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

August 2017

This policy supersedes the previous policies for Supervised Community Treatment (Nov 2009) and for Community Treatment Order Recall (Nov 2009)

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Policy title Community Treatment Order (Section 17A Mental Health Act 1983)

Policy reference

MHA09

Policy category Mental Health Act

Relevant to Staff working in Trust Inpatient and Community Teams

Date published January 2016

Implementation date

January 2016

Date last reviewed

August 2017

Next review date

February 2018

Policy lead Dominique Merlande, Mental Health Law Manager

Contact details Email: Dominique.merlande@candi.nhs.uk Telephone: 0203 317 7141

Accountable director

Claire Johnston, Director of Nursing and People

Approved by (Group):

Mental Health Law Committee

Approved by (Committee):

Quality Committee January 2016

Document history

Date Version Summary of amendments

May 2008 2 Reviewed and updated

Nov 2009 3 Policy redrafted to reflect the MHA 2007

Jan 2016 4 Policy redrafted to reflect the MHA Code of Practice

(2015) changes

Aug 2017 4.1 Clarity on handling CTO3 Form and need to upload

form to Carenotes (Section 12.7)

Membership of the policy development/ review team

Dr Stefania Bonaccorso, Consultant Psychiatrist Acute Division Dr Sergi Costafreda, Consultant Psychiatrist SAMH Division Ian Griffiths, Clinical Divisional Lead Acute Division Heston Hassett, Deputy Mental Health Law Manager/Mental Capacity Act Lead Dominique Merlande, Mental Health Law Manager Simon Rowe, Corporate and Clinical Policy Manager Deborah Wright, Head of Social Work and Social Care

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Consultation Margaret Adedeji, Matron (Acute)

Paul Calaminus, Chief Operating Officer

Peter Cartlidge, Associate Divisional Director (SAMH)

Aisling Clifford, Associate Divisional Director (Acute)

Rachel Cockerton, Practice Development Nurse

Cath Gilchrist, Mental Health Act Officer

Sital Gorasia, Mental Health Law Officer

Elaine Greer, Associate Divisional Director (R&R)

Debra Hall, Mental Health Law Coordinator

Dr Suzanne Joels, Divisional Clinical Lead (SAMH)

Claire Johnston, Director or Nursing and People

Karen Jones, Service manager (Acute)

Ann Jumawan, Matron (Acute)

Dr Vincent Kirchner, Medical Director

Dr Koye Odutoye, Deputy Medical Director

Sophie Philipou, Practice Development Nurse

Dr Ian Prenelle, Divisional Clinical Lead (R&R)

Stanley Riseborough, Deputy Director of Nursing and People

Andy Stopher, Deputy Chief Operating Officer

DO NOT AMEND THIS DOCUMENT

Further copies of this document can be found on the Foundation Trust intranet.

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Contents Page

1 Trust Values 4

2 Policy and Governance 4

3 Policy Statement 5

4 Executive Summary 5

5 Duties and Responsibilities 5

6 Definitions 6

7 Community Treatment Orders‟ Criteria 7

8 Considering a Community Treatment Order 7

9 Initiating a Community Treatment Order 7

10 Treatment 10

11 Duration and Extension of Community Treatment Orders 14

12 Recall and revocation 14

13 Effect of Section 136 and Other Admissions 18

14 Missing and AWOL Patients 20

15 Transfers 21

16 Discharge 22

17 Custodial Detention 24

18 Training 24

19 Dissemination and Implementation Arrangements 25

20 Monitoring and Audit Arrangements 25

21 Review of the policy 25

22 References 26

23 Associated documents 26

Appendix 1: Equality Impact Assessment Tool 27

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1. Trust values

Camden and Islington NHS Foundation Trust developed its set of six values with more than 500 service users and members of staff. Our values are important to us. They are our promise to patients as well as to each other that we will behave in a certain way, no matter what our job title is or how under pressure we feel. Our commitment to our values makes us who we are. It gives our service users confidence that they will be treated in the most compassionate way possible as they go through their journey to recovery. It also gives us pride in the knowledge we are providing the best care. Our values show that we are welcoming, respectful and kind. Professional in our approach. Positive in our outlook. Working as a team, we are your partner in care and improvement. These values are part of a wider campaign, Changing Lives which is helping to drive up the standards of care across the Trust. In simple terms our values assure our service users that:

They will receive a warm welcome throughout the journey to recovery;

They, their dignity and their privacy will always be respected;

Their care will be founded on compassion and kindness;

They will receive high quality, safe care from a highly trained team of professionals;

We work together as a team to ensure they feel involved and offer solutions and choices – „no decision about you, without you‟;

We are positive so they can feel hopeful and begin their journey of recovery knowing we will do our very best.

Trust value Yes/No

They will receive a warm welcome throughout the journey to recovery Yes

They, their dignity and their privacy will always be respected; Yes

Their care will be founded on compassion and kindness Yes

They will receive high quality, safe care from a highly trained team of professionals

Yes

We work together as a team to ensure they feel involved and offer solutions and choices – „no decision about you, without you‟

Yes

We are positive so they can feel hopeful and begin their journey of recovery knowing we will do our very best.

Yes

2. Policy and governance

A policy is an organizational statement of rules and standards which govern performance and actions required to be followed by those in employment by the Trust. A policy provides a framework for the Trust to work within and should specify actions which are required. A policy may include detailed procedures which supply standardized methods of performing clinical or non-clinical tasks by providing a series of actions to be conducted in a certain order to achieve a safe and effective outcome in a consistent method by all concerned.

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Policies should take account of existing good quality evidence. The Whittington Health Library provides a library service to the Foundation Trust and can assist with literature searches and finding evidence to inform policy and practice. For more information please contact:

Richard Peacock Librarian Whittington Health Library 020 7288 3607 richardpeacock@nhs.net

Good governance lies at the heart of all successful organizations. Good governance helps protect the Trust, its staff and service users from poor decisions and exposure to risks. All Trust policies must be compliant with the relevant statutory legislation, eg: the Mental Health Act 1983 (which was amended in 2007) and national expectations, e.g.: the NHS Litigation Authority Risk Management Standards 2012-13. A policy which has not been scrutinized and approved by the appropriate Trust committee but is being used by staff could lead to poor practice being delivered which could potentially harm service users and have consequences for staff. It is therefore essential that in either developing or revising a policy, managers ensure that the proper governance procedures have been followed. By following the correct governance procedures, we all help to reduce risk and assure safe and effective care is delivered to service users.

3. Policy statement

This policy sets out the standards and procedures for all health and social care professionals employed by, or acting on behalf of Camden and Islington NHS Foundation Trust who are involved in the operation of Community Treatment Orders (CTOs) under section 17A of the MHA 1983.

This policy reflects the requirements of the Mental Health Act 2008 as well as the 2015 Code of Practice to the Mental Health Act.

4. Executive summary

An in-patient subject to a treatment section (without a restriction) i.e. Sections 3, 37, 47 or 48 can be placed on a Community Treatment Order (CTO) under section 17A of the Mental Health Act 1983.

A CTO allows the patient to be discharged from hospital under conditions agreed to ensure they receive medical treatment for mental disorder, prevent a risk of harm to their health or safety and/or protect other people.

Patients cannot be treated against their will in the community, except when they lack capacity in emergencies. Medical treatment in the community has to be authorised by the patient‟s consent or, if they lack capacity to consent to treatment, there must be no conflict with an advance decision, attorney or deputy and no use of force (see Trust policy on Consent to Examination and Care 9.7). Either way treatment certificates requirements must be met before treatment can be administered.

CTO patients can be recalled to hospital for up to 72 hours if they need to be assessed or to receive treatment for a mental disorder in hospital and there would be risk of harm to themselves or others or if this is considered the appropriate response to breaking one of the mandatory conditions.

