ANNEX F
ROLE OF PSYCHIATRIC SUPERVISOR - (PATIENTS ON CONDITIONAL DISCHARGE)
1. These Notes are for the guidance of consultant psychiatrists who take on the role of supervising psychiatrist to a patient who, having been made subject to special restrictions, is conditionally discharged from hospital by the Mental Health Tribunal under section 193(7) of the 2003 Act. They may also be of value to other clinical staff, such as Community Psychiatric Nurses ( CPNs), who become involved with the psychiatric supervision of such patients. The Notes cover the responsibilities of those involved with the patient after discharge from hospital and the action to be taken in some of the circumstances which may arise while the patient is in the community. The Notes are not intended to limit the clinical freedom of the supervising psychiatrist to treat the patient as he or she sees fit. They are intended, however, to cover those aspects of the work which may not be familiar and to give examples of, and guidance in, procedures and practices which have been found, over the years, to be most effective.
2. At any time, there are around 60 restricted patients on conditional discharge and under supervision in the community.
THE ROLE OF THE SUPERVISING PSYCHIATRIST
3. It is Scottish Ministers' aim 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 need be. It is recognised that this places great reliance on the personal skills and dedication of individual supervisors. While it will not always be possible to predict and thus prevent dangerous behaviour, it is important that the supervisor sets out to provide more than just crisis intervention. This is underpinned by good risk assessment prior to the patient leaving hospital.
4. The supervising psychiatrist, in any case, is ultimately responsible for all matters relating to the mental health of the patient, including the regular assessment of the patient's condition, the monitoring of any necessary medication and the consideration of action in the event of deterioration in the patient's mental disorder.
5. The supervising psychiatrist will be expected to indicate prior to discharge the appropriate manner and frequency of psychiatric supervision and treatment, in any particular case. The minimum frequency of contact is determined by the interval which the Mental Health Tribunal directs that reports on the patient's progress should be made to Scottish Ministers. However there will, of course, be many cases in which the supervising psychiatrist considers more frequent contact appropriate. Reports to Scottish Ministers are dealt with separately in Chapter 11 and paragraphs 26 to 29 below.
6. The supervising psychiatrist should be prepared to be directly involved in the treatment and rehabilitation of the patient and to offer constructive support to the patient's progress in the community, rather than simply checking that the patient is free from symptoms and 'staying out of trouble'. The supervising psychiatrist should also be prepared to work with other professionals involved in the patient's care, including the social work supervisor and possibly the general practitioner, CPN and hostel staff. It will normally be expected that this is placed in the context of a multidisciplinary team and Care Programme Approach ( CPA). It is good practice for CPA planning to take place at least 3 months prior to the proposed discharge. In addition, the principles of the Integrated Care Pathway Framework for Mentally Disordered Offenders should be applied ( NHSHDL (2001) 9).
7. Scottish Ministers recognise that many supervising psychiatrists have had little or no experience of restricted patients and the legislation and procedures entailed. However, there is a great deal of support available from various sources. Scottish Executive Health Department ( SEHD) officials and the SEHD Psychiatric Adviser can provide information about an individual case or advice on any aspect of supervision, including the legal framework.
8. While requests for change in status and reports require to be made in writing, telephone contact for discussion and updating is encouraged and SEHD officials and the Psychiatric Adviser will make themselves available, where possible, to meet multidisciplinary teams and discuss care plans and related issues. Responsible Medical Officers are encouraged to use this resource.
9. RMOs may choose to supervise their own restricted patients after conditional discharge. This is an obvious course if the patient is to be discharged into the immediate vicinity of the discharging hospital. In other cases a supervising psychiatrist should be chosen who is within easy travelling distance of the patient and can easily keep in touch with the other professionals involved in the case, particularly the social work supervisor. It may be appropriate, in some cases, for the RMO to supervise the patient for an initial period of several months and then to make arrangements for a local consultant psychiatrist to take over as supervising psychiatrist. Whenever such a handover occurs, the change of RMO should be notified to the SEHD and the supervising social worker, and the RMO should ensure that the new RMO is given all necessary information on the patient, ideally, through a CPA meeting.
10. Important elements in effective supervision include the development of a close relationship with the patient and working in partnership with the social work supervisor. The social work supervisor is also responsible for overseeing that the patient meets the requirements of the licence and takes action where there is any default. The frequency of supervision should be such as to detect any deterioration in the patient's mental health or behaviour at an early stage. This will often be augmented by community psychiatric nurse visits in between contact with the supervising psychiatrist. It is understood that the doctor/patient relationship may be made more difficult by the fear or resentment of a conditionally discharged patient of being "policed" by the supervisors.
