CHAPTER EIGHT - TRANSFERS BETWEEN HOSPITALS OR RETURN TO PRISON
To another hospital involving a reduction in the level of security
8.1 This type of transfer might be appropriate when a patient who has been in a hospital with special security ( e.g. the State Hospital) is considered no longer to need these conditions. Usually this will result from an improvement in the patient's mental disorder and behaviour through treatment and rehabilitation. Alternatively the patient may have been transferred to more secure conditions because of a particular set of circumstances which no longer apply and it may, therefore, be appropriate to return the patient to conditions of lesser security.
8.2 The courts and Scottish Ministers have the power to specify hospital units. This is to differentiate between "medium" and "non-secure" psychiatric care under the same management. In these cases Scottish Ministers personal approval is required. Currently the only facility meeting this criteria is the Orchard Clinic, although plans are underway for other medium secure units in Glasgow and the west and north of Scotland.
8.3 Scottish Ministers must personally approve all transfers to conditions involving a drop in security i.e. from the State Hospital or from a unit which has medium secure status to a local hospital. They will not normally consider transfers to conditions of lesser security in advance of formal plans having been agreed between the patient's current and future RMOs unless a bed is available or is likely to become available in the near future. With respect to patients who are subject to a compulsion order/restriction order, a transfer for treatment direction or a hospital direction, Scottish Ministers must approve all transfers whether to higher, lower or equivalent levels of security under section 218(3) of the 2003 Act. The accepting RMO is expected to personally assess the patient before agreeing to become the RMO. Experience has shown that transfers often take some time to arrange and to prepare the patient for the transfer. In some cases, the patient's condition might deteriorate or change with the result that the original approval given might no longer be appropriate in the circumstances and have to be reviewed or reconfirmed. It should be noted that gaining approval for the transfer once the arrangements are in place and a bed is available can normally be achieved quickly and will not delay the transfer. It is important, however, that the multidisciplinary team planning the transfer keep in close contact with Scottish Executive Health Department ( SEHD) officials to ensure that they have provided all the relevant information and that the process proceeds smoothly.
8.4 The RMO should discuss at an early stage with the Psychiatric Adviser the possibility of transfer for the patient. While the Psychiatric Adviser cannot agree transfer - as that decision rests with Scottish Ministers - they will be able to indicate what issues would need to be addressed before a case can be prepared for Scottish Ministers' consideration. The RMO should also inform the patient's local authority to ensure that forward care planning, if required, is alerted at an early stage. This is particularly important for 'out of area' transfers.
8.5 In considering such a move, Scottish Ministers will need to be reassured about the patient's progress and behaviour, why the patient is considered to no longer need the conditions of special security and what the plans are for the patient's future care. The information required by the SEHD is contained in Annex C.
8.6 On receipt of the formal recommendation for transfer, the Psychiatric Adviser may visit the patient if they have not done so recently and discuss with the RMO plans for transfer. Once a receiving hospital and RMO have been identified, a full case conference involving both multidisciplinary teams (including relevant social work staff) should be arranged. In certain controversial or high profile cases, it may be helpful to invite SEHD officials - who can help identify possible areas of concern and discuss how these might be addressed.
8.7 Thereafter, SEHD officials will start to prepare a case for the Scottish Ministers' consideration. It is at this point that the SEHD may identify areas where further information is required and request this from the RMO. It is good practice for pre-transfer visits to take place as they help familiarise the patient with the accommodation and build up a therapeutic relationship with the multidisciplinary team at the receiving hospital. If pre-transfer visits do not take place, the reasons for this should be clearly set out in the letter recommending transfer. Requests for suspension of detention should be submitted in the usual way. Where a number of pre-transfer visits are considered appropriate, a block request may be submitted - see Chapter 5 and Annexes B3 and C for details.
8.8 Once all arrangements are agreed and after the patient has successfully completed any agreed pre-transfer visits, the SEHD will seek the agreement of Scottish Ministers to the transfer. In some circumstances, officials can seek an "in principle" decision on transfer from Ministers, subject to a bed becoming available at the receiving facility.