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If assessment on recall concludes the patient needs to be further detained in hospital, the CTO can be revoked and the patient would be detained under their original section i.e. Sections 3, 37, 47 or 48.

5. Duties and responsibilities The Chief Executive has ultimate responsibility for ensuring that mechanisms are in place for the overall implementation, monitoring and revision of policy. The Director of Nursing and People is the executive director responsible for this policy, but will delegate authority for the operational implementation and ongoing management of the policy to the Mental Health Law Manager. The Mental Health Law Manager is responsible for reviewing this policy every three years. The Associate Director, Governance and Quality Assurance, via the Clinical and Corporate Policy Manager, is responsible for ensuring:

Dissemination and implementation of the policy

Identification of any resource implications to enable compliance

Training and monitoring systems are in place

Regular review of the policy takes place. Associate Divisional Directors are responsible for implementation of the policy within their own spheres of management and must ensure that:

All new and existing staff have access to and are informed of the policy

Ensure that local written procedures support and comply with the policy

Ensure the policy is reviewed regularly

Staff training needs are identified and met to enable implementation of the policy. Each registered healthcare professional is accountable for his/her own practice and will be aware of their legal and professional responsibilities relating to their competence and work with the Code of Practice of their professional body. All Trust staff are responsible for ensuring that they:

Are familiar with the content of the relevant policy and follow its requirements

Work within, and do not exceed, their own sphere of competence.

6. Definitions

Care Quality Commission: The regulator established by the Health and Social Care Act 2008 of all providers of regulated health and social care. This includes care provided under the Mental Health Act 1983.

Mental Health Act (MHA): The term used within this policy to refer to the Mental Health Act 1983 which is, the legislation that deals with the care and treatment of people who are mentally disordered? Code of Practice: The Code required within the MHA which defines good practice for exercising powers and functions under the MHA, and is something which all persons exercising functions under the MHA should have regard to.

Approved Clinician (AC): a person approved by the Secretary of State to act as an approved clinician for the purposes of the MHA. Some decisions under the Act can only be

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taken by people who are approved clinicians. All responsible clinicians must be approved clinicians.

Responsible Clinician (RC): The Approved Clinician who has overall responsibility for the care and treatment of a patient subject to the MHA. Certain decisions (such as renewing a patient‟s detention or placing a patient on a community treatment order) can only be taken by the responsible clinician. Approved Mental Health Professional (AMHP): A role defined within the Act which includes the responsibility for making applications for detention under Part II of the MHA. Mental Capacity Act 2005: Act of Parliament that governs decision-making on behalf of people, aged 16 years and over, who lack capacity, both where they lose capacity at some point in their lives, for example as a result of dementia or brain injury, and where the incapacitating condition has been present since birth. Independent Mental Health Advocates (IMHA) provide an additional safeguard for patients who are subject to the Act. They support patients to exercise their rights and ensure they can participate in the decisions that are made about their care and treatment. They do not replace any other advocacy or support services and work in conjunction with other services. They help qualifying patients to obtain relevant information and to understand their position including their rights and aspects of their treatment.

Absent Without Leave (AWOL): A patient is described as being AWOL when they are detained under the Mental Health Act and missing from hospital, including where they have not returned from leave or are absent without leave. This also applies to patients under Guardianship Orders or Community Treatment Orders who have been recalled but have not returned to hospital.

Second Opinion Appointed Doctor (SOAD): An independent doctor appointed by the CQC who gives a second opinion on certain types of medical treatment for mental disorder.

7. Community Treatment Orders’ Criteria

Community Treatment Orders can be used where:

Patients are detained in hospital for treatment under section 3 of the Act or

They are detained for treatment without restriction under Part 3 of the Act (i.e. patients detained under an unrestricted hospital order (section 37), an unrestricted hospital direction (section 45A) or transfer direction (sections 47 or 48) and

They are suffering from a mental disorder of a nature or degree which makes it appropriate for them to receive medical treatment

They need to receive such treatment for their health or safety or for the protection of others and

Such treatment can be provided without the patient continuing to be detained in a hospital, subject to the patient being liable to be recalled and

It is necessary that the RC should be able to exercise powers to recall the patient to hospital and

Appropriate medical treatment is available for the patient

8. Considering a Community Treatment Order

8.1 A Community Treatment Order must be considered:

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When considering section 17 leave lasting more than 7 consecutive days (or where leave is extended so the total leave granted exceeds 7 consecutive days)

If a Tribunal recommends that the RC should consider a CTO (tribunals can recommend consideration of CTO when deciding on applications for discharge; they cannot place patients on CTO or instruct that RCs should do so)

8.2 It is good practice to consider CTO whenever a patient who meets the criteria is

considered for discharge from hospital.

9. Initiating a Community Treatment Order

ASSESSMENT AND CONSULTATION

9.1 Decisions about placing someone on CTO are the responsibility of the RC, but they require the agreement of an Approved Mental Health Professional (AMHP) and full consultation. It is important consultation starts at an early stage. There are no time limits for completing consultation and assessment, but expiry dates of current sections will be relevant.

9.2 Consultations should involve:

The patient

Where relevant (and subject to usual considerations of patient confidentiality) the patient‟s family and/or nearest relative, and any carers

Any advocate or Independent Mental Health Advocate (IMHA)

If the patient lacks capacity, anyone with authority under the Mental Capacity Act 2005 (MCA) to act on the patient‟s behalf

The multi-disciplinary team involved

The patient‟s GP (if there is one)

The Community RC, if there is to be change in RC responsibility

9.3 The RC, with the assistance of the care co-ordinator and/or AMHP as appropriate should make a full clinical assessment including:

Reviewing the patient‟s history

Assessing the risk of deterioration if the patient is discharged from in-patient care

Assessing any related risks of the patient refusing or neglecting to receive treatment

9.4 The RC must be satisfied that risk of harm arising from the patient‟s disorder is sufficiently serious to justify the power to recall a patient to hospital for treatment.

9.5 The AMHP‟s role is to consider the wider social context for the patient, how the

patient‟s social and cultural background may influence the environment in which they will be living, the support available, and whether conditions proposed are necessary or appropriate.

9.6 The AMHP may be one who is already involved in the patient‟s care and treatment as

part of the multi-disciplinary team, but can be any AMHP. The AMHP may be acting on behalf of any willing local social services authority. If no local social services authority is willing to provide an AMHP, responsibility lies with whichever authority would be responsible for providing section 117 aftercare.

9.7 Whether or not the AMHP is personally involved with the patient, it is imperative that he

or she meets with the patient to explore the wider social context and any other related issues.

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9.8 If the AMHP does not agree with the RC that the patient should go onto CTO, then the CTO cannot be made. It is not appropriate for the RC to approach another AMHP for an alternative view.

ALLOCATION OF RC 9.10 In most cases the appropriate Responsible Clinician for a patient who is subject to a

Community Treatment Order will be the Consultant Psychiatrist from the Community Team who will be providing care for the patient once discharged from hospital.

9.11 The inpatient Responsible Clinician who has initiated the Community Treatment Order

must liaise with Approved Clinicians in the Community Team to establish who will take on the Responsible Clinician role. The community Responsible Clinician must always be established prior to Community Treatment Order being made.

FORMS AND DOCUMENTATION

9.12 If the RC and AMHP agree, the CTO is made using a Form CTO1:

Parts 1 and 3 are completed by the RC

Part 2 is completed by the AMHP

9.13 It should be noted that Part 1 and Part 2 must be completed before the RC completes Part 3.

9.14 The RC must specify:

The date and time when the CTO comes into effect. Patients are no longer liable to be detained from this date.

