Before the introduction of Community Treatment Orders in the 2007 Mental Health Act, the way that mental health professionals often allowed patients to leave hosptial 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.
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