COMMUNITY TREATMENT     ORDERS    Professor Anselm Eldergill
Introduction   The supervision application (‘supervised discharge’) provisions in    the 1983 Act were repealed by the 20...
Initial steps — Considering an order
Considering an order   The responsible clinician cannot grant or    allow more than seven consecutive days    section 17 ...
What is ‘considering’?   ‘21.10 The requirement to consider SCT    does not mean that the responsible    clinician cannot...
Alternatives   No leave — the patient remains detained    in hospital under their treatment order   Section 17 leave/ext...
Making the order
Who makes the order?17A(4) — The responsible clinician maynot make a community treatment orderunless—   in their opinion,...
The criteria17A.(5) The relevant criteria are that—    (a) the patient is suffering from mental disorder of a nature or d...
Attaching conditionsA community treatment order shall specify the conditions to which the patient is to be subject.       ...
Remember …   The conditions must not be so    severe as to constitute a    deprivation of liberty;   Th e    conditions ...
Form CTO1 and the AMHP
Forward-dating orders‘25.28 If the responsible clinician andAMHP agree that the patient should bedischarged onto SCT, they...
Form CTO1, Part 3
Definitions
DefinitionsThe definitions are important:(1)   Only ‘the responsible clinician’ may make an order. Who is the responsible ...
Who is the responsible clinician?“the responsible clinician” means –   (a) in relation to a patient liable to be detained...
Meaning of ‘mental disorder’             1983 Act                       1983 Act as amendedA person may only be placed on ...
The learning disability exception   This general definition of mental disorder is     “learning    subject to one excepti...
‘Medical treatment’145.–(1 ) In this Act, unless the context otherwiserequires … “medical treatment” includes nursing,[OUT...
Example•   Mr Jones is receiving psychological    intervention.•   Ms Smith is being cared for and    supervised by a soci...
‘Appropriate’ medical treatment’145.—(1AB) References in this Act toappropriate medical treatment shall beconstrued in acc...
‘Appropriate medical treatment’6.11 The other circumstances of a patient’s case might include factors such as:   the pati...
But …..6.12 Medical treatment need not be the mostappropriate treatment that could ideally be madeavailable. Nor does it n...
‘Hospital’145.—(1) In this Act, unless the context otherwiserequires …. “hospital” means—a) any health service hospital wi...
‘Health service hospital’For the purposes of the National Health Service Act 2006:“health service hospital” means a hospit...
Registered establishments    “HOSPITAL WITHIN THE MEANING OF          PART II OF THIS ACT”•    By section 34(2), unless th...
Treatment outside hospital in the community
Normal rules: patients has capacity            TREATMENT REQUIRES TWO THINGS SOAD CERTIFICATE                 AUTHORITY TO...
Normal rules: patients has capacity (2)            WHEN A SOAD CERTIFICATE IS NOT REQUIRED      The medication is being g...
‘Immediately necessary’Treatment is ‘immediately necessary’ if one of the following conditionsap p l i e s :  1   The trea...
Normal rules: patient lacks capacity           TREATMENT REQUIRES TWO THINGS SOAD CERTIFICATE                 AUTHORITY TO...
Section 64D (No capacity)   THE TREATMENT WAS GIVEN BY THE APPROVED CLINICIAN IN CHARGE OF THE    TREATMENT OR UNDER THAT...
Normal rules: patient lacks capacity    WHEN A SOAD CERTIFICATE IS NOT REQUIRED CAPACITY   The medication is being given ...
Emergency treatment (no capacity)1. The person ‘giving’ the treatment reasonably believes that   the patient lacks capacit...
Mental Capacity Act 2005   Do not be tempted to use section 5 of the Mental Capacity    Act 2005 to supplement the rules ...
SOAD consultations   SOADs are required to consult two people (“statutory    consultees”) before  issuing  certificates a...
Suspending and varying conditions
Suspending and varying conditions        SUSPENDING                         VARYING   25.42 Suspension of one          2...
Recalling the patient to hospital
Recalling the patient   The responsible clinician may recall a community    patient to hospital if in her/his opinion:   ...
The notice of recall   25.55 The responsible clinician must complete a written notice of recall    to hospital, which is ...
The effect of recall          MAXIMUM DETENTION PERIOD OF 72 HOURS   “When the patient arrives at hospital after recall, ...
Treatment during the recall period              1                                    2                              3 Cert...
Alternatives to recall   Admission under section 2: does not revoke the CTO   Informal admission   A f re sh se c t i o...