The reasons why the patient meets the criteria

The CTO conditions

9.15 It may be sensible, in some circumstances, to identify a future date to allow time for arrangements to be put in place before the patient is discharged from hospital, but any delay should be for a short period only. It is recommended this should not be longer than two weeks to avoid complications if the patients‟ mental state or circumstances change in the period between the completion of the form and the start of CTO.

9.16 The CTO commences and authority to detain is suspended on the date set out on the

CTO1 form. The patient can remain in hospital as a voluntary patient after that date.

9.17 Once the CTO1 Form has been completed and signed by both the RC and the AMHP, the RC is responsible for ensuring it is submitted to the local Receiving Officer (MHA Officer or Duty Nurse) who will receive it on behalf of the Hospital Managers. The form must be uploaded to EPR by the MHA Officer.

9.18 The following documents must be submitted with the completed CTO1 Form.

A copy of the CPA care plan. If the fully completed care plan is not yet available a typed/hand written summary of the provisions of the care plan must be attached. The completed CPA care plan must be made available on EPR/sent to the MHA Officer within two weeks;

A statement must be recorded on EPR by the inpatient RC regarding the patient‟s capacity to consent to treatment using the C&I Test for Capacity form;

If the patient is deemed to lack capacity to consent to treatment, the inpatient RC must lodge a SOAD request with the CQC (within 48hrs of the CTO starting).

9.19 There is no mechanism for amending or rectifying a defective Form CTO1 or any other CTO form once it has been completed. It is therefore trust policy that the form should be run past a Receiving Officer (Mental Health Act Officer or equivalent) before

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signature. Minor errors and slips of the pen may be corrected and initialled without affecting the validity of the CTO.

INFORMATION FOR PATIENT, NEAREST RELATIVES, CARERS AND OTHERS 9.20 Information must be given to the patient both orally and in writing. These are not

alternatives. Those providing information to patients should ensure that all relevant information is conveyed in a way that the patient understands. It is not sufficient to repeat what is already written on an information leaflet as a way of providing information orally.

9.21The Mental Health Act Officer should send written information to the patient and the

patient‟s nearest relative, unless the patient objects to this.

9.22 Information should be provided about the decision to discharge a patient onto CTO and the reasons for it, including any conditions applied and what services will be available for the patient. The Care Co-ordinator must provide the patient with details of:

The provisions of the CTO patient is subject to, and the effect of those provisions

The rights of their nearest relative to discharge them (and what can happen if the RC does not agree with that request)

The effects of CTO, including the conditions which they are required to keep to and the circumstances in which the RC may recall them to hospital

The reasons for CTO

The maximum length of the current period of CTO

How CTO may be ended at any time if it is no longer required or the criteria for it are no longer met

How CTO will be reviewed in the two months before the end of the current period of CTO. It should be made clear that CTO will not be discharged or extended automatically and that decisions will depend on circumstances when CTO is reviewed.

Any treatment they will receive on CTO and the rules about its provision

Who has the power to discharge them from CTO

Their rights to apply to the Tribunal and to the Associate Hospital Managers

Their rights to request an IMHA

9.23 The Care Co-ordinator must also provide the patient with the relevant information leaflet at the point of placing the patient on CTO. The Care Co-ordinator must follow up and provide additional written and verbal information and clarification throughout the period of CTO recording their efforts on the Trust 132 Rights form on EPR.

9.24 The Trust Information for Patients, Nearest Relatives, Carers and Others Policy

highlights the specific times when patients should be informed of their rights.

CONDITIONS

9.25 All CTOs must include two mandatory conditions. Patients must make themselves available:

For medical examination by the RC when needed for consideration of extension of CTO

If a SOAD needs to examine them to consider providing a Part 4A treatment certificate.

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9.26 RCs, with the agreement of the AMHP, may also set additional conditions to:

Ensure that the patient receives medical treatment for mental disorder

Prevent a risk of harm to the patient‟s health or safety

Protect other people.

9.27 When considering additional conditions:

The patient, and (subject to the usual considerations of patient confidentiality) any others with an interest, such as a relative or carer, should be consulted

The patient‟s specific cultural needs and background should be taken into account.

9.28 Any conditions should:

Be kept to a minimum consistent with achieving their purpose so that patients and professionals are not set up to fail

Restrict the patient‟s liberty as little as possible, consistent with achieving their purpose

Have a clear rationale, linked to one or more of the purposes above

Be clearly and precisely expressed, so that the patient can understand what is expected.

9.29 Other than the mandatory conditions, no other conditions are directly enforceable. 9.30 RCs can vary or suspend the conditions. This may occasionally be necessary, for

instance to reflect a temporary change in the patient‟s circumstances such as an informal admission or a short trip away from the area. The Act gives RCs the power to do this without consulting anyone. Trust policy is that any proposed changes should normally be discussed with the patient, any carers or advocate involved and the clinical team. If conditions have recently been agreed with an AMHP it would be good practice to discuss any proposed changes with that AMHP. Any condition no longer required should be removed.

9.31RCs should record any variations on Form CTO2 and any suspension on the CNWL

form „Suspension Of Conditions Of A Community Treatment Order‟ and send it to the Mental Health Law Office. Any decision to vary or suspend conditions should be recorded in the clinical notes.

10. Treatment

AUTHORITY TO TREAT 10.1 CTO patients are subject to treatment rules set out in Part 4A of the Act. These

rules differ depending on whether or not the patient has capacity to consent to the treatment in question. Medication for mental disorder (as described in section 58 of the Act) can normally only be given if:

There is authority to give it (for patients with capacity, „authority‟ is provided by obtaining their consent); and

If treatment is to be given after the initial period on CTO, a treatment certificate has been issued.

10.2 Capacity to Consent to Treatment: Treatment cannot be forced on a patient who has capacity and refuses to consent. If the patient has the capacity to consent to the treatment in question, the patient‟s own consent provides the authority for giving it. There are no exceptions to this rule, even in emergencies. In an emergency, treatment can be given without consent only if they are formally recalled to hospital. For patients aged under 16, capacity means competence to consent.

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10.3 No Capacity to Consent to Treatment: If someone else is empowered under the Mental Capacity Act 2005 to consent on the patient‟s behalf, they would provide the necessary authority. They could be an the donee of a Lasting Power of Attorney, a Court Appointed Deputy or the Court of Protection itself.

10.4 In any other case, there will only be authority to treat a patient who lacks capacity to

consent to treatment if the following conditions are met:

The person giving the treatment has taken reasonable steps to establish whether the patient does or does not have capacity to consent to treatment and

Having taken those steps, the person giving the treatment reasonably believes the patient lacks the capacity to treatment and

Either the person giving the treatment has no reason to believe that the patient objects to the treatment, or the person giving the treatment does have reason to believe that the patient objects, but it is not necessary to use any force against the patient in order to give the treatment and

The person giving the treatment is either the approved clinician who is in charge of the treatment in question, or someone acting under that approved clinician‟s direction and

Giving the treatment does not conflict with an advance decision made by the patient and

Giving the treatment does not conflict with a decision lawfully made by an LPA donee, a Court Appointed Deputy or the Court of Protection.

10.5 In deciding whether a patient objects to treatment, the person concerned must

consider all the reasonably ascertainable evidence. The question is simply whether the patient objects. The reasonableness (or unreasonableness) of the objection is irrelevant.

10.6 The 3rd, 4th, 5th and 6th conditions above do not apply if treatment is immediately

necessary and:

Either it is not necessary to use force against the patient; or

The treatment needs to be given in order to prevent harm to the patient, and the use of force used is a proportionate response to the likelihood of the patient suffering harm and the seriousness of that harm.

