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Key Words:
Mental Health Act, Code of Practice
Version:
Version 3
Approved by:
MHA Governance Delivery Group
(MHAGDG)
Ratified by:
Quality and Safety Committee
Date this version
was ratified:
January 2024
Please state if
there is a reason
for not
publishing on the
website
N/A
Review date:
December 2025
Expiry date:
May 2026
Type of
Procedural
document (tick
appropriate box)
Clinical
√
Non-Clinical
Mental Health Act
Procedural Document
Statement/Key Objectives:
This document provides for the procedures required under
the requirements of the Mental Health Act 1983 within
Leicestershire Partnership NHS Trust.
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Contents Pg
1.0 Quick Look Summary 3
1.1 Version Control and Summary of Changes 3
1.2 Key individuals involved and consulting on the document 3
1.3 Governance 3
1.4 Equality Statement 4
1.5 Due Regard 4
1.6 Definitions that apply to this procedure 4
2.0 Purpose and Introduction 5
3.0 Policy requirements 5
4.0 Duties within the Organisation 5
5.0 Monitoring compliance and effectiveness 6
6.0 Mental Health Act 1983 – Guiding Principles 6
7.0 The Procedures 8
7.1 Overall Assessment 9
7.2 Section 2 Application 10
7.3 Section 2 Admission and Maintenance 11
7.4 Section 3 Application 12
7.5 Section 3 Admission and Maintenance 13
7.6 Section 4 Application and Admission 14
7.7 Section 5 Emergency Holding Powers 15
7.8 Section 17 Leave of Absence 16
7.9 Section 17a CTO Assessment and Application 17
7.10 Section 17a CTO Maintenance 18
7.11 Section 17a CTO Recall and Revocation 19
7.12 Discharge Tribunal Service – Mental Health 21
7.13 Discharge Managers Panel Members 22
7.14 Discharge Nearest Relative 23
7.15 Part 4 Consent to Treatment 24
7.16 Part 4a Consent to Treatment Section 17a (CTO) 25
7.17 Death of a person subject to the Act 27
7.18 Section 19 Transfer of Authority to Detain 28
7.20 Section 132 Duty to Provide Statutory Information 29
8.0 References and Bibliography 30
Appendix 1 – Training requirements
Appendix 2 – The NHS Constitution
Appendix 3 – Due regard screening template
Appendix 4 – Data Privacy Impact Assessment Screening
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1.0 Quick Look Summary
This policy will remain subject to version control, assurance and monitoring details as stated within its
content.
The purpose of this policy and related procedural documents is to provide all permanent employees of LPT,
together with those on bank, agency or honorary contracts with clear guidance in their application of ‘the Act’
(Mental Health Act 1983) in order that the Board may be assured of their responsibilities in terms of
compliance with the legislative requirements of the Act.
Employees as described above are expected to work within the guidance provided here and within the
associated documentation.
1.1 Version Control
Version
number
Comments
(description change and amendments)
1
2
Revision following policy expiry date
2.1
No changes
3
Review following expiry date and changes to Trust
Delegation Document
1.2 Key individuals involved in developing and consulting on the document:
- Dr Saquib Muhammad – Interim Medical Director/Chair MHAGDG
- Alison Wheelton – Senior Mental Health Act Administrator
- Members of the MHAGDG with responsibility for service distribution
1.3 Governance
Level 2 or 3 approving delivery Group - Mental Health Act GDG
Level 1 Committee to Ratify Procedure - Quality and Safety Committee
1.4 Equality Statement
Leicestershire Partnership NHS Trust (LPT) aims to design and implement policy documents that meet the
diverse needs of our service, population, and workforce, ensuring that none are placed at a disadvantage
over others.
It takes into account the provisions of the Equality Act 2010 and promotes equal opportunities for all. If you
require this document in another format please contact the Corporate Governance Team.
This document has been assessed to ensure that no one receives less favourable treatment on the
protected characteristics of their age, disability, sex (gender), gender reassignment, sexual orientation,
marriage and civil partnership, race, religion or belief, pregnancy and maternity.
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1.5 Due Regard
LPT will ensure the Due Regard for equality is taken and as such will undertake an analysis of equality
(assessment of impact) on existing and new polices/procedures in line with the Equality Act 2010. This
process will help to ensure that:
- Strategies, policies and procedures and services are free from discrimination
- LPT complies with current equality legislation
- Due regard is given to equality in decision making and subsequent processes
- Opportunities for promoting equality are identified
Please refer to due regard assessment in the appendices to this document.
1.6 Definitions that apply to this procedure
The Act
The Mental Health Act 1983 (as amended, including by the Mental Health
Act 2007, the Health and Social Care Act 2012 and the Care Act 2014).
Detained
patient
Unless otherwise stated, a patient who is detained in hospital under the
Act, or who is liable to be detained in hospital but who is(for any reason)
currently out of hospital.
Detention
(and
detained)
Unless otherwise stated, being held compulsorily in hospital under the
Act for a period of assessment or medical treatment. Sometimes referred
to colloquially as ‘sectioning’.
CQC
The CQC (Care Quality Commission) look after the rights and concerns
of all those who are held under the Act and aim to ensure the Act is being
properly used. The CQC is also responsible for the provision of SOADs
(see below under ‘Second Opinion Appointed Doctors) when required.
CTO
Community Treatment Order - Power under sections 17A-17G that
enables a patient to be discharged from detention in hospital but to
remain subject to recall.
IMHA
Independent Mental Health Advocate – Specialist advocates who support
detained patients and those on CTO, ensuring that the safeguards laid
out in the legislation are followed, commissioned in Leicester,
Leicestershire and Rutland by POWhER.
NR
Nearest Relative - Not to be confused with ‘Next of Kin’, a patient cannot
choose their Nearest Relative. It is a term specific to the Act and the
Nearest Relative has a legally defined role (see section 26 of MHA). The
Nearest Relative has certain powers and is entitled to receive certain
information regarding a patient who is subject to the Mental Health Act
unless the patient objects.
SOAD
Second Opinion Appointed Doctor - The CQC retain responsibility for the
provision of SOADs in response to requests from clinicians when
ensuring that a patient who does not or cannot consent to certain
treatment that it is only given if it is medically necessary. Also required to
ratify the treatment provided to CTO patients irrespective of whether
consent is forthcoming. In this role they are acting independently of the
detaining hospital on behalf of the CQC.
RC
Responsible Clinician – Clinician in charge of the patient’s care and
treatment under the requirements of the Act
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2 Purpose and introduction
This Procedural Document sits within the series of Mental Health Act related documents, and sets out the
procedures for compliance with the both good practice and statutory requirements of the Act.
The aim of the procedural documents is to provide clear guidance to staff when undertaking their duties on
behalf of the Trust as detailed in the Trust’s Delegation document for use by those who have responsibility
for the care and treatment of person(s) subject to the relative provision of the Mental Health Act to which
this document applies.