MEDICATION
11. For many conditionally discharged patients, continuation of medication is crucial to avoid a relapse and the attendant possibility of increased risk. It is important, therefore, that the supervising psychiatrist is fully informed, before discharge, of the patient's medical history, including details of current medication and what is known of its effects, side-effects and the effect on the patient's condition and behaviour if medication is stopped. The supervision of medication after discharge is the responsibility of the supervising psychiatrist but the social work supervisor, the patient's general practitioner and, where appropriate, the community psychiatric nurse and hostel staff will also need to have basic information about medication.
12. Medication issues should be covered in periodic discussions about a patient between the psychiatric and social work supervisors. Immediately after discharge and again when any change or cessation of medication has been made, the supervising psychiatrist should inform other members of the multidisciplinary team of the arrangements made, including when, where and by whom medication is to be given. Unless this information is clearly understood by all concerned, there is potential for confusion resulting in adverse consequences for the patient and for others.
13. Where CPNs have been involved in the after-care and supervision of restricted patients, they have proved extremely helpful, especially in respect of the administration and monitoring of medication. However, the supervising psychiatrists may make whatever arrangements they think fit for patients to receive their medication and for the monitoring of those arrangements.
14. Under the provisions of the 2003 Act, compliance with medication can be made a compulsory condition of discharge.
LIAISON BETWEEN THE SUPERVISING PSYCHIATRIST AND OTHER PROFESSIONALS INVOLVED, AND THEIR ROLE:
The social work supervisor
15. The social work supervisor may have more frequent contact with the patient than the supervising psychiatrist and will provide practical support to the patient in his everyday life, especially in matters relating to accommodation, relationships and employment. Separate guidance for social work supervisors is at Annex G.
16. The social work supervisor may be the key worker in the necessary liaison between all those involved with a patient in the community, having contact with those providing accommodation, employers or day care staff, relations, general medical practitioners and the supervising psychiatrist. However, provisions vary from area to area and this key worker role may also be taken by the CPN.
17. Meetings may take place in the patient's home, the supervisor's office or other venues. Visits should normally be at least once a week for the first month after discharge reducing to once each fortnight and then once each month as the supervisor judges appropriate. The social work supervisor may consider more frequent contact to be necessary, particularly while the patient settles down after release from hospital. Where a social work supervisor recommends a change in the frequency of supervision, they should first discuss this with the supervising psychiatrist and then notify the Psychiatric Adviser in writing as soon as possible.
18. Close liaison between the supervising psychiatrist and the social work supervisor is essential if supervision is to be effective. Both supervisors should be involved in the pre-discharge discussions about the patient's community care as part of the CPA process. 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. As paragraph 11 above recommends, the supervising psychiatrist should inform the social work supervisor of the nature of any 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, whilst not primarily concerned with the patient's mental health during his or her regular contact with the patient, may identify indicators of medication difficulties (and, possibly, indicators of other problems arising) which are helpful to the psychiatrist.
20. The supervising psychiatrist should send a copy of all reports to the Psychiatric Adviser to the social work supervisor, who should reciprocate.
21. On receipt of the social work supervisor's reports and at any other time during supervision, the supervising psychiatrist should be ready to contact him or her to discuss the patient's case and review progress.
Liaison with other professionals
22. All conditionally discharged patients should be registered with a general medical practitioner and arrangements for this should be made before discharge by the discharging hospital. The discharging hospital should inform the general practitioner of the names and addresses of the patient's supervising psychiatrist and social supervisor. The supervising psychiatrist should, at least, contact the general practitioner to give him brief details of the patient's background and current status as a conditionally discharged patient, to explain his or her role as supervising psychiatrist and to provide the general practitioner with a point of contact in the event of any concern about the patient's mental condition. It is understood that in some circumstances, the general practitioner may appropriately be an active participant in the CPA and should, at least, receive copies of the CPA minutes.
23. The work of other clinical personnel involved with the patient, such as psychiatric nurses or psychologists, should be under the general direction of the supervising psychiatrist who should consult them periodically about the patient's progress.
24. The availability of a well-developed community psychiatric nursing service is of key importance to successful rehabilitation in many cases. It is understood that the best support and supervision occurs when the community psychiatric nurse and psychiatrist work together in any case as part of a team.
25. As regards other professionals involved, such as social workers, hostel staff, day care staff and voluntary sector workers, the social work supervisor may be the key worker in liaison. However, it is expected that all will work under the leadership of the supervising psychiatrist within the CPA.
