Mental Health Act Policy

Transcription

1 8.7 Lincolnshire Partnership NHS Foundation Trust Mental Health Act Document Type: New or Replacing: DOCUMENT VERSION CONTROL Mental Health Act Policy Replacing Version No: 3 Date Document First Written: July 2010 Date Document First Implemented: November 2008 Date Document Last Reviewed and Updated: October 2014 Implementation Date: 28 th April 2011 Author: Approving Body: Various co-ordinated by Legal Services Manager Quality Committee Approval Date: Committee, Group or Individual Monitoring MHA Monitoring Committee the Document Review Date: October 2017

2 Mental Health Act Policy Executive Summary This policy covers the application of the Mental Health Act 1983 [herein MHA] as amended including the procedures to be followed by staff and the associated documentation. It is not intended to be an alternative to following the specific wording of the MHA but is intended as a user-friendly guide. Where there is any conflict between this policy and the legislation, the legislation will prevail. In difficult situations, advice should be sought from the Legal Services Manager or Mental Health Act Manager.

3 Contents 1. Introduction 2. Legislation, Guidance and Policy Documents Considered 3. Definitions and Acronyms 4. Duties 5. Application of the Mental Health Act Policy Statement 5.2 Standards 5.3 Procedures 6. Implementation 7. Monitoring Overall Assess Process Section 2 Application Process Section 2 Admission & Maintenance Section 3 Application Process Section 3 Admission & Maintenance Section 4 Application & Admission Process Section 5 Holding Powers Section 17 Leave Community Treatment Orders Assessment & Application Process Community Treatment Orders Maintenance Community Treatment Orders Recalling and Revoking Section 18 Absent Without Leave Section 29 Displacement of Nearest Relative Discharge Mental Health Tribunals Discharge Hospital Managers Hearings Discharge Nearest Relative Part 4 Consent to Treatment Part 4A Consent to Treatment (CTO patients) Section 7 Guardianship Death of a Detained/CTO patient Voting Rights Withholding Post Section 135 Warrants Section 136 Police Detention Power Section 19 Patient Transfer (Internal and External) Section 117 Aftercare Transport of patients Changing Responsible Clinician 8. Associated Documentation

4 1. Introduction 1.1 The Trust is required to deliver services to its service users within the legal framework of the Mental Health Act 1983 and in accordance with the Mental Health Act Code of Practice (2015) and associated guidance. 1.2 In the application of legislative provisions, codes, and guidance, together with this policy and other linked documents, professionals, staff and stakeholders must have regard to the principles of the European Convention on Human Rights, as set out in the Human Rights Act These principles pervade all actions and decisions taken and any incompatibility identified, which cannot be resolved by individuals, should be reported to Chief Executive s Office. 1.3 This policy will apply to all employees of the Trust, including Non-Executive Directors, Hospital Managers, Governors, bank staff, volunteers, individuals on secondment and trainees or those on a training placement within the Trust and temporary staff employed through an agency. Staff from other organisations or companies undertaking work on Trust premises must abide by the relevant legislation and regulations and should be made aware of the pertinent parts of this policy. 1.4 The purpose of this policy is to protect service users and the public, provide staff with guidance to ensure compliance with the provisions of the Mental Health Act, to protect the staff and the Trust from litigation and to assist staff in undertaking duties. 1.5 All of the documents denoted in purple throughout this policy are standard templates or forms which staff are expected to utilise. Most are available on the Trust intranet site. However, some will be available from alternative sources. The table at section 8 details where they can be obtained. Amendments may be made to these forms so stockpiles should not be created and the forms should be regularly reaccessed. 1.6 If you wish to make a suggestion regarding amendment to this policy please see Creation and Management of Trust Documents (Corporate Governance Document). 1.7 This policy, the procedures and the associated documentation have been approved by the Quality Committee. They will be reviewed by the MHA Monitoring Committee every two years or sooner if required by changes to legislation or guidance. The Chief Executive s Office will maintain a version of old policies for a minimum of 10 years in line with the recommendations contained within Records Management NHS Code of Practice (2006). 1.8 If staff are unsure of their responsibilities at any time they should discuss this with their line manager. If staff are unsure of their legal responsibilities or the legal implications of their action the Team s Senior manager should contact the Legal Services Manager and/or Mental Health Act Manager. In the first instance all requests for advice or assistance should be made by telephone/ providing background information to the situation, the specific question being asked, the risks and the urgency of the request. Most advice can be provided direct from the Chief Executive s Office but on occasions the Chief Executive s Office may instruct external solicitors. 1.9 LPFT staff whilst undertaking the role of AMHP are acting on behalf of the Local Authority as described within the Section 75 agreement. Whilst staff are performing in