10.7 As in Part 4, treatment is immediately necessary if it is:

• Immediately necessary to save the patient‟s life; or • A treatment which is not irreversible, but which is immediately necessary to

prevent a serious deterioration of the patient‟s condition or • A treatment which is not irreversible or hazardous, but which is immediately

necessary to alleviate serious suffering by the patient (not applicable to ECT); or • A treatment which is not irreversible or hazardous, but which is immediately

necessary to prevent the patient from behaving violently or being a danger to himself or to others, and represents the minimum interference necessary to do so (not applicable to ECT).

CERTIFICATE REQUIREMENTS 10.8 For medication which would fall within section 58 of the MHA, the treatment must be

reviewed and certified as appropriate by a SOAD or by the Responsible Clinician. This must take place either by the end of one month from the start date of the CTO, or if the patient is still within the three month period of treatment without consent, by the end of that three month period whichever is the later. Neither of these applies to ECT treatment.

10.09 When receiving the CTO1 form, the MHA Officer should:

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Determine the date the certificate will be required;

Ensure a capacity statement has been completed by the inpatient RC.

Ensure the inpatient RC has made arrangements to request a SOAD visit immediately (and at the very latest 48 hours after CTO starts, in line with CQC guidance), if the patient is deemed to lack capacity.

10.10 If the patient is deemed to have capacity and consents to treatment, the community

RC will complete a CTO12 form, certifying that the patient has capacity and consents to treatment. The CTO12 form must be completed either during the CPA meeting when the CTO is made or before the end of the period of treatment without treatment certificate.

10.11 The CTO12 form can only be completed by the RC who is responsible for the patient

after the CTO commences. If the role of RC changes from in-patient to community, this will be the responsibility of the community RC.

10.12 The CTO12 form will need to be reviewed, with a new form completed, every time

there is a change of RC. 10.13 The RC must ensure the following information is recorded on the CTO12 Form

before submitting it to the Mental Health Act Office:

i the patient‟s name and address is correctly spelt,

iii all the relevant drugs are listed, including medication given “as required” (PRN).

iv the route through which each treatment should be given is recorded (e.g. oral, intra-muscular (I/M), or intravenous (I/V),

v the BNF category of each drug/preparation is given,

vi the dose limits of each treatment is given (e.g. within BNF limits),

vii the number of preparations in each BNF category are given.

10.14 A CTO patient who has consented may at any time withdraw that consent or lose the

capacity to consent. If they lose capacity, a SOAD request will need to be lodged with

the CQC by the RC. If they withdraw consent, treatment can no longer be lawfully

administered in the community. 10.15 If the patient lacks capacity to consent to treatment, a SOAD certificate is required.

The RC who places the patient on CTO must lodge a SOAD request with the CQC. 10.16 Arrangements for the SOAD visit should be planned in advance. Consideration

should be given to the most appropriate venue for the SOAD to examine the patient, which may well be a community venue:

The mandatory conditions require that patients attend hospital for examination. However the definition of a “hospital” under the MHA 1983 is quite wide and covers CMHTs as well as outpatient clinics. The choice of venue should reflect the fact that people on CTO are community patients and it may not be convenient or therapeutic for them to see a SOAD in hospital.

The treatment proposed and notes of any relevant multi-disciplinary discussion must be given to the SOAD at the time of the visit or before. SOADs may also wish to access other records. If the visit takes place at the local Community Team, it will be the responsibility of the care coordinator to make those records available to the SOAD.

SOADs are not expected to visit patients‟ home addresses.

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Recall procedures can be used to require patients to attend for SOAD examination, but this should be a last resort.

10.17 SOADs should normally have the opportunity to interview the patient in private, but

others may attend if the patient and the SOAD wish, or the Risk Assessment suggests the SOAD may be at significant risk of physical harm from the patient, and the SOAD agrees.

10.18 SOADs are required to consult two persons who have been professionally concerned with the patient‟s medical treatment. At least one of the statutory consultees must not be a medical doctor (but need not be a nurse), and neither may be the clinician in charge of the proposed treatment or the responsible clinician. Teams should identify appropriate consultees, who should normally include the patient‟s care co-ordinator, and should ensure they are available for consultation. 10.19 The patients care co-ordinator will be responsible for co-ordinating the SOAD visit if it

should take place at the local Community Team. This will include booking a room for the SOAD to examine the patient, making relevant records available and ensuring statutory consultees have been contacted and are available to discuss the patient‟s case with the SOAD.

10.20 If the SOAD reviews the patient and decides not to issue a certificate, treatment must

end immediately. 10.21.The Part 4A certificate is no longer valid if:

The patient stops (even if only temporarily) being an CTO patient

The SOAD specifies a time limit for a course of treatment, and the time limit has been reached

The certificate was given on the basis that the patient consented, but the patient no longer consents or has lost the capacity to consent

The certificate was given on the basis that the patient lacked capacity to consent, but the patient now has that capacity

There has been a change in medication.

EMERGENCY TREATMENT FOR PATIENTS LACKING CAPACITY OR COMPETENCE

10.22 Medication can be given as emergency treatment if it meets one of the following conditions:

a) To save the patient‟s life;

b) To prevent a serious deterioration of the patient‟s condition, and the treatment does not have unfavourable physical or psychological consequences which cannot be reversed;

c) To alleviate serious suffering by the patient and the treatment does not have unfavourable physical or psychological consequences which cannot be reversed and does not entail significant physical hazard;

d) To prevent the patient behaving violently or being a danger to themselves or others, and the treatment represents the minimum interference necessary for that purpose, does not have unfavourable physical or psychological consequences which cannot be reversed and does not entail significant physical hazard.

However, if it is necessary to use force against the patient to give the treatment:

Treatment must be needed to prevent harm to the patient

Such force must be a proportionate response to the likelihood of the patient suffering harm and to the seriousness of that harm.

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10.23 Any decision to give treatment in these circumstances should be clearly recorded on

the Trust Urgent Treatment form. This form must be uploaded to EPR by the MHA Officer. A copy of this form must also be sent to the local MHL Office. The provisions above do not dispense with the need for a SOAD certificate and they should only be used pending the visit of a SOAD.

10.24 The RC must ensure the following information is recorded on the Trust Urgent Treatment form:

i the patient‟s name is correctly spelt,

iii all the relevant drugs are listed, including medication given “as required” (PRN).

iv the route through which each treatment should be given is recorded (e.g. oral, intra-muscular (I/M), or intravenous (I/V),

v the BNF category of each drug/preparation is given,

vi the dose limits of each treatment is given (e.g. within BNF limits),

vii the number of preparations in each BNF category are given.

11. Duration and Extension of CTO

11.1 A CTO lasts for an initial period of six months. It can be extended for a further six months and then for a year at a time.

11.2 During the final two months of the CTO, the RC must examine the patient in order to

decide whether the patient meets the criteria for CTO extension. The RC may recall the patient to hospital for this purpose. Being available for this examination is one of the mandatory conditions.

11.3 The criteria for extension are the same as those for making a CTO. If the RC

considers the conditions are met, they must:

Consult one or more other people who have been professionally concerned with the patient‟s medical treatment and

Arrange for an AMHP to consider the extension.

11.4 The AMHP who is asked to consider the extension cannot also be the consultee. If the AMHP is already involved in the patient‟s treatment (e.g. as care coordinator) they cannot fulfil both of these roles: at least one additional professional must be consulted.

11.5 If the AMHP does not agree to an extension, the CTO would not automatically end

until the date it is due to expire. The RC should consider whether the patient should be discharged from CTO and an alternative care plan devised.

11.6 If extension is agreed, a Report Extending Community Treatment Period, Form CTO7,

is submitted to the MHA Officer acting on behalf of the managers of the responsible hospital:

The RC completes Parts 1 and 3

The AMHP completes Part 2

The MHA Officer completes Part 4 on behalf of the managers of the responsible hospital.