REPORTS TO THE SCOTTISH MINISTERS
26. Once a patient has been conditionally discharged, Scottish Ministers require reports on the patient's progress from both the supervising psychiatrist and the social work supervisor each month. officials, by telephone and in writing.SEHDIt is essential that these reports are provided timeously and any failure to provide reports will be followed up by Repeated failure to provide reports may result in a letter being issued to the Medical Director of the local NHS Board. Reports are submitted to the SEHD whether the patient was discharged by authority of Scottish Ministers (prior to October 2005) or by the Mental Health Tribunal. In some cases, Scottish Ministers may ask for more frequent reports in the initial period after discharge. This would be made clear at the beginning of supervision.
27. After a period in the community of not less than a year when a conditionally discharged patient has settled and is maintaining a steady pattern of life, the supervising psychiatrist may consider it appropriate to submit reports to the SEHD at longer intervals. A recommendation may be made to the SEHD that reports be made at three monthly intervals (the maximum interval permissible).
28. It is helpful if reports to the SEHD are completed in the manner shown on the sample form attached at Appendix 1. After the completion of initial summary data, the report itself should convey sufficient information to enable Scottish Ministers to consider whether the patient may remain in the community or whether, 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 supervisors feel may be of relevance.
29. As indicated at paragraph 20 above, all reports to the SEHD should be copied to the social work supervisor, and they should be discussed with him or her as necessary. Regular CPA meetings should continue. In addition, for about a year, a copy of each report should be sent for information to the patient's former RMO at the hospital from which the patient was discharged (if the RMO is not also the supervising psychiatrist).
Changes in address
30. If the patient wishes to change his address the supervising psychiatrist or social work supervisor MUST write to Health Department officials to seek agreement to the change of address.
Change in supervising psychiatrist
31. Although the name of the supervising psychiatrist is not usually entered on a warrant of discharge, it is important that the SEHD are notified as soon as possible of any change of supervising psychiatrist. If a supervising psychiatrist moves from a post and is unable to continue supervision of the patient, they should make arrangements for another suitable consultant to take over the case as soon as possible and alert SEHD to the name of the new psychiatric supervisor.
32. The social work supervisor should be informed of any impending change of supervising psychiatrist.
Patients' holidays
33. A conditionally discharged patient is not precluded, by his status, from having holidays away from home. However, the patient should always discuss plans for such holidays with both the social work supervisor and supervising psychiatrist. If a period of absence is agreed, the supervising psychiatrist will wish to consider whether any special medication arrangements will be necessary. Any proposals for the patient to leave the United Kingdom which should include details of the patient's plans, any perceived risk attached to the holiday proposals, and any work which has been done to reduce these should be put to Departmental officials for their observations. While it is not unknown for patients on conditional discharge to holiday out with the United Kingdom, this would not normally be advisable in the first year following discharge.
POST-DISCHARGE CONTACT WITH THE DISCHARGING HOSPITAL
34. The practice of copying supervisors' reports to the discharging hospital for a period of about a year after discharge can have practical benefits for both the hospital and the supervisors. It is clearly helpful for the hospital staff to know how their former patient is progressing in the community and their knowledge and experience of the patient at close quarters may enable them to make helpful suggestions about the patient's management during the early stages of his discharge. A supervising psychiatrist needing further background information about a patient or to discuss the patient's behaviour should make direct contact with the previous RMO. All hospitals will expect and welcome such approaches.
ACTION IN THE EVENT OF A BREACH OF CONDITIONS OR CONCERN ABOUT THE PATIENT'S CONDITION
35. 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.
36. If a supervising psychiatrist is concerned about a conditionally discharged patient's mental state or behaviour or has reason to fear for the safety of the patient or of others, he may decide to take immediate local action to admit the patient to hospital for a short period with the patient's consent.
37. Telephone discussion in such circumstances is welcomed by the Psychiatric Adviser or officials in the SEHD. In normal office hours an officer should be contacted at the Scottish Executive Health Department, St Andrew's House, Regent Road, Edinburgh EH1 3DG. Officials may also be contacted out of office hours, if required. Details of appropriate office hours contact numbers can be found at Annex A1.
Recall to Hospital
38. 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.
e. the patient breaches any of the conditions of discharge
f. the patient takes illicit drugs
39. 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.
