Many 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.
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
A 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?
Update on 01st April 2015 – since writing this article, a new Code of Practice has come into effect in England. It doesn’t substantially alter the post but certain reference numbers have changed. My summary post about the new Code of Practice (2015) is here, the new Reference Guide is here and the full document is here. The Code of Practice (Wales) remains unchanged.
The Mental Health Cop blog
– won the ConnectedCOPS ‘Top Cop’ Award for leveraging social media in policing.
– won the Digital Media Award from the UK’s leading mental health charity, Mind
– won a World of Mentalists #TWIMAward for the best in mental health blogs
– was highlighted by the Independent Commission on Policing & Mental Health
– was referenced in the UK Parliamentary debate on Policing & Mental Health
– was commended by the Home Affairs Select Committee of the UK Parliament.