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CHAPTER ELEVEN - CONDITIONAL DISCHARGE
Introduction
11.1 The Mental Health Tribunal are empowered to order the conditional discharge of a patient who no longer requires to be detained in hospital for treatment or for the protection of others and to impose such conditions as it sees fit. This chapter may be subject to change as a result of recommendations contained in the Mental Welfare Commission's report following the case of a patient on conditional discharge who killed. The report is not expected until the end of the year at the earliest.
11.2 In general, a restricted patient's discharge from hospital is subject to certain conditions, the exception being those restricted patients who are also life sentence prisoners. Please refer to Chapter 7 for guidance on these patients. The conditions usually imposed are those of residence at a stated address, supervision by a social worker and psychiatrist. However, additional conditions may be recommended either for the protection of the public or of the patient. Under the 2003 Act, a recommendation may be made to Scottish Ministers to vary these conditions at any time.
11.3 The purpose of formal supervision resulting from conditional discharge is to protect the public from further serious harm in two ways: firstly, by assisting the patient's successful reintegration into the community after what may have been a long period of detention in hospital under conditions of security; and secondly, by closely monitoring the patient's mental health for any perceived increase in the risk of danger to the public so that steps can be taken to assist the patient and protect the public. Conditional discharge also allows a period of assessment of the patient in the community before a final decision is taken on whether to remove the control imposed by the restriction order by means of an absolute discharge. It is important to stress the need for the multidisciplinary team to work closely to ensure that effective and thorough pre-discharge planning takes place and that each agency is aware of its respective procedures and protocols.
When Conditional Discharge might be appropriate
11.4 On admission of a restricted patient to hospital, the RMO will, together with the rest of the multi-disciplinary clinical team, seek not only to treat the patient's mental disorder but to understand the relationship, if any, between the disorder and the patient's behaviour. The aim will be to understand what led to the dangerous behaviour which resulted in the patient's detention and, as the mental disorder is treated in hospital, to assess the extent to which that treatment has reduced the risk of the patient behaving in a dangerous manner if returned to the community.
11.5 In some cases, this period of assessment and treatment may take several years. Only when the patient's condition has so improved that the level of risk to the public is reduced to the extent that detention in hospital is no longer considered necessary, should the RMO recommend the patient's conditional discharge. The Scottish Executive Health Department ( SEHD) Psychiatric Adviser would usually assess the patient when plans for discharge are well underway and flag up to the RMO any issues which may need to be addressed. When the RMO considers it appropriate, he should make a recommendation to Scottish Ministers, who will then automatically refer the case to the Mental Health Tribunal. It should be noted that the Mental Health Tribunal has the power to order a "deferred conditional discharge", which is a provisional decision and is likely to be used when a full care package is not yet in place.
What information is required?
11.6 Further details of the type of information required are contained in Annex D. It will be for the Mental Health Tribunal to determine the sufficiency of evidence in each case.
How is it achieved?
11.7 The clinical team in the detaining hospital will begin preparations for a patient's conditional discharge before authority for discharge is sought. These preparations include the patient's personal preparation for life outside the hospital, consideration and choice of suitable accommodation, employment or other daytime occupation and identification of a social work supervisor and a supervising consultant psychiatrist. The Scottish Executive will alert the Director of Social Work for the receiving local authority area as soon as pre-discharge planning begins, copying the letter to the RMO. The Director will then identify a social work supervisor following consultation with the RMO. In all cases, it is recommended that the social work supervisor is a mental health officer. (A mental health officer will generally be a qualified and experienced social worker who has undergone added accredited training in mental disorder and mental health law.) In some cases, particularly if the patient has a history of offending behaviour or a diagnosis of personality disorder it is recommended that the social worker has forensic training and experience.
11.8 The supervisors should ensure that the patient has adequate support and monitoring to make a successful transition to life in the community. They should ensure that the overall approach they adopt is based on the principles of the Care Programme Approach ( CPA). It assumes that use of the CPA is standard practice for all patients who have required treatment in secure conditions and who require continuing support to minimise risk. The CPA care plan forms the basis for discharge, through-care and aftercare arrangements and specifies individual and agency responsibilities. The arrangements for future contact with the patient's supervisors should be discussed, and the patient should be assured that his supervisors are there to help. The patient should be advised how to get in touch with his supervisors should any difficulty arise between the times of formal visits.
