ChristmasFireplace

Section 17 Leave

17Many reports of patients “going AWOL” are actually better described as patients “becoming AWOL” because they have failed to return from leave.  A legal condition of being AWOL occurs in various circumstances and not just in relation to patients who suddenly decide to leave a mental health unit without permission.  Often, it is because they have been granted an authorised period of “section 17 leave” and failed to return from it.

I’ve heard a few officers grumble about this, especially if the person concerned has been an AWOL patient a few times by failing to return.  “Why would you grant leave if they’re not going to come back?!” … type grumbles.

Section 17 leave is an important part of care and recovery and is used in relation to a lot of longer-term mental health patients.  It should not be confused with discharging a patient subject to a community treatment order which is granted under s17A of the Mental Health Act.  Section 17 leave may be used to grant shorter periods of leave from hospital in the build up to discharging patients on to a CTO, but they are distinct legal concepts.

It would be quite inconceivable for hospitals to admit someone under the MHA with an acute mental health condition that may mean someone is severely self-neglecting in many important day-to-day ways and then keep them detained until a ‘big bang’ event where they are entirely released.  Appropriate use of s17 leave can assist in preparing patients for discharge and by allowing them to build up personal confidence and a level of personal responsibility that ensures when discharge does arrive they are prepared for it.  If upon discharge, the imposition of a CTO is appropriate to continue to ensure recovery, then that can also be considered.

We should remember: some patients were so unwell upon their admission that provisions of the MHA are used to take over very basic aspects of day to day living that a lot of people take for granted, like control of financial affairs, etc..  To return to a position where patients who may previously have been financially abused or reckless with their money have control of it, is not always going to be something that can be achieved by an “all or nothing” approach.  Equally, there are other reasons why patients who find themselves compulsorily detained need careful management and support as they recover and this is what section 17 leave is at least partly intended to facilitate.

THE LAW

Section 17(1) covers the Responsible Clinicians entitlement to grant leave with any conditions that may be necessary “in the interests of the patient or for the protection of other persons.”  The RC also has a right under s17(4) to recall patients from leave, revoking their leave of absence.

Where a patient who has been granted leave fails to return to hospital upon its completion, or where they fail to return if recalled from such leave when it is revoked, then they become absent without leave, under the MHA.  This then entitles an AMHP, anyone on the staff of the relevant hospital, a constable or anyone else authorised by the managers of the hospital, to take the patient into detention under s18 MHA and return them to the hospital.  << There is no power of entry in respect of this authority.  Should entry need to be forced in order to detain someone under s18 who is AWOL from s17 leave, then a warrant needs to be obtained under s135(2) MHA.

A CHRISTMAS TALE

ChristmasFireplaceA few days before Christmas, I became aware of an incident the police were asked to attend at an address in connection with a section 3 patient who had been afforded a few hours of accompanied leave.  The leave was to visit relatives ahead of the Christmas period and conditions had been attached to the grant of this leave by the Responsible Clinician in charge of a patient’s care.  The leave was for a specified number of hours; to visit a particular address and that the patient must be accompanied by three staff throughout.

The police were called because the patient had decided, not unreasonably, that they would prefer to spend Christmas with their family than return to hospital and they refused to do so as the leave period drew to a close.  When staff had attempted to encourage the patient to return it was reported they had become verbally resistant and the police were called.  I admit that this fairly innocuous little job got me thinking about the broad role of the police in our whole mental health system.

Do as you’re told or we’ll call the police. << Is this unfair?

The leave in this particular case had been accompanied leave and as with all such events, would have been risked assessed and this, one presumes, would have included decisions about staffing: how many staff, which staff, and any particular training or experience required bearing in mind the specific needs of the patient, etc., etc.?  And yet officers found a patient who was compliantly getting into a vehicle as they arrived.  They found relatives wondering why the police had been called who went on to describe the person as ‘upset’ rather than resistant or aggressive.

It raised questions in my mind (again) about how we get to a position where the risk assessment around accompanied leave includes no ability (or willingness?) to manage resistant or potentially just reluctant patients.

I’m sorry to bang this drum again, but: do we see a connection between patients’ perceptions of the police and police perceptions of patients, if the contact between the two groups is often predicated upon conflict and the need for the use of force?  In just the same way that relationships between the police and other parts of the community can be positively developed, so can this be done here, but only if we all move beyond thinking of the police as the paramilitary wing of a coercive mental health system.  The Ardenleigh liaison officer story shows this very well, indeed.