3. Policy requirements
This procedure will remain subject to version control, assurance and monitoring details as stated in the
over-arching policy.
The Mental Health Act 1983 remains primary legislation, the Code of Practice (revised in 2015) provides
for the good practice by which the Act is implemented.
The Guiding Principles, set out at the front of the Code, provide for its statutory status, the following
therefore provides for both primary legislation and good practice, and the local procedures that are written
in accordance with them.
4. Duties within the Organisation
The Trust Board has a legal responsibility for Trust policies and for ensuring that they are carried out
effectively.
Trust Board Sub-committees have the responsibility for ratifying policies and protocols.
Directors and Heads of Service are responsible for:
- ensuring that comprehensive arrangements are in place regarding adherence to this policy and
how this policy is applied within their own department.
- ensuring that team managers and other management staff are given clear instruction about the
policy arrangements so that they in turn can instruct staff under their direction.
These arrangements will include:
- Distributing information about the policy in a timely manner throughout the
Directorate/Department or Service to a distribution list which will be agreed in advance with
local managers.
- Ensuring all staff has access to the up-to-date policy, either through the intranet, or if policy
manuals are maintained that the resources are in place to ensure these are updated as
required.
- Maintaining a system for recording that the policy has been distributed and received by staff
within the department/service and for having these records available for inspection upon
request for audit purposes.
Senior Managers, Matrons and Team leaders are responsible for:
- Providing this information to all new (applicable) staff on induction. It is the responsibility of
local managers and team leaders to have in place a local induction that includes this policy.
- Ensure that their staff know how and where to access the current version of this policy; via
intranet.
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Consent
- Clinical staff must ensure that consent has been sought and obtained before any care,
intervention or treatment is delivered. Consent can be given orally and/or in writing. Someone
could also give non-verbal consent as long as they understand the treatment or care about to
take place. Consent must be voluntary and informed and the person consenting must have the
capacity to make the decision.
- In the event the patient’s capacity to consent is in doubt, clinical staff must ensure that a mental
capacity assessment is completed and recorded. Someone with an impairment or a
disturbance in the functioning of the mind or brain is thought to lack the mental capacity to give
informed consent if they cannot do one of the following:
o Understand information about the decision
o Remember that information
o Use the information to make the decision
o Communicate the decision
5. Monitoring compliance and effectiveness
The MHA Code of Practice 2015 at Chapter 37 states the following:
37.11 The ‘Trust’ should put in place appropriate governance arrangements to monitor and review the
way that functions under the Act are exercised on its behalf. Many organisations establish a Mental
Health Act steering or scrutiny group especially for that task, and whilst recognising that the Act is a
legal framework for the delivery of care, also monitor and review via clinically focussed forums. Ideally,
such forums should have representation from the Board or registered manager.
The MHAGDG monitors the reporting of risk through established Trust procedures i.e. the Risk Register.
The CQC will test application of the Code of Practice Trust-wide as part of their Inspection Programmes and
as part of their focused MHA Reviewer visits for detained patients, which are broader than the remit of this
overarching policy document.
Monitoring compliance will be recorded through the monthly MHA Census which is reported through the
Service Reports to the MHAGDG.
6. Mental Health Act 1983 – The Guiding Principles
The MHA provides a legal framework within which clinicians can intervene where necessary to protect
people with mental disorder themselves and, sometimes, to protect other people as well. However, with the
power to intervene compulsorily comes the responsibility to do so only where it is right and to the highest
possible standards.
The Trust remains responsibility for the delivery of care and treatment for all patients in receipt of its
services. Where those patients remain subject to the provisions of the Act, the Trust has a statutory
responsibility to ensure those provisions are met.
The principles that guide the application of the Act are set out at the front of the accompanying Code of
Practice. Compliance with the statutory requirements of the Act is also very much reliant on compliance
with those principles and with the guidance contained in the Code itself.
As such the Trust writes all relevant policy and procedural documents in accordance with the Code (and
Guiding Principles). These documents can be found as appendices to this Policy.
The Guiding Principles are as follows:
• Least restrictive option and maximising independence
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Where it is possible to treat a patient safely and lawfully without detaining them under the Act, the
patient should not be detained
• Empowerment and involvement
Patients should be given the opportunity to be involved in planning, developing and reviewing their
own care and treatment to help ensure that it is delivered in a way that is as appropriate and effective
for them as possible.
• Respect and dignity
Patients and carers should be treated with respect and dignity. Practitioners performing functions
under the Act should respect the rights and dignity of patients, and their carers while also ensuring
their safety and that of others.
• Purpose and effectiveness
Care, support and treatment under the Act should be given in accordance
with up-to-date national guidance and/or current best practice from professional bodies where this is
available.
• Efficiency and equity
Commissioners and providers, including their staff, should give equal priority to mental health as they
do to physical conditions.
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7. The Procedures
The following suite of procedures form the basis of this document and provide for the guidance staff require in
different scenarios when applying the Mental Health Act 1983 and associated Code of Practice.
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7.1 Overall Assessment
Call is made to AMHP referral co-ordinator requesting a Mental Health Act assessment. Call may be made by Care co-ordinator/ Lead professional,
police, crisis team, GP, NR, Family member etc. AMHP Referral co-ordinator obtains all relevant names and numbers and asks if an interpreter/
signer will be required. Ask if there is any information regarding LPA/ ADRTs. (If OOH, referral made to Emergency Duty Team (EDT))
AMHP referral co-ordinator contacts appropriate AMHP on the rota (EDT OOH).
AMHP refers to Section 12 App process (Local Authority)
Need for detention discussed and agreed. Appropriateness of section 2 or section 3 decided as per MHA and Code of Practice.
Admission required?
Y
N
If the patient meets criteria for section 2 and needs to be in hospital
as a matter of urgency a section 4 can be used
Patient is not detained
Section 2 or Section 3
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7.2 – Section 2 Application
Appropriate transport arranged by AMHP (Police to be contacted if high risk) in accordance with Multi-Agency Joint Conveyance Agreement
Most senior Section 12 doctor conducting assessment arranges for a bed or can delegate but retains responsibility.
Doctors complete 1 x Form A3 or 2 x Form A4
AMHP completes Form A2 ensuring correct address of hospital including name of Trust. AMHP informs NR of application and their rights (including
right to refer to IMHA). AMHP discusses the IMHA service with the patient. AMHP should check all forms for consistency and correctness.
AMHP (and others dependant on risk assessment) goes with patient to hospital and personally delivers application for admission and
accompanying medical recommendations to hospital ward staff. Delivery of papers can be delegated in exceptional circumstances. The reasons
for this must be appropriately recorded. If the AMHP does not accompany should phone the hospital later to confirm admission.