Revoking the CTO
Revocation         EXAMINATION AND REVOCATION OF THE CTO   Where a community patient has been recalled, the RC may revoke...
Revoking the CTO   “If the patient requires in-patient treatment    for longer than 72 hours after arrival at the    hosp...
Renewal and discharge
Renewing the orderUnless renewed, the order expires after six months after the day on which it wasmade. The first renewal ...
Discharging CTOs    WHO CAN DISCHARGE               BARRING ORDERS   Mental Health Tribunal        The nearest relative ...
Mental Health Tribunals
CTO tribunals72 Powers of tribunals(1) Where application is made to a Mental Health Review Tribunal by or in respect of a ...
Section 3 tribunals72 Powers of tribunals(3A) Subsection (1) above does not require a tribunal to direct thedischarge of a...
Section 117 after-care
The duty under section 117‘It shall be the duty of the Primary Care Trust orLocal Health Board and of the local social ser...
Care Quality Commission
CQC’s remit   (a) to visit and interview in private patients detained under this Act    in hospitals and registered estab...
IMHAs
Independent Mental Health Advocates• From April 2009, advocacy services must be  available to patients who are subject to ...
An IMHA’s functionsThe help available to qualifying patients from IMHAs must includehelping the patient to obtain and unde...
Legal representation?• The help available from advocates must also include ‘help (by  way of representation or otherwise)’...
Visiting and access to records•   In order to provide the patient with help, an IMHA may visit and    interview the patien...
The Code of Practice
Code of Practice   s.118—The Secretary of State    shall prepare, and from time to    time revise, a code of practice    ...
Purpose principle   Decisions under the Act    must be taken with a    view to minimising the    undesirable effects of  ...
Least restriction principle   People taking action    without    a   patient’s    consent must attempt    to keep to a mi...
Respect principle   People taking decisions under the Act    must recognise and respect the    diverse      needs,     va...
Participation principle   Patients     must    be    given    the    opportunity to be involved, as far as is    practica...
Effectiveness, efficiency andequity principle   People taking decisions    under the Act must    seek     to   use     th...
Using the principles   All decisions must, of course, be lawful and    informed by good professional practice. Lawfulness...
Weighing up the alternativesCTOs, guardianship, section 17
CTO or section 17 Leave?
CTO or guardianship?
DOLs and CTOs
Is the patient eligible for DOLs?                      CTO PATIENT IN A CARE HOME1.   Not if accommodating the person in t...
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Community treatment orders

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Community treatment orders

  1. 1. COMMUNITY TREATMENT ORDERS Professor Anselm Eldergill
  2. 2. Introduction The supervision application (‘supervised discharge’) provisions in the 1983 Act were repealed by the 2007 Act. From 3 November 2008 onwards, it was no longer possible to make a supervision application. In their place is a ‘Supervised Community Treatment’ order. Following discharge into the community, the scheme is similar to that of conditional discharge under a restriction order, with the responsible clinician taking the role of the Minister of Justice. The original section 3 application/section 37 order remains in existence, and does not require renewal, while the patient remains subject to the CTO. If the CTO is revoked then the patient is again liable to detention under the original section 3 application/section 37 order.
  3. 3. Initial steps — Considering an order
  4. 4. Considering an order The responsible clinician cannot grant or allow more than seven consecutive days section 17 leave unless s/he ‘first considers whether the patient should be dealt with under section 17A (CTO order) instead.’ Section 17(2A)
  5. 5. What is ‘considering’? ‘21.10 The requirement to consider SCT does not mean that the responsible clinician cannot use longer-term leave if that is the more suitable option, but the responsible clinician will need to be able to show that both options have been duly considered. The decision, and the reasons for it, should be recorded in the patient’s notes.’ Code of Practice
  6. 6. Alternatives No leave — the patient remains detained in hospital under their treatment order Section 17 leave/extended section 17 l ea ve Community treatment order DOLs scheme Court of Protection order Discharge treatment order and revert to informal status
  7. 7. Making the order
  8. 8. Who makes the order?17A(4) — The responsible clinician maynot make a community treatment orderunless— in their opinion, the relevant criteria are met; and an approved mental health professional states in writing— (i) that s/he agrees with that opinion; and (ii) that it is appropriate to make the order.
