Absent without leave, absent and missing persons Policy. Choice, Responsiveness, Integration & Shared Care

Transcription

1 Absent without leave, absent and missing persons Policy Choice, Responsiveness, Integration & Shared Care

2 Worcestershire Mental Health Partnership NHS Trust Information Reader Box Document Type: Document Purpose: Unique identifier: Title: Target Audience: Description: Superseded Documents: Ratified by: Policy To ensure an appropriate response to patients who are absent without leave or absent. CP0001 Absent without Leave, Absent and Missing Persons Policy Inpatient and Community Staff A guide to the appropriate identification, search and response to absent patients. Hospital Discharge Policy & Transfer Policy Quality Committee Ratification date: December 2010 Implementation date: January 2011 Review period: 3 years Version update date: Review date: January 2014 Owner: Responsible group: Chief Operating Officer, Acute & Older Adult Business Unit Leads Acute Care Forum Contact Details: Acute & Older Adult Business Unit Leads The electronic copy of this document is the only version that is maintained. Printed copies may not be relied upon to contain the latest updates and amendments.

3 CONTENTS POLICY 1. Introduction 2 2. Definitions 2 3. Absent without leave 2 4. Detained patients 2 5. People subject to guardianship 3 6. People subject to supervised community treatment 3 7. Other situations in which patients are in legal custody 3 8. Section 137 and Missing person Responsibilities Monitoring implementation Practice development service improvement Policy validation Equality impact assessment 6 GUIDANCE 15. Introduction Procedure Assessment Risk assessment for all inpatients Actions to be taken to ascertain that a patient is absent Action to be taken if the patient is found or returns Action to be taken if the patient is confirmed as missing Temporary absence Action A, B, or C Action A: Post authorised leave for patients detained under the Mental Health Act Action B: community team involvement required Action C: police involvement required Action to be taken if the patient is still missing after 24hrs Action to be taken when the patient is found Return of detained inpatient Inpatients assessed as being of minimum risk who go missing Inpatients assessed as being at risk who are absent Absent patients 12 1 P age

4 1. Introduction and purpose of policy 2. Definitions a. This policy defines the responsibilities and provides guidelines for medical practitioners, and staff within Worcestershire Mental Health Partnership NHS Trust and police officers, in relation to the appropriate identification, searching for, reporting of and subsequent requirements for dealing with patients who are absent without leave or absent. b. The purpose of the policy is to ensure that staff: i. address the legal status of the patient; ii. reflect the level of risk identified; iii. provide appropriate services in the least restrictive manner; iv. liaise with appropriate individuals and agencies; v. consider the cultural, spiritual and any identified special needs of the absent without leave patient or missing person; and vi. adhere to the rights and principles outlined in the Mental Health Act and the Police and Criminal Evidence Act a. A patient who is subject to the provisions of the Mental Health Act 1983 [as amended in 2007] can be absent without leave. b. A patient who is NOT subject to the provisions of the Mental Health Act 1983 can be absent but not absent without leave. c. A patient who is absent or absent without leave can be defined as a missing person i.e. they cannot be found. 3. Absent Without Leave a. Under section 18 of the Mental Health Act 1983, patients are considered to be absent without leave in various circumstances, in particular when they: 4. Detained patients i. have left the hospital in which they are detained without their absence being agreed (under section 17 of the Act) by their responsible clinician; ii. have failed to return to the hospital at the time required to do so by the conditions of leave under section 17; iii. are absent without permission from a place where they are required to reside as a condition of leave under section 17; iv. have failed to return to the hospital when their leave under section 17 has been revoked; v. are supervised community treatment patients who have failed to attend hospital when recalled; vi. are supervised community treatment patients who have absconded from hospital after being recalled there; vii. are conditionally discharged restricted patients whom the Secretary of State for Justice has recalled to hospital; or viii. are subject to guardianship and are absent without permission from the place where they are required to live by their guardian. a. Detained patients who are absent without leave may be taken into custody and returned by an approved mental health professional (AMHP), any member of the hospital staff, any police officer, or anyone authorised in writing by the hospital managers. 2 P age