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7.3 – Section 2 Admission & Maintenance
Nurse completes Form H3 and MHA1 Scrutiny Form and Section 132 Rights Form on SystmOne, giving patient a copy of the relevant DoH
information leaflet – scans and emails copies of the statutory papers and the above forms to the MHA Office immediately, sending the originals in
the internal post using the ‘pink’ envelope system.
The admitting nurse, or named nurse, continues to inform patient of their rights in accordance with section 132 of the MHA recording each
attempt (and where the patient hasn’t understood) on SystmOne
The MHA Administrators scrutinise statutory papers in accordance with MHA2 Scrutiny form and write to the patient further informing them of
their rights, following local procedures for medical scrutiny of forms.
At each MDT the necessity for the patient to remain under section
should be reviewed and documented.
Consent to Treatment - Patient can be detained for 28 days & is subject to Part IV consent rules. For the purposes of obtaining a Form T2 or Form
T3 it will be assumed that treatment commences on the first day of detention. RC should inform MHA Administrators of the date treatment starts
if it is later than the first day of detention.
Section 17 leave may be granted.
At day 14 MHA Administrators email RC and Ward Matron reminding
date of expiry
By day 21 a decision should be made regarding the need for section 3.
Section 3 required?
2
nd
reminder sent after 21 days if no response received.
RC (which could be delegated
to NIC) arranges for AMHP &
second medical
recommendation.
RC completes MHA7 End of
Section Form sends to MHA
Office ASAP.
Y
N
See process 7.4 below
RC informs patient that they
are an informal patient and
what this means and
documents conversation in the
healthcare record.
RC completes first medical
recommendation.
MHA Office writes to patient
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7.4 – Section 3 Application
Most senior Section 12 doctor conducting assessment arranges for a bed or can delegate to Crisis teams but retains responsibility.
Doctors agree what is the appropriate treatment and where this can be given and complete 1 x Form A7 or 2 x Form A8, documenting all the
various alternatives on the paperwork.
AMHP completes Form A6 ensuring correct address of hospital including name of Trust. AMHP informs NR of their rights (including right to refer
to IMHA). AMHP should check all forms for consistency and correctness.
AMHP (and others dependant on risk assessment) goes with patient to hospital and personally delivers application for admission and
accompanying medical recommendations to hospital ward staff. Delivery of papers can be delegated in exceptional circumstances. The reasons
for this must be appropriately recorded. If the AMHP does not accompany should phone the hospital later to confirm admission.
AMHP consults with NR. If this is not appropriate or possible reasons must be documented. If the NR objects to the use of section 3 the section
cannot be applied. If NR maintains objection AMHP should consider displacement under s 29 if grounds are met. AMHP consults own legal
department.
A section 2 cannot be used as an alternative.
Appropriateness of section 3 agreed by all assessors
Appropriate transport arranged by AMHP (Police to be contacted if high risk) in accordance with agreed Multi Agency Conveyance document.
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7.5 – Section 3 Admission & Maintenance
At each MDT the necessity for the patient to remain under section should be reviewed.
Consent to Treatment - Patient can be detained for 6 months initially & is subject to Part IV consent rules. For the purposes of obtaining a Form T2
or Form T3 it will be assumed that treatment commences on the first day of detention (under section 2 or 3). RC should inform the MHA admin
team of the date treatment starts if it is later than the first day of detention.
Section 17 leave may be granted
After 4 months MHA Admin Team email the RC and ward to ascertain
if the patient is to be discharged or for Form H5 and CQC s61 (if Form
T3 in situ), if section 3 to be renewed (or potentially Form CTO1 if
patient is to be discharged onto CTO).
By 4 months a decision needs to be made regarding the continuing
need for section 3
If no response with 2 weeks MHA Office emails RC and Ward manager
again
2
nd
professional completes Part 2 of Form H5 and returns to RC at
least 4 weeks before expiry of section.
End of Section form completed by RC and sent to MHA Office ASAP.
Y
N
Where applicable patient informed by RC that they are an informal
patient and what this means (including section 117 aftercare) and this
is documented in the healthcare record.
If RC believes continued detention necessary, then RC completes part
1 of Form H5 and sends to 2
nd
Professional by the 5 month date. If RC
does not consider continued detention necessary completes Form
End of Section Form and returns to MHA Office
2
nd
Professional agrees with the RC that there is a continued need for detention under section 3?
RC completes Part 3 of Form H5 and returns to MHA Office ASAP.
CQC s61 also completed if patient had a Form T3 in situ.
Patient can be detained for a further 6 months at their initial
renewal and then annually. MHA Office will co-ordinate Managers
Panel Review and/or referral to Tribunal
MHA Admin team write to patient and advise of informal status
Nurse completes Form H3 and MHA1 Scrutiny Form and Section 132 Rights Form on SystmOne giving patient a copy of the relevant DoH
information leaflet – scans and emails copies of the statutory papers and the above forms to the MHA Office immediately, sending the originals in
the internal post using the ‘pink’ envelope system.
The admitting nurse, or named nurse, continues to inform patient of their rights in accordance with section 132 of the MHA recording each
attempt (where the patient hasn’t understood) or reminder on SystmOne
The MHA Administrators scrutinise statutory papers in accordance with MHA2 Scrutiny form and write to the patient further informing them of
their rights, following local processes to comply with medical scrutiny requirements
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7.6 – Section 4 Application & Admission Process
If the patient meets criteria for section 2 and needs to be in hospital as a matter of urgency a section 4 can be used . Preference should always be
given to using two doctors from the admitting hospital to complete a section 2, rather than using a section 4.
If a risk is identified an assessor should not be left alone with the service user. If the police or ambulance are not at the premises to support the
remaining assessor then the second assessor should arrange for a deputy. This could be the crisis team or a nurse from the admitting ward.
Particular regard should be had to the risk posed to the patient and/or others and arrangements made as appropriate.
AMHP (and others dependant on risk assessment) goes with patient to hospital and personally delivers application for admission and medical
recommendation to hospital ward staff. Delivery of papers can be delegated in exceptional circumstances. The reasons for this must be
appropriately recorded. If the AMHP does not accompany should phone the hospital later to confirm admission.
Doctor conducting assessment arranges for a bed.
AMHP completes Form A10 ensuring correct address of hospital including name of Trust. AMHP informs NR of application and their rights
Doctor completes Form A11.
The patient can be detained for a maximum of 72 hours or until the RC assesses the patient and determines that they do not meet the criteria for
further detention (whichever is sooner). The patient is not subject to Part IV consent rules and therefore any treatment provided must be in
accordance with common law consent or the Mental Capacity Act.
RC sees patient as soon as possible and assesses need for further detention.
Appropriate transport arranged by AMHP (Police to be contacted if high risk). AMHP/Section 12 doctor signs an ‘Authority to convey form’ if
another agency (e.g. police or EMAS) are conveying.
