfer. On receipt of the written confirmation, the CWP clinical team care coordinator will fax a copy to the Mental Health Act Team and confirm arrangements that have been made for the transfer. The Mental Health Act Administrator will complete the transfer Form CTO10 formally transferring the responsibility of care from CWP to the new trust. The CTO and previous detention papers, consent forms and hearing decisions, will be sent with the CTO10 to the new responsible trust. A copy of all paperwork will be retained for the case notes. The Mental Health Act Team will update CareNotes accordingly. 8. Transfer to/from Guardianship 8.1 Patients detained under Section 3 may be transferred to Section 7, Guardianship, if the criteria is met. The local authority must be consulted, agree to the transfer and specify a date on Page 8 of 13

which transfer is to take place. Once agreed the local authority completes Form G6. If the local authority is not the proposed guardian, that person must also sign Form G6 to record their agreement to the transfer. Guardianship will take effect as per the date specified. However, it will be treated as if guardianship had begun on the date the person was admitted to hospital on the original section, and the expiry date will be calculated in accordance with the original application. 8.2 Patients subject to Guardianship may be transferred to hospital is an AMHP makes an application for Section 3, accompanied by two medical recommendations. The local authority will complete Form G8 to authorise the transfer. The patient must be admitted within fourteen days of the application. Section 3 will be calculated as if the application was made on the same date as the guardianship order. 9. Transfer of Restricted Patients between hospitals, both within and outside the Trust Section 19 and associated regulations enable a restricted patient to be transferred to another hospital with the consent of the Secretary of State for Justice. The normal rules of Section 19 transfer do not apply. Once a decision has been made to transfer a patient suitable authority must be sought using the appropriate proforma (Mental Health Casework Section, MHCS, forms are available on the Ministry of Justice website). The Secretary of State s role is to ensure transfers preserve public safety, where appropriate respect the feelings and fears of victims and others who may have been affected by the offences. When authorising a transfer the Secretary of State may stipulate a specific hospital/unit. Where an urgent transfer is required it may be sufficient for the transferring and receiving clinicians to provide confirmation of their assessments and availability of appropriate treatment in writing to the MHCS. Such situations include where there is a serious risk of self-harm or harm to others which cannot be safely managed in the current hospital. Where such concerns exist the caseworker at MHCS should be contacted initially. 10. Transfer of Patients between Jurisdictions 10.1 Cross Border transfer from Scotland, Northern Ireland, Isle of Man/Channel Islands to England (and Wales) Section Section 2,3 Hospital Order, Hospital Direction, Transfer Direction Restriction Order Community Treatment Order Guardianship Conditionally Discharged patients Restricted patients Effect of transfer to England Patient treated as if they were newly detained on the date of transfer Patient treated as if they were made subject to the corresponding order on the date of transfer. Restriction continues following transfer Patient treated as if they had been detained and immediately discharged onto CTO on the day they arrive to live in England/Wales Patient treated as if an application was made on the day they arrive to live in England/Wales Transfer can only take place with the agreement of the Secretary of State If the restriction was due to end on a fixed date, this is not affected Page 9 of 13

10.2 Authority to Transfer From Scotland Northern Ireland Isle of Man / Channel Islands Authority Required Transfers must be approved by the Scottish Ministers in accordance with the provisions of the Mental Health (Care and Treatment ) (Scotland) Act 2003. Transfers must be approved by the Department of Health, Social Services and Public Safety for Northern Ireland Transfers require approval from the relevant island authorities 10.3 Arrangements for Transfer It is up to the authority from where the patient is being transferred to decide whether to authorise the transfer in accordance with local legislation. They will require evidence that arrangements have been made for the patient to be received in England/Wales before transfer will be agreed. The hospital managers of the receiving hospital are required to complete Form M1 to record the admission of the patient. Steps must be taken, as soon as reasonably practicable, to inform the patient s nearest relative (if applicable) of the transfer. For patients transferred on a CTO, as soon as practicable, the conditions of the CTO must be agreed. The RC must specify these conditions on Form CTO9, with the agreement of an AMHP. 10.4 Cross Border Transfers from England and Wales to Scotland, Northern Ireland, Isle of Man/Channel Islands. Section Section 2,4 and 3 Hospital Order with or without restrictions Section 37 Hospital Direction (with or without a limitation direction) Section 45A Transfer Direction (with or without a restriction direction under Section 49) Section 47 or 48 Effect of transfer from England The Secretary of State may issue a transfer warrant. A warrant will be issued only if the Secretary of State believes it to be in the patient s best interests to be removed and that relevant arrangements have been made. NB A warrant cannot be issued for the transfer of patients remanded to hospital under Section 35 or 36, an interim hospital order under Section 38, or detained under the holding powers of Section 135, 136 or Section 5. Further guidance may be found in Chapters 35, 36 and 37 of the Reference Guide 2015. 11. Repatriation of Foreign Patients The Act has provisions under which certain detained in-patients may be repatriated to a jurisdiction outside the UK, Isle of Man and Channel Islands. The Secretary of State may authorise a person s removal if that person is: Page 10 of 13