5 the role of an AMHP they will seek appropriate legal advice from the Local Authorities Legal Services Department. 2. Legislation, Guidance and Policy Documents Considered 2.1 This policy is not a substitute for the legislation, regulations and Codes of Practice to which all staff must adhere. The list below is not intended to provide a complete list of the legislation governing the practice of NHS employees. Staff should ensure they receive regular training which will inform them of any changes. Mental Health Act 1983 (and Regulations) Mental Health Act 2007 (and associated regulations) Tribunals, Courts and Enforcement Act 2007 Human Rights Act 1998 Equalities Act 2010 Childrens Act 1989 Childrens Act 2004 Mental Capacity Act 2005 Police and Criminal Evidence Act 1984 Mental Health Act Code of Practice 2015 Mental Health Act Reference Guide 2015 Supervised Community Treatment: A Guide for Practitioners, NIMHE, Leave of Absence for patients Subject to Restrictions: Guidance for Responsible Clinicians, Ministry of Justice, This policy has been written in consideration of the Health and Social Care Act 2008, associated Regulations and the CQC Essential Standards of Quality and Safety. Regulation 11 of the Health & Social Care Act 2008 (Regulated activities) regulation Definitions and Abbreviations 3.1 Definitions Advance Decision to Refuse Treatment (ADRT) - At a time when a patient has the capacity to make the decision they may decide that if they lack capacity at some point in the future they do not want to receive certain forms or methods of treatment. Advance Decisions can only be made by people 18 or over. If an advance decision relates to life sustaining treatment (such as resuscitation) it must be in writing and witnessed ideally by a carer or relative or if this is not appropriate an advocate or independent third party - but not by a member of Trust staff unless there are special circumstances. 1 Care Quality Commission (CQC) - Took over from the Mental Health Act Commission (as well as the Health Care Commission and the Commission for Social Care Inspection) in April 2009 to look after the rights and concerns of all those who are held under the Act. The CQC ensures the Act is being properly used and sends SOADs when required. Community Treatment Order (CTO) Power under sections 17A-17G that enables a patient to be discharged from detention in hospital but to remain subject to recall. Also referred to as Supervised Community Treatment (SCT) 1 For further information see Trust s MCA policy

6 Court Appointed Deputy - In certain situations where an individual does not have a Lasting Power of Attorney (LPA) but a series of decisions needs to be made the Court of Protection may appoint a deputy who will then take on the same functions as an attorney either for a specified period or indefinitely. Independent Mental Health Advocate (IMHA) Specialist advocates who support detained patients and those on CTO, ensuring that the safeguards laid out in the legislation are followed. Lasting Power of Attorney (LPA) - A Lasting Power of Attorney (LPA) is a formal legal document which confers on the attorney (or donee as it sometimes called) the authority to make decisions on the patient s behalf. There are 2 types of LPA: Personal Welfare and Property & Affairs. The decisions that can be made by the attorney will depend on the type of attorney they are and what is written in the LPA. To be valid an LPA must be formally written down, signed and registered with a body known as the Office of the Public Guardian. An LPA can also be verified through this body and should be verified if a paper copy cannot be presented to staff. Mental Health Tribunal (MHT) - Independent statutory body responsible for hearing patients appeals against detention. Acts as a mobile court. They are now classified as firsttier tribunals as per the Tribunals, Courts and Enforcement Act Nearest Relative - Not to be confused with Next of Kin, a patient cannot choose their Nearest Relative. It is a term specific to the Act and the Nearest Relative has a legally defined role (see section 26 of MHA). The Nearest Relative has certain powers and is entitled to receive certain information regarding a patient who is subject to the Mental Health Act. In contrast a patient can choose their Next of Kin but the Next of Kin will have no legal standing. Second Opinion Appointed Doctor (SOAD) - Sent by the CQC to ensure that when a patient does not or cannot consent to certain treatment it is only given if it is medically necessary. Also required to ratify the treatment provided to CTO patients irrespective of whether consent is forthcoming. In this role they are acting independently of the detaining hospital on behalf of the CQC. Section lapse occurs when a section expires without the Responsible Clinician exercising their power to discharge under section 23 MHA or the patient is not further detained under a section 3 MHA. Technical lapse: when a section expires following assessment by an amhp and Responsible Clinician where the two professionals have a difference of opinion in relation to the appropriateness of whether the patient should be detained under section 3 MHA. Substantive lapse: where a section expires and there has been no further assessment by an amhp and/or Responsible Clinician in respect of the next steps in relation to the patient s detention status. Supervised Community Treatment (SCT) Refers to the regime applied when someone is subject to a Community Treatment Order (CTO). A Guardianship enables a patient to receive treatment outside of hospital and is social led, predominantly focusing on a patient s welfare needs. The patient is received into the care of a guardian whom has three specific powers: exclusive right to decide where the patient lives, require the patient to attend treatment and facilitate access by a doctor, AMHP or another relevant person.

7 A Hospital Managers Hearing conducts a similar function to the Tribunal service in that the patient can apply to a panel of three members who will consider consider whether the statutory criteria for detaining a patient continue to be met. In the event that the criteria is not met, the Hospital Managers can discharge the patient. Aftercare (Section 117) is defined by the Care Act 2014 as:- [A service] meeting a need arising from or related to the person s mental disorder and which reduces the risk of a deterioration of the person s mental condition (and, accordingly, reducing the risk of the person requiring admission to a hospital again for treatment for the disorder. 3.2 Abbreviations AC Approved Clinician ADRT Advance Decision to Refuse Treatment AMHP Approved Mental Health Professional AWOL Absent Without Leave BIA Best Interests Assessor CoP Code of Practice (The Mental Health Act Code of Practice) CQC- Care Quality Commission CRHT Crisis Resolution and Home Treatment CTO- Community Treatment Order ECT Electro-Convulsive Therapy EDT Emergency Duty Team (Lincolnshire County Council) EMAS East Midlands Ambulance Service HM Hospital Managers IMHA Independent Mental Health Advocate LPA Lasting Power of Attorney MHA Mental Health Act MHRT Mental Health Review Tribunal MOJ Ministry of Justice NIC Nurse in Charge NR Nearest Relative OOH Out of Hours RC Responsible Clinician SOAD Second Opinion Appointed Doctor SCT Supervised Community Treatment

