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4. CHAPTER FOUR - GUIDANCE WHILE IN HOSPITAL
4.1 This chapter deals with the role of the Responsible Medical Officer, the importance of detailed reporting, risk management and provides guidance on a range of other issues which may affect restricted patients while they are detained in hospital.
Role of the Responsible Medical Officer
4.2 The Responsible Medical Officer ( RMO) has the primary responsibility for the patient's care and treatment. The RMO is responsible for planning this with due regard to public safety and ensuring that it is implemented within the confines of his responsibility for that patient and the legislative framework. The RMO must work in close co-operation with all others within the hospital involved with the care of the patient and with the Scottish Executive Health Department ( SEHD).
4.3 SEHD would usually expect an RMO to be a Consultant Psychiatrist or Consultant Forensic Psychiatrist. However, we appreciate that in some circumstances, i.e. annual leave, it may be necessary for a Specialist Registrar (SpR) to act as RMO in the Consultant's absence. In such cases, the Consultant or Medical Director must inform SEHD in writing prior to any period where an SpR will act as RMO.
4.4 Paragraph 2.6 of this Memorandum sets out the effect of special restrictions on a patient to whom these apply and outlines the responsibilities of Scottish Ministers and the Mental Health Tribunal, under the 2003 Act, in relation to that patient's care. It is the responsibility of the RMO to recommend to the Psychiatric Adviser any action to be considered by Scottish Ministers or the Mental Health Tribunal.
4.5 The RMO must ensure, in consultation with other relevant parties within the hospital, that any incidents or other unusual issues relating to the patient are reported to the SEHD immediately, and that the notifications and routine reports mentioned in the following paragraphs are submitted timeously. More detail on this is contained in Chapter 6.
reports on restricted patientsRMO
4.6 Under sections 182(2) and 183(2) of the 2003 Act for compulsion order/restriction order patients, and section 206(2) and 207(2) for those patients subject to a transfer for treatment direction or hospital direction, the RMO must, in the 2 month period ending with the anniversary of the date on which the order was made, examine and report on the patient to Scottish Ministers. The report must contain the information outlined in section 183(3) or sections 206(3) and 207(3) of the 2003 Act, in addition to any particulars which Scottish Ministers may require ( see Annex B1 for guidance). These reports should be accompanied by completed form CORO1 or HD1 ( see Annex J). While the RMO should involve other medical staff in his care team in preparation of any reports, the RMO must take responsibility for all reports to the SEHD on a restricted patient. Reports not prepared by the RMO must be countersigned by the RMO to indicate agreement with the opinion given.
Admission report
4.7 Scottish Ministers require a report to be provided on each patient admitted to hospital (whether from court or on transfer from prison or another hospital) within 3 months of admission and annually thereafter (from the date of admission as a restricted patient). A copy of the Part 9 Care Plan should accompany this report and any subsequent annual report. For restricted patients admitted to the State Hospital, an admission history is routinely provided after the patient has been in hospital for 6 weeks. This may form part of the patient's 3-monthly report following admission, provided that there is a brief update on the patient's current mental state.
State Hospital intermediate and annual review reports
4.8 While there is no statutory requirement for such reports to be provided to Scottish Ministers, it is considered good practice for an RMO to copy these reports, as they relate to restricted patients, to the Psychiatric Adviser.
Annual reports
4.9 Scottish Ministers require that RMOs should prepare and submit a report on each restricted patient annually on the anniversary of the date they received their hospital disposal or were admitted to hospital under a transfer for treatment direction. The SEHD will issue a letter asking the RMO for an annual report on the appointed date. The report must be signed by the patient's RMO. In preparing reports, the RMO is expected to take into account the views of the multidisciplinary team caring for the patient, and in particular the views of the mental health officer. The annual report should be accompanied by form CORO1 for those patients on a compulsion order and restriction order or form HD1 for those patients subject to a hospital direction or transfer for treatment direction.
Content of reports
4.10 Each report (admission, 3 month, annual), in addition to providing background information on the patient at this stage, must provide the RMO's opinion of the patient's current mental state and detainability under the mental health legislation at the time of making the report. (Psychiatrists will be familiar with these tests as they are the admission criteria set out in section 182(3)(b) of the 2003 Act.) Each report must also contain the patient's CHI number. For further details of the information to include in the report please see the guidance offered in paragraph 4.6.