8.9 Once Scottish Ministers have responded to the recommendation for transfer, SEHD officials will notify the RMO of the outcome. If approval is given to the transfer, officials will liaise with the RMO to ascertain the date of transfer. A letter will thereafter issue to the Medical Directors and RMOs of both hospitals. The letter must remain with the patient's medical records as the formal record of the transfer. If approval is not given, officials will provide the reason for deferral and discuss with the RMO any further requirement for patient's care and rehabilitation. As in Chapter 9, paras 15 and 25 of the Forensic Code of Practice, it is good practice for the RMO to consult and notify the MHO in cases of transfers.
8.10 The SEHD will notify the Mental Welfare Commission of the patient's transfer.
Transfer to the State Hospital from conditions of lower security
8.11 In certain circumstances it may be necessary for the multidisciplinary team in a local or medium secure unit to consider transferring a patient to the special security of the State Hospital i.e. on account of his dangerous, violent or criminal propensities. When considering such a transfer, reference should be made to section 102(1) of the National Health Service (Scotland) Act 1978 which reflects the same statutory test which was set out in S29(4) of the 1984 Act and this may be used as the 'test' at an appeal hearing. Where a patient is accepted for transfer to the State Hospital permission must be sought from Scottish Ministers. However, SEHD officials appreciate that, by its nature, a transfer to the State Hospital may need to be effected urgently, and are willing to accept telephone and fax contact from the RMO where an immediate permission is required. The patient and their named person should be notified of the transfer 7 days, where possible, in advance. Where urgent transfer is required or where it is felt that to inform the patient prior to transfer may lead to a further deterioration in their behaviour, this notification may be made "after the fact".
Transfer to hospital with same level of security
8.12 These transfers will take place for any number of reasons such as a hospital closing, further developments in a patient's care or rehabilitation or to move the patient closer to family and friends. In any case where the primary reason for transfer is to allow the patient to be closer to family and friends, a supporting social work report must be provided.
8.13 Transfers to a hospital with the same level of security also require Scottish Ministers' approval but in practice this is done by SEHD officials in consultation with the Psychiatric Adviser. The RMO should write to the Psychiatric Adviser with details of the reason for the transfer, the receiving hospital and RMO, evidence that the RMO has agreed to accept the patient, and the initial care plan following transfer. The Psychiatric Adviser will consider whether it is necessary to arrange a visit to the patient and RMO. Pre-transfer visits by the patient to the receiving hospital should be considered and SEHD approval sought for these through the normal suspension of detention procedure for restricted patients. Where a number of pre-transfer visits are considered appropriate, a block request may be submitted - see Chapter 5 for details.
8.14 Once the SEHD, in consultation with the Psychiatric Adviser, has approved the transfer, officials will write to the RMO indicating that the transfer is approved. Thereafter officials will liaise with the RMO to ascertain the date of transfer. A letter will issue to the Medical Directors and RMOs of both hospitals. The letter must remain with the patient's medical records as the formal record of the transfer. Following transfer, the new RMO must write to the Psychiatric Adviser to confirm their view on the appropriateness of continuing the same level of suspension of detention prior to transfer. The new RMO must not assume that the approval given previously for suspension of detention transfers with the patient.
Transfer to another ward within the same hospital
8.15 Transfers to another ward within the same hospital do not require Scottish Ministers' personal approval. However, where a patient is moving from a locked to an unlocked ward the RMO should consult with SEHD and the Psychiatric Adviser. The RMO should write to the Psychiatric Adviser with details of the reason for the transfer, the new ward and RMO (if appropriate) and the initial care plan following transfer. The Psychiatric Adviser will consider whether it is necessary to arrange a visit to the patient and RMO. All other ward to ward transfers are at the discretion of the RMO, who should inform the SEHD when such a transfer takes place.