8 4. Duties Individual/ Group Chief Executive Board of Directors and Board Sub-Committees. Hospital Managers/ Mental Health Act Managers MHA Monitoring Committee Approved Clinician Responsible Clinician Responsible For: As Accounting Officer of the Trust the Chief Executive has ultimate responsibility for staff and organisational adherence to legislation, guidance and policy. Ensuring appropriate management chains are in place to enable adherence to this policy. Ensuring that the Trust has in place the necessary policies and procedures to enable staff to meet the standards aimed at by the Trust. Allocating resources required for implementation of policy. Receiving reports and approving action plans as detailed at section 7. Proper implementation of the Act as delegated by the Board of Directors Attending regular update training Holding review meetings when a patient s detention or CTO is renewed with the power to discharge the patient. Holding appeal hearings when a patient appeals against their detention or CTO with the power to discharge the patient. Receiving applications for admission under the Act* Authorising transfers to other hospitals* Providing information to patients in accordance with section 132 & Chapter 4 of the Code of Practice* Providing information to victims in accordance with the Domestic Violence, Crime and Victims Act 2004* and Chapter 40 MHA Code of Practice Withholding mail where appropriate* Referring patients to MHRT where appropriate* (* These duties are delegated) Director lead for the Mental Health Act Disseminating of any new case law. Providing a forum for resolving of operational issues in relation to MHA. Providing support and guidance to all clinicians. Receiving reports and approving action plans as detailed at section 7. Monitoring the incidents. Attending regular update training and training as required by the Strategic Health Authority to retain AC status. Informing the Learning & Development Centre department that they have completed AC training. Discharging duties under the MHA including in particular: Being responsible for Admissions Granting leave via section 17 Issuing CTOs Consulting with their professionals Leading the clinical team Abiding by applicable professional codes of practice. Ensuring all appropriate staff are aware who the consultant oncall is and how to contact them for times when they are unavailable. Maintaining of their patients sections including renewal,

9 AMHP AMHP lead AMHP administration Care co-ordinator/lead Professional discharge, granting leave and writing reports for MHRTs and HM meetings/hearings. Referring patients to an Independent Mental Health Advocate (IMHA) where appropriate. Discharging duties under the MHA. Attending regular update training and training as required by Lincolnshire County Council to retain AMHP status. Abiding by any Codes of professional practice. Performing duties laid down in the Act/ Code of Practice including: Overall responsibility for coordinating assessment process Interviewing Service User Make applications for admission of patients if it is appropriate and all the criteria are met, having regard to the guiding principles and the code of practice. Identify Nearest Relative (NR) and inform/consult Ensure property is secure and pets/dependants are looked after Deciding on appropriateness of CTOs and CTO revocations. Referring patients to an Independent Mental Health Advocate (IMHA) where appropriate Attending regular update training Continuing to inform patients of their rights and documenting on form R1. Referring patients to an Independent Mental Health Advocate (IMHA) where appropriate Discharge Planning, visiting patient 2 nd Professional Attending regular update training Providing second opinion at renewal of section Admitting Nurse Attending regular update training Receiving and scrutinising paperwork Completing forms H3, H3a, (or CTO4),R1 and R2 on admission Inpatient Named Nurse Attending regular update training Continuing to inform patients of their rights and documenting on form R1. Section 117 Awareness STAT (IMHA) where appropriate Mental Health Act Attending regular update training Administration Team Scrutinising legal paperwork on behalf of the Hospital Managers, issuing reminders re statutory deadlines and ensuring rectification of errors. Providing written information to patients Coordinating MHRTs Coordinating Hospital Managers Meetings & Hearings Capturing and presenting MHA data Auditing compliance with legislation Informing CQC of patient deaths (delegated to the Risk department for CTO patients and the in-patient unit for in-patient deaths). AWOL notification (delegated to the in-patient unit for CQC notification and the Risk department for reporting) Corresponding with the CQC as appropriate Any other functions delegated to them by the Hospital Managers Registering aftercare arrangements Legal Services Manager Providing advice to staff on the application of the Act.

10 Learning and Development Department Divisional Managers / Clinical Directors / Quality Improvement and Assurance Leads / Service Managers All Staff Safeguarding Ensuring appropriate and sufficient training is available and promoted to give staff the knowledge and skills to comply with this policy. Ensuring information on training is easily accessible to staff. Ensuring a training database is maintained of each staff member s attendance at training Providing reports on the uptake of training as per the requirements at section 7. Ensuring staff are familiar with this policy (including volunteers, placement staff, students, temporary staff and contracted staff) Ensuring staff have the tools, resources and skills to deliver the standards detailed in this policy and to undertake the tasks requested of them. Ensuring all efforts are made to facilitate staff attendance at mandatory training as defined in the HR Policy Handbook. Ensuring relevant legislation, Codes of Practice and guidance are available to staff. Gathering assurance that requirements and standards are being met and providing reports to the Director of Operations as detailed at section 7 and as required. Practicing within the legislative framework and update knowledge of such accordingly. Complying with professional Codes of Practice relevant to their discipline. Following the procedures described in this policy and aim to achieve the target standards. Undertaking all mandatory training as identified in HR Policy Handbook and any training essential for their particular role or duties. Cooperating with management to meet requirements Providing reports to Divisional Managers/Clinical Directors / Quality Improvement and Assurance Leads / Service Managers on the performance against standards for their team. Responsibility for training on safeguarding issues for Hospital Managers and AMHPs Providing information for victims in accordance with Domestic Violence, Crime and Victims Act 2004 Further information on duties can be found in the Scheme of Delegation (Corporate Governance Document) Duties for other Organisations ULHT LA (LCC) Implement MHA appropriately in own organisation. Seek advice using access to AMHPs own legal advice EMAS POLICE