11.9 The 1999 policy statement on health, social work and related services for mentally disordered offenders in Scotland set out guidance for the organisation of safe care and accommodation, supported by joint working between all relevant agencies. The policy and principles are well understood by the Partnership Agencies. A care pathway document published in 2001 provided a planning and audit tool on which to base service re-design or measure progress towards overall objectives. The guidance promotes multi-agency and multi-disciplinary working to ensure services provide quality care and rehabilitation that responds to individual needs, under conditions of appropriate levels of security and with regard for public safety. Guidance published in 2000 on the management and reduction of risk in mental health care settings generally also highlights the factors to be taken into account when considering patient, staff and public safety and offers advice on a range of key issues and approaches including procedures to review critical incidents.
11.10 In addition, an amendment to the Management of Offenders Bill, which comes into force in spring 2006, provides a robust statutory framework for ensuring that justice and health work in partnership in providing services to those deemed to pose a continuing risk to the public. The amendment offers an opportunity to review and update the current general policy for integrated care management in respect of mentally disordered offenders. A sub-group of the Forensic Mental Health Managed Care Network will take forward the revision of the care programme approach guidance.
Pre-discharge procedures
11.11 As outlined in 11.7 above, the clinical team in the detaining hospital must consider a number of issues when making preparations for a patient's conditional discharge. However, prior to identifying such things as suitable accommodation, employment or other day-time occupation, the multidisciplinary team must consider where they intend to discharge the patient. In some cases there may be reasons why the patient should be discharged out of the area in which the hospital is located and, in such cases, the multidisciplinary team must make a thorough assessment of all of the factors involved. These might include:
- support from the patient's family and friends, if appropriate, and whether this would be available out of area;
- the patient's care needs and whether an appropriate package and care team, knowledgeable in the needs of the patient, could be organised out of area;
- the views and location of the victim and/or victim's family;
- the views of the patient on the resettlement plan and their attitude to moving to a new area;
- is such a resettlement in the best interests of the patient, e.g. because of risk to or from the victim or because of a detrimental influence from peers who may lead the patient astray?;
- what are the risks of a change of area and care at such a vulnerable stage in the patient's rehabilitation and do these outweigh the benefits of such a move?;
- possible adverse publicity.
In summary, the rights and wishes of the patient have to be balanced against those of the victim with due consideration being given to effect of the added complexities of an out of area discharge and change of multidisciplinary team at a vulnerable transition in the patient's care. Where the clinical team are in any doubt, they may seek advice from the Psychiatric Adviser or other officials at the SEHD.
11.12 A carefully thought out programme of suspension of detention will also form part of the essential pre-discharge procedures. Overnight stays in the patient's identified accommodation are a key part of the programme and will enable the clinical team to appropriately assess how well the patient is adapting to their new lifestyle. SEHD recommend that a patient complete at least 4 months of overnight stays building from one night per week to the maximum of four nights per week on monthly increments. In exceptional circumstances it may be possible to extend this further.
11.13 As soon as the prospective social work supervisor and the prospective supervising psychiatrist are known, they should discuss the patient's after-care and supervision arrangements. A care programme meeting should be arranged at least three months prior to the proposed discharge date and the patient placed on the Care Programme Approach ( CPA). In areas where CPA does not exist, a multidisciplinary team will need to be set up based on the principles of the CPA and should meet regularly both before and after the patient is discharged. These discussions are important both as a means of combining hospital and community expertise in the setting up of practical arrangements most suited to the patient and also in enabling the prospective supervisors to familiarise themselves with the patient before discharge. The multidisciplinary team should consider, where appropriate, including representatives from the housing association or local council housing department, or the police in the care planning process and ensure that copies of the CPA or multidisciplinary team meeting minutes are copied to the Psychiatric Adviser for information.
11.14 The supervising psychiatrist must visit the hospital at least once to meet the patient before discharge. Ideally, the supervising social worker will also visit the patient at least once before discharge. In addition, the supervising psychiatrist should peruse all the patient's notes and make their own assessment and take part in at least one multi-disciplinary case conference. By doing so, they will be able to discuss the case with the RMO and the staff of all disciplines who know the patient. On this visit contact must also be made with the social work supervisor. If it should happen that the supervising psychiatrist is not invited by the discharging hospital to take part in pre-discharge discussions and preparations, the supervising psychiatrist should ask, in the first place directly, for a suitable contact with the hospital multidisciplinary team. In the unlikely event of no response (or of an inadequate response), officials in the SEHD may be able to help.
Provision of written information by the discharging hospital
11.15 In addition to the pre-discharge contact recommended in paragraph 11.14, it is essential that the supervising psychiatrist and social worker should receive, as early as possible before discharge, detailed written information about the patient which can be retained for reference.
