Elena Wells

Amember of: EE Se NHS)
Association of UK University Hospitals | Sussex Partnership
—_ : NHS Foundation Trust

Swandean - Trust HQ
Arundel Road

; ; Worthing
Private & Confidential West Sussex

Mrs Catharine Palmer BN13 3EP
Assistant Coroner

Dear Mrs Palmer

10 February 2021

Re: The late Miss Elena WELLS

Thank you very much for your letter of 23rd November under cover of which you raised
two matters of concern under Paragraph 7, Schedule 5 of the Coroners and Justice Act
2009 and Regulation 28 and 29 of the Coroner's (investigations) Regulations 2013, arising
from the inquest of Elena Wells concluded on 9th November 2020.

The Trust and Brighton and Hove City Council (BHCC) wish to reiterate our condolences
to the family of Elena Wells. The Prevention of Future Deaths report has provided us with
a further opportunity to address gaps in guidance and policy between the Trust and BHCC
to ensure there is the provision of a continuous package of care, support and monitoring
for voluntary patients, like Elena, who are waiting a short period of time for admission to an
acute mental health bed.

This response has been developed in partnership between the Trust and BHCC. | want to
take this opportunity to stress that both organisations recognise their joint responsibilities
in these circumstances and whilst | understand BHCC will be required to respond
separately, both organisations wish to ensure that communication between us is as
constructive as possible.

The Trust and BHCC have a long history of partnership working and integrated service
delivery. Both organisations have delivered integrated adults and older adults secondary
mental health and adult social care services in the City for a number of years via a formal
s75 Partnership Agreement.

The two key issues which both organisations have considered to formulate this response
are:

1. Actions taken to improve communication and clearly define
responsibility between the Trust and the BHCC in order to improve the safety
of patients with serious mental illness who are awaiting admission to an
acute psychiatric hospital.

one cher Bxccuive:

Head office: Sussex Partnership NHS Foundation Trust, Swandean, Arundel Road, Worthing, West Sussex, BN13 3EP
www. sussexpartnership.nhs.uk

A teaching trust of Brighton and Sussex Medical School

In response, the Trust is in the process of developing a new Crisis Resolution Home
Treatment Team (CRHT) Operational Policy. An interim policy was presented to the
Operational Management Board in December 2020 and it was agreed the CRHT teams
would work to this whilst the policy is further developed by the newly appointed Trust wide
Urgent Care Pathway Lead.

The interim policy includes details of when an inpatient admission has been agreed for a
patient but a bed is not immediately available, then the CRHT will support the person
whilst they are waiting to be admitted. Within the interim policy it also details that if the
level of risk increases and the CRHT are not able to safely support the patient, then this
will need to be escalated to senior managers and support put in place from other urgent
care services such as The Havens.

Along with support from the Adult Operational Services, the Urgent Care Pathway Lead
will be leading on finalising the interim CRHT operational policy. This work which is
underway, will include a clear referral pathway for AMHP’s who have assessed a person
as needing admission. This pathway will reflect the integrated working arrangements in
Brighton and Hove and is being jointly developed by BHCC and the Trust’s Operational
Leads and will define the key responsibilities and tasks of the Approved Mental Health
Practitioners, Urgent Care Services and Assessment and Treatment Services in the
management of patients awaiting informal or compulsory psychiatric admission.

Operational Leads are also completing further work to identify points of contact within the
Trust outside of the operational hours of CRHT. As this work is currently being completed,
the Trust can forward this policy once finalised if required.

As widely reported nationally, the demand for acute mental health provision is profoundly
challenged, in part, due to the impact of the Covid 19 pandemic. Both the Trust and the
wider health and social care economy are undertaking a number of actions to improve the
position which includes purchasing an additional 45 acute psychiatric beds in the
independent sector within Sussex; to ensure that patients receive their care as locally as
possible and to ensure we can facilitate acute admissions for patients with the least delay.
The Trust has developed close working relationships with other Providers, enabling
patients to receive the same level of care, treatment and discharge planning that they
would if under the care of Sussex Partnership NHS Foundation Trust (SPFT). This
includes attendance at weekly ward rounds and oversight of all admissions and discharges
by our Clinical Lead Nurses for acute bed management and the recent development of our
Clinically led Intensive Support Teams (IST). The IST is a senior multi-disciplinary team of
SPFT clinicians who work closely with independent sector providers to ensure optimum
care for all our patients as well as discharge planning.