11 5. Application of the Mental Health Act 5.1 Policy Statement In making any decisions under the Mental Health Act the guiding principles should be considered. These are laid out in Chapter 1 of the Mental Health Act Code of Practice and can be summarised as follows: Empowerment and Involvement patients should be fully involved in decisions about care, support and treatment. The views of families, carers and others, if appropriate, should be fully considered when taking decisions. Where decisions are taken which are contradictory to views expressed, professionals should explain the reasons for this. Least Restrictive and Maximising Independence where it is possible to treat a patient safely and lawfully without detaining them under the MHA, the should not be detained. Wherever possible a patient s independence should be encouraged and supported with a focus on promoting recovery wherever possible. Respect and Dignity Patients, their families and carers should be treated with respect and dignity and listened to by professionals. Purpose and Effectiveness Decisions about care and treatment should be appropriate to the patient, with clear therapeutic aims, promote recovery and should be performed to current national guidelines and/or current, available best practice guidelines. Efficiency and Equality Providers, Commissioners and other relevant organisations should work together to ensure that the quality and are given equal priority to physical health and social care services. All relevant services should work together to facilitate timely, safe and supportive discharge from detention Decisions made under the MHA are supported and informed by the clinical assessment and care planning process (including CPA) and detention under the Mental Health Act is not a substitute for following these processes (as described in the Clinical Care Policy) All staff should ensure that their decisions made and actions taken in respect of patients subject to the Mental Health Act follow the procedures laid out in the legislation. All decisions made and action taken should be in accordance with the Code of Practice and the Reference Guide unless there is cogent reason(s) for deviation References to paragraphs in the procedures at 5.3 are paragraphs in the Mental Health Act Code of Practice (2015) All situations in which the procedures detailed below aren t/cannot be followed should be recorded as an incident on the electronic risk management system, classified as breach of MHA. 5.2 Standards All action taken in respect of patients subject to the MHA will be in accordance with the MHA and the procedures outlined in this policy AMHP administrator will inform Crisis Team. Order of preference: Patient s own GP, GP from patient s surgery, s12 doctor who knows patient, any section 12 doctor, other appropriate doctor, doctor from same team as first recommendation (only to avoid section 4). If any problems are

12 encountered in obtaining the attendance of doctors then the AMHP should inform the AMHP Administrator who will complete an incident report on the electronic risk management system There should be no conflicts of interest between the assessors; financial, business, professional or personal (para ). Consult with legal department if in any doubt. All three assessors must not be from the same team. Crisis team should be considered to be part of hospital team, therefore avoid assessors from the crisis team and the ward team completing an assessment together. Two doctors from the admitting hospital should be used for medical recommendations only in accordance with conflict of interest regulations and when it proves necessary to avoid the inappropriate use of section 4. Again crisis teams should be considered part of the hospital team If one of the assessors is not a specialist in the area (eg LD, child, older person) then consult with specialist on-call (para 14.39) 5.3 Procedures

13 5.3.1 MHA Assessment Process Doctors approached by the NR to make a medical recommendation should advise the use of an AMHP (para14.32) Call is made to AMHP Administrator requesting a Mental Health Act assessment. Call may be made by Care co-ordinator/ Lead professional, police, crisis team, GP, NR, Family member etc. AMHP Administrator obtains all relevant names and numbers and asks if an interpreter/ signer will be required. Ask if there is any information regarding LPA/ ADRTs. (If OOH, referral made to Emergency Duty Team (EDT)) AMHP Administrator contacts appropriate AMHP on the rota (EDT OOH). AMHP contacts patient s GP* and appropriate s12 doctor (specialist to case if possible). AMHP liaises with Crisis team where necessary. AMHP Administrator Arrangements made for at least one of the doctors to attend with the AMHP to conduct assessment (para 14.45). Assess risk. If 2 nd doctor cannot attend whilst AMHP and 1 st doctor at property, AMHP to arrange to meet 2 nd doctor (para 14.46). The two doctors should discuss the case Need for detention discussed and agreed. Appropriateness of section 2 or section 3 decided as per MHA and Code of Practice. Admission required? Consider whether patient should be subject to Deprivation of Liberty Safeguards or detained under the MHA See (section 2) or (section 3). If the patient meets criteria for section 2 and needs to be in hospital as a matter of urgency a section 4 can be used (para ). See N Appropriate services arranged by the AMHP in conjunction with the Crisis Resolution and Home Treatment (CRHT) Team where appropriate If an AMHP has concerns about the assessment process then to discuss with another AMHP on the rota (AMHP Administrator can facilitate) or LCC Legal Team. An incident report should be completed on the electronic risk management system as soon as possible, classified as Breach of MHA. This can be done by the AMHP Administrator if notified by the AMHP.