5 b. A patient who has been required to reside in another hospital as a condition of leave of absence can also be taken into custody by any member of that hospital s staff or by any person authorised by that hospital s managers. c. Otherwise, responsibility for the safe return of patients rests with the detaining hospital. If the absconding patient is initially taken to another hospital, that hospital may, with the written authorisation of the managers of the detaining hospital, detain the patient while arrangements are made for their return. In these (and similar) cases people may take a faxed or scanned copy of a written authorisation as evidence that they have the necessary authority without waiting for the original. 5. People subject to Guardianship a. People subject to Guardianship who are absent without leave from the place where they are required to live may be taken into custody by any member of the staff of the responsible local authority or by any person authorised in writing by the local authority or their representatives within the Trust or by the private guardian (if there is one). 6. People subject to Supervised Community Treatment a. People subject to Supervised Community Treatment who are absent without leave may be taken into custody and returned to the hospital to which they have been recalled by an Approved Mental Health Professional, a police officer, a member of staff of the hospital to which they have been recalled, or anyone authorised in writing by the managers of that hospital or by the responsible clinician. 7. Other situations in which patients are in legal custody a. In addition, there are various situations in which patients are considered to be in legal custody under the Act. These include, for example: 8. Sections 137 and 138 i. the detention of patients in places of safety under section 135 or 136; ii. the conveyance of patients to hospital (or elsewhere) under the Act, including where patients are being returned to hospital when they have gone absent without leave; and iii. where patients leave of absence is conditional on their being kept in custody by an escort. a. If patients who are in legal custody for such other reasons abscond, they may also be taken into custody and returned to the place they ought to be, in accordance with the Act. 9. Missing Person a. A missing person is defined as anyone whose whereabouts is unknown whatever the circumstances of disappearance. They will be considered missing until located and their well-being or otherwise established. b. There will be circumstances where a person is missing but police involvement may not be required, i.e. tracing a long lost relative. Appropriate action may be a referral to other relevant agencies that may provide assistance. (Guidance on the management recording and investigation of missing persons - Association of Chief Police Officers ) 10. Responsibilities and duties a. All staff i. All cases of absent without leave, absent or missing must be reported as Patient Safety Incidents on the Sentinel Incident Reporting system ii. All detained patients who are absent without leave and due to the risk they pose the police are involved must be reported as Serious Incidents 3 P age

6 b. Trust Board i. Setting policy for the organisation through powers delegated to relevant committees; ii. Ensuring policy is implemented through agreed management arrangements; iii. Ensuring they are alerted to relevant issues arising that may affect policy implementation. c. Chief Executive d. Directors i. Ensuring that arrangements are in place so that employees are fully aware of their statutory, organisational and professional responsibilities and that they are fulfilled; ii. Ensuring that the arrangements in support of policy are fully implemented through inclusion in Business Unit Performance Reviews; iii. In order for this responsibility to be effectively discharged, Executive Directors and senior colleagues will have specific delegated responsibility to support the Chief Executive in this process. i. Strategic development and implementation of policy, corporately and within their areas of control; ii. the appropriate assessment and management of risks; iii. effective delegation of responsibilities within their areas of control; iv. ensure appropriate human resource management procedures are in place and where necessary, carried out v. provide suitable support mechanisms for members of staff suffering from the negative effects of stress vi. effective support for managers decisions and recommendations in terms of the provision of appropriate resources; vii. a framework is in place to ensure that staff are adequately skilled and experienced to safely undertake their work; viii. necessary reporting procedures are in place; ix. a framework is in place to monitor compliance with policy. e. Business Unit Leads and Senior Managers i. Ensure that all staff are aware of and comply with the policy ii. Liaise with police as appropriate particularly with regard to media contact iii. Ensure that the necessary transport and escort arrangements for return are authorised and in place iv. Receive and review data from West Mercia Constabulary on incidents of absconding from Trust premises v. Ensure that planned audit of AWOL takes place on an annual basis vi. Review audit results and take appropriate action f. Ward and Team Manager (Inpatient and Community) i. Ensure that all staff are aware of and comply with the policy ii. Ensure that staff are aware of the necessity to carry out risk assessments on admission to identify the risk of absconding iii. Ensure that staff incorporate risk assessments into care plans, which are reviewed and updated 4 P age