Nurse completes Form H3 and MHA1 Scrutiny Form and Section 132 Rights Form on SystmOne giving patient a copy of the relevant DoH information leaflet – faxes
copies of the statutory papers and the above forms to the MHA Office immediately, sending the originals in the internal post using the ‘pink’ envelope system.
The admitting nurse, or named nurse, continues to inform patient of their rights in accordance with section 132 of the MHA recording each
attempt (where the patient hasn’t understood) or reminder on SystmOne.
Section 3
RC arranges (or delegates to NIC) for s3
assessments to be undertaken (2 new
medical recommendations & application
required)
(refer to Section 3 process)
No detention required
RC completes End of Section Form and
sends to MHA Office ASAP.
RC informs patient that they are informal
and what this means.
Section 2
RC completes Form A4 and sends to MHA
admin team ASAP.(refer to section 2
process)
MHA Team inform patient by letter of outcome
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7.7 – Section 5 Holding Power
• Inpatient (not in ED or outpatient dept) wanting to leave hospital premises.
• Staff feel that the patient would be a risk to self or others if allowed to leave.
• Staff attempt to discuss/reason with patient.
• Patient is still refusing to stay on premises.
Nurse makes every effort to contact RC or nominated deputy. Is the RC or nominated deputy immediately available?
N
After examination does RC/nominated deputy consider that
detention under MHA may be necessary and that a MHA assessment
should take place?
Message left for RC/nominated deputy to attend ward urgently
Patient informal
RC/ nominated deputy completes Form H1, scans
and email to the MHA Office, sending originals
through the pink envelope system and internal post
ASAP (fax).
Y
N
Is patient receiving treatment for mental disorder in a mental health
ward?
Patient detained under section 5(2)
NIC (RMN or RNLD level 1 or 2) completes Form H2
Patient detained under section 5(4)
The patient can be detained with minimum force necessary for a
maximum of 72 hours or until a MHA assessment has taken place
(whichever is sooner) and is not subject to Part IV consent rules
and therefore any treatment provided must be in accordance with
common law consent or the Mental Capacity Act
The patient can be detained with minimum force necessary for a
maximum of 6 hours or until the RC/nominated deputy attends
(whichever is sooner) and is not subject to Part IV consent rules and
therefore any treatment provided must be in accordance with
common law consent or the Mental Capacity Act
Has RC/nominated deputy arrived within 6 hours?
MHA assessment arranged by nurse ASAP.
If prior to the MHA assessment being completed the AC/nominated
deputy decides that further assessment and detention is not
required s/he should complete End of Section Form and email to the
MHA Office ASAP
N
Nurse completes Section 132 Rights Form on SystmOne giving patient a copy of the relevant DoH information leaflet, emails copies of the
statutory papers and the above forms to the MHA Office & puts originals in the internal post using the ‘pink’ envelope system.
Y
N
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7.8 – Section 17 Leave
Planned Section 17 Leave
Emergency Section 17 Leave
In the case of emergency section 17 leave i.e. to an acute hospital for medical treatment, the Responsible
Clinician may complete the Section 17 leave form on SystmOne retrospectively to accommodate the
immediate transportation of the patient. All other principles above apply.
Decision made by RC ONLY to grant section 17 leave. For restricted patients under Part 3 of the MHA (those subject to section 41 or 49
restrictions) Home Office permission will be required (co-ordinated by the RC)
Named nurse or NIC ensures that the patient is aware of any conditions and AWOL procedures. A contingency plan should be agreed in case the
patient does not return.
Leave forms completed in accordance with Trust Policy on SystmOne – copy given to patient and/or carers/relatives as appropriate
At the time when the patient requests to go out on their assigned leave the named nurse or NIC completes risk assessment and exercises
discretion (if leave refused nurse documents reasons). Patient informed that if they have any problems they should return to hospital.
If patient fails to return from leave at the specified time the AWOL procedure should be followed
On the patient’s return from leave the named nurse/NIC should review the leave with the patient and document in accordance with local
procedures
Leave of absence conditions agreed by RC and MDT in consultation with the patient.
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7.9 – Community Treatment Orders Assessment & Application Process
Patient subject to section 3 or section 37.
RC in consultation with MDT considers the possibility of CTO. CTO must be considered where prolonged section 17 leave (more than 7 consecutive
days and nights) is being granted.
In-patient team liaise with the appropriate community team and a Care Co-ordinator is identified if the patient does not already have one, in line
with the assessment, care planning and transfer processes. Community RC identified and informed that CTO is being considered.
CPA/section 117/ pre-discharge planning meeting takes place at which the community team who would become responsible for the patient if
placed on a CTO are represented. Conditions required to maintain the patient’s mental health discussed and agreed (in line with section 17B)
Care co-ordinator, in liaison with the in-patient team, ensures that assessments updated and Care Plan reviewed to incorporate proposed
conditions. Crisis and contingency plan completed/reviewed to include triggers and recall arrangements (including Crisis team contact details).
The patient and the community team must be consulted in the formulation of these plans.
The views and the likely co-operation of the patient should be considered in line with the guiding principles of the MHA. The CTO will not provide
lawful authority to enforce the conditions so if a patient does not agree to the conditions or does not have the capacity to agree to the conditions
then a CTO is not likely to be effective. Where an individual lacks capacity to agree to the proposed conditions (e.g. residency or treatment) then
the provisions of the Mental Capacity Act may provide the sufficient lawful authority to provide the necessary care/treatment.
RC completes part 1 of Form CTO1 and passes to an AMHP (In determining the most appropriate AMHP consideration must be given to their
knowledge of the patient, their potential involvement with the patient post-discharge, their availability (EDT AMHPs will not undertake CTO
applications).
AMHP agrees that a CTO is appropriate and that the conditions are
in accordance with section 17B
AMHP does not agree that a CTO is appropriate and/or that the
conditions are not in accordance with section 17B
CTO is not applied
AMHP completes Part 2 of Form CTO1 and returns to RC.
RC completes Part 3 of Form CTO1 at date and time when patient discharged and sends to
MHA Office within 24 hours – or at the very least prior to discharge.
If RC changes as a result of discharge onto CTO, the MHA Office should be advised along with
the CTO1
Patient (and relatives/carers as appropriate) is given copy of care plan (from CPA) and crisis
and contingency plan and follow-up date.
The CTO does not provide express legal authority to convey. This would require alternative
legal authority (e.g. consent).
Patient discharged onto CTO.
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7.10 – Community Treatment Orders: Maintenance
The idea behind CTO is closer monitoring of those patients presenting a higher risk of deterioration and therefore regular contact should be
maintained. CTO patients should be seen as soon as possible after discharge from hospital and at least within 48 hours.
The conditions of a CTO are not legally enforceable and nothing can therefore be forced against the patient’s will. Conditions can be amended by
the RC completing Form CTO2 to allow for changes in circumstances.