14 5.3.2 Section 2: Admission for Assessment and Treatment for up to 28 days Most senior Section 12 doctor conducting assessment arranges for a bed. (para 14.77) or can delegate to Crisis teams but retains responsibility. Doctors complete 1 x Form A3 or 2 x Form A4 AMHP completes Form A2 ensuring correct address of hospital including name of Trust. AMHP informs NR of application and their rights (including right to refer to IMHA). AMHP discusses the IMHA service with the patient and calls relevant Advocacy service to make a referral if appropriate. AMHP should check all forms for consistency and correctness. If a risk is identified one assessor should not be left alone with the service user. If the police or ambulance are not at the premises to support the remaining assessor then the second assessor should arrange for a deputy. This could be the crisis team or a nurse from the admitting ward. Particular regard should be had to the risk posed to the patient and/or others and arrangements made as appropriate. Appropriate transport arranged by AMHP (Police to be contacted if high risk). AMHP/ Section 12 doctor signs an Authority to convey form, Form C1 if another agency (e.g. Police or EMAS) conveying. AMHP makes arrangements for the care of any pets and the securing of the patient s property (para 14.88) If there is any danger of loss or of damage to the patient s property, the AMHP must ensure that the relevant protection of property procedures are adhered to. Ring ward of receiving hospital when transport arrives to inform them that they are on the way (para 17.20). AMHP (and others dependant on risk assessment) goes with patient to hospital and personally delivers application for admission and accompanying medical recommendations to hospital ward staff. Delivery of papers can be delegated in exceptional circumstances. The reasons for this must be appropriately recorded. If the AMHP does not accompany should phone the hospital later to confirm admission. Receiving nurse must check the papers for any errors that fundamentally invalidate the section (para 35.8) and challenge the AMHP for appropriate explanations before accepting papers on behalf of the Managers. If on arrival at the hospital stated in Form A2 the bed has been taken, the patient should be admitted (see 5.3.3) and then transferred if at all possible (see ). The original hospital should assist in finding another bed at an alternative hospital. An incident report must be completed on the electronic risk management system ASAP by the ward manager/nic classified as Breach of MHA. If the patient was not admitted to the original hospital the AMHP will need to complete a new application but not destroy old one. An incident report must be completed on the electronic risk management system ASAP by the ward manager/nic classified as Breach of MHA. See 5.3.3

15 5.3.3 Section 2 Admission & Maintenance Patient admitted to hospital. Admitting nurse completes Form H3 & Form H3a, scans them into Sliverlink (informing MHA Admin) and original papers kept on file on the ward. Admitting nurse asks if LPA or any ADRTs and ascertains if AMHP referred to IMHA. Admitting nurse should also bear in mind that a Form A1 may be present rather than a Form A2 where the NR has made the application. Admitting nurse communicates outcome to NR, GP, Doctors providing medical recommendations and Care co-ordinator. If restricted patient, telephone Ministry of Justice to inform them of detention Admitting nurse completes Form R1 & Form R2 and makes a referral to IMHA where appropriate (automatic referral if patient lacks capacity). If rights are not immediately understood to revisit the following day and repeated again on day 8 or as close to as possible. In completing Form R1 and providing information in accordance with section 132 of the MHA the admitting nurse should ensure that all reasonable steps are taken to ensure the patient understands: their right to an IMHA, their right to apply to the MHRT within 14 days of admission under section 2 and their right to appeal against their detention to the Hospital Managers at any time. The patient should be provided with relevant Department of Health leaflets available from the Department of health website. MHA Admin Team complete Form H3b and record date of detention on central records The MHA Admin team write to the patient further informing them of their rights. Details entered on electronic patient record system by MHA admin team. If necessary, get papers rectified within 14 days. MHA Admin team send medical recommendations to a Nominated doctor who completes Form H3c. Immediately upon admission the Named Nurse should refer the patient to an IMHA unless the patient objects (to be recorded on Form R1).The patient s named nurse should ensure that the patient is informed of their rights on a regular basis [as detailed above] and Form R1 is signed each time. Patient can be detained for 28 days & is subject to Part IV consent rules. For the purposes of obtaining a Form T2 or Form T3 it will be assumed that treatment commences on the first day of detention. RC should inform MHA Admin of the date treatment starts if it is later than the first day of detention. See Section 17 leave may be granted. See At each MDT the necessity for the patient to remain under section should be reviewed and documented in Review Summary Each week, MHA Admin team send a list of sections on a ward detailing when each section is to expire for which they have not received Form D1 or appropriate section paperwork to the Mental Health Act Manager By day 21 a decision should be made regarding the need for section 3. Section 3 required? N Medical Health Act Manager contacts RC to request action. RC completes first medical recommendation. RC (which could be delegated to NIC) arranges for AMHP (via AMHP) and the AMHP arranges this and the second medical recommendation. Forms A6 & A7/A8 completed and sent to MHA Admin Team. RC completes Form D1 sends to MHA Admin Team ASAP. RC informs patient that they are an informal patient and what this means and documents conversation in the healthcare record. MHA admin team to write to patient The MHA admin team will inform the ward manager/nic that they need to complete an incident report on the electronic risk management system for any situations where Form D1 or appropriate section paperwork is not received classified as Breach of MHA. Mental Health Act Manager notifies MHA Committee of breach outlining whether the lapse is considered substantive or technical. Mental Health Act Manager provides details to the MHA Committee on the reasons for the classification and what steps have been taken to mitigate future occurrences. See All situations where Form D1 or appropriate section paperwork not received before date of section 2 expiry will be investigated and reported to the appropriate Executive and Board Committees.