7 g. Individual members of inpatient staff i. In the event of an absence; ii. Ascertain if the patient is absent iii. Organise a search iv. Contact appropriate persons as per guidance v. Inform the police if appropriate as per guidance vi. Take action if the patient is found or returns from missing as per guidance vii. If the patient is missing take actions A, B or C as per guidance, viii. Complete appropriate documentation. ix. Keep relevant line managers updated on any developments x. Arrange for a return assessment within 24hrs of return to the ward and amend the care plan xi. Liaise with West Mercia communications room with regard to the OIS log h. Medical Staff i. Take part in reviews of the situation ii. Complete appropriate Mental Health Act documentation in respect of detained patients iii. Conduct a medical examination of the patient when returned to the ward and take appropriate action i. Working groups and committees 11. Monitoring implementation i. This policy is owned by the Acute Care Forum a. West Mercia Constabulary provides a breakdown of the incidents of absconsion from Trust premises [where they have been contacted] to the Adult Acute Business Unit Lead. b. An audit of compliance with this policy will be annual and included in the Acute and Older Adult Business Unit audit plans. c. Learning from the audit and clinical expertise will be disseminated to inpatient staff through the Acute Care Forum. NHSLA Criteria Lead Monitoring Frequency Committee The organisation has an approved, documented process for managing risks associated with service users who are absent without leave (AWOL). As a minimum it should include a) Duties Business Unit Leads Audit Annual Acute Care Forum b) procedure used when a service user absents themselves from an inpatient setting Business Unit Leads Audit Annual Acute Care Forum c) procedure used when a service user fails to return from a period of leave of absence Business Unit Leads Audit Annual Acute Care Forum d) process for learning the factors that arise from AWOL incidents Business Unit Leads Audit Annual Acute Care Forum e) process for monitoring compliance with the above As above As above As above As above 12. Practice development and service improvement a. The Worcestershire Mental Health Partnership is committed to ensuring its workforce is confident, competent and capable. The Practice Development and Service Improvement Team [PD&SIT] develop a yearly training prospectus which 5 P age

8 describes the courses on offer, to whom they are aimed, how often they need to be updated and how to make a booking. The training prospectus can be accessed via the Intranet and internet. b. Attendance Monitoring 13. Policy validation If a person is registered to attend a course and does not attend the information is registered with the PD&SIT will notify the person s line manager of the nonattendance. It is the responsibility of the line manager to ensure staff attends appropriate statutory, mandatory and essential training. a. All policies ratified for use by the Trust contain the following information: 14. Equality impact assessment GUIDANCE 15. Introduction 16. Procedure i. A designated owner with responsibility for ensuring an appropriately skilled professional will lead the development and/or review of the policy in line with timescales set by the Work Group work plan ii. A Working Group, whose work plan identifies their responsibilities with regard to the development and/or review of the policy, monitoring compliance and signing off the policy within agreed timescales prior to ratification by the Governance Committee. a. This policy has been impact assessed to ensure that it does not discriminate. a. On admission and throughout their stay inpatients are asked to inform staff if they wish to leave the ward. b. All inpatients must be formally assessed as to the level of risk associated with leaving the ward with or without permission and the actions to take should this happen. c. Evidence - A study has shown that patients abscond for various reasons, including boredom, being frightened of other patients, have household responsibilities, feeling isolated or worried about the security of their home. In those inpatients that absconded, although psychiatric symptoms contributed to the decision to leave, the person was able to give additional and rational reasons for absconding. Bowers et al (1999) a. This procedure sets out the steps, which may be done simultaneously when dealing with an absent inpatient. It applies to all inpatient areas and to both detained and informal inpatients. b. It defines the roles and responsibilities of health and social care mental health professionals and the police. c. Health and social care mental health professionals, and the police, where involved, must use their professional judgement to take any action that is deemed necessary to protect the safety of the patient and the public based on an assessment of risk for each individual patient. d. It should be noted that the nurse in charge of the ward referred to throughout the policy may delegate duties and responsibilities to a delegated nurse. 17. Assessment of Risk a. Health and social care mental health professionals should be aware of and apply the guidance relating to risk assessments contained in the Clinical Risk Assessment and Management Guidelines [CP0099] and the Care Programme Approach Policy and Procedure [CP0007] 6 P age