Transfer back to prison
8.16 A patient who is the subject of a transfer for treatment direction from prison to hospital may be considered for transfer back to prison once the RMO considers that the patient no longer needs to be detained in hospital for treatment and may be absolutely discharged under the 2003 Act. The RMO is required to consider the conditions set out in section 206(4) and 207(3) of the Act.
8.17 When considering "serious harm", it is relevant to consider the environment into which he will be transferred. Different considerations may apply depending on whether he is being released into the community or back to prison.
8.18 A patient who is subject to a hospital direction may also be transferred to prison to complete his sentence. The same tests as set out in paragraphs 8.16-8.17 apply.
8.19 In considering such a move, the SEHD will need to be reassured about the patient's progress and behaviour, why the patient is considered to no longer need treatment in hospital and what plans there are for the ongoing care of the patient's mental health while in prison, if appropriate. The Psychiatric Adviser will assess the patient and provide a view to the SEHD. The SEHD will need to be reassured that the patient no longer presents a risk of serious harm to the public as a result of their mental disorder.
8.20 The information required by the SEHD will therefore include:
- Patient's treatment and progress while in hospital;
- Evidence of patient's current mental disorder and behaviour;
- Confirmation that the prison medical team has assessed the patient and are prepared to accept the patient into their care; and, if appropriate,
- details of any Care Programme Approach ( CPA) arrangements made.
8.21 Under section 210(2) of the 2003 Act, where Scottish Ministers are satisfied that the patient no longer requires to be detained in hospital, they shall revoke the direction to which the patient is subject and return them to prison. The patient will be returned to the prison from which they were originally transferred.
8.22 Where Scottish Ministers decide not to revoke a transfer for treatment direction or hospital direction, they shall make a reference to the Mental Health Tribunal in terms of section 210(3) of the 2003 Act.
8.23 The Mental Welfare Commission will be notified of the patient's return to prison.
Transfer to Scotland
8.24 Transfer to a hospital in Scotland may be appropriate for a patient who is Scottish or who has close family ties in Scotland. While the legislation permits such a transfer, there are some particular issues to be addressed before it may be approved. It should be noted that a patient may only be transferred if they would be legally detainable under equivalent Scottish legislation.
8.25 Immediately the receiving hospital is contacted about the transfer and before agreeing to it, the RMO approached must contact the SEHD about the transfer. This is especially important where the patient is a transferred prisoner as it is not possible to transfer a prisoner from prison in England to a hospital in Scotland. SEHD officials will liaise with the Home Office, Northern Ireland Office or country of origin and will seek background information on the patient including:
- diagnosis and detainability;
- index offence and criminal history;
- police reports;
- details of patient's care and treatment in hospital; and
- reasons for transfer (if this relates to family circumstances, a social work report will be required).
SEHD officials will also require a copy of the receiving RMO's assessment of the patient including their view on the patient's detainability.
8.26 SEHD officials will seek the views of the Office of the Solicitor to the Scottish Executive ( OSSE) on whether the patient would be legally detainable under Scottish legislation. If this is not the case, the patient cannot be transferred.
8.27 Once it is agreed in principle that the patient may be accepted, the receiving RMO may proceed to liaise with the patient's current RMO in arranging the transfer.
8.28 If pre-transfer visits are required, these should not take place before the patient's detainability under Scottish legislation has been confirmed. Thereafter, it is the responsibility of the sending hospital to arrange such visits with the receiving hospital. The Home Office or Northern Ireland Office will prepare and issue a warrant for the patient's transfer to the receiving hospital in Scotland. It should be noted, however, that the patient will require a transfer warrant from the SEHD for return to hospital out with Scotland at the end of any visit.
8.29 Once the SEHD, having consulted the Psychiatric Adviser, has agreed that the patient may be accepted for transfer, officials will notify the receiving RMO and the Home Office/Northern Ireland Office/country of origin. The receiving RMO should liaise with the patient's present hospital to arrange the transfer. A warrant will be required. The SEHD should be informed when the patient has been transferred. After 3 months, an admission report will be required on the patient with annual reports thereafter.
