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ANNEX G
ROLE OF SOCIAL WORK SUPERVISOR (PATIENTS ON CONDITIONAL DISCHARGE)
1. The term "social work supervisor" is used throughout the Notes to mean the mental health officer who has responsibility to report to Scottish Ministers on the progress in the community of such a patient. The social work supervisor will be identified by the Chief Social Work Officer in the local authority area in which the patient will reside on conditional discharge following a referral from the RMO. Reports are initially completed on a monthly basis and a copy of the form used for this purpose is attached at Appendix 2.
2. It is essential that the social work supervisor should receive, as early as possible before discharge, detailed written information (if this is not already available) about the patient which can be retained for reference in the files of the supervising agency. It will normally be expected that this information will be received at least 3 months prior to discharge and form part of the CPA planning process. This will ensure that there is full written information about the case on record if required for an incoming supervisor or senior officers in the agency at any time.
3. The Responsible Medical Officer at the discharging hospital is advised that the full information provided to the social work supervisor for retention should cover the following aspects of the case:
a) a pen-picture of the patient including his diagnosis and current mental state;
b) admission social and medical history;
c) summary of progress in hospital;
d) present medication, duration of medicine/treatment intervals, reported effects and any side effects;
e) a risk assessment and management plan, including any warning signs which might indicate a relapse of mental state or a repetition of offending behaviour together with the time lapse in which this could occur;
f) a report on present home circumstances; and
g) supervision and after-care arrangements which the hospital considers appropriate and inappropriate in the particular case (this could be provided in a copy of the CPA minutes or care plan).
4. If a social work supervisor has not received the information detailed prior to the date of discharge, it should be requested from the discharging hospital. If such a request is not met, officials of the Scottish Executive Health Department ( SEHD) should be notified.
POST DISCHARGE PROCEDURES
5. It is Scottish Ministers' hope that, by means of conditional discharge of a restricted patient, any risk should be minimised by effective supervision, by appropriate support in the community or by recall to hospital, if necessary. It is recognised that this hope places great reliance on the personal skills and dedication of individual social work supervisors. While it will not always be possible to predict and thus prevent dangerous behaviour, it is important that the social work supervisor sets out to provide more than just crisis intervention.
6. The specific requirements of supervision will vary from case to case and an individual patient's needs will vary over time. It is impossible, therefore, to draw up a blueprint for successful supervision. However, there are some elements in the role of a social work supervisor which are important if supervision is to be effective in achieving its purpose.
7. A social work supervisor may have many difficult decisions to make when working with a conditionally discharged patient. The patient should consult the supervisor when considering any significant change in circumstances, for example, a new job, new home, financial matters or a holiday. Careful consideration of risk should precede any such proposal and the supervisor should advise the patient against taking any step which, in the supervisor's view, would involve an unacceptable degree of risk. Some proposals will involve the social work supervisor making a special report to the SEHD (see references to change of address and holidays in paragraphs 28 to 31 below).
8. A sound knowledge of the case is essential if the social work supervisor is to be able to spot warning signs before dangerous behaviour occurs. As a matter of good practice, the social work supervisor should be involved in the Care Programme Approach meetings prior to conditional discharge and have an opportunity before discharge to meet the patient and discuss the patient with those in hospital who know him best. Social work supervisors should seek to build on this initial background to the case by establishing a close working relationship with the patient after discharge. If the patient is in close contact with, or living with, friends or relatives the social work supervisor should also see them regularly.
9. The protection of the public from serious harm is enhanced by the successful reintegration into the community of the patient. Supervisors should, therefore, have a positive and constructive approach towards the patient's rehabilitation rather than simply monitoring progress.