16 5.3.4 Section 3 Application for Admission for Trust Appropriateness of section 3 agreed by all assessors (Refer to Code of Practice). Most senior Section 12 doctor conducting assessment arranges for a bed. (para 14.77) or can delegate to Crisis teams but retains responsibility. Doctors agree what is the appropriate treatment and where this can be given (para ) and complete 1 x Form A7 or 2 x Form A8, documenting all the various alternatives on the paperwork. AMHP consults with NR. If this is not appropriate or possible reasons must be documented. If the NR objects to the use of Section 3 the section cannot be applied. If NR maintains objection AMHP should consider displacement under Section 29 if grounds are met. AMHP consults LCC legal department. A section 2 cannot be used as an alternative. AMHP completes Form A6 ensuring correct address of hospital including name of Trust. AMHP informs NR of their rights (including right to refer to IMHA). AMHP discusses the IMHA service with the patient and calls relevant advocacy service to make the referral if appropriate AMHP should check all forms for consistency and correctness. If a risk is identified one assessor should not be left alone with the service user. If the police or ambulance are not at the premises to support the remaining assessor then the second assessor should arrange for a deputy. This could be the crisis team or a nurse from the admitting ward. Particular regard should be had to the risk posed to the patient and/or others and arrangements made as appropriate. Appropriate transport arranged by AMHP (Police to be contacted if high risk). AMHP/ Section 12 doctor signs an Authority to convey form, Form C1 if another agency (e.g. Police or EMAS) conveying. AMHP makes arrangements for the care of any pets and the securing of the patient s property (para 14.88) If there is any danger of loss or of damage to the patient s property, the AMHP must ensure that the relevant protection of property procedures are adhered to. Ring ward of receiving hospital when transport arrives to inform them that they are on the way (para 17.20). AMHP (and others dependant on risk assessment) goes with patient to hospital and personally delivers application for admission and accompanying medical recommendations to hospital ward staff. Delivery of papers can be delegated in exceptional circumstances. The reasons for this must be appropriately recorded. If the AMHP does not accompany should phone the hospital later to confirm admission. If on arrival at the hospital stated in Form A6 the bed has been taken, the patient should be admitted (see 5.3.5) and then transferred if at all possible (see ). The original hospital should assist in finding another bed at an alternative hospital. An incident report must be completed on the electronic risk management system ASAP by the ward manager/nic, classified as Breach of MHA. If the patient was not admitted to the original hospital the AMHP will need to complete a new application but not destroy old one. If the new hospital was not named as one where appropriate treatment is available on Form A7 or both Form A8s then there would be no authority for detention unless new Form A7 or 2 x Form A8 completed naming new hospital. An incident report must be completed on the electronic risk management system ASAP by the ward manager/nic classified as Breach of MHA. See 5.3.5

17 5.3.5 Section 3 Admission & Maintenance Patient admitted to hospital. Admitting nurse completes Form H3 & Form H3a scanned into Silverlink (informing MHA Admin) and originals held in patient field on the ward. Admitting nurse asks if LPA or any ADRTs and ascertains if AMHP referred to IMHA (automatic referral where patient lacks capacity). Admitting nurse should also bear in mind that a Form A5 may be present rather than a Form A6 where the NR has made the application. Admitting nurse communicates outcome to NR, GP, Doctors providing medical recommendations and Care co-ordinator. If restricted patient, telephone Ministry of Justice to inform them of detention Immediately upon admittance, the admitting nurse completes Form R1 and Form R2 and makes a referral to IMHA where appropriate. If rights are not immediately understood to revisit the following day. In completing Form R1 and providing information in accordance with section 132 of the MHA the admitting nurse should ensure that all reasonable steps are taken to ensure the patient understands: their right to an IMHA, their right to apply to the MHRT and their right to appeal against their detention to the Hospital Managers at any time. The patient should be provided with relevant Department of Health leaflets available from the Department of Health website. Notify NR of outcome and rights including right to apply for discharge. The MHA Admin team complete Form H3b and record date of detention on central records. The MHA admin team write to the patient further informing them of their rights. Details entered on electronic patient record system by MHA admin team After 3 days the Named Nurse should refer the patient to an IMHA (if they have not already been referred) unless the patient objects (to be recorded on Form R1). The named nurse should ensure that the patient is informed of their rights on a regular basis and Form R1 is signed each time (as a minimum every 3 months or when their section changes/renewed. See also para 4.29). Patient can be detained for 6 months initially & is subject to Part IV consent rules. For the purposes of obtaining a Form T2 or Form T3 it will be assumed that treatment commences on the first day of detention (under section 2 or 3). RC should inform the MHA admin team of the date treatment starts if it is later than the first day of detention. See At each MDT the necessity for the patient to remain under section should be reviewed and documented in Review Summary Section 17 leave may be granted. See By 4 months a decision needs to be made regarding the continuing need for section 3 (if CTO is considered see 5.3.9). Assessment made of whether patient has the capacity to object to the renewal and outcome documented (see ) Ward Manager to identify 2 nd professional and inform MHA Admin team (If the patient has a care co-ordinator from a community team it will be this individual or an AMHP from that team. If not, it will be a nurse from the ward who has overall responsibility for the patient provided they meet the criteria (see COS para ). Each week, MHA Admin team send a list of sections on a ward detailing when each section is to expire for which they have not received Form D1 or appropriate section paperwork to the Mental Health Act Manager Medical Health Act Manager contacts RC to request action. If RC believes continued detention necessary then RC completes part 1 of Form H5 and sends to 2 nd Professional by the 5 month date. If RC does not consider continued detention necessary completes Form D1 and returns to MHA Admin Team. 2 nd Professional agrees with the RC that there is a continued need for detention under Section 3 2 nd professional completes Part 2 of Form H5 and returns to RC at least 4 weeks before expiry of section. RC completes Part 3 of Form H5 and returns to MHA admin team ASAP. CQC s61 also completed if patient had a Form T3 in situ. 2 nd Professional completes Part 1 of Form H5a and discusses with RC Form D1 or part 2 of Form H5a completed by RC and sent to MHA Admin Team ASAP. Where applicable patient informed by RC that they are an informa l patient and what this means (including section Patient can be detained for 117 aftercare) and this is a further 6 months at their documented in the initial renewal and then healthcare record. Consider LPFT annually. Mental whether Health Act an v.3 alternative opion October 2015 should be sought The MHA admin team will inform the ward manager/nic that they need to complete an incident report on the electronic risk management system for any situations where Form D1 or appropriate section paperwork is not received classified as Breach of MHA. Mental Health Act Manager notifies MHA Committee of breach outlining the details of the lapse. Mental Health Act Manager provides details to the MHA Committee around what steps have been taken to mitigate future occurrences. Where the MHA admin team receive a Form H5a with Part 1 and Part 2 completed they will complete an incident report on the electronic risk management system. Hospital Managers and the Director of Operations informed and a way forward agreed.