  9. 9. The criteria17A.(5) The relevant criteria are that— (a) the patient is suffering from mental disorder of a nature or degree which makes it appropriate for him to receive medical treatment; (b) it is necessary for his health or safety or for the protection of other persons that he should receive such treatment; (c) subject to his being liable to be recalled as mentioned in paragraph (d) below, such treatment can be provided without his continuing to be detained in a hospital; (d) it is necessary that the responsible clinician should be able to exercise the power under section 17E(1) below to recall the patient to hospital; and (e) appropriate medical treatment is available for him.
  10. 10. Attaching conditionsA community treatment order shall specify the conditions to which the patient is to be subject. COMPULSORY CONDITIONS The order shall specify conditions that the patient makes her/himself available for the purposes of being examined in connection with (1) the order’s renewal, and (2) the furnishing of a consent to treatment certificate. The patient may be recalled to hospital if s/he fails to comply with either of these two conditions. DISCRETIONARY CONDITIONS It may only specify such other conditions as the responsible clinician and an AMHP agree are necessary or appropriate for the purpose of (a) ensuring that the patient receives medical treatment; (b) preventing risk of harm to the patient’s health or safety; (c) protecting other persons. If a community patient fails to comply with any of these additional conditions, ‘that failure may be taken into account for the purposes of exercising the power of recall.’ VARYING AND SUSPENDING CONDITIONS The conditions may be varied or suspended from time to time.
  11. 11. Remember … The conditions must not be so severe as to constitute a deprivation of liberty; Th e conditions must be proportionate and comply with Article 8.
  12. 12. Form CTO1 and the AMHP
  13. 13. Forward-dating orders‘25.28 If the responsible clinician andAMHP agree that the patient should bedischarged onto SCT, they shouldcomplete the relevant statutory formand send it to the hospital managers.The responsible clinician must specifyon the form the date that the communitytreatment order (CTO) is to be made.This date is the authority for SCT tobegin, and may be a short while after thedate on which the form is signed, toallow time for arrangements to be put inplace for the patient’s discharge.’
  14. 14. Form CTO1, Part 3
  15. 15. Definitions
  16. 16. DefinitionsThe definitions are important:(1) Only ‘the responsible clinician’ may make an order. Who is the responsible clinician?(2) The patient must be suffering from a ‘mental disorder’. What does this mean?(3) The patient’s mental disorder must be of a kind (‘a nature or degree’) which makes it appropriate for them to receive ‘medical treatment’. What sorts of professional help constitute ‘medical treatment’?(4) A CTO may only be made if ‘appropriate’ medical treatment is actually available to them. When is treatment ‘appropriate’?(5) After the CTO is made, in certain circumstances the patient may be recalled to ‘hospital’. What is a ‘hospital’? Medical treatment Mental Disorder Hospital
  17. 17. Who is the responsible clinician?“the responsible clinician” means – (a) in relation to a patient liable to be detained by virtue of an application for admission for assessment or an application for admission for treatment, or a community patient, the approved clinician with overall responsibility for the patient’s case; (b) in relation to a patient subject to guardianship, the approved clinician authorised by the responsible local social services authority to act (either generally or in any particular case or for any particular purpose) as the responsible clinician;
  18. 18. Meaning of ‘mental disorder’ 1983 Act 1983 Act as amendedA person may only be placed on one  Whatever the section, it is now onlyof the longer-term 6 month orders if necessary to show that the patienttwo doctors agree that s/he suffers suffers from a ‘mental disorder’.from: Mental illness, or  ‘Mental disorder’ means ‘any disorder Mental impairment, or or disability of mind.’ Severe mental impairment, or Psychopathic disorderBy section 1(3), no one may be dealt By section 1(3), no one may be dealtwith as mentally disordered by with as mentally disordered by reasonreason only of: only of: Promiscuity or other immoral  Dependence on alcohol or drugs. conduct Sexual deviancy Dependence on alcohol or drugs.
  19. 19. The learning disability exception This general definition of mental disorder is “learning subject to one exception: disability” means a “A person with learning disability shall not be state of arrested or considered by reason of that disability to be incomplete suffering from mental disorder for the purposes of sections 17A (making a CTO) and 17E development of (recalling a CTO patient to hospital).” mind which The purpose of this exception was to preserve includes significant the old position that a person with a learning impairment of disability may not be placed on one of the intelligence and longer-term/six month section unless their social functioning. ‘learning disability’ is associated with abnormally aggressive or seriously irresponsible conduct.