10. It is recommended that meetings should take place at least once a week for at least the first month after discharge reducing to once each fortnight and then once each month as the social work supervisor judges appropriate. These are considered to be minimum periods. Sometimes the SEHD will request that more frequent meetings take place. Generally, individual supervisors will consider more frequent meetings appropriate, particularly for the initial period of the first year during which the patient settles down to life in the community. Meetings may take place at the supervisor's office, in the patient's home or other venues. The social work supervisor's visits to the "home territory" should be in accordance with good practice and local risk management protocols. If, after a period of not less than a year, a social work supervisor considers that supervision at monthly intervals is unduly frequent, then he should consider the case for recommending 3 monthly intervals - see paragraph 25 below.
11. When a social work supervisor is absent from his or her post even for a short period, for example when on leave, it is important that responsibility for the case should be transferred to a colleague and that both the patient and the supervising psychiatrist should know whom to contact as social work supervisor. If absences are to be for longer than two months, the Chief Social Work Officer of the Local Authority and SEHD should be informed. Paragraph 29 below deals with permanent changes of social work supervisor.
12. When changes in social work supervisors occur, it is important that the outgoing supervisor passes to his successor full information about the case and supplements this with oral briefing. A change of supervisor may be upsetting for a patient and care should be taken to ease the transition.
13. As well as the importance of a close and informed relationship between the supervising social worker and the patient, the most valuable element in successful supervision is liaison with other professionals involved in the case. This aspect is discussed separately in paragraphs 16 to 20 below.
SHARING OF INFORMATION
14. This is covered briefly in Chapter 14 of this Memorandum. Except where medical information is concerned, it will usually be the social work supervisor who has to make decisions. Those to whom it may be appropriate to disclose information about a patient's background include hostel staff, landladies or landlords, employers, those providing voluntary work or placements and, in some circumstances, partners. In all cases information should only be disclosed on a "need to know" basis and only of the essential details.
15. Decisions about sharing of information should be taken by the social work supervisor in the light of their knowledge of the case, their professional judgement and in cases of doubt they are advised to consult managers or other members of the clinical team. In general, information about the patient should be disclosed only on a "need to know" basis and only with the full knowledge and agreement of the patient. Information should only be given against the patient's wishes when there are strong overriding reasons for doing so. Such reasons, include the patient's known propensity for offending in circumstances to which the accommodation, or job, may give rise. For example, the supervisor of a patient with a history of offending against a child should be particularly conscious of the fact in discussions with those providing accommodation which does or may also contain children or those providing employment or voluntary work which may bring the patient into contact with children.
LIAISON WITH OTHERS INVOLVED IN THE PATIENT'S CARE
The supervising psychiatrist
16. The consultant psychiatrist who acts as the supervising psychiatrist to a conditionally discharged patient is responsible for all matters relating to the mental health of the patient. The manner in which that responsibility is carried out in a particular case will depend on the needs of the patient. However, the psychiatrist, like the social work supervisor, is asked to report to the SEHD on the patient's condition on a monthly basis initially after discharge.
17. Should the patient's mental health deteriorate, the supervising psychiatrist will consider whether steps are necessary to arrange for the patient to receive additional out-patient treatment or to be admitted to hospital for treatment either voluntarily or by recall (see also paragraphs 32-39 below). Any decision to admit the patient for short-term treatment on a voluntary basis will generally be taken with the knowledge of, and often in consultation with, the social work supervisor as part of the regular review process. In all cases he should be advised when the patient is admitted or discharged in these circumstances.
18. Close liaison with the supervising psychiatrist is essential if supervision is to be effective. Both supervisors should be involved in the pre-discharge discussions about the patient's after-care and it is expected that they will meet at least once at this stage, probably at the Care Programme Approach meeting. They should agree a common overall approach to the patient's treatment, after-care and reintegration into the community and discuss how they can liaise effectively after discharge.
19. If the patient will be taking medication, the supervising psychiatrist should inform the general practitioner and the social work supervisor of the nature of the medication, its effects on the patient's condition and behaviour and any possible side effects. The psychiatrist should also inform the social work supervisor of the arrangements to be made for the medication to be given, including when, where and by whom, and of any changes in those arrangements. With this information the social work supervisor, while not primarily concerned with the patient's mental health, may identify changes in the patient's state of mind during his or her regular contact with the patient which may be helpful to the psychiatrist.