But if we are always building our contacts around conflict, including where it is low level and within the skills set of trained psychiatric nurses, is it any wonder there are trust and perception problems?

The Mental Health Cop blog won the Mind 2012 Digital Media Award, in memory and in honour of Mark Hanson.
The Awards celebrate the “best portrayals of and reporting on mental health in the media.”

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12 thoughts on “Section 17 Leave”

  1. I’ve several issues with how MH staff deal with Sec 17 AWOL patients. Firstly the staff at my local MH unit don’t know their own policies so when a patient goes missing for the 10th time in as many weeks they insist on calling police rather than holding of for an hour or two. Despite them returning under their own steam an hour or two late the previous 9 times.

    Also the staff refuse to collect AWOL patients when they know where they are instead calling police.

    And don’t even start me about their inability to ask for the patients mobile number prior to them leaving are asking where their ‘friend’ lives.

    Finally, why do the patients instantly go from being a low enough risk to themselves and others to be allowd out alone to being high risk if they’re 1 minute late?

    1. The answer to the first is probably about policy and the personal responsibility of the staff involved.

      If an eighteen bedded unit has 4, or possibly 3 staff on duty, are you seriously suggesting that one (or more likely two of them) should leave the unit to go collect an AWOL patient? In these circumstances I would imagine there would just be more AWOL patients and other incidents. Our local policy suggests that members of the local community team should make the first attempt to locate AWOL patients I. An attempt to reduce the number of calls to the local force. This seldom achieved much except a delay to the patient being returned.

      And the answer about why a patient becomes higher risk once they break the terms of their leave seems to me to be self evident. If they comply with leave conditions and times they demonstrate their understanding and hopefully improving mental state, and capacity to progress to greater leave. If they fail so to do then the opportunity given to them has shown they lack the ability or desire to comply with the boundaries and rules. Which means they they have carry a greater potential risk towards them self or others. It’s a crude comparison but it seems a bit like asking why does someone become a criminal when they break the law?

      1. I think how the NHS resources it’s legal obligations under the CoP MHA is a matter for the NHS and it’s fair enough for officers like Sectioned Detection to say so where we know this has a knock on effect for policing. After all, the NHS feel entitled – and rightly so – to make noises about inappropriate decisions by police officers that have a knock-on for them. As long as we’re doing it respectfully and with a view to learning and improvement, I’m not sure it matters that we tell each other the truth.

        I can’t agree with your point about risk assessment: patients who are high risk are at very real risk of causing death / serious injury, either to themselves or others. If such a person is high risk at 0905hrs, why were that at total liberty at 0855hrs? What has the ten minutes inherently done to them as individuals or their risk? More realistically, risk is over-estimated or even inflated.

      2. I am more than happy to agree that mental health services are under resourced (although I think you were quite careful in not actually saying that) as are the police….. from my reading of it, the CoP is incredibly woolly on the issue of AWOL patients essentially leaving much of it to local policy.

        Risk is frequently inflated but should someone be on section at all if their risk doesn’t justify detention? That’s not a staff nurse’s job to decide. Any change in presentation can demonstrate increased risk and then it might be a staff nurse’s job to use sec 5(4) but use of the mental health act always carries with it a presumption that someone poses a risk towards self or others. I think it’s only after the event, or lack of event, that you can be clear someone was low risk.

        You can trade insults about different agencies but my local policy requires the police to be informed of an AWOL. We might leave it a few minutes in the hope the patient will return but if something goes wrong in that ten minutes that’s a career and a job gone. And things can go wrong, and might have already which may be why there is a delay in someone returning.

        My personal view is that with the cuts occurring some major incidents will take place that will lead to the see saw of funding coming back our way. Call me defensive if I don’t want my career to be a casualty in the mean time.