Transfer out of Scotland
8.30 Patients may be transferred to hospitals in other jurisdictions in appropriate circumstances. For instance, a patient who is not Scottish may wish to return to their home area or to be nearer family and friends. For some patients, it may be beneficial to transfer them for a period to a hospital which can cater specifically for their special needs and/or give them treatment which is not available in Scotland. Patients from Northern Ireland who have been transferred to the State Hospital because of their requirement for conditions of special security should be returned to Northern Ireland when they no longer require such conditions.
8.31 Transfers between jurisdictions require some additional consideration to ensure that the process is completed successfully. The information required would depend on whether the transfer is to a hospital with the same level of security or to conditions of lesser security. It is also necessary for SEHD officials to liaise with the officials in the receiving jurisdiction to ensure that they are content to receive the patient before the transfer can be finalised.
8.32 It is the responsibility of the RMO to identify a receiving hospital and to ensure that any financial considerations are managed satisfactorily. If this should prove difficult to finalise, the RMO should contact the SEHD who may be able to provide some assistance through liaison with officials in the receiving country.
8.33 In considering transfer requests involving a drop in the level of security, Scottish Ministers will need the same type of information as contained in Annex C. Information on the following will also be required:
- why it is considered appropriate to transfer the patient to another jurisdiction;
- whether the patient is in agreement with the transfer; and
- the plans for his future care.
8.34 On receipt of the transfer request and supporting information, the Psychiatric Adviser will visit the patient and discuss with the RMO the plans for transfer. Notwithstanding the distances involved, it may still be helpful to hold a full case conference with both care teams and, if necessary, officials from the SEHD to discuss any matters of concern and ensure that the arrangements proceed smoothly.
8.35 Pre-transfer visits should be given serious consideration by the care teams. If arranged, they will require approval in the normal way and a transfer warrant to accompany the patient to the new hospital if the suspension of detention includes an overnight stay. A similar transfer warrant must be issued by the appropriate department of the receiving jurisdiction when the patient returns to hospital from the visit.
8.36 The SEHD will also contact officials in the receiving jurisdiction to gain their approval to the transfer which is necessary before final approval for the transfer can be sought.
8.37 Thereafter, if the transfer is to conditions of lesser security, the SEHD officials will prepare a case for Scottish Ministers' consideration. It is at this point that the officials may identify any further information required and request this from the RMO. Once all arrangements are agreed and after the patient has successfully completed any agreed pre-transfer visits, officials will seek Scottish Ministers' agreement to the transfer.
8.38 Where the transfer is to a hospital with the same level of security and can be approved by the SEHD, officials will let the RMO know when the transfer is agreed. Officials will continue to liaise with the RMO and the Home Office, Northern Ireland Office or country of origin to ensure provision of a transfer warrant for the patient at the appropriate time.
8.39 On receiving approval from Scottish Ministers to a transfer to lesser security, the SEHD will notify the RMO. Before the patient's actual transfer, the Department will prepare and issue to the RMO a transfer warrant. This warrant must accompany the patient on their transfer to the new hospital and be filed in the patient's medical records as the formal record of the transfer.
8.40 Where Scottish Ministers agree to the removal of a patient from Scotland, they shall give written notice to: the patient; the patient's named person; the mental health officer; and the Mental Welfare Commission. In a case where removal is to a place in the UK, this notice will be given at least 7 days before the proposed removal date, and this period extends to 28 days where the removal is to a place out with the UK. Where the patient consents to transfer or where urgent transfer is required, Scottish Ministers may waive the need for prior notice. However, they must inform the Mental Welfare Commission of their decision to waive notice and the reasons for this decision.
Other Transfers
8.41 There are other types of transfer which an RMO may encounter, for instance, the transfer of a restricted patient on conditional discharge, the transfer back to the home country of a person held in hospital and transferred from prison.
8.42 The RMO should contact SEHD officials for specific advice about any planned transfers.