It should be noted that Part 1 should be completed before Part 2 and Part 2 before Part 3.

11.7 The furnishing of the RC‟s report gives authority for the extension. A report is

considered furnished to the Hospital Managers at the moment it is handed to an officer

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who is authorised by the Managers to receive it, or when it is put in the hospital‟s

internal mail system.

11.8 There is no mechanism under the MHA 1983 for the CTO7 form to be amended. It is therefore strongly recommended that the form is discussed with and checked by the local Receiving Officer (Mental Health Act Officer or Duty Nurse) before it is signed and furnished. Minor errors and slips of the pen may be corrected and initialled without affecting the validity of the extension.

11.9 The patient should be informed in person of the extension. This should normally be

done by the RC. The MHA Officer must also write to the patient and the nearest relative (if the patient has no objection) explaining the extension and their rights.

11.10 Whenever a CTO is extended the MHA Officer will also make arrangements for the

Associate Hospital Managers to review the case.

12 Recall and Revocation

VOLUNTARY ADMISSION/CONSIDERING RECALL 12.1 If a CTO patient, who is in the community, wishes to come into hospital voluntarily they

do not need to be recalled or have their CTO revoked. Such patients can go into hospital informally for any length of time and will remain a CTO patient throughout that time (subject to the expiry of their CTO). During that period the patient‟s RC will need to consider suspending or varying the conditions of the CTO particularly if there are any conditions concerning the patient's residence. The treatment of the mental disorder of such patients is still governed by Part 4A. The holding powers set out in section 5 of the MHA cannot be used in respect such patients, and recall may need to be considered where appropriate.

12.2 Recall is a serious step and should only be considered when other options including

the involvement of the Crisis Team or informal admission have failed or are inappropriate.

12.3 The RC may recall a patient on CTO to hospital for treatment if:

The patient needs to receive treatment for a mental disorder in hospital; and

There would be risk of harm to the health or safety of the patient, or to other persons, if the patient was not recalled.

12.4 Patients can be recalled if the RC believes they need in-patient treatment or risks cannot be managed in any other way, even though no conditions have been breached. Any action must be proportionate to the level of risk

12.5 Patients may also be recalled if they break either of the two mandatory conditions to

make themselves available for examination. However, failure to comply with a condition should not in itself be enough to justify recall unless the criteria above are also met. The first response should be to assess whether the situation can be managed without using recall powers.

12.6 Recall to hospital for treatment should not become a regular or normal event for any

patient on CTO. If a patient is being considered for regular recalls, the RC and the team should review whether CTO is working for the patient.

THE RECALL PROCESS 12.7 If it is decided that recall is necessary, the RC completes a Notice of Recall to Hospital

(Form CTO3) and ensures a copy of it is sent (either by themselves, by the care

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Coordinator or by another team member) to the Receiving Officer (Local Mental Health Act Officer or Duty Nurse) for the relevant hospital. The CTO3 form must also be

uploaded to Carenotes. There is no mechanism under the MHA for the CTO3 form to be amended. It is therefore strongly recommended that the form is discussed with and checked by a Receiving Officer (Local Mental Health Act Officer or Duty Nurse) before it is signed and submitted. Minor errors and or slips of the pen may be corrected and initialled without effecting the validity of the recall.

12.8 The RC is responsible for overseeing the recall process. Practical aspects of the

recall process may be allocated to other workers, subject to discussion and agreement with team managers and/or multi-disciplinary teams. On-call and Duty Consultants will take the role of RC during out-of hours.

12.9 The recall process requires careful planning to manage risks, minimise potential

distress to the patient and anyone else involved, and maximise the chances of participation. There should be early liaison with any other agencies involved, including the ambulance service and police where necessary.

12.10 A Recall Notice provides authority for the patient to be detained in a specified

hospital, which may be different from the responsible hospital and may include an out-patient clinic. The NHS Act 2006 defines a hospital as:

Any institution for the reception and treatment of persons suffering from illness

Any maternity home, and

Any institution for the reception and treatment of persons during convalescence or persons requiring medical rehabilitation.

12.11 Decisions about the most appropriate recall unit will need to balance the best interests of the patient, including the least restrictive option in the circumstances, expected duration of recall (if this can be anticipated), and the resources available to manage a detained patient for a period which may last up to 72 hours. Patients can be transferred from one hospital to another during a recall period. Arrangements for recall and potential further admission if CTO is revoked should also take account of age and needs.

12.12 A patient can be recalled to a different hospital from the one where they were

originally detained and place on CTO. If this happens, a copy of the recall notice must be provided to the Managers of the new hospital.

12.13 The Recall Notice is only effective once served on the patient. There are three ways

the notice can be served:

Handing it to the patient personally, which means the notice becomes effective immediately

Delivering it to their usual address by hand, which means it comes into effect immediately after midnight (technically on the next day)

Sending it by First Class Post to their usual address, which means it is not effective until the second business day after posting (weekends do not count as business days, so a Notice posted on a Friday, for instance, would not be effective until the following Tuesday)

12.14 It is suggested the last option would increase delay and may increase risks. It is

recommended that this should be avoided wherever possible.

12.15 Once served, the Recall Notice provides authority to take and convey the patient to hospital, if necessary. If the patient does not return voluntarily or if they abscond after they have arrived at hospital on recall they are regarded as AWOL. They can be taken into custody under section 18 of the Act and taken to hospital by any AMHP, any police

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officer (or other constable), any officer on the staff of the hospital in question, or any person authorised in writing by the managers of that hospital.

12.16 If access to the patient cannot be gained, it may be necessary to apply for a warrant

under section 135 of the Act. The Code suggests a warrant under section 135 (2) should be used, in which case the warrant cannot be applied for until the patient is liable to be taken into custody i.e. after the Recall Notice is deemed served. .

12.17 A Recall Notice does not have to be executed. Arrangements should be in place for

telephone communication if necessary between the RC and anyone executing the Notice so that different options can be discussed. There may be circumstances when it is more appropriate for the patient to remain in the community. Alternative options should always be explored, such as including involving the Crisis Team if appropriate. The Recall Notice is issued by the RC who retains final responsibility for deciding whether it should be executed or not.

12.18 If a Recall Notice is either not executed or not served for any other reason, the RC

must invalidate it by drawing a line through the entire document and writing „void‟ across it, together with a date, time, printed name and signature. The voided Recall Notice should be kept on the patient‟s notes and a copy should be sent to the MHA Officer.

12.19 Once the patient arrives at hospital, the Receiving Officer must complete Form

CTO4, recording the arrival time and send it to the MHA Officer. The patient can be detained on recall for up to 72 hours from the time or arrival.

12.20 During the recall period the patient must be assessed by the clinical team and the RC

must decide whether they can continue on CTO. The RC should interview the patient personally during this period. The clinical team must consult the patient and (subject to usual confidentiality considerations) any carers, to decide what steps are appropriate. This may include variations in the conditions, changes in the care plan or further admission.

12.21 If the assessment is not completed during the 72-hour period the patient can leave

and CTO continues. It should be noted that section 5(2) or 5(4) cannot be used to hold the patient after the 72-hour period has expired.

12.22 If a patient absconds while they are on recall the 72-hour period starts again once

they return to the hospital voluntarily or are taken into custody, provided they are returned before the expiry of the CTO or the end of the six month period starting with the first day of the absence without leave, if that is later.

TREATMENT ON RECALL: MEDICATION 12.23 Part 4A does not apply to the treatment of CTO patients once they are recalled to

hospital. Authority to treat a recalled patient would generally revert to Part 4 of the Act. However, there are three exceptions to the Part 4 provisions which are set out below:

The first exception is that if the proposed medication would otherwise require a Certificate under Section 58 or 58A but there is a Part 4A Certificate (CTO11) specifically directing that the medication can be given on the patient‟s recall, then the medication can be given without the need for a Part 4 Certificate.