11.16 Discharging hospitals are advised that the full package of information provided to the supervising psychiatrist and social work supervisor for retention should cover the following aspects of the case:
- a pen-picture of the patient including his diagnosis and current mental state, present medication and reported effects and any side-effects;
- admission, social and medical history including any use of drugs and alcohol;
- psychiatric history;
- criminological history including its relationship to illness and other problem areas and a detailed note of the index offence* (if the patient is a sex offender, it should refer to his statutory requirement to register with the police following discharge);
- summary of progress in hospital;
- a report on present home circumstances;
- a risk assessment and management plan, including any warning signs which might indicate a relapse of his mental state or a repetition of offending behaviour together with the time lapse in which this could occur; and
- supervision and after-care arrangements which the hospital considers both appropriate and inappropriate in the particular case. (This could be supplemented by a copy of the CPA minutes or community care plan.)
* Where there are difficulties in obtaining details of the index offence, e.g. summary of court proceedings, the RMO should contact officials in the SEHD who may be able to assist in obtaining this information.
11.17 The supervising psychiatrist should receive this information from the discharging hospital before agreeing to accept the patient into his care and should inform SEHD officials if this information is not received within a reasonable time to enable them to assist in obtaining this necessary information.
11.18 In addition, the discharging hospital should provide details of the circumstances of the offence which led to the patient's admission to hospital and of the legal authority for that admission. Again if this information is not received, SEHD officials should, if notified, be able to assist in obtaining this.
Conditions of Discharge
11.19 The conditions of discharge may be varied, if necessary, from time to time. Should the supervisors wish to recommend a change in any of the formal conditions of discharge, e.g. the patient's address, they should make a recommendation to Scottish Ministers. Examples of specific conditions of discharge are:
- address;
- compliance with medication;
- regular psychiatric and social work supervision;
- victim issues;
- drug/alcohol testing; and
- psychological interventions.
This list is by no means exhaustive. Conditions are designed to meet the needs and manage the risks posed by individual patients. A patient may make an application to the Mental Health Tribunal to vary their conditions of discharge or they may appeal to the Tribunal against any variation in their conditions by Scottish Ministers.
Reporting
11.20 In addition to the supervising psychiatrist and social work supervisor, the Community Psychiatric Nurse ( CPN) may also be asked to provide reports on a patient's progress in the community. CPNs often form a key part of the multidisciplinary team and have a good knowledge of the patient. All supervisors will be asked to complete report forms at specified intervals, initially on a monthly basis (see specimen forms at Appendices 1 and 2 but should naturally take the initiative in contacting the SEHD quickly should the patient be involved in any unusual or serious incidents and or should the patient's mental condition deteriorate sufficiently to give cause for concern. When completing reports supervisors should consider the following, although not exhaustive, list of issues:
- any change in mental state;
- any concerning behaviour;
- failure to attend appointments with supervisors or other members of the multidisciplinary team;
- non-compliance with medication or proposed change to medication;
- abuse of drugs/alcohol;
- any change of address; and
- any changes to the level of supervision/support or other aspects of the care plan.
11.21 Besides reporting to Scottish Ministers on a regular basis, the two supervisors should keep in touch with each other (and other social care agents in the community) about the patient. The psychiatric supervisor will be required to provide annually a report on the patient's condition and progress, i.e. in addition to supplying the more frequent reports mentioned earlier. It is expected that the patient will remain on the Care Programme Approach for the duration of their conditional discharge.
11.22 Conditions of discharge must be stringently adhered to by the patient and monitored closely by the supervising team. In the event of a breach of any of the conditions of discharge, this should trigger automatically formal consideration or whether recall is appropriate. This might best be carried out in a Care Programme Approach setting or similar. If recall is not considered to be appropriate, the justification for not recalling the patient and what steps the team are taking to monitor the patient following the breach must be clearly set out and reported to officials in SEHD immediately.
Right of Appeal
11.23 When the Mental Health Tribunal orders conditional discharge they will advise patients of their appeal rights. Patients should continue to be reminded of these rights, and of their right to approach the Mental Welfare Commission on any aspects of their care about which they might feel aggrieved. In addition, each patient's case will automatically be referred to the Mental Health Tribunal after 2 years, where no other reference or application has been made during that period.
11.24 Annex F, covers in more detail the role of the Psychiatric Supervisor and Annex G, the role of the Social Work Supervisor.
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