Guidance on reporting on patient's mental state and detainability
4.11 Section 182(3)(b) and (4) and section 183 of the 2003 Act outline the factors an RMO must take into account when assessing the continuing liability to detention of any patient subject to a compulsion order and restriction order.
4.12 The RMO must provide their present diagnosis for the patient including whether they consider that the patient suffers from a mental disorder. In the 2003 Act, mental disorder is defined as:
- mental illness;
- personality disorder; or
- learning disability
4.13 When preparing a report to Scottish Ministers, the RMO must meet the requirements of section 182(3) of the 2003 Act. Those requirements are to carry out a medical examination of the patient or to arrange for an approved medical practitioner to carry out an examination, and to consult with the mental health officer. When carrying out the examination, the RMO has to consider whether the conditions mentioned in section 182(4) of the 2003 Act continue to apply. These conditions are:
(a) that the patient has a mental disorder;
(b) that medical treatment which would be likely to -
(i) prevent the mental disorder worsening; or
(ii) alleviate any of the symptoms or effects of the disorder,
is available for the patient; and
(c) that if the patient were not provided with such medical treatment there would be a significant risk -
(i) to the health, safety and welfare of the patient; or
(ii) to the safety of any other person.
4.14 The RMO must then go on to consider -
(i) whether, as a result of the patient's mental disorder, it is necessary, in order to protect any other person from serious harm, for the patient to be detained in hospital, whether or not for medical treatment;
(ii) whether it continues to be necessary for the patient to be subject to the compulsion order; and
(iii) whether it continues to be necessary for the patient to be subject to the restriction order.
4.15 When considering "serious harm" it is relevant to consider the environment into which the patient might be transferred. This will involve an assessment of the likelihood of the patient re-offending and the likely nature of any such re-offending. This should be informed, where appropriate, by a full multidisciplinary assessment of potential risks. The RMO should take into account all relevant circumstances, including the patient's past history. Different considerations may apply depending on whether he is being released into the community or back to prison.
4.16 If the patient is a transferred prisoner the RMO should also consider whether the patient should be returned to prison establishment. Scottish Ministers are not required to transfer back to prison anyone who is suffering from a mental disorder, where the effect of such is that it is necessary to protect the public from serious harm that the patient remain in hospital.
4.17 Provision of these reports is the main route through which the SEHD obtains current information on a restricted patient. It is therefore important that the RMO ensures that all relevant information on the patient is provided. This should include any information which might provide further background detail on a patient which was not previously available or has become clearer or more detailed with time. The RMO may at any time provide information to SEHD on a patient and must in any case provide reports on any serious incidents which affect a patient at the time of their occurrence. ( See Chapter 6).
4.18 If, in the interval between annual reports, the RMO considers that the patient's mental condition has changed in such a way that Scottish Ministers should be informed, they should take the initiative in making any additional report or recommendation which they consider appropriate. In assessing proposals regarding restricted patients, the SEHD looks for evidence of both appropriate risk assessment and effective risk management. See paragraphs 4.20 to 4.22, Chapter 5 and Annex B2 for further information on risk assessment. This will enable Scottish Ministers to consider what action, if any, needs to be taken in the light of the RMO's current view on the patient.
4.19 Any other unusual factor, for example, if the hospital receives information about any form of application to the Mental Health Tribunal, appeal to the Courts or further charges brought against the patient, should be notified at once to the SEHD.
Risk Assessment
4.20 The annual reports to Scottish Ministers represent the basic information which the RMO is required by the legislation to provide to Ministers on a restricted patient. However, in order to manage the patient's case and to give approval for suspension of detention, transfers, etc, it is very helpful if the SEHD is able to build up fuller details of the patient and to be kept updated on their progress in hospital.
4.21 Scottish Ministers' principal aims are to provide for the protection and security of the public and to secure individuals' rights and freedoms under the law. Ministers are therefore responsible for ensuring that risk to the public is taken into account fully in all decisions which involve a restricted patient. In order to do this, considerable detail is required about the patient, including both present circumstances and history. Officials in SEHD welcome risk assessments prepared using standardised clinical risk assessment tools such as HCR-20 or RAMAS but recognise that these tools are not always available. In such circumstances SEHD are happy to accept the information listed at Annex B2, as part of a systemic approach to risk assessment . It should be recognised that the risk that a patient may present can vary over time and with the patient's condition. The SEHD will reassess the risk that a patient might present at appropriate points and, in particular, before giving approval for any suspension of detention or transfer. It would, therefore, be appropriate for the RMO to provide full, multidisciplinary risk assessment information to the SEHD at significant points in a patient's care.