18 5.3.6 Section 4 Application & Admission Process If the patient meets criteria for section 2 and needs to be in hospital as a matter of urgency a section 4 can be used (para ). Preference should always be given to using two doctors from the admitting hospital to complete a section 2, rather than using a section 4 (para ). All uses of section 4 should be reported as an incident on the electronic risk management system. The AMHP referral co-ordinator can undertake this if notified by the AMHP. Doctor conducting assessment arranges for a bed. (para 14.77) or can delegate to Crisis teams but retains responsibility. Doctor completes Form A11. AMHP completes Form A10 ensuring correct address of hospital including name of Trust. AMHP informs NR of application and their rights (including right to refer to IMHA). AMHP discusses the IMHA service with the patient and calls Relevant Advocacy Service to make the referral if appropriate. AMHP should check both forms for consistency and correctness. If a risk is identified an assessor should not be left alone with the service user. If the police or ambulance are not at the premises to support the remaining assessor then the second assessor should arrange for a deputy. This could be the crisis team or a nurse from the admitting ward. Particular regard should be had to the risk posed to the patient and/or others and arrangements made as appropriate. Appropriate transport arranged by AMHP (Police to be contacted if high risk). AMHP/Section 12 doctor signs an Authority to convey form Form C1 if another agency (e.g. police or EMAS) transporting. AMHP makes arrangements for the care of any pets and the securing of the patient s property (para 14.88) If there is any danger of loss or of damage to the patient s property, the AMHP must ensure that the relevant protection of property procedures are adhered to Ring ward of receiving hospital when transport arrives to inform them that they are on the way (para 17.20). AMHP (and others dependant on risk assessment) goes with patient to hospital and personally delivers application for admission and medical recommendation to hospital ward staff. Delivery of papers can be delegated in exceptional circumstances. The reasons for this must be appropriately recorded. If the AMHP does not accompany should phone the hospital later to confirm admission. Patient admitted to hospital. Admitting nurse completes Form H3 & Form H3a and scans onto silverlink informing to MHA Admin team within 1 working day along with original detention papers. Admitting nurse asks if LPA or any ADRTs and ascertains if AMHP referred to IMHA. Admitting nurse communicates outcome to NR, GP, Doctor providing medical recommendation and Care co-ordinator. If restricted patient, telephone Ministry of Justice to inform them of detention Immediately upon admittance, admitting nurse completes Form R1 & Form R2 and makes a referral to IMHA where appropriate. In completing Form R1 and providing information in accordance with section 132 of the MHA the admitting nurse should ensure that all reasonable steps are taken to ensure the patient understands their rights. The patient should be provided with relevant Department of Health leaflets available from the Department of Health website. The patient can be detained for a maximum of 72 hours or until the RC assesses the patient and determines that they do not meet the criteria for further detention (whichever is sooner). The patient is not subject to Part IV consent rules and therefore any treatment provided must be in accordance with common law consent or the Mental Capacity Act (see Clinical Care Policy). RC sees patient as soon as possible and assesses need for further detention. Section 3 RC arranges (or delegates to NIC) for s3 assessments to be undertaken (2 new medical recommendations & application required) (see and 5.3.4). Section 2 RC completes Form A4 and sends to MHA admin team ASAP. See No detention required RC completes Form D1 and sends to MHA admin team ASAP. RC informs patient that they are informal and what this means. The MHA admin team will inform the ward manager that they need to complete an incident report on the electronic risk management system for any situations where Form D1 or appropriate section paperwork not received. All situations where Form D1 or appropriate section paperwork not received will be investigated and reported to the appropriate Executive and Board Committees.