Patients should be regularly reminded of their rights (at least every 6 months) and provided with the appropriate Department of Health leaflet.
This conversation should be recorded on SystmOne using the appropriate form.
All patients subject to CTO will be supported through CPA.
Patient will initially be subject to CTO for 6 months and is subject to Part 4A consent rules
After 4 months MHA Admin team write to RC and care co-ordinator
advising of requirement to review the patient is extension of the CTO
is being considered, a Form CTO7 for renewal including a Capacity
Statement Form will be attached
AMHP completes part 2 of
Form CTO7 and returns to RC
at least 4 weeks before expiry
of CTO
RC completes End of Section
form and forward to the MHA
Office
RC completes part 3 of Form
CTO7 and MHA4 and returns
to MHA admin team ASAP
If no response within 2 weeks MHA admin team
write to RC and care co-ordinator again
Patient should be regularly reviewed by the RC and Care co-ordinator
and the necessity for the patient to remain subject to CTO should be
reviewed and documented
By 4 months a decision needs to be made regarding the continuing
need for CTO.
If RC believes continuation of CTO is necessary then RC completes
part 1 of Form CTO7 and sends to AMHP by the 5 month date (In
determining the most appropriate AMHP consideration must be given
to their knowledge of the patient, their potential involvement with
the patient post-discharge, their availability (EDT AMHPs will not
undertake CTO extensions). If RC does not consider continued CTO
necessary, they must complete End of Section return to the MHA
Office.
AMHP agrees with RC that there is a continued need for CTO?
Y
N
Part 4A Consent Rules
Compulsory treatment cannot be given to a patient on a CTO under
the same conditions as those subject to part 4.
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7.11 – Community Treatment Orders: Recalling and Revoking
Following assessment RC decides if recall necessary and if criteria in section 17E met. The patient can be recalled to any hospital. RC should
ascertain where there is a bed through hospital admission procedures. RC completes Form CT03 (using carbonated pad if in patient’s home and
copier is not available). Form CT03 copied x 2
If the patient does not return willingly to the hospital stated on Form CT03 voluntarily after recall is active they are AWOL. A warrant can be
applied for under section 135(2) by any employee of LPT if the patient is at home and refusing entry
Once in hospital NIC completes Form CT03 and emails to MHA admin team ASAP (within 1 working day) along with copy of Form CTO3. Patient
can be detained for 72 hours only and can be transferred during 72 hours. (Form CT06 if transferred to a different Trust). Section 132 rights
should be recorded on the form on SystmOne.
Alternatives to recall may include informal admission if the patient is has the capacity to consent to this and is consenting, use of the MCA if the
patient lacks capacity or application for a warrant under section 135.
Informal admission: The admission is documented in the same was as other informal admissions. The patient is free to leave at any point unless
restrictions under the MCA can be applied (note s5(2) and 5(4) CANNOT be used). If the patient cannot be kept in hospital under the Mental
Capacity Act then there is no lawful authority to stop them leaving the hospital unless they pose a real and immediate danger to others. The
patient remains subject to Part 4A consent procedures. Where a patient is admitted informally consideration should be given to recall at the
earliest opportunity.
Section 135 warrant (see 5.3.23).: Provides the possibility of forcing entry to a property and removing the individual to a place of safety while an
assessment is carried out as to whether they require recall where they are refusing entry for assessment. The patient remains subject to Part 4A
consent procedures (see 5.3.18). An AMHP would be required to make the application prior to recall being effective and the patient being
‘AWOL’
Form CTO3 (original) can be handed to the patient (and if accepted becomes active immediately), posted through their letterbox (active the next
day – i.e. after midnight), or posted (active on 2
nd
working day after posting – this is not normally appropriate. OOH where the Form CTO3 was
completed at the ward/unit the Crisis Team will be expected to take the form to the patient’s home (or other location).
Care Plan and Crisis and Contingency Plan and CTO statutory forms should contain information about the most appropriate method of ensuring
the patient receives the care they need should their mental health deteriorate and these plans should be updated following any change in
circumstances.
Crisis team may receive telephone calls in relation to crisis situations involving
CTO patients OOH. It may also be discovered that a patient is on a CTO
following the application of a s136. Where ward staff receive a call for the crisis
team they should ascertain if the patient is on CTO and if so make immediate
contact with the crisis team.
In Hours
Out of Hours
Patient regularly seen and monitored by the Care co-
ordinator and/or associated team. Concerns/risks reported
to the RC.
Where the patient is non-compliant with conditions/ mental health deteriorates or there is a change in circumstances either reported by the
carers/relatives or directly by the care team to RC, where a patient is at risk of deterioration the patient should be monitored closely and pre-
emptive arrangements made for re-admission to hospital, including recall. Recalls should normally be affected in normal working hours.
Care Co-ordinator discusses situation with RC and they
discuss next steps.
Transport arranged by the Team. Police assistance requested where risk indicated. Reasonable force can be used to transport the patient.
Where Crisis Team believe recall may be required they should contact the RC
immediately to discuss next steps. The patient should be asked to attend the
ward/unit.
Page 20 of 34
RC completes Part 1 of Form CTO5 and passes to AMHP(In determining the most
appropriate AMHP consideration must be given to their knowledge of the patient,
their potential involvement with the patient post-discharge, their availability (EDT
AMHPs may refuse to undertake CTO revocations)).
Within 72 hours RC decides if patient requires a further period of detention in hospital or can be discharged to continue with their CTO. Further
detention required?
Once admitted on recall patient is subject to consent to treatment provisions following recall – see Consent Flowchart
Y
N
Patient discharged from hospital within the 72
hours (although they can remain ‘informally’) and
their CTO continues as previously.
PART 4A of the MHA (Consent to Treatment)
provisions remain in place
AMHP completes part 2 of Form CTO5
and returns to RC.
RC completes part 3 of Form CTO5 and
returns to MHA Office ASAP
AMHP agrees with RC that there is a need for revocation?
Y
N
Patient’s original detention order
immediately becomes reactivated,
beginning on the day of revocation
Part 4A of the MHA (Consent to
Treatment) provisions remain in place
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7.12 – Discharge: Mental Health Tribunal
Times when the patient and NR have the right to apply for a Tribunal:
• Within 14 days of s2 commencing (patient only)
• Once in each period of s3 detention or CTO (patient only)
• Once in each period of s37 or CTO (starting from the 2
nd
period) (patient and NR where applicable)
• Following displacement of NR (12 months) (NR)
• Following barring of discharge by NR (28 days) (NR)
Times when Hospital Managers automatically refer a patient to the Tribunal:
• After six months of detention if the patient has not applied (including time on section 2)
• Every 3 years if the patient has not applied (from the date of the last tribunal) (every year if <18)
• On revocation of CTO
Patient should be regularly informed of their rights and confirmation of this discussion confirmed on Rights Form on SytmOne. This discussion
should include information regarding the patient’s right to apply to the Mental Health Tribunal.