Locally, the Care Delivery Services [CDS] in Brighton has established an Urgent Demand
Oversight meeting that enables the CDS Leads to have daily oversight of our patients
requiring admission to hospital. This meeting is informed by the various Operational
meetings that take place daily in our Community, Urgent and Acute Care Services and is
described in the enclosed Terms of Reference (appendix 1).

Page 2 of 5

The function of these meetings is to consider and review the service demand for the day
ahead, confirming available resources and re-planning as needed to ensure teams are
able to deliver services safely and as required. Representatives from these service areas
then attend the Oversight Meeting, along with the Deputy Service Director and Bed
Manager to review the overall demand for Urgent and Acute Care Services.

The Oversight Meeting provides a focus on patients like Elena, who are waiting in the
community for inpatient care, confirms the support package that is being provided, and by
whom.

The Trust and their Commissioners have developed a number of additional urgent care
services posts, pre and during the Covid-19 pandemic, in response to the demand on
services but also as part of the wider strategic investment into mental health services and
the response to the NHS Long Term Plan. This includes the expansion of the Sussex
Mental Health Line to become a 24 /7 Sussex wide free phone service, an A&E diversion
service for Children & Young People, the opening of Crisis Cafes in Brighton, Worthing,
Eastbourne and Crawley and clinical pathways to redirect patients with mental health
presentations away from A&E departments.

The Trust has a system of clinical bed management led by senior nurses which operates 7
days a week. This system is supported by administrative bed managers and a single point
of access for referrals to the Trust's Health Based Places of Safety (HBPoS) - both of
which operate on a 24/7 basis. The Trust manages its acute bed provision on a Sussex
wide basis to ensure patients can access acute care as soon as is practicable once a
decision to admit has been made.

All demand for inpatient care is subject to clinical prioritisation as outlined in the Trust's
Bed Management Policy and prioritisation is subject to immediate adjustment in light of
continuous and dynamic risk assessment by the Trust's Urgent Care and Assessment and
Treatment Services as outlined in the above point.

2. It is requested that the Trust consider ways of providing extra support
and supervision to those patients who are waiting for an urgent admission,
particularly those who may be left alone at home for any period until a bed is
available.

When a patient is assessed as requiring admission but the person will need to wait for a
bed to be available, the Approved Mental Health Professional (AMHP) will develop an
immediate safety plan with the patient and family/carer aimed at keeping the person safe
until a bed is sourced. As part of the process of requesting a bed this immediate safety
plan will be shared as part of the CRHT gatekeeping process and the Lead Practitioner if
applicable.

In addition, as part of the Sussex wide investment and developments in Urgent Care, the
Trust is developing a trusted assessor model so that AMHP's and s12 Doctors can
complete assessments on behalf of CRHT in order that patients can avoid being
repeatedly assessed and can start receiving care and treatment sooner.

Page 3 of 5

Current practice is that the CRHT will accept referrals as made by the Council's AMHP's;
independent s12 Doctors and Lead Practitioners working within the Assessment and
Treatment Services in order to provide patients with a package of care whilst an inpatient
bed is identified.

This package of support would be formulated and delivered in partnership with other
services, including the patient's family and carers as clinically indicated and depending on
the assessed level of risk.

In June 2019, Brighton and Hove Mental Health Services opened the Haven at Mill View
Hospital which has 4 Assessment Bays in Brighton - a psychiatric decision unit which
provides a 24/7 service for patients to receive an extended period of assessment whilst
presenting in crisis. Where patients present in extremis, provision can be made to
accommodate them at the Haven for longer than 24hrs. During the early stages of the
Covid 19 pandemic, the Trust developed an additional Haven in Worthing and expanded
the capacity and opening hours of the Urgent Care Lounges in Eastbourne, Hastings and
Crawley. Where the patient's individual profile and risk allow it, both Havens and Urgent
Care Lounges throughout the Trust can be used to support patients, for a short period of
time, i.e. patients who have been identified as requiring an admission to hospital whilst
waiting for an acute bed to become available. This would be considered on a case by case
basis and forms part of a total package of care and support for a patient based on an
assessment of their needs and risk.