20. The social work supervisor should send a copy of all reports to the SEHD to the supervising psychiatrist, who should reciprocate.
Other professionals
21. All conditionally discharged patients should be registered with a general medical practitioner and arrangements for this should be made by the discharging hospital. The supervising psychiatrist and the social work supervisor should always keep the general practitioner informed of any significant development in the case.
22. Other clinical staff involved may include a community psychiatric nurse or a psychiatric nurse based at the supervising psychiatrist's hospital whose responsibilities would include visiting the patient to administer and/or monitor his medication.
23. Finally, hostels and centres providing day care are likely to have several members of staff involved with the patient on a day-to-day basis.
24. The social work supervisor may be the key worker in liaison between those involved in the patient's care and support. At the beginning of supervision and with subsequent changes in arrangements, the social work supervisor should discuss the broad approach to the patient's after care with others involved and invite them to contact him or her if there is any cause for concern about the patient's condition or behaviour.
REPORTS TO SCOTTISH MINISTERS
25. Scottish Ministers require reports on the patient's progress from both supervisors one month after conditional discharge and every month thereafter until it is recommended by both supervisors that three monthly intervals is sufficient. It is essential that these reports are submitted timeously and any failure to provide reports will be followed up by the SEHD, by telephone and in writing. The SEHD Psychiatric Adviser should be consulted and agreement reached prior to the reports being changed from one month to three months. Reports are submitted to the SEHD whether the patient is discharged by Scottish Ministers (prior to October 2005) or the Mental Health Tribunal.
26. After a period of at least 12 months in the community, when a conditionally discharged patient has settled down and is maintaining a steady pattern of life, the social work supervisor may consider it appropriate to submit reports to the SEHD at longer intervals, reflecting a belief that the patient can manage well with supervision. The social work supervisor may write to the Psychiatric Adviser recommending that his or her reports be made at three monthly intervals. The SEHD will not agree to reporting intervals of more than three months while supervision continues.
27. It is helpful if reports to the SEHD are completed in the manner shown on the sample form attached at Appendix 2. Initially, reports will be on a monthly basis. After the completion of initial summary data, the report itself should convey sufficient information to enable the SEHD to consider whether the patient may remain in the community or whether, in the patient's own interests or for the protection of the public, steps should be taken to return him to hospital. The report should include a detailed account of the issues outlined in Chapter 11, paragraph 11.20, as well as any other issues which a supervisor may consider relevant. If the social work supervisor has identified any signs of deterioration in the patient's mental health or behaviour, these should be described in detail, together with any steps already taken to improve the situation and any further proposals for doing so. Finally, the report should include the social work supervisor's plans for the patient's continued support and rehabilitation. To provide such reports it is essential that all incidents, contacts, reviews and developments are clearly and comprehensively recorded on the patient's social work file.
Changes in address
28. If the patient wishes to change his address or to be away from the address for more than a short absence, and the social work supervisor agrees that the new accommodation proposed is suitable, the supervising psychiatrist or social work supervisor MUST write to the Psychiatric Adviser to seek agreement to the change. (Although, in an emergency the social work supervisor may have to agree to a change of address without prior reference to the SEHD in which case he should contact the Psychiatric Adviser as soon as possible thereafter.) Agreement to routine changes of address may be sought at any time before the proposed change and need not await the next report. It would be helpful if details were given of the new accommodation proposed and the reasons for the change. The supervising psychiatrist should be kept informed (see paragraph 20).
Change in Social Work Supervisor
29. Allocation of a new social work supervisor should be done through the Chief Social Work Officer of the Local Authority. SEHD must be notified as soon as there is a permanent change of social work supervisor. (Paragraph 11 above deals with temporary absences from work of the social work supervisor, for example during leave.)