  2. 31 December 2012

    Dear Mentalhealth Cop,
    Happy New Year to you and thank you so much for your inspirational and inspiring blog – it is so helpful to have an understanding police officer explaining the law as it affects anyone with mental health issues and their families and friends.
    I totally agree with you that the law is at odds with commonsense in regards the Mental Health Act 1983 [amended 2007] and that how does a low risk patient become a high risk patient the minute the clock strikes twelve and Cinderella – for we are in the panto season! – races out of the palace leaving her shoe on the steps in her flight to go home!
    I am lobbying my MP for a change in the Mental Health legislation in its entirety as it seems to me that we are fast becoming a nation of fearing our own shadows, lest the police be called for even a minor argument that might be easily resolved just with a modicum of commonsense and goodwill.
    The prisons are overcrowded and surely we do not need more people imprisoned on grounds of breaking Mental Health legislation which is moribund and not fit for purpose!
    Thank you very much for your great help.
    Best wishes
    Rosemary

    Rosemary Cantwell

  3. http://nationalpsychosisunitsurvivor.blogspot.co.uk/

    This is an interesting blog from a former patient and I would verify this is very true.

    This is a step beyond local level and so is the private sector hospital where my daughter is now. There is the complete opposite as opposed to local care.

    In these shocking institutions there is rigid control and manipulation.

    Locally there is much more freedom to allow Section 3 patients to go out unescorted and unsupervised. This has resulting in a serious incident on more than one occasion relating to my vulnerable daughter. Not only was I threatened but my neighbours. The association of someone I felt was highly unsuitable who should have been more readily supervised led to her going missing several times. In the time she went missing drugs (prescribed drugs) were not properly being taken and yet staff did not seem concerned and I do not think were being helpful to the police as I felt they knew exactly where she was and did not wish to disclose here whereabouts as they knew I did not like the person concerned who was violent and had “black moods” according to my daughter – hardly suitable friendship and this person then tried to threaten me and knows where I live. I had to confront him more than once.

    On one occasion my daughter went missing whilst on a Section 3 – allowed to go to her scheme with another patient who posed as her carer. A member of staff found it funny. Police time wasted looking for her when she had money – had a nice day out apparently but the wards are so dismal and just like prison – at least a prisoner has more rights. If a patient is vulnerable and drugged up to their necks on chemicals they cannot always defend themselves in a harsh and unfair system that fails to protect vulnerable people as on the wards, much is covered up. I soon got to find out this when I got my hands on the files and found out about some serious incidents. They say they are not responsible for voluntary patients but that is not true.

    On another occasion my daughter was missing – all her possessions stolen by friends she had made in the street. Nothing to do in the scheme, food rotting, washing overflowing, bins overflowing. ON a huge amount of drugs my daughter was going downhill – she did not previously take drugs to get into that situation – this is the result of one prescribed drug after the other being pushed at her and not being listened to when complaining of serious side effects leading to 8 admissions into hospital. Both care under social services and NHS failed her. The law is being interpreted in a very different way by the Maudsley and Cambian. Every visit is escorted, every phone call supervised and that is because I have complained about the shocking awful care and how human rights are being ignored.

    The more negative experiences an already vulnerable person experiences under the current hospital system and social services, the more they get to a stage where they lose hope and coupled with the effects of the drugs that can make someone into a dream like state during the day, they lose everything and so many people put their trust in these professionals when I have looked further – when I could see the drugs did not work and made her violent and aggressive like never before I did some good research and got in touch with leading professionals such as Dr Ann Blake Tracy, Dr William Walsh, prof David Healy. I cannot blame a patient for not wanting to return to these dreadful units where they sometimes keep a patient for 2 years – after being institutionalised for 2 years that person comes out needing more one to one case. When drugged up to their necks on powerful mind altering drugs that have different names but should be called Prozac, social services do not wish to provide such one to t one care and spend the necessary money. So they were spending hundreds of pounds on an empty flat that eventually was given to someone else. If they had given a small amount of direct payments then this would have kept my daughter out of trouble, provided suitable companions of her own age.

    As regards the law, locally, human rights are acknowledge to the point where such incidents detailed above occur but the law is interpreted like a prison sentence with all rights stripped beyond local level when someone is referred to the Bethlem or beyond that. As it happened everything has failed for my daughter and so many others I am in touch with and from very nice backgrounds too because these drugs have turned their sons and daughters making it impossible for them to have come and live at home. However, I never lose hope and I feel that a complete change in the law and current system is needed.

    Now you can see why a patient goes AWOL. On the wards there is nothing to do – food is not nice, weekends and bank holidays – nothing to do – forced to take prescribed drugs regardless of what effect they may have. Volatile patients and noisy atmosphere, etc etc. My daughter is now in a place described as a four star hotel and with lovely food etc – she has suffered no end with the experimentation and drug pushing of the Bethlem and has been sent miles away from home and family and is not encouraged to have contact. Quite frankly this is like a religious cult – all about control and I can see manipulation and I want a full investigation done by Mr Cameron, Mr Clegg and Mr Hunt and the complaints procedure is also useless and a waste of public money. You go through all the stages only to have your case shut down and that is not good enough especially if something serious has happened to that person on the ward and the CQC turn around and say they are not interested in individual cases. This whole system is wrong in my opinion.

