Before the introduction of Community Treatment Orders in the 2007 Mental Health Act, the way that mental health professionals often allowed patients to leave hospital if they felt that full discharge in the earliest stages of recovery was too big a step, was to grant ever-longer periods of section 17 leave. We know that when first used, leave is often granted for just a couple of hours, possibly subject to conditions including a member of staff supervising someone. Last Christmas we were called to a patient on supervised s17 leave who had been given three hours to visit family on Christmas Eve and was understandably reluctant to have to return from and miss a happy family occasion.
But as recovery progresses, leave could become longer and eventually unsupervised and with fewer restrictions to it. It was not uncommon for leave to eventually last for weeks at a time and for it to be re-granted after the patient’s return and a meeting with their care team, during which administration of medication could take place. This was a particularly useful way of ensuring that if patients decided after a short-while to stop their medication or not to turn up for what otherwise may have been an outpatient appointment, they could be returned by the police after failing to show up on the expiration of their leave and medication then given under Part IV of the Mental Health Act.
Community Treatment Orders were intended to be another way of achieving the same thing. Instead of someone remaining a “section 3 patient on leave”, they would become a CTO patient and this order may carry conditions in addition to compliance with medication. It could include residence, curfew, drug-testing, etc.; and conditions could be amended or removed over time. Should clinicians be unhappy with a patient’s lack of recovery, a recall notice could be served and the patient then must return to hospital or become AWOL and liable to return by force. When recalled, they could be compelled to remain in hospital for 72hrs during which time the CTO could be revoked entirely if this were deemed necessary.
CTO OR EXTENDED s17 LEAVE?
Community Treatment Order legislation did not ban the use of extended s17 leave – so which do you do? Well, leave under s17 which is “extended leave” – greater than seven consecutive days – should not be granted unless the responsible clinician has first considered a CTO. One obvious point from my perspective about the decision, is that CTOs are bureaucratic to operate when recalls are required. If someone fails to show up at 10am when their s17 leave expires, they are now AWOL and can be re-detained. If the patient had a condition to attend a monthly outpatient clinic at 10am and they fail to show up, the recall process must be instigated.
I am aware of a recent case where a patient had for months on end been refusing medication in the community and each time, he’d be recalled from his CTO, medicated by force in hospital and then discharged on his CTO. During the recall process, police officers were prone to misunderstanding the law around these situation because we have had no training on CTOs since their introduction. (I have written a “Quick Guide to recalls and revocations” to get you through it.) I once attended a meeting with a mental health team and a patient’s family to discuss a police mishandling of a CTO recall and was told to give assurances that such misunderstandings will “never happen again”. I proceeded to outline CTO and other recall cases where mental health professionals have got the law wrong, effectively asking the police to assault and falsely imprison people and I also noticed that direct legal questions I asked of the professionals present went unanswered, thus proving that even professionals with extensive training in this law get it wrong. << We need far, Far, FAR more training on mental health law – all of us!
IT’S GOOD TO TALK
The meeting led to an agreement that I would email all of my police area about this patient and explain the CTO recall process. I cut-and-paste the “Quick Guide” into an email and sent it over 400 officers, copied to the mental health team. Hopefully, next month, we will have a consistent approach to it all! …
Obviously, what I didn’t countenance was that the responsible clinician would ditch the CTO plan in favour of the old-fashioned “extended leave plan”. I also didn’t countenance that they would fail to tell me that the management plan had changed for this patient. So I recently attended to work to find that patient’s name on an incident log, with the police having asked all the relevant questions about recall notices and so on, only to be in some difficulty communicating with the NHS and the preceding duty inspector telling me, he thought they were pulling his chain. I spoke to them. After some closed questioning of the type normally reserved for interviewing suspects, I managed to work out that they had resorted to old-fashioned extended leave and hadn’t told us – no wonder we were confused!
Police officers need to be sure that they have a lawful basis for their coercion of other human beings: not least because when it goes awry, their world can fall apart so they need to be confident they were acting properly in the first place. We need and are entitled to clarity about the laws governing a patient so we can make our own assessment of the legality of asking officers to coerce vulnerable people and so the officers may be defended if there is criticism of their legal action or inaction.
More training all round! – jointly, if at all possible.
Winner of the President’s Medal, the Royal College of Psychiatrists.
Winner of the Mind Digital Media Award
All opinions expressed are my own – they do not represent the views of any organisation. (c) Michael Brown, 2013
I try to keep this blog up to date, but inevitably over time, amendments to the law as well as court rulings and other findings from inquests and complaints processes mean it is difficult to ensure all the articles and pages remain current. Please ensure you check all legal issues in particular and take appropriate professional advice where necessary.
Government legislation website – www.legislation.gov.uk
Mental Health Cop 
never understood why medics who are responsible for large chunks of the MHA get less initial training and refresher training than AMHPs and ward staff even less
CTO’s – the greatest human rights disaster
I was told by a MH ward manager a few nights ago that I didn’t need a warrant to enter the house of a patient on Sec 17 leave. He’d been doing the job for 30 years and how stupid I must be for thinking that I do need one. It was the responsibility of the police to go and get them. Why on earth would he send staff? Oh and I wont need an ambulance just stick her in a police van.
When he was advised to read the hospitals policies and the MHA codes of practice he swore at me and told me that if I didn’t go and get them he would have my job for neglect.
How is a frontline cop supposed to deal with that? It is partly the fault of the police though because we’ve always just done what we are told and it has became accepted practice.
Quite right – if he did that to one of mine, I’d be down the hospital like a flash to educate him. I hope you took his name and complained up your chain?
Thank you MentalHealthCop for this post – It has cleared up the question that I had regarding Extended leave Vs CTO. I haven’t been able thus far to grasp the difference. The person that I care for has been on extended leave for about 4 years now. It has also confirmed some of the experiences I have had with the Mental Health “Professionals” in Birmingham. I was not aware that a CTO had to be considered. I was given the impression and told that there would be no real difference in the case of the person I care for. I just wanted to say thanks for caring enough. It is encouraging! I will be following and reading more.
I agree with Joanna the is the biggest Human Rights disaster ever, it is a total disgrace , I hope that mindfreedom uk will start to have some impact on this injustice to many. May this lady be remembered forever https://www.youtube.com/watch?v=BBJBMXw7-fw . Barbaric is to kind a word for the mistreatment of a Human being.