On receipt of application (of any route) the Tribunal will request:
1. Authority’s statement (MH Admin supply this)
2. RC’s report
3. Social circumstances report (from Care Co-ordinator if open to Community Team or Local Authority if not)
4. In-patient nursing report (as appropriate)
The MHA Office will co-ordinate submission of documentation within statutory timescales
MHA admin team will request reports from the relevant professionals providing a deadline for completion (3 weeks from the date of application
generally or 1 day before the Tribunal for section 2 patients). All instances where reports are not available at least 1 working day prior to the
Tribunal will be recorded as incidents on the electronic risk management system.
Date offered by the Tribunal Office (within 7 days of application for section 2 patients).
Relevant professionals should inform the MHA Office of any dates that they or the patient (or nominated representative) would be unable to
attend so that they can liaise with the Tribunal Office to arrange a mutually convenient date and time.
MHA admin team liaise with the named nurse/ ward manager to establish if the patient has the capacity to appoint or instruct their own
solicitor/representative. The patient should be provided with a list of solicitors specialising in mental health law (which should be available from
each ward/unit – the Trust does not allow the display of posters advertising individual solicitors. Nor does it make recommendations.)
Where the patient lacks capacity to appoint/instruct a representative it is the responsibility of the Tribunal to appoint a representative for the
patient.
Medical member of Tribunal will examine patient before the Tribunalif requested by representative
Tribunal panel sits at the hospital to review the case. The attendance of the RC, the Care co-ordinator and the named nurse (if in-patient) is
expected.
All parties (including patient, representative, advocate and NR as well as health professionals) informed of date, time and venue.
After private discussion, the decision of the tribunal will be announced verbally at the end of the hearing to all present.
The written decision must be sent to all parties concerned within 7 days of the hearing.
CPA/section 117/Pre-discharge planning meeting held to consider plans should Tribunal discharge the patient. Assessments and Care Plans
updated
If the patients asks to withdraw their application at any time the MHA office should be informed immediately so that they can formally withdraw
the application.
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7.14 – Discharge: Managers Panel Members’ Review Meetings & Appeal
Hearings
Patient should be regularly informed of their rights and confirmation of this discussion confirmed on SystmOne. This discussion should include
information regarding the patient’s right to apply to the Managers Panel Members.
Patient / NR requests an appeal hearing or H5 received
MHA Office request reports from the relevant professionals providing
a deadline for completion:
MHA Office arrange for a minimum of 3 Managers Panel Members to convene
Relevant professionals should inform the MHA Office of any dates that they or the patient
(or nominated representative/advocate) would be unable to attend so that they can liaise
with the Managers Panel Members to arrange e a mutually convenient date and time.
All parties (including patient, representative, advocate and NR as well as RC and other
health professionals) informed of date, time and venue. If reports have not been received a
reminder will be sent with the date of the meeting.
The MHA Office record the decision and send the written decision to all parties concerned within 7 days of the hearing.
Times when the patient (or LPA) and NR have the right to apply for a Managers’ Panel Members Hearing:
• At any time during detention in hospital under the MHA (patient and NR)
• At any time whilst subject to CTO (patient and NR)
Times when Hospital Managers automatically hold a renewal meeting:
• On renewal of detention under section 3 or 37 (receipt of Form H5)
• On extension of CTO (receipt of Form CTO7)
• Following the barring of discharge by NR (receipt of Form M2)
If patient has capacity the MHA
admin team liaise with the co-
ordinator to establish if the
patient wishes to attend the
hearing, if not then a paper
hearing will be held
CPA/section 117/Pre-discharge planning meeting held to consider plans should the HM panel discharge the patient. Assessments and Care Plans
updated.
Chair of Managers’ Panel completes relevant decision form. Panel also complete Highlighting concerns form if any concerns or issues raised.
Form CTO7 (including RC’s report) received by MHA admin team
together with capacity form
If the patient does have
capacity or does wish to
attend the hearing
Attendance of RC, AMHP and named nurse (inpatients only) is
expected.
The Panel will communicate the decision verbally to the
patient.
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7.15 – Discharge by Nearest Relative
Nearest Relative (NR) writes letter expressing their wish to discharge the patient and sends to ward or MHA Office.
From the moment of receipt (by any staff member) there are only 72 hours for the following process to be enacted or the NR is able to discharge
the patient.
If received by Ward staff:
• Ward staff date and time receipt of letter & sign with their
designation.
• Notify MHA Office immediately by phone.
• Leave message on voicemail if out of hours.
• Notify RC immediately
If received by MHA admin team
• MHA Office to date & time receipt of letter and sign with
their designation
• MHA Office will notify RC & ward immediately and issue RC
with Form M2 to complete if s/he wishes to block the
discharge.
MHA Office send letter to NR acknowledging receipt of letter.
RC has 72 hours from receipt of the letter to consider whether it is possible to block the discharge. Does RC wish to block discharge?
Y
N
RC notifies MHA Office ASAP by email and End of Section form MHA7
RC informs the patient that they are informal and what this means.
RC completes part 1 of Form M2 declaring that “if discharged [the
patient], would be likely to act in a manner dangerous to other
persons or to himself/herself” and sends to MHA Office ASAP
MHA Office complete part 2 of Form M2 and write to the NR
informing them of the outcome.
MHA admin arrange a Hospital Managers’ hearing
If the Hospital Managers uphold the barring the NR is prevented
from applying for discharge again for 6 months.
MHA Office write to the NR informing them of the outcome and to
patient.
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7.16 – Part 4 Consent to Treatment
The following procedure is applicable to patients detained under sections 2, 3, 36, 37, 38 and 45A
Is the treatment for Mental Disorder?
Y
N
The MHA does not provide sufficient lawful authority to provide the
treatment. Alternative lawful authority is required (See Consent to
Treatment Policy)
What is the treatment proposed?
Psycho-surgery (s57)
Patient must have capacity and
must consent. SOAD must be
requested. SOAD completes
Form T1
ECT (s58A)
18+ with capacity- Form T4
<18 with capacity- Form T5
(SOAD)
Lacks capacity – Form T6
(SOAD) (can’t conflict with LPA
or ADRT)
Medication (s58)
Other Treatment
Can be given without consent
under section 63.
Does the patient have capacity to consent to the treatment? Document on designated form on RiO
Y
N
RC completes SOAD Request and sends to CQC.
RC informs MHA Office when first treatment given under detention.
After 2 months following first administration under detention (including whilst on section 2) MHA Office write to RC requesting Form T2 or Form
T3 is completed.
Does the patient consent to all the treatment or the plan of
treatment proposed (discussion and outcome documented in
Healthcare record)
N
Y
RC and patient complete Form T2 including BNF category, route and
dosage.