  4. I support the sentiments above and join this lady in sending my greetings for this new year. I too take issue with how law in general is interpreted when and who by. Examples of abuse of power and process are legion which makes it more like playing roulette than the sensible administration of relevant law. On that matter I have a question if I may put it? The term ‘moderation’ applied to postings on this and other sites is unclear to me. Could it be clarified please? Does it mean that the moderator is acting as a person with the power to remove posts that though they may be factual might cause discomfort or embarrassment to officials. In other words are moderators censors in reality ensuring that an authority or the establishment can appear to be open to questioning always provided the decision makers retain the right to evade any searching questions that might lead to the truth actually becoming public knowledge or information. ‘How does a low risk patient become a high risk patient the minute the clock strikes twelve’ is surely a very good question but for me the more important question is ‘who decides and how?’

    There have been many members of the public who find that when they make a complaint to the police about what they consider to be a criminal matter to be informed ‘That is not a police matter’

    Who makes that sort of decision and how? Can the public be excused for believing that makes it possible for the police to avoid tackling serious criminal matters such as fraud by designating them ‘Civil matters’ If that decision is made by a police officer who has not carried out any investigation is it not possible that could result in a miscarriage of justiice? Who decides and how? May I put the same question with regard to moderation?

  5. Hello “Excellent Friend” and Happy New Year. I love this subject as it causes no end of confusion and differences of opinion and interpretation. I am happy to say that in Thames Valley we are building good understanding with our partners about when it is appripriate for police to be involved and to what extent! However, what remains unclear is whether S18 “should” be or “may” be applied when police discover/recover someone who is AWOL. We regularly have situations where we have located someone who has been reported to us as AWOL. Ocasionally when we contact the hospital and ask what they would like us to do we are told that they no longer have a bed as they have, not unreasonlably, given it to someone else. So we have a person who is AWOL, no S17 leave having been granted but the hospital telling us they don’t actually want the person back as they have no bed. So I go back to the “should” or “may”. If a person is AWOL do the hosptial have a right to be able to say “just leave them there if they are ok” if a consultant has not authorised S17 leave? Do police have an obligation to take the person into custody if they are AWOL eventhough the hospital has stated they have no bed? I think leglislation states that the authorised person “may” return them not “should”. Personally I think we should return them to the relevant ward and the problem is then with the detaining hospital to make any necessary arrangements. I am uncomfortable with police leaving someone who is AWOL. However, is it also reasonable for us to do as the ward requests and leave them if they are in a “safe” location? Both scenarios have happened in TVP area on a number of occassions and both with less than satisfactory outcomes. glad to hear what others think.

    1. Where do you come up with this stuff?! … Happy New Year to you too!

      I would say, it is not a judgement for the police to make about whether a legal detained AWOL remains somewhere. If the hospital want to come out or send the CMHT or AMHP services to make that judgement and put the correct legal framework around it all, that’s fine.

      If not, s18 it is … instinctive view.

  6. It would be helpful to see some of the stereotypical responses challenged – particularly the knee jerk ‘resources’ response.

    Use of police to force admission, force medication or seclusion inside a hospital or force return from leave of absence is not only about resources. It is also about attitudes and perception of role.

    The police are perceived as being an appropriate agent of force.

    Increasingly the nurses do not perceive themselves as a being an agent of force, social control, public protection. This stance may be further encouraged in response to proposals to increase patient choice of provider.

    People need to be open about this and hold the debate … what is the down side to passing off use of force with seriously mentally ill people from nurses to police? … Is this the right thing to do? … What are the risks to those seriously ill people?

    1. I do agree – totally. For example, I find it particularly interesting following a recent debate about MH law and Nearest Relatives making applications under the Act, that AMHPs wish to monopolise that aspect of it: “they wouldn’t have the forms”, “wouldn’t know what to do” etc., etc. … whereas when a person is subejct to an application for admission the only person per se who has a right to use force is the AMHP. I have never, ever known it done. They always want to delegate that authority to the police.

      I do worry about the police becoming the paramilitary wing of mental health services.

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