4.22 When the RMO provides additional information, this ensures that the SEHD is fully aware of all relevant issues and allows the development of a full picture of the patient. This in turn assists the management of the case. In particular, it can help ensure that when requests, such as for suspension of detention, are made by the RMO, the SEHD has readily available most, if not all, of the necessary information required to enable it to make a decision. If the Department needs to seek additional information from the RMO before making a decision, this inevitably leads to delay in approving the request and might, on occasion, mean that the outing has to be postponed until the necessary information has been obtained and assessed.
4.23 While it is for the RMO to consider how to provide this information, in the past the SEHD has found the following reports useful in maintaining current records on the patient and informing decisions:
- periodic nursing reviews;
- periodic security reviews (for State Hospital patients);
- other reports by professionals the patient comes into contact with in the hospital, such as occupational therapy;
- psychology reports;
- care plan objectives and suspension of detention programmes
- social work reports on patient and family and other contacts*; and
- victim factors.
(* It should be noted that where a patient is visiting the home of a relative or friend for the first time, a social work report will be required prior to the visit being authorised.)
Drug and alcohol misuse while in hospital
4.24 In the case of many restricted patients, their mental illness may be adversely affected by drug and alcohol misuse and in some cases may have led, albeit indirectly, to their admission to hospital. Misuse of alcohol and/or drugs either while in hospital or while on suspension of detention can have a detrimental effect on a patient's rehabilitation and can increase the risks to staff and other patients within the hospital. The RMO should ensure that all incidents of this type are reported to the Psychiatric Adviser along with details of the action taken. Circular NHSHDL (2002) 41 provides guidance on safe care approaches for staff, patients and visitors and on the management of those with a drug misuse or alcohol problem in mental health care settings.
Marriage
4.25 Scottish Ministers have no specific power to agree to or withhold permission for restricted patients to marry. In terms of the Marriage (Scotland) Act 1977 the Registrar is required to consider any objections to a marriage under section 5 of the 1977 Act and if satisfied that the objections are valid, the marriage cannot proceed. One of the grounds forming a legal impediment to a marriage is set out at section 5(4)(d) and states that "one or both of the parties is or are incapable of understanding the nature of a marriage ceremony or of consenting to marriage".
4.26 While ultimately it is for the Registrar to satisfy himself on this point, there is an onus on Scottish Ministers if they have any doubts that this condition is satisfied to communicate these to the Registrar in writing as required in the Act. It is, therefore, important that we are informed of any impending marriage plans to allow the Psychiatric Adviser and the RMO to provide their view on whether consent and understanding is likely to be clearly there. The fact that the patients are detainable in terms of the 2003 Act does not necessarily mean they are incapable of understanding the nature of marriage or of giving appropriate consent.
4.27 In the case of a marriage ceremony within a hospital, it will be for the managers of that hospital to consider whether this is appropriate. In the case of a marriage ceremony out with the hospital, Scottish Ministers' consent will be required for suspension of detention for inpatients.
Withholding correspondence
4.28 Section 281 of the 2003 Act sets out the statutory powers of hospital managers in withholding mail. Mail may be withheld:
(a) if the addressee has requested that communications addressed to him by the patient should be withheld; or
(b) if the managers of the hospital consider that the correspondence is likely -
(i) to cause distress to the person in question or any other person who is not on the staff of the hospital; or
(ii) to cause danger to any person.
Any request for the purposes of paragraph (a) of this subsection requires to be made by a notice in writing to the managers of the hospital, the RMO or Scottish Ministers. This provision applies to all patients detained in hospital. Sections 281 to 283 of the 2003 Act set out further information about when the power to withhold mail does not apply, when managers of the hospital may open and inspect any postal package, the functions of the managers of the hospital and the duty to notify the Mental Welfare Commission.
Requests from the media to interview restricted patients
4.29 The decision on whether it is appropriate for a restricted patient to be interviewed by the media rests with the RMO and the managers of the hospital. The RMO will have to consider whether it is clinically appropriate for the patient to take part in the programme and address the questions of the patient's competency and appropriateness of the interview. RMOs should clearly record their reasons for their conclusions and a copy of this should be sent to the SEHD.
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