The second exception from the need to obtain a Part 4 Certificate is where a Part 4A Certificate was not required because either one month has not passed since the commencement of the CTO, or less than three months have passed since the start of the period of treatment without consent.

The third exception is where a Part 4A Certificate (Form CTO11 or CTO12) authorised a programme of treatment in the community but does not specify that the treatment can be given a recall (It should be noted that a CTO12 form does not authorise treatment on recall). In those circumstances the treatment can be

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continued on recall if the Approved Clinician (AC) in charge of the treatment considers that discontinuing it would cause the patient serious suffering.

12.24 The RC must complete the Trust Urgent treatment form on recall and revocation form

highlighting the fact that treatment is being administered under one of the above exceptions.

12.25 If the third exception above is relied upon it only applies pending compliance with

section 58. 12.26 If none of the exceptions above apply, the authority to provide medication for a

patient‟s mental disorder during the recall period reverts to Part 4 of the Act and can only be provided:

With the patient‟s consent, or

If applicable, under Sections 57 or 58 with the authorisation of a SOAD, or

In an emergency (under section 62 (1)).

12.27 Urgent treatment under section 62 (1) means medication is immediately necessary to either:

Save the patient‟s life, or

Prevent a serious deterioration of the patient‟s condition, and the treatment does not have unfavourable physical or psychological consequences which cannot be reversed or

Alleviate serious suffering by the patient and the treatment does not have unfavourable physical or psychological consequences which cannot be reversed and does not entail significant physical hazard or

Prevent the patient behaving violently or being a danger to themselves or others, and the treatment represents the minimum interference necessary for that purpose, does not have unfavourable physical or psychological consequences which cannot be reversed and does not entail significant physical hazard.

12.28 If the patient is compulsorily treated on recall, a review of treatment will be required

by the CQC. This should be done by completing a CQC Section 61 Review of Treatment Form when the CTO is next extended by the RC under S20A.

TREATMENT ON RECALL: ECT

12.29 As with the provision of medication on recall, Part 4A does not apply to ECT treatment provided on recall and in general terms the authority to administer ECT would revert to the provisions of Part 4 of the Act and specifically the provisions of Section 58A. However, there are a number of exceptions allowing treatment to be given without the Part 4 requirements being met, these are:

Where there is a Part 4A Certificate in place (CTO11 form) which specifically authorises ECT if the patient is recalled and the patient consents to the treatment or lacks capacity to consent.

Where ECT was being provided in the community to the patient under a Part 4A Certificate, but that Certificate did not specify that it could be given on recall, a treatment programme can be continued if the AC in charge of the treatment considers that discontinuing it would cause the patient serious suffering. In this situation a fresh SOAD visit should be requested.

12.30 It should be noted that if the second exception above is relied upon, it only applies pending the completion of a SOAD certificate under s58A.

12.31 If none of the exceptions above is applicable, ECT can only be given:

With the patient‟s consent and the appropriate SOAD authorisation, or

If the patient lacks capacity, with the appropriate SOAD authorisation, or

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In an emergency (under Section 62).

12.32 A relevant Part 4 Certificate (T4, T5 or T6 Form) will be required. REVOCATION 12.33 Following assessment on recall, if the RC considers the patient needs further

treatment in hospital they may recommend that the CTO be revoked. The RC must then ask for an assessment by an AMHP.

12.34 If the AMHP disagrees with the RC‟s assessment, the patient returns to the

community and CTO continues. If the AMHP agrees that the criteria for revocation are met, the RC and AMHP complete a Revocation of Community Treatment Order Form (CTO5) and the patient needs to be informed. The CTO5 form must be submitted to the local MHA Officer. There is no mechanism to amend the CTO5 form, so the form should be checked by the MHA Officer prior to submission. Minor errors and slips of the pen may be corrected and initialled without effecting the validity of the CTO.

12.35 The patient‟s CTO ends and they are regarded as if they had been admitted for

treatment under whichever section they were originally detained under before commencing the CTO. They are detained for up to six months starting from the date of revocation. The detention can be renewed in the same way as other treatment orders.

12.36 Where a patient‟s CTO is revoked, the hospital managers will refer the patient's case

to the Tribunal within one week of the revocation.

TREATMENT ON REVOCATION 12.37 Treatment continues under Part 4, however the same exceptions as noted above for

recall can be used. As a consequence, in the short term treatment can be authorised via a Part 4A Certificate if it falls within the exceptions noted previously. It should however be noted that reliance on a Part 4A Certificate on revocation can only be for so long as it takes for normal compliance with Part 4 to be completed i.e. a SOAD Certificate under Part 4. Additionally, with regard to ECT on revocation, a Part 4A Certificate will not provide authorisation if the patient has capacity and refuses, unless withdrawal would cause serious suffering. The emergency provisions noted previously may also be relevant depending on the urgency of the situation.

13 Effect of Section 136 and Other Admissions

SECTION 136 13.1 If the police take a CTO patient to a place of safety under section 136 the patient

should be assessed to establish whether:

They require additional support to remain in the community and/or a variation in the CTO conditions, in which case they can be released back into the community;

They require admission, in which case assessment should establish whether it is possible for them to be admitted informally.

13.2 If the patient requires admission and it is considered the patient cannot be admitted informally it will be necessary for the RC to use recall powers. Local arrangements should specify when the Duty Consultant should be contacted if there are likely to be delays contacting the RC.

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13.3 An application under section 3 cannot be made for a known CTO patient, but there may be exceptional cases where it is appropriate to use section 2.

INFORMAL ADMISSION 13.4 There is no reason why a CTO patient cannot agree to be admitted informally and

there may be occasions when this is the best option. The RC should consider suspending or varying any unnecessary conditions during admission.

13.5 If an informal CTO inpatient wishes to leave hospital and it appears to ward staff that

the circumstances suggest they need to be assessed for continuing admission, the RC must consider exercising the recall power. The use of section 5(2) or 5(4) is not permitted under such circumstances.

SECTION 2 ADMISSION 13.6 An admission under section 2 would not invalidate the CTO. Patients might be

detained under section 2 if the assessing team are unaware of their CTO status. As soon as it has been clarified that the patient is subject to a CTO, the RC should assess the patient to determine the best option. This might be to discharge the patient from section 2 to continue CTO in the community, informal admission or recall with later consideration of revocation if necessary.

SECTION 3 ADMISSION 13.7 If a CTO patient is detained on the basis of an application for admission for treatment

under section 3, they will automatically cease to be a CTO patient if, immediately before going on to CTO, they had been detained on the basis of a previous application under section 3 (rather than an order or direction under Part 3).

GUARDIANSHIP 13.8 The same position applies if a patient is received into guardianship as a result of an

application under Part 2. NEW ORDERS OR DIRECTIONS UNDER PART 3 13.9 If a CTO patient is admitted to hospital as a result of a hospital order, hospital and

limitation direction or transfer direction, or given a guardianship order under Part 3 of the Act, they automatically cease to be a CTO patient. This is because the new order or direction brings to an end the application, or direction to which the patient was subject immediately before going on CTO. However, if a court order (or the conviction on which it is based) is subsequently quashed on appeal, section 22 will apply as if the order or direction had never happened and the patient had instead been in prison since the quashed order or direction was made. If less than six months has passed since the quashed order or direction was given, the patient automatically becomes a CTO patient again.

ADMISSIONS ELSEWHERE 13.10 If a CTO patient is detained at another hospital (under different Hospital Managers):

An informal admission would not invalidate the CTO.