The Trust has five HBPoS co-located within acute psychiatric hospitals which are used for
the assessment and treatment of patients who have been detained under Mental Health
Act 1983 Section 136. During the first wave of the Covid pandemic, the Trust designated
three of the Havens and Urgent Care Lounges as Alternative HBPoS in order to increase
capacity and avoid patients having to attend Acute Trust A&E departments for support and
treatment with mental health. In the event of significant acute bed demand and to meet
patients assessed needs, in extremis the Trust can temporarily admit patients to a HBPoS
whilst an acute bed is identified. When this occurs, the use of the HBPoS is actively
monitored by the Clinical Bed Management Team with person seen as having top priority
for an inpatient bed.

All Acute Hospitals across Sussex have 24/7 Mental Health Liaison Teams in place and
therefore, in extremis patients can be supported to attend A&E departments to mitigate
any risk whilst awaiting an acute inpatient admission. A&E Departments were formally
classified as HBPoS in the national guidance in response to the changes to the Mental
Health Act in December 2017. In the most urgent situation, if a patient's presentation
alters dramatically, the Trust would seek support from Sussex Police or the South East
Coast Ambulance Service as appropriate.

The Trust's core community secondary mental health care services are described as
Assessment and Treatment Services (ATS). These are multi-disciplinary teams which
provide care and treatment under the Care Programme Approach. Elena was known to the
East Brighton ATS and had an allocated Lead Practitioner.

Page 4 of §

In the circumstances to which this response is directed, the patient's Lead Practitioner
would provide a key part of the patient's care plan whilst waiting for an admission to acute
psychiatric hospital, in partnership with other community and urgent care services,
provision from the community and voluntary sector and any identified carers or family
resources as appropriate. Any plan of care in these circumstances would be subject to the
Trust's Care Programme Approach and Safe and Effective Assessment and Management
of Clinical Risk Policies.

Our colleagues at BHCC approve and support the above arrangements and lines of
communication between the local AMHP Services and the Trust is now clear on its clinical
responsibility for patients like Elena.

| trust this letter reassures you that we have taken steps to improve the support that we
provide to our patients at the point they are recommended for inpatient admission and
throughout their pathway.

Yours sincerely

ONE Ae en.
aa
NJ

Chief Executive

Enc. Terms of Reference (appendix 1)

Page 5 of 5

INHS

Sussex Partnership
NHS Foundation Trust

Appendix 1

B&H Adult CDS Urgent Demand Oversight Meeting

Ratification Date February 2021. ~—s Owner _ SE
oe : : : Deputy Director

Purpose

The Urgent Demand Oversight Meeting (ODOM) enables the CDS Leads to have

daily oversight of our patients requiring support from our acute and urgent care
services.

Representatives from these service areas are required to attend the UDOM, along
with the Deputy Service Director and Bed Manager to review the overall demand for
Urgent and Acute Care Services.

Duties

Feedback will be reported from the various ‘handover’ or ‘huddle’ meetings that take
place daily in our Community, Urgent and Acute Care Services by the nominated
representatives.

The function of these meetings is to consider and review the service demand for the
day ahead, confirming available resources and re-planning as needed to ensure
teams are able to deliver services safely and as required.

The UDOM will receive an update from each service area for the purpose of:
1. Confirming that services across the CDS can be delivered safely as required
2. To consider the deployment of resources as needed
3. Identify any patients requiring urgent admission to acute care services,
ensuring interim support arrangements are in place, by whom, and consider
any barriers or additional actions that may be required
4. Confirm additional communication arrangements as needed

Members

¢ Deputy Director (chair) Representation is required from

¢ General Manager community (or acute, community and urgent care
nominated rep) services,

e Clinical Lead Nurse Manager (or
nominated rep)
e Urgent Care Service Manager (or

nominated rep)

« Bed Manager

In addition to the above team level
representation is required from:

e MHLT

e CRHTT

e The Haven

Frequency

Meetings will be held via Skype and take place daily at 12 noon.

_Communication

The chair will share a brief summary following the meeting and will include:
1. Service area briefings
2. Acute care demand
3. Any identified actions and further communication arrangements

This will be shared with all attendees, senior operational managers, CDS
Professional Leads and Clinical Directors, and Operations Director.

Reporting .

The activity reported to the Urgent Demand Oversight meeting (UDOM) will be
informed by the following arrangements:

2 Activity Via -UDOM

Clinical Lead Nurse
Manager

Bed Manager

Acute Care (all wards and Daily Huddle meeting
HBPOS)

AMHP

AMHP Handover

Community (all teams) Huddle meetings (3 x General Manager
weekly) and via Service Community
Manager reporting (daily)
CRHTT Daily Handover meeting CRHTT Team Lead
MHLT Daily Handover meeting Clinical and Team Leads

Daily Handover meetings Team Lead

Review

These terms of reference will be reviewed in February 2021 and annually
thereafter or as required.