9 18. Risk Assessment for all inpatients a. All patients should have a risk assessment to identify their risk of going missing upon admission for in-patients (or prior to admission where this is feasible). This risk assessment should include previous history and any patterns of absconding or going missing and vulnerability. It should also address the patients cultural, spiritual or identified special needs in relation to them being missing from the service. b. The assessment must be subject to regular review and updating and must reviewed whenever any changes in the patient s condition or risk profile are identified. c. Each assessment and review should be clearly recorded in their paper clinical file and communicated to all relevant staff. Known triggers must be recorded e.g. phone calls from particular friends and relatives. If a decision is reached that the patient may go missing, certain details of the description should be completed upon admission or at that time e.g. height and weight etc. The documentation of these particulars and physical characteristics must be kept in the patient s clinical case file. d. The assessment should identify whether the risk is active or passive; i. Active - the inpatient is likely to knowingly and overtly attempt to leave the clinical area ii. Passive the inpatient may be confused and/or disorientated and may wander out of or away from the residence or clinical area if unsupervised e. All inpatients that are assessed as presenting a risk of absconding should have a clearly recorded care plan which forms part of the health record and which identifies appropriate levels of observation, supervision and security of clinical environment for the level of risk assessed. This care plan must be subject to regular review and must be communicated to all staff that need to be aware. 19. Actions to be taken to ascertain that a patient is absent a. The nurse in charge of the ward must communicate with all staff on duty to establish that the patient has left the ward without the knowledge of the staff. b. The nurse in charge of the ward may ask other patients if they have any knowledge of the missing patient s whereabouts. c. The nurse in charge of the ward must organise an immediate thorough search of the ward including places such as cupboards and under beds etc. If the person is not found on the ward the nurse in charge will organise a search of the hospital grounds and will attempt to contact the person via their mobile phone number where they are know to own one. d. The nurse in charge will contact appropriate family or carers, any other known contacts and the person s home number to establish last contact and share information which is appropriate to the patients assessed risks. e. The nurse in charge of the ward, in consultation with the inpatient and community mental health team, will consider the implications for the patient and others of the assessed risks. f. The police should always be informed immediately if a patient who is absent is: i. considered to be particularly vulnerable to harming themselves; ii. considered to be particularly vulnerable to being harmed by others; iii. considered to be a danger to others; or iv. subject to restrictions under Part 3 of the Mental Health Act 1983 g. The nurse in charge of the ward must balance, in relation to informing the police, the risk to the patient and staff collecting the patient against the risks of the patient remaining outside the safety of the hospital. 7 P age

10 h. When conducting a search the staff should take, where available, a ward or personal mobile phone. 20. Action to be taken if the patient is found or returns a. Where the police have been informed about a missing patient, the nurse in charge will immediately advise the police if the patient is found or returns. b. The nurse in charge will inform members of inpatient and community staff that the patient has been found or has returned even if they were unaware that the patient had been absent. c. The nurse in charge will inform the patients family and carers, where the patient has given prior permission or where an assessment of the risks deem it appropriate, that the patient has been found or has returned even if they were unaware that the patient had been absent. d. If the patient is found and refuses to return the member of staff should contact the ward and advise them of the situation. The nurse in charge, in consultation with the line manager or duty nurse manager will determine what further action needs to be taken. 21. Action to be taken if the patient is confirmed as missing a. If the patient is confirmed as missing [as per the definition] the nurse in charge of the ward must inform the Consultant Psychiatrist, ward medical staff, their line Manager and, out of hours, the Clinical Coordinator and on-call Manager and others as deemed appropriate. b. The nurse in charge, in consultation with the doctor and the line manager and, out of hours, the Clinical Coordinator and on-call Manager and others as deemed appropriate should decide what action, if any, is required. This will take into account, history, clinical presentation and the risk identified and a review of those risks as the patient is now missing and the details of the assessment & actions should be recorded and actioned. 22. Temporary Absence a. The absence should be categorised as a temporary absence if the care team assess that the circumstances indicate: i. the patient has deliberately or unthinkingly absented themselves but their whereabouts are known; ii. the patient will either return of their own accord, go home or go to the home of a friend or relative; and iii. there is no apparent IMMINENT risk of them suffering or causing significant harm. b. If the absence is categorised as a temporary absence the nurse in charge of the ward and Consultant in charge of the patient s care remain responsible for managing the absence and for keeping the absence under continuous review. c. A patient who is initially categorised as temporary absent can be subsequently recategorised as missing if the level of risk increases due to a change of circumstances. 23. Action A, B or C a. Action A, B or C must be taken as appropriate to the circumstances. If there is a risk of violence, or there is concern for the welfare of the patient, e.g. if they lack capacity and are in pyjamas or unsuitable clothes for the weather conditions, Action C must be taken. 24. Action A - Post Authorised Leave for Patients Detained under the Mental Health Act a. If a patient detained under the Mental Health Act goes absent without obtaining prior authorisation or does not return from a period of authorised Section 17 leave when 8 Page