SOAD attends the ward. They will discuss the proposed treatment
with the RC, one nurse and one other professional (non nurse/non-
medic) involved in the patient’s care.
If SOAD believes treatment is appropriate (and where against
patient’s wishes is medically necessary) they will complete Form T3.
If within 2 weeks a Form T2 or a Form T3 has not been sent to the MHA admin team they will send a reminder to the RC
The Form T2 or a Form T3 should be reviewed by the RC at regular intervals and at each renewal of section or change in section status. Where the
patient’s capacity changes or they change their mind regarding the provision of consent a new Form T2 or Form T3 should be completed as
appropriate and the old one superseded (marking as such)
Copies of Form T2 and/or Form T3 to be sent to the MHA Office. A copy must also be attached to the prescription card.
It is the responsibility of anyone who prescribes, dispenses or administers medication to a detained patient after 3 months of being treated under
detention to ensure that all medication is legally authorised by a Form T2 or a Form T3.
Treatment in an emergency must follow the provisions of section 62. If medication is to be provided in an emergency Form T3a must be
completed. If ECT is to be provided in an emergency Form C6 must be completed.
25 | P a g e
7.17 – Part 4A Consent to Treatment (CTO patients)
The following procedure is applicable to patients who are subject to CTO whilst they are in the community or are voluntarily in hospital as informal
patients.
Is the treatment for Mental Disorder?
Y
The MHA does not provide sufficient lawful authority to provide the treatment. Alternative
lawful authority is required (See Consent to Treatment in Clinical Care Policy).
What is the treatment proposed?
ECT (s58A)
SOAD must be requested and Form CTO11
completed before treatment can be given
Medication (s58)
Other Treatment
Can be given only if the patient or LPA (or
court-appointed deputy) consents or if
patient lacks capacity if it is in their best
interests and not against LPA/ADRT.
A request for a SOAD to complete Form CTO11 will have been made by the RC on application of the CTO
Y
N
Consent can be given by LPA/Deputy.
OR
Treatment may be given in the best interests of the patient as long as:
• It does not conflict with an ADRT
• It does not conflict with an LPA/Deputy
• It is in the patient’s best interest
• No reason to believe patient objects or force is not required
Form CTO11 required after 1 month.
Does the patient consent to all the treatment or the plan of
treatment proposed
Y
SOAD visit arranged (irrespective of capacity) with Care co-ordinator.
Does the patient have capacity to consent to the treatment? (Undertake capacity assessment if any doubt and outcome documented)
N
Treatment cannot be given.
Consider recalling the patient
to hospital (if criteria met).
For first month of CTO
treatment can be given. After
one month Form CTO11
required.
It is the responsibility of anyone who prescribes, dispenses or administers medication to a CTO patient after 1 month of being treated whilst on
CTO to ensure that all medication is legally authorised by a Form CTO11.
The Care co-ordinator should arrange for a copy of Form CTO11 to be given to the patient, a copy to be sent to the GP, a copy attached to any
relevant prescription charts and a copy placed in the healthcare record. The original must then be sent to the MHA admin team.
Once recalled to Hospital/CTO revoked - The patient becomes subject to Part 4 consent to treatment provisions as though they had never
been discharged onto CTO (see 7.3.17). Therefore a certificate (Form T2, T3, T4, T5, T6) is required to authorise treatment with only 3 exceptions:
Treatment in an emergency must follow the provisions of section 64B (with capacity) or section 64G (lacking capacity). If medication is to be
provided in an emergency Form C6 must be completed. If ECT is to be provided in an emergency Form C6 must be completed.
If the patient does not attend the SOAD appointment the SOAD will require evidence from the care co-ordinator/MHA admin team that all efforts
have been made and the patient has been informed of the consequences of not attending. If the SOAD is not satisfied that appropriate
arrangements were made s/he will ask for new SOAD referral to be made.
The SOAD will discuss the proposed treatment with the RC, one nurse and one other professional (non nurse/non-medic) involved in the patient’s
care. If SOAD believes treatment is appropriate, they will complete Form CTO11. They will also include on the form treatment that may be
provided should the patient be recalled to hospital.
26 | P a g e
If it has been less than 1 month since patient
discharged onto CTO (i.e., does not have
Form CTO11)
If the treatment is explicitly written on Form
CTO11 as being authorised following recall.
If the treatment was being given on CTO and
the RC believes discontinuing would cause
the patient suffering.
The Form T2, T3 etc should be reviewed and arrangements made for a new certificate where necessary as the above exceptions will only apply
whilst a new certificate is obtained.
Treatment in an emergency must follow the provisions of section 62. If medication is to be provided in an emergency C6 must be completed. If ECT
is to be provided in an emergency C6 must be completed.
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7.18 – Death of a Detained/ CTO Patient
Patient is declared deceased whilst subject to the provisions of the MHA (including CTO)
Inform the MHA Office ASAP.
Responsible Clinician liaises with the Compliance Team for the completion and timely submission of the CQC Notification of Death Form (in-
patient/CTO.
The MoJ requires immediate notification of the death of a restricted patient, this remains the responsibility of the RC in conjunction with the
Compliance Team. For restricted patients NIC informs MOJ immediately.
Death of patient procedures followed.
28 | P a g e
7.19 – Section 19 Transfer
Patient subject to MHA requires transfer – RC to discuss with patient and care team and document reasons.
From one Trust ward/unit to another Trust ward/unit.
From a Trust ward/unit to a hospital managed by a different
Trust
Ward Manager/ NIC informs MHA Office immediately.
RC remains responsible for patient until transfer is complete
and agrees transfer of care with accepting RC.
MHA Office should be informed at the EARLIEST opportunity
and will provide original detention papers to Ward Matron
Original section papers and Form H4 must accompany the
patient for transfer.
Receiving hospital sign and date Form H4
Staff member accompanying patient requests a photocopy
of Form H4
Copy sent to MHA Office
Where patient is transferred to the Trust from another Trust/Local Authority the individual accepting the transfer must ensure that the original
section papers are received (including Form H3) and checked as well as the relevant transfer documentation (see above) before accepting
responsibility or signing transfer documentation. In exceptional circumstances photocopies may be accepted by the admitting nurse. For transfer
into the Trust of section 2 or section 3 patients the admitting nurse should follow the procedure described in 7.3.3 or7.3.5 respectively. All
paperwork should be sent to the MHA admin team ASAP (within 1 working day).
The responsibility for CTO patients can be transferred to another Trust/Independent Hospital by completion of Form CTO10 whilst the patient
remains in the community or by completion of Form CTO6 during the 72 hours of recall.
RC informs Ward Matron (inpatients) or Care Co-ordinator
(CTO patients- see notes below) who completes form H4 can
be delegated in accordance with Delegation Document
RC is responsible for patient until transfer is complete and agrees
transfer of care with accepting RC.
INTERNAL TRANSFER
The patient remains under the authority of LPT.