40. Scottish Ministers have no objection to a conditionally discharged patient being admitted to a hospital, informally for a short period of observation or treatment. The SEHD 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 a conditionally discharged patient to remain in hospital for more than a short time ( e.g. a few weeks) 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. However, each case is considered on its individual circumstances and there may be occasions where a longer, informal admission is considered appropriate. The supervising psychiatrist is encouraged to discuss such cases with the Psychiatric Adviser, if they are in any doubt.
41. Where a conditionally discharged patient is admitted to hospital informally, the supervising psychiatrist should consider whether the patient is able to consent to treatment. The RMO should also consider whether, if the patient chose to discharge themselves, they would allow them to do so. If they would not, the supervising psychiatrist should give consideration to formal recall to prevent any possibility of breaching the patient's rights under the European Convention on Human Rights [ HL v UK (Bournewood) 5 October 2004]. Where there is any doubt about the appropriateness of continued informal admission, the supervising psychiatrist is encouraged to contact the Psychiatric Adviser for further advice.
42. Whether Scottish Ministers decide to recall a patient depends largely on the degree of danger which the particular patient might present in relation to deterioration in his mental disorder. Where the patient has in the past shown himself capable of serious violence, comparatively minor irregularities in behaviour or failure of co-operation would be sufficient to raise the question of the possible need for recall. On the other hand, if the patient's history does not suggest that he is likely to present a serious risk, Scottish Ministers may not wish to take the initiative unless there are indications of a probable physical danger to other persons. There are cases in which recall to hospital for a period of observation can be seen as a necessary step in continuing psychiatric treatment. Each case is assessed on its merits by SEHD and a decision is reached after consultation with the doctor(s) concerned and with the social work supervisor.
43. 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. Officials in the SEHD should be informed as soon as a recalled patient is back in hospital or in case of any difficulty.
44. 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 supervising psychiatrist may be able to recommend the patient's further discharge after only a short while, but in other cases what has been learned about him in the community or slow response to treatment may point to a need for a longer period of compulsory detention in hospital. The patient, or the patient's named person, has the right of appeal to the Mental Health Tribunal within 28 days of formal recall.
Absconding patients
45. A conditionally discharged patient may leave the approved address and break off contact with both supervisors. In such cases, the social work supervisor should report the fact to the SEHD immediately and make every effort to locate the patient. The SEHD may decide 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.
46. 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
47. If a patient has committed an offence and a prosecution is pending, and if he is in custody and he is no danger to himself, Scottish Ministers will usually let the law take its course. In that event, the court will be able to decide whether the patient needs a fresh medical disposal, whether some other non-medical disposal is called for, or whether the most appropriate course would be for the patient to be recalled to hospital. In this last event, the court may, for example, convict the patient but impose no penalty or only a nominal penalty in the knowledge that Scottish Ministers have in mind to recall the patient at once to hospital.
48. If a conditionally discharged patient is convicted of a further offence and the court imposes a non-custodial sentence, and recall to hospital is not considered appropriate, the terms of the previous conditional discharge will continue and the supervisors should resume their roles.
49. If a conditionally discharged patient is convicted of a further offence and the court imposes a sentence of imprisonment, Scottish Ministers will often reserve judgement on the patient's status under the 2003 Act until he nears the end of his prison sentence. Scottish Ministers may decide to make a reference to the Mental Health Tribunal recommending the patient's absolute discharge, so ending his liability to detention under the 2003 Act. Or they may decide to allow his continued conditional discharge under conditions of residence, social work supervision and psychiatric supervision; or to direct his recall to hospital on release from prison. Whatever decision Scottish Ministers take, and its timing, will depend on the length of the prison sentence imposed, the nature of the offence and 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
50. Scottish Ministers normally require active supervision and reporting to be kept up for at least five years after discharge from hospital when the offence which resulted in the patient's admission to hospital was a serious one, and for at least two years in less serious cases. However where, for example, a patient requires continued medication in the community for the control of symptoms which might otherwise lead to dangerous behaviour, it may be necessary to retain conditions for a much longer period.
51. Where both supervisors agree that neither social work nor psychiatric supervision is required, both should write to the Psychiatric Adviser to recommend the patient's absolute discharge. The social worker should include a full community care assessment to support the viability, safety and effectiveness of the proposed absolute discharge. Scottish Ministers will make a reference to the Mental Health Tribunal and if the Tribunal agrees to the absolute discharge of a conditionally discharged patient, a warrant will be issued and copied to both the patient and the supervisors. Such a decision does not, of course, preclude continuing contact between the patient and the supervisors on a non-statutory basis.
52. A conditionally discharged patient has the right to make an application to the Mental Health Tribunal seeking a variation in the conditions of their discharge or seeking an absolute discharge.