19 5.3.7 Section 5 Holding Power Inpatient (not in A&E or outpatient dept) wanting to leave hospital premises Staff feel that the patient would be a risk to self or others if allowed to leave. Staff attempt to discuss/reason with patient Patient is still refusing to stay on premises NIC makes every effort to contact AC or nominated deputy. Is the AC or nominated deputy immediately available? After examination does AC/nominated deputy consider that detention under MHA may be necessary and that a MHA assessment should take place? N Message left for AC/nominated deputy to attend ward as a matter of urgency. AC/ nominated deputy completes Form H1 and send to MHA admin ASAP (fax). N Patient remains informal and is free to leave unless the provisions of the Mental Capacity Act could be used to restrict the patient in the patient s best interests. N Is patient receiving treatment for mental disorder in a mental health ward? NIC (RMN or RNLD level 1 or 2) completes Form H2 Patient admitted under section 5(2) Patient admitted under section 5(4) Admitting nurse completes Form H3a and sends to MHA Admin team ASAP (within 1 working day) along with original Form H1 or Form H2 Immediately upon admittance, admitting nurse completes Form R1 & Form R2 The patient can be detained with minimum force necessary for a maximum of 72 hours or until a MHA assessment has taken place (whichever is sooner) and is not subject to Part IV consent rules and therefore any treatment provided must be in accordance with common law consent or the Mental Capacity Act (see Clinical Care Policy). The patient can be detained with minimum force necessary for a maximum of 6 hours or until the AC/nominated deputy attends (whichever is sooner) and is not subject to Part IV consent rules and therefore any treatment provided must be in accordance with common law consent or the Mental Capacity Act (see Clinical Care Policy). Continue to attempt to make contact with the AC/nominated deputy. Has AC/nominated deputy arrived within 6 hours? N AC/nominated deputy completes Form H1. Patient admitted under section 5(2). The start time is the time section 5(4) commenced. Does AC/nominated deputy consider that detention under the MHA may be necessary? NIC completes final part of Form H2 and sends to MHA admin team ASAP MHA assessment arranged by NIC ASAP (AMHP/BIA referral co-ordinator can assist). AC/nominated deputy to complete medical recommendation. If prior to the MHA assessment being completed the AC/nominated deputy decides that further assessment and detention is not required s/he should complete Form H1a and send through to the MHA admin team ASAP (fax). N NIC completes Form H2 and sends to MHA admin team ASAP (fax) Patient becomes informal and is free to leave unless the provisions of the Mental Capacity Act could be used to restrict the patient in the patient s best interests. NIC informs patient that they are informal and what this means. If on assessment the AMHP does not believe that further detention is required the RC should inform MHA Admin immediately Incident report on electronic risk management system completed by NIC. The MHA admin team will inform the ward manager that they need to complete an incident report on the electronic risk management system for any situations where Form H2 or appropriate section paperwork not received. All situations where appropriately completed Form H2 or appropriate section paperwork not received will be investigated and reported LPFT Mental Health to Act the v.3 appropriate Executive and October Board 2015 Committees.

20 5.3.8 Section 17 Leave Patient detained under MHA Patient requests leave of absence Reviewed by RC & team at MDT review When consider leave of absence, RC s should have regard to paragraph and Chapter 31 [which considers whether s. 17 leave, guardianship or CTO are more appropriate] of Code of Practice In assessing whether to grant section 17 leave consideration must be given to any implications at the time for child or vulnerable adult safeguarding concerns. Where there are concerns, the relevant procedures must be followed (see Clinical Care Policy) In circumstances where any risk to a child/children has been identified, schools and other relevant agencies will be notified of the Section 17 leave in accordance with the relevant procedures. Decision made by RC to grant section 17 leave. For restricted patients under Part 3 of the MHA (those subject to section 41 or 49 restrictions) the RC can only grant discretional leave within the secure perimeter fence of the unit (leave within the secure perimeter fence is classified as grounds leave ). All other leave (including onto non-secure ULHT hospital grounds) is classified as community leave and must be granted in advance for each individual patient by the Ministry of Justice following application by the RC. Leave of absence conditions agreed by RC and MDT in consultation with the patient. Is leave for more than 7 consecutive days and nights (i.e. the patient will not be resident on the ward for a week or more)? RC should consider using a CTO [see page 350 of Code of Practice for relevant factors]. RC completes Form L2 (only RC can complete. See for changing RC). All previous Form L1 and Form L2 should be struck through and marked as superseded and filed appropriately. N RC completes Form L1 (only RC can complete. See for changing RC). All previous Form L1 and Form L2 should be struck through and marked as superseded and filed appropriately. Named nurse or NIC completed Form R1 ensuring that the patient is aware of any conditions and AWOL procedures. A contingency plan should be agreed in case the patient does not return. Copy of leave form sent to MHA Admin Team and other relevant professionals as stated on form (If leave greater than 3 days GP informed but responsibility still lies with RC). Copy given to patient. At the time when the patient requests to go out on their assigned leave the named nurse or NIC completes risk assessment and exercises discretion (if leave refused nurse documents reasons). Patient informed that if they have any problems they should return to hospital. Leave documented in the patient s healthcare record. On the patient s return from leave the success and outcome should be documented by the named nurse/nic in the patients healthcare record. If patient fails to return from leave at the specified time the AWOL procedure should be followed (see ) In cases of emergency if the patient is in need of urgent medical treatment (eg if an elderly patient has fallen out of bed and has a suspected fractured hip) and needs to be moved to the General Hospital for the medical treatment the patient can be moved and the Form L1 or Form L2 completed retrospectively by the RC at the earliest opportunity. Any outpatient hospital appointments, optician appointments, dental appointments etc must be planned and the Form L1 or Form L2 completed by the RC in advance of the appointment.