  20. 20. ‘Medical treatment’145.–(1 ) In this Act, unless the context otherwiserequires … “medical treatment” includes nursing,[OUT: and also includes care, habilitation andrehabilitation under medical supervision],psychological intervention and specialist mentalhealth habilitation, rehabilitation and care;145.–(4) Any reference in this Act to medicaltreatment, in relation to mental disorder, shall beconstrued as a reference to medical treatment thepurpose of which is to alleviate, or prevent aworsening of, the disorder or one or more of itssymptoms or manifestations.
  21. 21. Example• Mr Jones is receiving psychological intervention.• Ms Smith is being cared for and supervised by a social work member of the local CMHT.• No doctor is involved in their cases.• Both are receiving ‘medical treatment’ for the purposes of the Act.
  22. 22. ‘Appropriate’ medical treatment’145.—(1AB) References in this Act toappropriate medical treatment shall beconstrued in accordance with section 3(4) …3.—(4) In this Act, references to appropriatemedical treatment, in relation to a personsuffering from mental disorder, arereferences to medical treatment which isappropriate in his case, taking into accountthe nature and degree of the mental disorderand all other circumstances of his case.
  23. 23. ‘Appropriate medical treatment’6.11 The other circumstances of a patient’s case might include factors such as: the patient’s physical health …; any physical disabilities the patient has; the patient’s culture and ethnicity; the patient’s age; the patient’s gender, gender identity and sexual orientation; the location of the available treatment; the implications of the treatment for the patient’s family and social relationships, including their role as a parent; its implications for the patient’s education or work; and the consequences for the patient, and other people, if the patient does not receive the treatment available … e.g. a prison sentence.
  24. 24. But …..6.12 Medical treatment need not be the mostappropriate treatment that could ideally be madeavailable. Nor does it need to address everyaspect of the person’s disorder. But the medicaltreatment available at any time must be anappropriate response to the patient’s conditionand situation.
  25. 25. ‘Hospital’145.—(1) In this Act, unless the context otherwiserequires …. “hospital” means—a) any health service hospital within the meaning of the National Health Service Act 2006 or the National Health Service (Wales) Act 2006; andb) any accommodation provided by a local authority and used as a hospital by or on behalf of the Secretary of State under that Act; andc) any hospital as defined by section 206 of the National Health Service (Wales) Act 2006 which is vested in a Local Health Board;
  26. 26. ‘Health service hospital’For the purposes of the National Health Service Act 2006:“health service hospital” means a hospital vested in the Secretary of State forthe purposes of his functions under this Act or vested in a Primary Care Trust, anNHS trust or an NHS foundation trust“hospital” means—a) any institution for the reception and treatment of persons suffering from illness [which term includes mental disorder]b) any maternity home, andc) any institution for the reception and treatment of persons during convalescence or persons requiring medical rehabilitation, and includes clinics, dispensaries and out-patient departments maintained in connection with any such home or institution ...
  27. 27. Registered establishments “HOSPITAL WITHIN THE MEANING OF PART II OF THIS ACT”• By section 34(2), unless the Act expressly states otherwise, Part II of the Act — and, therefore, the CTO provisions — applies to ‘registered establishments’ as well as to hospitals, and any reference to a hospital in Part II ‘shall be construed accordingly’.• A ‘registered establishment’ is an establishment which is registered (under the Care Standards Act 2000) as an ‘independent hospital’ in which treatment or nursing (or both) are provided for persons liable to be detained under the Mental Health Act 1983.
  28. 28. Treatment outside hospital in the community
  29. 29. Normal rules: patients has capacity TREATMENT REQUIRES TWO THINGS SOAD CERTIFICATE AUTHORITY TO GIVE THEFOR SECTION 58 TYPE TREATMENT TREATMENTS The patient consents to the(Except during the first month treatment. after the CTO is made)
  30. 30. Normal rules: patients has capacity (2) WHEN A SOAD CERTIFICATE IS NOT REQUIRED  The medication is being given during the one month period beginning with the day on which the CTO was made; or  The treatment is ‘immediately necessary’ and the patient consents to it, i.e. there is authority to give it.Treatment is ‘immediately necessary’ in the same circumstances as section 62
  31. 31. ‘Immediately necessary’Treatment is ‘immediately necessary’ if one of the following conditionsap p l i e s : 1 The treatment is immediately necessary to save the patient’s life. 2 The treatment is not irreversible and its administration is immediately necessary to prevent a serious deterioration of the patient’s condition. 3 The treatment is not irreversible or hazardous, and its administration is immediately necessary to alleviate serious suffering by the patient. 4 The treatment is not irreversible or hazardous, and its administration is both immediately necessary and the minimum interference necessary to prevent the patient from behaving violently or being a danger to himself or to others.