EXTERNAL TRANSFER
The patient transfers to the authority of another provider
This process will be reversed for transfers into LPT from
another provider.
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7.20 – Section 132 Duty to Provide Information
Maintaining accurate records of section 132 in accordance with the legislative and Code of Practice requirements is essential in ensuring
compliance and best practice.
The Trust provides for the electronic recording of section 132. It is the responsibility of the nursing staff (with responsibility for patients
subject to the Act) to ensure accurate and up to date records are maintained.
Electronic recording - There are several electronic forms each with a specific purpose that follow the patient’s detention pathway. These
forms should be completed at relevant points in that pathway.
• The six forms are:
S132 – at the point of detention
S132 – Review (revisit)- at least monthly for inpatients
S132 – Regrade of detention order
S132 – Renewal or Extension (CTO)(this will provide for the revisit of rights for CTO patients)
S132 – Discharge from detention
S132 – Going onto a CTO
It is the responsibility of qualified nursing staff to familiarise themselves with the process and the relevant forms.
30 | P a g e
8. References & Bibliography
Mental Health Act 1983 (legislation.gov.uk)
Code of practice: Mental Health Act 1983 - GOV.UK (www.gov.uk)
Mental Health Act 1983: reference guide - GOV.UK (www.gov.uk)
31 | P a g e
Appendix 1 Training Requirements
Training Needs Analysis
Training topic:
Mental Health Act 1983
Type of training:
(see study leave policy)
☐ Mandatory (must be on mandatory training register)
X Role specific
☐ Personal development
Directorate to which the
training is applicable:
X Adult Mental Health
X Community Health Services
☐ Enabling Services
X Families Young People Children / Learning Disability/ Autism
Services
☐ Hosted Services
Staff groups who require
the training:
Band 5 nurses and above
Regularity of Update
requirement:
Three-yearly
Who is responsible for
delivery of this training?
Senior MHA Administrator
Deputy to the Senior MHA Administrator
Have resources been
identified?
Yes
Has a training plan been
agreed?
Yes
Where will completion of
this training be recorded?
X ULearn
☐ Other (please specify)
How is this training going to
be monitored?
Through reporting to the MHA GDG
32 | P a g e
Appendix 2 The NHS Constitution
• The NHS will provide a universal service for all based on clinical need, not ability to pay.
• The NHS will provide a comprehensive range of services.
Shape its services around the needs and preferences of individual patients, their families and
their carers
Y
Respond to different needs of different sectors of the population
Y
Work continuously to improve quality services and to minimise errors
Y
Support and value its staff
Y
Work together with others to ensure a seamless service for patients
Y
Help keep people healthy and work to reduce health inequalities
Y
Respect the confidentiality of individual patients and provide open access to information about
services, treatment and performance
Y
33 | P a g e
Appendix 3 Due Regard Screening Template
Section 1
Name of activity/proposal
Mental Health Act Procedural Document
Date Screening commenced
January 2024
Directorate / Service carrying out the
assessment
Enabling Directorate
Name and role of person undertaking
this Due Regard (Equality Analysis)
Alison Wheelton
Senior MHA Administrator
Give an overview of the aims, objectives and purpose of the proposal:
AIMS: This procedure aims to provide staff with delegated responsibility under the Mental Health Act
and in accordance with the Trust Delegation Document, with the knowledge to undertake those
responsibilities.
OBJECTIVES: To ensure staff have the necessary knowledge and tools to ensure the authorisation,
implementation and recording and monitoring of the Mental Health Act is done so in accordance with
legislative and good practice requirements.
Section 2
Protected Characteristic
If the proposal/s have a positive or negative impact please give
brief details
Age
Positive impact as this procedure is supportive to staff who fall
within the remit of the Equality Act 2010, ensuring consistency in
approach for all staff irrespective of who they are.
Disability
As above
Gender reassignment
As above
Marriage & Civil Partnership
As above
Pregnancy & Maternity
As above
Race
As above
Religion and Belief
As above
Sex
As above
Sexual Orientation
As above
Other equality groups?
As above
Section 3
Does this activity propose major changes in terms of scale or significance for LPT? For example, is
there a clear indication that, although the proposal is minor it is likely to have a major affect for people
from an equality group/s? Please tick appropriate box below.
No
High risk: Complete a full EIA starting click
here to proceed to Part B
Low risk: Go to Section 4.
Section 4
If this proposal is low risk please give evidence or justification for how you
reached this decision:
This procedure outlines staff responsibilities and is in accordance with legislative and statutory
requirements
Signed by reviewer/assessor
Alison Wheelton
Date
16/01/24
Sign off that this proposal is low risk and does not require a full Equality Analysis
Head of Service Signed
Deeanne Rennie
Date
16/01/24
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Appendix 4 Data Privacy Impact Assessment Screening
Data Privacy impact assessment (DPIAs) are a tool which can help organisations identify the most
effective way to comply with their data protection obligations and meet Individual’s expectations of
privacy.
The following screening questions will help the Trust determine if there are any privacy issues
associated with the implementation of the Policy. Answering ‘yes’ to any of these questions is an
indication that a DPIA may be a useful exercise. An explanation for the answers will assist with the
determination as to whether a full DPIA is required which will require senior management support, at
this stage the Head of Data Privacy must be involved.
Name of Document:
Mental Health Act 1983 Procedural Document
Completed by:
Alison Wheelton
Job title
Senior MHA Administrator
Date January 2024
Screening Questions
Yes /
No
Explanatory Note
1. Will the process described in the document involve
the collection of new information about individuals?
This is information in excess of what is required to
carry out the process described within the document.
No
2. Will the process described in the document compel
individuals to provide information about them? This is
information in excess of what is required to carry out
the process described within the document.
No
3. Will information about individuals be disclosed to
organisations or people who have not previously had
routine access to the information as part of the
process described in this document?
No
4. Are you using information about individuals for a
purpose it is not currently used for, or in a way it is not
currently used?
No
5. Does the process outlined in this document involve
the use of new technology which might be perceived
as being privacy intrusive? For example, the use of
biometrics.
No
6. Will the process outlined in this document result in
decisions being made or action taken against
individuals in ways which can have a significant impact
on them?
No
7. As part of the process outlined in this document, is
the information about individuals of a kind particularly
likely to raise privacy concerns or expectations? For
examples, health records, criminal records or other
information that people would consider to be
particularly private.
No
8. Will the process require you to contact individuals in
ways which they may find intrusive?
No
If the answer to any of these questions is ‘Yes’ please contact the Data Privacy Team via
Lpt-dataprivacy@leicspart.secure.nhs.uk
In this case, ratification of a procedural document will not take place until review by the Head of Data
Privacy.
Data Privacy approval name:
N/A
Date of approval
Acknowledgement: This is based on the work of Princess Alexandra Hospital NHS Trust