An application for section 2 would not invalidate the CTO. If the patient was originally detained under section 3 an application for section 3 would invalidate the CTO and would stand even when it was subsequently discovered that the patient was subject to a CTO.

DEPRIVATION OF LIBERTY

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13.11 CTO patients may sometimes need to be deprived of their liberty in situations where it

would not be appropriate to use recall or revocation powers, for instance in a care home or hospital where they need care or treatment for physical health problems.

13.12 If this happens Deprivation of Liberty Safeguards (DoLS) and the Trust Mental

Capacity Act Policy should be followed. DoLS can exist alongside the CTO, provided there is no conflict with the CTO conditions. It may be necessary for the RC to suspend or vary the CTO conditions.

13.13 DoLS cannot be used instead of recall under CTO if patients need to be detained in

hospital for further treatment for their mental disorder.

14 Missing and AWOL Patients

14.1 This section is concerned with patients who go missing while subject to CTO. CTO

patients are also treated as AWOL if they do not return to hospital after being served a Recall Notice.

14.2 If a CTO patient goes missing from their normal address the circumstances should be

reviewed. The level of risk they present to themselves or others is likely to mean they should be reported to the police as a missing person. CTO conditions may specify that the patient should reside at a specific place, but there are no powers to enforce such conditions or return an CTO patient who leaves their address.

14.3 Advice on procedure to be followed for SCT patients is set out in the following table:

Circumstances Action

If patient goes missing: Review risk assessment

RC/team consider reporting to police as a missing person

RC considers issuing Recall Notice

If Recall Notice issued: Patient liable to be taken into custody/returned to hospital by an AMHP, constable, any officer on the staff of the hospital, or any person authorised in writing by the managers of that hospital until

CTO expires (ignoring any extra time that would be allowed if the patient were to return or be taken into custody right at the end of that period)

or the end of the six month period starting with the first day of the absence without leave, if that is later

If the RC has already submitted Form CTO7 extending CTO, but the extended period has not yet started, Form CTO7 is disregarded

If patient has been AWOL one week:

MHA Officer or equivalent writes to the RC reminding them that Form CTO8 is required if the patient returns to hospital after twenty-eight days have elapsed and CTO is to be continued

If AWOL patient is taken into custody/attends the hospital voluntarily during the 28 days starting with the day they went AWOL:

Any extension report/Form CTO 7 is to be made in the normal way – and must therefore be agreed by an AMHP if returned in the final 2 months of the CTO, otherwise the section continues as normal.

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If AWOL patient is taken into custody/attends hospital voluntarily after being absent for more than 28 days:

RC reviews CTO

If RC confirms CTO, they complete Form CTO8

If no Form CTO8 submitted, CTO expires at the end of the period of 7 days starting with the day of the patient‟s arrival at hospital

If CTO period has not yet expired:

Form CTO8 confirms CTO – expiry date remains as before

If CTO period would have expired - or would expire on the day the CTO8 report is submitted:

Form CTO8 extends CTO

If CTO is due to expire during the two months starting with the day on which the CT08 report is submitted:

RC may (but need not) indicate on the form that it is also to act as an extension report

If the patient is AWOL at any point during the week which ends on the day CTO is due to expire, and an extension report has yet to be made:

If patient taken into custody/attends the hospital voluntarily during that period, CTO is treated as not expiring until the end of the week starting with the day they arrive at the hospital. RC should review CTO, complete CTO7 extension form if appropriate and contact an AMHP

If CTO would otherwise have expired twice since the patient went AWOL:

Form CT08 is treated as having extended CTO on both occasions

If patient still AWOL one week before the date on which authority to take the patient into custody/return them to hospital is due to expire:

MHA Officer or equivalent writes to the RC reminding them again that Form CTO8 is required if the patient returns to hospital and CTO is to be continued

If patient has not been taken into custody/does not attend hospital voluntarily before the end of the period during which they can be taken into custody under section 18:

CTO expires and no extension report can be made.

15 Transfers

15.1 Responsibility for CTO patients can be assigned between hospitals within the same Trust. This is not regarded as a transfer under the Act and there are no statutory form to complete however the Mental Health Act Officers must be informed. The MHL Office of the receiving hospital must write on behalf of the Hospital Managers to inform the patient of the assignment and give the hospital details either before or soon after it takes place. The new hospital becomes the responsible hospital and is treated as if it were the detaining authority when the patient was originally detained in hospital.

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15.2 The responsible hospital for a CTO patient in the community can be assigned to another hospital managed by a different organisation (with their agreement). Transfer should be in accordance with CPA transfer arrangements and should involve the RC and Care Coordinator. The MHL Office must complete a CTO10 form on behalf of the Hospital Managers.

15.3 Recalled patients can be transferred to a hospital managed by another organisation

using form CTO6 during the 72 hours Recall period. A copy of the previously completed CTO4 form should be provided to the receiving hospital to ensure time limits are adhered to. If the receiving hospital was not previously the responsible hospital it would only become the responsible hospital if responsibility was reassigned using the procedures set out above.

15.4 If a community patient under broadly equivalent legislation in Scotland, the Isle of Man

or any of the Channel Islands is removed to England, their arrival in England is recorded using form M1 (date of reception of a patient in England). If they are to be treated as if they are subject to CTO, form CTO9 is completed by the RC (Part 1) and an AMHP (Part 2). As when starting CTO, any conditions must be specified on form CTO9 and have the written agreement of an AMHP.

16 Discharge 16.1 Discharge from CTO means complete release from liability to detention under the Act

in hospital or in the community, regardless of who orders it. It is not the same as discharge from hospital onto CTO. The patient will continue to be entitled to aftercare services under section 117 unless they are assessed as no longer needing those services.

16.2 If a CTO patient is to be discharged, the MHA Officer should inform the patient and

nearest relative.

16.3 CTO patients can be discharged by:

The RC

The First Tier Tribunal

The Associate Hospital Managers

The nearest relative (for patients originally on section 3 only)

16.4 The Code should not simply be allowed to lapse. DISCHARGE BY THE RC 16.5 The RC may discharge a patient at any time. If the patient no longer meets the criteria

for CTO the RC should discharge them immediately by completing the Trust Section 23 discharge form. There is no statutory requirement to consult with any other person, but the RC should discuss the position with the patient, the care team and any carers as part of the care planning process.

DISCHARGE BY THE NEAREST RELATIVE 16.6 If the patient was initially on section 3, the nearest relative can order discharge. The

nearest relative can order a patient‟s discharge from CTO during a period of recall, but they have no power to order their release from hospital to continue CTO in the community.

16.7 The nearest relative must write to the Hospital Managers giving at least 72 hours

notice. The 72 hour period starts to run from the time when the notice is received by

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the Receiving Officer (Mental Health Act Officer or Duty Nurse), delivered by post at the hospital it is addressed to, or put in the internal mail.

16.8 The MHA Officer must notify the RC as soon as discharge notice is received from a

nearest relative. The RC may sign a report using Form M2 within 72 hours barring the discharge under section 25 of the Act on the basis that they consider that the patient, if discharged, would be likely to act in a manner that is dangerous to other people or to themselves. This vetoes the nearest relative‟s decision to discharge the patient and prevents the nearest relative from discharging the patient from CTO at any time in the six months following the date of the report.

16.9 If the RC bars a nearest relative discharge order the MHA Officer will arrange a review

by the Associate Hospital Managers and advise the nearest relative that they also have a right to apply to the Tribunal. The nearest relative can apply to the Tribunal once during the 28 days beginning with the day they were informed of the barring report.