  32. 32. Normal rules: patient lacks capacity TREATMENT REQUIRES TWO THINGS SOAD CERTIFICATE AUTHORITY TO GIVE THEFOR SECTION 58 TYPE TREATMENT TREATMENTS (1) An LPA donee or a Court of(Except during the first month Protection deputy has consented after the CTO is made) to the treatment; or (2) Giving the treatment is authorised under section 64D.
  33. 33. Section 64D (No capacity) THE TREATMENT WAS GIVEN BY THE APPROVED CLINICIAN IN CHARGE OF THE TREATMENT OR UNDER THAT PERSON’S DIRECTION. BEFORE GIVING THE TREATMENT, THAT CLINICIAN TOOK REASONABLE STEPS TO ESTABLISH WHETHER THE PATIENT LACKED CAPACITY TO CONSENT TO THE TREATMENT OR, IF THE PATIENT WAS AGED UNDER 16, WHETHER S/HE WAS COMPETENT TO CONSENT TO THE TREATMENT. WHEN GIVING THE TREATMENT, THAT CLINICIAN REASONABLY BELIEVED THAT THE PATIENT LACKED CAPACITY TO CONSENT TO IT OR, IF THE PATIENT WAS AGED UNDER 16, REASONABLY BELIEVED THAT S/HE WAS NOT COMPETENT TO CONSENT TO IT. [IN THE CASE OF A PATIENT AGED 18 OR OVER ONLY] THE TREATMENT DID NOT CONFLICT WITH AN ADVANCE DECISION WHICH S/HE WAS SATISFIED WAS VALID AND APPLICABLE, OR WITH A DECISION MADE BY A DONEE OR DEPUTY OR THE COURT OF PROTECTION. AND EITHER THAT CLINICIAN HAD NO REASON TO BELIEVE THAT THE PATIENT OBJECTED TO BEING GIVEN THE TREATMENT; OR IF S/HE HAD REASON TO BELIEVE THAT THE PATIENT OBJECTED TO BEING GIVEN IT, IT WAS NOT NECESSARY TO USE FORCE AGAINST THE PATIENT IN ORDER TO GIVE IT.
  34. 34. Normal rules: patient lacks capacity WHEN A SOAD CERTIFICATE IS NOT REQUIRED CAPACITY The medication is being given during the one month period beginning with the day on which the CTO was made; or The treatment is ‘immediately necessary’ and a donee or deputy, or the Court of Protection, has consented to it; or The conditions in section 64G for giving emergency treatment to a patient who lacks capacity are met.Treatment is ‘immediately necessary’ in the same circumstances as section 62
  35. 35. Emergency treatment (no capacity)1. The person ‘giving’ the treatment reasonably believes that the patient lacks capacity to consent to it (or is not competent to consent to it);2. The treatment is immediately necessary (see previous slide);3. Where it is necessary to use force in order to give the treatment— (a) the treatment needs to be given in order to prevent harm to the patient; and (b) the use of such force is a proportionate response to the likelihood of the patient’s suffering harm, and to the seriousness of that harm. Section 64G
  36. 36. Mental Capacity Act 2005 Do not be tempted to use section 5 of the Mental Capacity Act 2005 to supplement the rules in the MHA 1983 as to when a CTO patient who lacks capacity may be given treatment in the community. This is because section 28(1A) of the Mental Capacity Act 2005 provides that, ‘Section 5 [of the MCA] does not apply to an act to which section 64B of the Mental Health Act applies (treatment of community patients not recalled to hospital).’
  37. 37. SOAD consultations SOADs are required to consult two people (“statutory consultees”) before issuing certificates approving treatment. One of the statutory consultees must be a nurse; the other must not be either a nurse or a doctor. Both must have been professionally concerned with the patient’s medical treatment, and neither may be the clinician in charge of the proposed treatment or the responsible clinician (if the patient has one). SOADs must provide written reasons in support of their decisions to approve specific treatments for patients.