Patient holidays
30. A conditionally discharged patient is not precluded by his status from having holidays away from home. The patient should always discuss plans for such holidays with the social work supervisor so that the suitability of the arrangements can be considered. During the first six months after discharge, for absences from home of two weeks or more, the social work supervisor should notify the Social Work Department in the holiday area and should inform the patient whom to contact there in case of problems arising. Holidays abroad do not allow any form of supervision to continue and should be considered very carefully. Any proposals for the patient to leave the United Kingdom should be put to the Psychiatric Adviser for approval. However, it is worth noting that a request for a patient to go abroad would not normally be considered until they had been on conditional discharge for at least a year.
31. The supervising psychiatrist should be informed of any of the above proposals. In the case of proposed absences from the patient's home, consideration of special medication arrangements to cover the absence may be necessary.
ACTION IN THE EVENT OF A BREACH OF CONDITIONS OR CONCERN ABOUT THE PATIENT'S CONDITION
32. 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.
33. If the social work supervisor has reason to fear for the safety of the patient or of others, he should contact the supervising psychiatrist immediately. The consultant may decide to initiate local action to admit the patient to hospital without delay with the patient's consent. Whether or not such action is taken, and even if the supervising psychiatrist does not share the social work supervisor's concern, the social work supervisor should report to the SEHD at once.
34. Telephone discussion in such circumstances is welcomed by SEHD officials, who may be contacted at the Scottish Executive Health Department, St Andrew's House, Edinburgh EH1 3DG. Officials may also be contacted out of office hours, in the event of an emergency. A list of contact numbers is attached at Annex A1.
Recall to hospital
35. Under section 202 of the 2003 Act, Scottish Ministers have the power to recall a patient from conditional discharge. In practice, a formal warrant of recall is issued by SEHD officials following a recommendation from the supervising psychiatrist and consultation with the Psychiatric Adviser. In cases of urgency, the warrant can be faxed to the RMO. Formal recall cannot take place without a warrant issued by Scottish Ministers. It is not possible to specify all the circumstances in which Scottish Ministers may decide to exercise their powers to recall to hospital a conditionally discharged patient, but in considering the recall of a patient they will always have regard to the safety of the public.
A report to the SEHD must always be made in a case in which:
(a) there appears to be an actual or potential risk to the public;
(b) contact with the patient is lost or the patient is unwilling to co-operate with supervision;
(c) the patient's behaviour or condition suggest a need for further in-patient treatment in hospital; or
(d) the patient is charged with or convicted of an offence.
36. Consideration of a case for recall will take into account any steps taken locally to remove the patient from the situation in which he presents a danger. Where the supervising psychiatrist decides not to formally recall the patient, they should provide a brief report to the SEHD outlining the reasons for their decision. This should be copied to the social work supervisor.
37. Scottish Ministers would have no objection to a conditionally discharged patient being admitted to a hospital informally for a short period of observation or treatment but the SEHD and the social work supervisor should be kept informed in these circumstances since the patient will again be subject to the formal conditions of his earlier discharge when he leaves hospital. However, it is generally inappropriate for the conditionally discharged patient to remain in hospital for other than a short time informally and Scottish Ministers would usually wish to consider the issue of a warrant of recall if the period of in-patient treatment seemed likely to be protracted. Each case is assessed on its merits by the Psychiatric Adviser in consultation with the Department and a decision is reached after consultation with the doctor(s) concerned and with the social work supervisor.
38. Where recall is considered by Scottish Ministers to be necessary and a warrant is signed to that effect, the patient may be returned in the most appropriate manner to the hospital specified on the warrant. If the patient will not return to hospital willingly, on being told of his recall, then the police should be informed. There is a general duty to inform a patient, within 72 hours of his recall to hospital, of the reasons for that recall. Where a social work supervisor is involved in returning the patient to hospital, this duty should be borne in mind. The SEHD should be informed as soon as a recalled patient is back in hospital, or in case of any difficulty.