Neither a British Citizen nor a Commonwealth citizen with the right of abode in the UK Receiving in-patient treatment in hospital for mental disorder in England, or Wales Detained under the Mental Health Act by virtue of an application, a hospital order, a hospital direction or a transfer direction. 11.2 Return to England of Patients Detained outside the UK, Scotland, Northern Ireland, Isle of Man/Channel Islands. The Act has no jurisdiction outside the UK. Therefore, patients detained elsewhere become informal once they arrive in England and Wales. In such cases consideration should be given to completing a Mental Health Act assessment as soon as possible, if applicable. 12. Statutory documents Form H4 Form G6 Form G8 Form G7 Transfer from one hospital to another hospital under a different trust Transfer from hospital to Guardianship Transfer from Guardianship of one person or social services authority to another Transfer from Guardianship to hospital (with admission papers) Form CTO10 Authority for assignment of responsibility for community patient to hospital under different managers Page 11 of 13

Appendix 1 Checklist for receiving formal transfers under Section 19 Name of patient Ward DOB Areas to check for Section 2 & 3 Actions to be taken Comment Tick box if correct Check that the relevant section papers are present and correct Check that all section renewal forms are present (if applicable) Form H5 Check that consent to treatment forms are present (if applicable) Check Form H4 (transfer authority) is present and Part 1 completed correctly by the original hospital If all the above are present and correct, complete Part 2 of Form H4 to accept transfer If not present, transfer cannot be accepted. Originating hospital to be contacted for copies If not present, transfer cannot be accepted. Originating hospital to be contacted for copies If not present, transfer cannot be accepted. Originating hospital to be contacted for copies If not present ensure this is completed before staff from originating hospital leave the ward If not present ensure this is completed before staff from originating hospital leave the ward A copy of Form H4, together with the section papers is to be faxed to MHA Team immediately Original section papers to be sent direct to MHA Team NB If possible request that a copy of the section papers are faxed prior to transfer to ensure paperwork is correct. Although it is good practice to receive the original section papers on transfer, this is not always possible. In these cases copies may be accepted and the MHA Team will arrange for the original papers to be forwarded as soon as possible by the originating hospital. Areas to check for part 3 patients (forensic sections) Ensure all relevant paperwork is present: Tick Box Sec 37 Sec 37/41 Sec 38 Sec 47 Sec 47/49 Sec 48 Sec 48/49 Hospital order from court. Form H4 authority for transfer only to be completed if patient transferred from another Trust. Hospital order (with restriction) including transfer authority from Ministry of Justice and Form H4 from originating hospital, if applicable Interim Hospital order from court Transfer authority for sentenced prisoner from court Transfer authority for sentenced prisoner (with restriction) Transfer authority for un-sentenced prisoner from court Transfer authority for un-sentenced prison (with restrictions) from Ministry of Justice Papers checked by Print Name Date Ward MHA Administrator check: Name Page 12 of 13 Date

Errors which will invalidate a section - Forms not signed by someone who is empowered under the Act to do so or the forms are not signed at all; - The Application is written out to the wrong hospital (a fresh application must be made); - The Application is written before the date of the medical recommendations (except Section 4); - The date of the Application is MORE THAN 14 days from the date that the Applicant first examined the patient; - If such errors are found, and the patient is already in hospital, consideration should be given to the implementation of 5(4) or 5(2) until a fresh application is made. Errors which can be rectified within 14 days - The leaving blank of any spaces on the form other than a signature; - Failure to delete one or more alternatives in places where only one can be correct; - The patient s forename, surname or address can be amended if they do not agree in all places; - Where each individual medical recommendation is valid but taken together they do not comply with the Act e.g. - 2 doctors from the same hospital - None of the doctors is Section 12 (2) approved - There are more than five clear days between the recommendations. Then one of the recommendations can be replaced by another within 14 days. This will be valid if, together, the 2 recommendations comply with the Act other than the timescales. Relevant forms for detention Section 2 Medical Recommendations: Application: Section 3 Medical Recommendations: Application: Section 4 Medical Recommendations: Application: Form A4 (2 of these forms) or Form A3 (1 form) Form A1 or Form A2 Form A8 (2 of these forms) or Form A7 (1 Form) Form A5 or A6 Form A11 (1 Form) Form A9 or A10 Please note that Applications to detain patients are only made by approved Mental Health Professionals or patients Nearest Relatives Page 13 of 13