  38. 38. Suspending and varying conditions
  39. 39. Suspending and varying conditions SUSPENDING VARYING 25.42 Suspension of one  25.43 A variation of the or more of the conditions conditions might be may be appropriate to appropriate where the allow for a temporary patient’s treatment change in circumstances, needs or living for example, the patient’s circumstances have temporary absence or a changed. Any condition change in treatment no longer required regime. The responsible should be removed. clinician should record any decision to suspend conditions in the patient’s notes, with reasons. Code of Practice
  40. 40. Recalling the patient to hospital
  41. 41. Recalling the patient The responsible clinician may recall a community patient to hospital if in her/his opinion: (a) the patient requires medical treatment in hospital for his mental disorder; and (b) there would be a risk of harm to the health or safety of the patient or to other persons if the patient were not recalled to hospital for that purpose. The RC may also recall the patient if s/he fails to comply with a condition that s/he makes her/himself available for examination for the purpose of a renewal or consent report. The power of recall ‘shall be exercisable by notice in writing to the patient’.
  42. 42. The notice of recall 25.55 The responsible clinician must complete a written notice of recall to hospital, which is effective only when served on the patient ... 25.56 Once the recall notice has been served, the patient can, if necessary, be treated as absent without leave, and taken and conveyed to hospital … The time at which the notice is deemed to be served will vary according to the method of delivery. 25.57 It will not usually be appropriate to post a notice of recall to the patient … First class post should be used. The notice is deemed to be served on the second working day after posting, and it will be important to allow sufficient time for the patient to receive the notice before any action is taken to ensure compliance. 25.58 … if the patient is unavailable or simply refuses to accept the notice ... the notice should be delivered by hand to the patient’s usual or last known address. The notice is then deemed to be served (even though it may not actually be received by the patient) on the day after it is delivered – that is, the day (which does not have to be a working day) beginning immediately after midnight following delivery.
  43. 43. The effect of recall MAXIMUM DETENTION PERIOD OF 72 HOURS “When the patient arrives at hospital after recall, the clinical team will need to assess the patient’s condition, provide the necessary treatment and determine the next steps. A recalled patient may be transferred to another hospital” (Code, Para. 25.63). The patient must be released after 72 hours if by then s/he has not been released and nor has the community treatment order has been revoked.
  44. 44. Treatment during the recall period 1 2 3 Certificate requirement is Certificate requirement not met: As urgent met Apply section 58 treatmentThe Part 4A/CTO SOAD The treatment is authorised Pendingcertificate expressly under section 58, e.g. under an compliance withprovides that the treatment old in-patient consent to section 58,is appropriate and may be treatment certificate. discontinuance ofgiven following recall, and the treatment, orany conditions attached to treatment plan,the certificate are satisfied. would cause serious suffering to the patient.(Provided this is the case, the The patient is treated as having beenlisted treatment may also be continuously detained during thegiven following revocation, section 3/37 and CTO period.pending compliance with section58) Check for withdrawal of consent; certificate time limits; loss of capacity; and change of approved clinician.
  45. 45. Alternatives to recall Admission under section 2: does not revoke the CTO Informal admission A f re sh se c t i o n 3 a p p l i c a t i o n Discharge the CTO as unworkable
  46. 46. Revoking the CTO
  47. 47. Revocation EXAMINATION AND REVOCATION OF THE CTO Where a community patient has been recalled, the RC may revoke the community treatment order if s/he is of the opinion that the section 3 conditions are satisfied and an AMHP agrees with that opinion and that it is appropriate to revoke the order. Where a community treatment order is revoked, the hospital managers must refer the patient’s case to a Mental Health Review Tribunal as soon as possible after the order is revoked.
  48. 48. Revoking the CTO “If the patient requires in-patient treatment for longer than 72 hours after arrival at the hospital, the responsible clinician should CT O consider revoking the CTO. The effect of revoking the CTO is that the patient will again be detained under the powers of the Act” (Code, Para. 25.65). The effect of revoking the CTO is that the managers have the same power to detain the patient under s.6(2) of the 1983 Act as if s/he had never been discharged; and for section 20 renewal purposes the patient is deemed to have been admitted under Section 3/37 section 3 on the day that the order is revoked.