39. After recall, a patient is once again detained as a restricted patient in pursuance of the legal authority which was operating immediately before the conditional discharge. In some cases, the patient may need to return to hospital for a short while but, in others, the lessons learned in the community may point to the need for a longer stay in hospital. The patient has a right of appeal to the Mental Health Tribunal within 28 days of recall.
Absconding patients
40. A conditionally discharged patient may leave the approved address without approval and break off contact with both supervisors. In such cases, the social work supervisor should report to the SEHD immediately and make every reasonable effort to locate the patient, contacting colleagues in other areas if there is reason to believe that the patient may have gone to a particular place in a different locality. The SEHD may decide simply to wait until the patient's whereabouts are known. If necessary, however, Scottish Ministers will issue a warrant for the recall of the patient, thus providing the police with the powers to bring the patient into custody.
41. If a conditionally discharged patient is suspected of having left his approved address to go abroad Scottish Ministers may decide to issue a recall warrant and alert the immigration authorities who would detain the patient on re-entry to the country. Any ensuing publicity which may arise as a result of a patient returning from abroad should be dealt with in accordance with the guidance issued in Chapter 6.
Further offending
42. If a conditionally discharged patient has committed an offence and legal proceedings are pending, Scottish Ministers will usually consider it advisable, if the patient is in safe custody and presents no danger to others, to let the law take its course so that the court may reach a fresh decision on the need for medical treatment or other measures, rather than recall the patient to hospital. The patient may be recalled if that is in agreement with the court's wishes and the doctors concerned agree that the patient meets the criteria for detention in hospital (for example if the court decides on conviction, to take no action or to impose a notional penalty in the knowledge that the patient will be returned at once to hospital.)
43. If a conditionally discharged patient is convicted of a further offence and the court imposes a non-custodial sentence, the terms of the previous conditional discharge will continue and the supervisors should resume their roles.
44. If a conditionally discharged patient is convicted of a further offence and the court imposes a sentence of imprisonment Scottish Ministers will usually decide to reserve judgement on the patient's status under the 2003 Act until he is near the end of his prison sentence. At that stage, Scottish Ministers will decide, on the medical recommendation, whether to make a reference to the Mental Health Tribunal recommending absolute discharge, to allow his continued conditional discharge under conditions of residence, social supervision and psychiatric supervision or to direct his recall to hospital on release from prison. Whatever decision is taken will depend largely on the length of the prison sentence imposed, the nature of the offence, the patient's mental state, both at the time of the offence and during the sentence of imprisonment, and the risk of danger to the public.
LENGTH OF SUPERVISION AND ABSOLUTE DISCHARGE
45. Each case should be assessed in accordance with the individual's mental health and other needs. However, Scottish Ministers would normally require active supervision and reporting to be kept up for at least 5 years after discharge in serious cases, and for at least two years in less serious ones. In some cases, for example, where a patient requires continued medication in the community for the control of symptoms which might otherwise lead to violent behaviour, it may be necessary to retain conditions for a much longer period.
46. If a social work supervisor considers that the patient no longer requires active supervision and that the safety of the public would not be at risk if the patient were not subject to supervision, the matter should be discussed with the supervising psychiatrist before an appropriate recommendation is put forward to the Psychiatric Adviser. The social work supervisor must provide a full comprehensive Community Care Assessment to support the viability, safety and effectiveness of the proposed absolute discharge. Evidence of a prolonged period of stability in the community which has been tested by a variety of normal pressures or experiences will be important. Supervisors should use their judgement and put forward a recommendation for an end to formal supervision whenever they consider it appropriate. Care should be taken, however, not to raise the patient's expectations as ultimately a decision on whether to grant an absolute discharge rests with the Mental Health Tribunal. The Psychiatric Adviser will then assess the patient and, if he/she is agrees with the recommendation, Scottish Ministers will make a reference to the Tribunal.
47. Such a decision does not, of course, preclude continuing contact between the patient and the supervisors on a non-statutory basis.
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