11 due to do so, the Responsible Medical Officer should decide whether they will authorise the absence or extension under Section 17 of the Act, or alternatively declare the patient to be Absent Without Leave (s.18 MHA 83). b. The Responsible Medical Officer has the option of extending or post-authorising leave under this provision if the circumstances indicate: i. they have deliberately or carelessly absented themselves; ii. they will return of their own accord or they are staying at their own home or the home of a friend or relative; and iii. they are not likely to suffer or cause significant harm whilst absent. c. If the Responsible Medical Officer authorises leave post absence, it should be categorised as Post Authorised Leave. In these circumstances, the nurse in charge of the ward and the Responsible Medical Officer remain responsible for managing and reviewing the absence. d. If there is no imminent risk to the patient or others, then a timescale will be agreed before the Police are informed based on the assessed risk or vulnerability of the patient by the Responsible Medical Officer and the nurse in charge of the ward. The decision will be recorded within the case notes. e. Within this timescale, a review will take place and further action decided upon. 25. Action B Community Team involvement required a. The nurse in charge will make contact with the appropriate Community Team or Crisis Resolution and Home Treatment Team to alert them to the fact that the patient is missing and request they prioritise assistance, including visiting the patient s property or known local connections, in order to assess situation. b. This action may take place at variable times following the person going missing, dependent on the risk assessment for the individual person. 26. Action C Police involvement required a. If, after consultation, the decision is made to involve the Police immediately, then the nurse in charge of the ward must contact the Police and inform them that the patient is missing and request the Police to place the patient s details on the COMPACT computer system and conduct a full Missing Persons investigation. b. If a risk assessment identifies that it is inappropriate for nursing or community staff to transport the patient without Police assistance, the reason must be given on the MISSING PERSON form [MPF1] c. The nurse in charge must complete a MISSING PERSON form [MPF1] with as much detail as possible and faxed or to the Police. d. The Police will attend the ward to discuss relevant details with the nurse in charge and/or other appropriate staff. e. The nurse in charge of the ward should inform the Police of the known risks the patient poses to themselves or other people. If there is someone identified as being at risk from the missing patient, the Police must be informed of the identity of the individual and any contact details made available. f. The nurse in charge of the ward must inform appropriate family and/or carers that the patient is missing and that the missing persons policy has been implemented and what actions and time scale for further actions have been implemented. g. The overriding concern is the safety of the patient, their family/carers and the public. If necessary, confidentiality can be overridden for this purpose, even if it is against the wishes of the patient for the family carers to be contacted. Note that there has to be sufficient reason to breach confidentiality and each professional should consider the consequences of breaking confidentiality versus the risks involved. 9 P age

12 h. If the patient is assessed to be a serious risk to specific others and it is possible to identity that person or persons, every effort should be made by the nurse in charge to notify them. Breaches in confidentiality and the rationale for such a breach should be recorded in the patient s clinical notes. i. A contemporaneous record of events must be made in the patient s clinical record, by the nurse in charge of the ward as the situation progresses. j. The nurse in charge will update the line manager and/or duty manager on any developments. k. The line manager will discuss with the inpatient manager or Business Unit lead if any further action is required. 27. Action to be taken if the patient is still missing after 24 hours a. If the patient is still missing after 24 hours, the nurse in charge, with the Consultant Psychiatrist in charge of the patient s care or Duty Consultant, the line manager (or duty manager), will review the situation and decide what, if any, further action is needed. b. The nurse in charge must keep appropriate family members and/or carers informed of any developments. It may be appropriate to ask the relevant community staff to visit the family etc. to offer support. A recorded of this communication must be kept in the nursing notes. c. The line manager will inform the inpatient manager and Mental Health Administrator of any developments and the inpatient manager will keep the Business Unit lead and Chief Operating Officer informed. d. The Chief Operating Officer will inform the Chief Executive of the situation if appropriate. e. The Police have responsibility for considering whether to inform the media about a missing patient to assist in locating them or to warn the public should they pose a significant risk to others. The decision will be made following Police liaison with the inpatient manager and Business Unit lead and out of hours with the on call manager. However, the decision whether or not to approach the media will always be retained by the Police. f. Staff must refer all contact from the press and media to the Chief Executives Office and out of hours to the on call Director via the on call manager. 28. Action to be taken when the patient is found a. When the patient is found, the following (where appropriate) must be informed: Family Inpatient Manager Chief Executive Carers Business Unit lead Clinical Coordinator Police Chief Operating Officer Care Coordinator Ward Manager Consultant Psychiatrist in charge of the patient s care On call Manager other involved medical staff Others as appropriate b. The patient should be returned to the ward in accordance with the Transportation of Patients Detained under the Mental Health Act 1983 Policy [CP0094], the Joint Protocol for Detention and Assessment of Individuals under s136 of the Mental Health Act 1983 [CP0097] c. Where identified as necessary by the nurse in charge, the patient should be examined by medical staff upon return to the ward. If there is any suggestion that the patient has been the victim or perpetrator of crime, the police should be 10 P age