  49. 49. Renewal and discharge
  50. 50. Renewing the orderUnless renewed, the order expires after six months after the day on which it wasmade. The first renewal is for another period of six months. Subsequent renewalsare for a year at a time.The order is renewed if: a) the responsible clinician examines the patient during the final two months of the order and certifies that it appears to her/him that the renewal conditions are satisfied; and b) A statement has been made in writing by an AMHP, stating that it appears to her/him that the renewal conditions are satisfied, and that it is appropriate to extend the community treatment period.When the responsible clinician determines whether s/he should continue to be ableto exercise the power to recall the patient to hospital, s/he must ’consider, havingregard to the patient’s history of mental disorder and any other relevant factors,what risk there would be of a deterioration of the patient’s condition if he were tocontinue not to be detained in a hospital (as a result, for example, of his refusing orneglecting to receive the medical treatment he requires for his mental disorder)’:See s.20A(7) Section 20A
  51. 51. Discharging CTOs WHO CAN DISCHARGE BARRING ORDERS Mental Health Tribunal  The nearest relative must give 72 hours notice of their Hospital managers intention to discharge the CTO. Nearest relative (Part 2 p a t i e n t s)  During that period, the responsible clinician can Responsible clinician bar discharge if of the opinion that the patient would, if discharged, ‘be likely to act in a manner dangerous to other persons or to himself.’
  52. 52. Mental Health Tribunals
  53. 53. CTO tribunals72 Powers of tribunals(1) Where application is made to a Mental Health Review Tribunal by or in respect of a patientwho is … a community patient, the tribunal may in any case direct that the patient bedischarged, and … (c) the tribunal shall direct the discharge of a community patient if they arenot satisfied –(i) that he is then suffering from mental disorder or mental disorder of a nature or degree whichmakes it appropriate for him to receive medical treatment; or(ii) that it is necessary for his health or safety or for the protection of other persons that heshould receive such treatment; or(iii) that it is necessary that the responsible clinician should be able to exercise the power undersection 17E(1) to recall the patient to hospital; or(iv) that appropriate medical treatment is available for him; or(v) [Where the tribunal is taking place because a barring order has been issued], that thepatient, if discharged, would be likely to act in a manner dangerous to other persons or tohimself.(1A) In determining whether the criterion in subsection (1)(c)(iii) above is met, the responsibleclinician (!) shall, in particular, consider, having regard to the patient’s history of mentaldisorder and any other relevant factors, what risk there would be of a deterioration of thepatient’s condition if he were to continue not to be detained in a hospital (as a result, forexample, of his refusing or neglecting to receive the medical treatment he requires for hismental disorder).
  54. 54. Section 3 tribunals72 Powers of tribunals(3A) Subsection (1) above does not require a tribunal to direct thedischarge of a patient just because they think it might be appropriate forthe patient to be discharged (subject to the possibility of recall) under acommunity treatment order; and a tribunal—a) may recommend that the responsible clinician consider whether to make a community treatment order; andb) may (but need not) further consider the patient’s case if the responsible clinician does not make an order.
  55. 55. Section 117 after-care
  56. 56. The duty under section 117‘It shall be the duty of the Primary Care Trust orLocal Health Board and of the local social servicesauthority to provide, in co-operation with relevantvoluntary agencies, after-care services for anyperson to whom this section applies until such timeas the Primary Care Trust or Local Health Boardand the local social services authority are satisfiedthat the person concerned is no longer in need ofsuch services; but they shall not be so satisfied inthe case of a community patient while he remainssuch a patient.’
  57. 57. Care Quality Commission
  58. 58. CQC’s remit (a) to visit and interview in private patients detained under this Act in hospitals and registered establishments and community patients in hospitals and establishments of any description and (if access is granted) other places; and (b) to investigate— (i) any complaint made by a person in respect of a matter that occurred while he was detained under this Act in, or recalled under section 17E above to, a hospital or registered establishment and which he considers has not been satisfactorily dealt with by the managers of that hospital or registered establishment; and (ii) any other complaint as to the exercise of the powers or the discharge of the duties conferred or imposed by this Act in respect of a person who is or has been so detained or is or has been a community patient.
  59. 59. IMHAs
  60. 60. Independent Mental Health Advocates• From April 2009, advocacy services must be available to patients who are subject to community treatment orders, guardianship or detention (except those held under sections 4, 5, 135 or 136).• Patients who are entitled to these advocacy services are called ‘qualifying patients’.• The hospital managers must inform a qualifying patient that advocacy services are available, and inform her/him as to how they can obtain that help.• An IMHA must comply with any reasonable request to visit and interview a qualifying patient which is made by an AMHP, or by their nearest relative or responsible clinician. However, the patient may decline the help.
  61. 61. An IMHA’s functionsThe help available to qualifying patients from IMHAs must includehelping the patient to obtain and understand information about:a) the Mental Health Act section to which s/he is subject;b) any conditions or restrictions to which s/he is subject under the 1983 Act, e.g. conditions of leave, conditions of residence, etc;c) what (if any) medical treatment is being given to them, or is being proposed or discussed, why, and the authority under which it is being or may be given;d) the legal requirements which apply, or will apply, in connection with such treatment.e) any rights which may be exercised under this Act by or in relation to them.