16.10 If the RC does not sign a barring report, the nearest relative‟s discharge takes effect

after 72 hours. ASSOCIATE HOSPITAL MANAGERS 16.11 The Associate Hospital Managers of the responsible hospital have powers to review CTOs and discharge patients. The Associate Hospital Managers:

May hold a review at any time at their discretion.

Must hold a review when the RC extends the CTO.

Should consider holding a review when they receive a request from (or on behalf of) a patient.

Should consider holding a review when the RC makes a report barring an order by the nearest relative to discharge a patient.

16.12 Consideration should be given to the most appropriate venue for the Associate Hospital Managers‟ review, in particular whether a particular location is convenient for the patient. It should not be assumed this will always be the hospital in which the patient was originally detained.

FIRST TIER TRIBUNAL 16.13 The patient can make an application for discharge to the Tribunal once during each

period of CTO. Any withdrawn application is disregarded and does not interfere with this right. The Tribunal cannot vary CTO conditions. The Tribunal can recommend that the RC considers CTO for a detained patient, but it cannot oblige an RC to make an order.

16.14 A patient may appeal to the Tribunal:

During each period of CTO

If CTO is revoked (during the initial six months starting on the day of revocation)

If CTO is extended

If they are detained under section 3 and CTO ends as a result.

16.15 There is no right to apply where a report is made under section 21B/Form CTO8 (authority for extension of CTO after AWOL for more than 28 days) unless this report also serves as an extension.

16.16 Anyone, including Hospital Managers, nearest relatives or patients themselves, may

ask the Secretary of State to consider making a referral to the Tribunal.

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16.17 The Hospital Managers have duties to refer cases to the Tribunal if cases have not been heard after defined periods. These periods are governed by a combination of rules governing CTO and automatic references to the Tribunal. Provisions are also dependent on the age of the patient and whether they were initially detained under Part 2 of the Act or Part 3. The MHA Officer should refer cases to the Tribunal in accordance with the table below:

CTO patient originally admitted under section 2 or 4

Six months from the date of first admission to hospital, whichever section was used

CTO patient originally admitted under section 3

Six months from the date of section 3 admission

CTO patient previously on a court guardianship order transferred to a court hospital order

Six months from the date of transfer from the guardianship order

CTO patient aged 18 or over If more than three years has passed without the patient‟s case being considered by the Tribunal

CTO patient under 18 If more than one year has passed without the patient‟s case being considered by the Tribunal

CTO patient transferred from outside England or Wales – aged 18 or over

Three calendar years from date they were admitted to hospital or treated as becoming a CTO patient in England or Wales

CTO patient transferred from outside England or Wales – under 18

One calendar year from date they were admitted to hospital or treated as becoming a CTO patient in England or Wales

CTO patient aged 18 or over originally detained under hospital orders, hospital directions or transfer directions under Part 3 of the Act without being subject to special restrictions

If more than three years has passed without the patient‟s case being considered by the Tribunal

CTO patient under 18 originally detained under hospital order, hospital direction or transfer direction under Part 3 of the Act without being subject to special restrictions

If more than one year has passed without the patient‟s case being considered by the Tribunal

CTO is revoked Refer to Tribunal in all circumstances, even if there has been previous referral/application

17. Custodial Detention 17.1 If a patient is detained in custody for a period of more than six months the CTO

automatically comes to an end.

17.2 If detention in prison or elsewhere lasts less than six months the CTO will continue in the normal way. If the person is released from custody during that six-month period, they are treated as if they had gone AWOL on the day of their release.

17.3 If the CTO would otherwise have expired, or be about to expire, expiry is delayed until

the end of the week starting with the day of the patient‟s return to hospital (if the patient had already been recalled to hospital when first imprisoned or if not with the day of the patient‟s release from custody). In effect this means RCs will always have at least a

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week in which to examine the patient and consider whether it is appropriate to submit a Form CT08 extending the CTO.

17.4 Although a CTO patient released from custody after less than six months is treated as

having gone AWOL, they may only automatically be taken into custody and returned to hospital if they had already been recalled to that hospital when they were first imprisoned. Even then, this can only be done during the 28-day period starting with the date of their release.

17.5 However, normal rules about recalling patients to hospital apply to patients released

from custody during whatever period remains of their CTO. So such a patient can, if necessary, be recalled to hospital with a view to making a report extending their CTO. If they then failed to attend they would be considered AWOL in the normal way and could be taken into custody at any time during the six months starting with the day they failed to attend.

18. Training

18.1 Specialist training on the Community Treatment Orders under Section 17A MHA is

available to all clinical staff from the Learning and Development Department.

18.2 Local Mental Health Act Officers provide local training sessions on request covering the requirements of Section 17A of the Mental Health Act.

18.3 Training on the Community Treatment Orders under Section 17A MHA is delivered by the Mental Health Law Hub. For further details of mental health law training, refer to the mental health law training brochure.

18.4 For training requirements please refer to the Trust‟s Mandatory Training Policy and

Learning and Development Guide.

18.5 For further details of available training, contact the Learning and Development Department.

19. Dissemination and implementation arrangements 19.1 The Associate Director, Governance and Quality Assurance, via the Clinical and

Corporate Policy Manager, will disseminate and implement the policy. 19.2 For clarification or support in the implementation of the policy, contact Dominique

Merlande, Mental Health Law Manager.

20. Monitoring and audit arrangements

20.1 The following aspects of this policy will be monitored and audited: - patient‟s length of stay following recall; - use of CTOs.

20.2 The Mental Health Law Manager will be responsible for carrying out the audits.

20.3 The audits will be undertaken every 3 years. They will be undertaken more

frequently when concerns have been raised via internal or external assurance sources e.g. mental health law related incident, legal claim, complaint, CQC MHA monitoring report.

20.4 The results will be reported to the Mental Health Law Monitoring Group, which

reports to the Mental Health Law Committee.

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20.5 Actions from the audit will be implemented by Associate Divisional Directors and monitored by the Mental Health Law Committee.

20.6 Learning from the audit will be shared in the Mental Health Law Committee.

Elements to be monitored

Lead How Trust will monitor compliance

Frequency Reporting

Acting on recommendations and Lead(s)

Change in practice and lessons to be shared

Use of section 17A

Mental Health Law Manager

KP90 returns Annually MHL Monitoring Group

MHL Committee

Required actions will be identified and completed in a specified timeframe

Required changes to practice will be identified and actioned within a specific time frame. A lead member of the team will be identified to take each change forward where appropriate. Lessons will be shared with all the relevant stakeholders

Patient‟s length of stay following recall

Mental Health Law Manager

Audit Bi-annually

MHL Monitoring Group

MHL Committee

21. Review of the policy

21.1 The review date will be two years from the date of ratification. If the review date is earlier or later than two years, a justification for this will be provided.

22. References

Mental Health Act 1983

Code of Practice to the Mental Health Act 1983

Mental Capacity Act 2005

23. Associated documents

Trust‟s Information for Patients, Nearest Relatives, Carers and Others Policy

Trust‟s Mental Capacity Act Policy

Trust‟s Mandatory Training Policy

Trust‟s Learning and Development Guide

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Appendix 1

Equality Impact Assessment Tool

Yes/No Comments

1. Does the policy/guidance affect one group less or more favourably than another on the basis of:

Race No

Ethnic origins (including gypsies and travellers) No

Nationality No The policy provides for information to be given in other languages where necessary.

Gender No

Culture No

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 The policy provides for alternative media to be used to give information where necessary.

2. Is there any evidence that some groups are affected differently?

No

3. If you have identified potential discrimination, are any exceptions valid, legal and/or justifiable?

N/A

4. Is the impact of the policy/guidance likely to be negative?

No

5. If so can the impact be avoided? N/A

6. What alternatives are there to achieving the policy/guidance without the impact?

N/A

7. Can we reduce the impact by taking different action?

N/A