13 informed and consideration be given to the securing evidence for forensic examination. d. A further assessment of the patient s needs should occur as soon as is practicable and the care plan amended as required. The nurse in charge must arrange for a return assessment to take place (including medical and nursing staff where appropriate) within 24 hours of the patient s return to the ward. e. The nurse in charge should liaise with West Mercia Police Communications Room and ask for an OIS log to be created to ensure that relevant information is contained within the police closing report on the investigation. This information will assist in any further episodes where the patient may go missing and may identify any potential risks and/or criminal activity that has taken place. 29. Return of Detained Inpatient a. All decisions made regarding the most appropriate form of return transportation will be based upon the risks identified in the patient s risk assessment, and a review of those risks following the absence of the patient. b. The Mental Health Act Code of Practice 2008 states [11.27 & 11.28] where a patient who is absent without leave from a hospital is taken into custody by someone working for another organisation, the managers of the hospital from which the patient is absent are responsible for making sure that any necessary transport arrangements at put in place for the patient s return. However, the organisation which temporarily has custody of the patient is responsible for them in the interim and should therefore assist in ensuring that the patient is returned. 30. Inpatients assessed as being of minimum risk who go missing a. Those patients who, through the risk assessment, are considered to be safe and able to arrange their own transport back to the hospital will be asked to do so if they are willing. b. For those patients found in the Worcestershire catchment area, if the patient is considered safe for staff to transport, an appropriate Manager will arrange for a member of staff and escort(s) to collect and return the patient. c. For those patients found outside the Worcestershire catchment area and the patient is able to be left safely for a period at the place in which they have been found the Ambulance Service may be asked to transport them back. 31. Inpatients assessed as being at risk who are absent a. Where the patient is considered to be at risk to themselves or others the Police may be asked to assist in transporting them back to hospital. In this case, reasons for the decision and full details of the risks identified must be passed to the Police when requesting their assistance. b. A full discussion regarding the appropriate method of return of the patient must take place between staff and Police when they arrive at the hospital to take further patient details. This must take into account risks identified, the six Caldicott principles and other factors that may influence the method of return, e.g. different risk factors such as being found in a public place rather than their home. c. Where patients are found out of the immediate catchment area of the Trust there return will again be based on the assessed risks. In these cases, an appropriate Manager will be responsible for identifying a suitable form of travel. d. In some cases it may be appropriate to allow the patient to return by their own method of transport (e.g. train if the patient has sufficient funds) or with a family member. e. It is unlikely that any Police force will transport a patient back to hospital from outside the Trust s catchment area. 11 P age

14 f. Use of a private transport company may be considered, e.g. Carers UK When using such companies, a Senior Manager will agree funding; ensure the company is advised of appropriate escort levels and patient s assessed risk. 32. Absent Patients a. There is no legal provision to return informal absent patients. b. However, face to face contact with the patient and their family etc. should be addressed by the Ward and Community Teams to ensure appropriate support is in place and the patient and their family have access to services should they require them later. c. If an absent inpatient is considered to be a risk to themselves, to others or from others due to their mental ill health, the Police must be advised of this and it will be their decision whether to use a section 136 MHA 83, if the patient is in a public place. 12 P age