  62. 62. Legal representation?• The help available from advocates must also include ‘help (by way of representation or otherwise)’ in ‘exercising any rights they have under the Act,’ including therefore hospital managers hearings and mental health tribunals.• However, patients remain entitled to free legal aid from a solicitor for tribunals and, according to the Department of Health, IMHAs ‘are not expected’ to take over the role of representing patients at tribunals. Similarly, paragraph 20.3 of the Code of Practice states that, ‘Independent mental health advocacy services do not replace any other advocacy and support services that are available to patients, but are intended to operate in conjunction with those services.’
  63. 63. Visiting and access to records• In order to provide the patient with help, an IMHA may visit and interview the patient in private, and also visit and interview any person who is professionally concerned with their medical treatment.• The IMHA may also require the production of and inspect any records which relate to the patient’s detention or treatment or to after-care services provided under section 117, including hospital and social services records. There are, however, some caveats to this right:• If the patient has capacity, an IMHA may not see their records unless the patient consents to this.• Where the patient lacks capacity, the IMHA may only see the relevant records if it would not conflict with a decision made by a Mental Capacity Act donee or deputy, and the recorder-holder considers that the records may be relevant to the help which is to be provided that their inspection is appropriate.
  64. 64. The Code of Practice
  65. 65. Code of Practice s.118—The Secretary of State shall prepare, and from time to time revise, a code of practice … for the guidance of … (2A) The code shall include a statement of the principles which the Secretary of State thinks should inform decisions under this Act. (2D) In performing functions under this Act [mental health professionals, hospital managers and staff] shall have regard to the code.
  66. 66. Purpose principle Decisions under the Act must be taken with a view to minimising the undesirable effects of mental disorder, by maximising the safety and wellbeing (mental and physical) of patients, promoting their recovery and protecting other people from harm.
  67. 67. Least restriction principle People taking action without a patient’s consent must attempt to keep to a minimum the restrictions they impose on the patient’s liberty, having regard to the purpose for which the restrictions are imposed.
  68. 68. Respect principle People taking decisions under the Act must recognise and respect the diverse needs, values and circumstances of each patient, including their race, religion, culture, gender, age, sexual orientation and any disability. They must consider the patient’s views, wishes and feelings (whether expressed at the time or in advance), so far as they are reasonably ascertainable, and follow those wishes wherever practicable and consistent with the purpose of the decision. There must be no unlawful discrimination.
  69. 69. Participation principle Patients must be given the opportunity to be involved, as far as is practicable in the circumstances, in planning, developing and reviewing their own treatment and care to help ensure that it is delivered in a way that is as appropriate and effective for them as possible. The involvement of carers, family members and other people who have an interest in the patient’s welfare should be encouraged (unless there are particular reasons to the contrary) and their views taken seriously.
  70. 70. Effectiveness, efficiency andequity principle People taking decisions under the Act must seek to use the resources available to them and to patients in th e most effective, efficient and equitable way, to meet the needs of patients and achieve the purpose for which the decision was taken.
  71. 71. Using the principles All decisions must, of course, be lawful and informed by good professional practice. Lawfulness necessarily includes compliance with the Human Rights Act 1998. The principles inform decisions, they do not determine them. Although all the principles must inform every decision made under the Act, the weight given to each principle in reaching a particular decision will depend on the context. That is not to say that in making a decision any of the principles should be disregarded. It is rather that the principles as a whole need to be balanced in different ways according to the particular circumstances of each individual decision.
  72. 72. Weighing up the alternativesCTOs, guardianship, section 17
  73. 73. CTO or section 17 Leave?
  74. 74. CTO or guardianship?
  75. 75. DOLs and CTOs
  76. 76. Is the patient eligible for DOLs? CTO PATIENT IN A CARE HOME1. Not if accommodating the person in the care home under DOLs would conflict with a requirement imposed on them under their CTO. CTO PATIENT IN HOSPITAL1. Not if the care or treatment in question consists wholly or partly of medical treatment for mental disorder.2. Not if accommodating the person in the hospital under DOLs would conflict with a requirement imposed on them under their CTO.3. Not if the person meets the criteria for being detained under section 2 or 3 of the Mental Health Act 1983 and they object to being in the hospital.

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