These terms of reference can be made available in alternative formats if required

aon Chief Executive
| i q : Hove Town Hall
Norton Road

Brighton & Hove eee Hove
City Council BN3 3BQ
Private and Confidential Date: 10 February 2021

Mrs. Catherine Palmer Our Ref:
Her Majesty's Assistant Coroner ur er:
for the City of Brighton and Hove Your Ref:

Phone:
By email only: Email:

Re: The late Miss Elena WELLS

| write in response to your report to prevent further deaths, made under paragraph 7, Schedule 5 of
the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations)
Regulations 2013.

The Inquest into Miss Wells’ death highlighted miscommunication and misunderstanding between
the Council's Approved Mental Health Professional (AMHP) team and staff within the Sussex
Partnership Foundation Trust (SPFT) about the role of the AMHP after a Mental Health Act 1983
(MHA) assessment by an AMHP and two section 12 doctors conclude that a patient should be
admitted to hospital for assessment or treatment. The AMHP is responsible for making an
application for the patient to be admitted to hospital (section 11 MHA). Applications must be
accompanied by two supporting medical recommendations (section 2 and 3 MHA).

The legislation and statutory Code of Practice is clear in the division of responsibility between the
AMHP, as a local authority employee, and the NHS. The Brighton and Hove Clinical
Commissioning Group (CCG) has contracted for the SPFT to deliver mental health services within
Brighton and Hove city. Therefore references in the legislation to the CCG in relation to mental
health are, for the purposes of Brighton and Hove, to be read as references to the SPFT.

Section 140 of the MHA places a duty on every CCG to notify every local social services authority
of the hospital/s available to it for receiving patients in special urgency. A copy of that provision is
attached.

The Code of Practice was produced in accordance with s118 MHA. The relevant paragraphs of
that Code are at paragraphs 14.77 to 14.99. That extract is attached.

The extracted paragraphs relate to the CCG duty to make available suitable beds for the admission
of patients, “it is not the responsibility of the applicant “[the AMHP] paragraph 14.77.

The AMHP should then be in a position to make the application for the patient's admission referring
to the beds available to the patient as notified by the CCG.

In the event of delay identifying a suitable bed for the patient, paragraph 14.86 states “AMHPs
should be supported by their local authority in these circumstances and should not be expected by
commissioners and providers to address the delay themselves. In the meantime, commissioners
should, in partnership with providers, ensure that alternative arrangements to meet the person's

1|Page

Chief Executive
) ) Hove Town Hall
Norton Road

Brighton & Hove Hove
City Council BN3 3BQ

needs pending the availability of a bed are accessible, eg crisis houses, and should communicate
those arrangements to the local authority.”

Where an AMHP decides that an application for detention is not required the decision should be
supported, where necessary, by another framework for care or treatment eg referring the patient to
social, health or other services (paragraph 14.104).

The local authority role in supporting its AMHPs is dependent on the SPFT informing it of suitable
resources available to meet the acute mental health needs of a patient particularly when there are
no beds immediately available. Recent discussions with SPFT have clarified how the AMHP can
ensure that an assessed patient is supported pending an admission to hospital.

Productive discussions have taken place between the local authority and SPFT staff to identify
what policies, practice guidance and communications need to be produced or amended to clarify
professional roles within the mental health legal framework. It is agreed that a simple Brighton and
Hove flowchart describing how an AMHP can ensure a patient post-assessment receives
necessary care or treatment without delay regardless of bed availability is essential. A draft
flowchart has already been produced. There is also a need for AMHPs to be accepted as Trusted
Assessors which would enable more efficient and faster referrals into SPFT services.

| have had the benefit of seeing a draft of the SPFT response to your regulation 28 report ahead of
the drafting of my response.

Based on the positive working relationship that exists between the local authority and the SPFT, |
am confident that we can achieve the clarity needed for our respective staff to be able to operate in
an appropriate manner to ensure patient safety. This task is being prioritised within the local
authority and we have agreed with the SPFT that the flowchart should be finalised by the end of
March 2021 confirming a local protocol between our organisations. In the interim the measures that
have been put in place already by SPFT eg. the introduction of a daily Urgent Demand and
Capacity meeting conducted by the Care Delivery Service, the availability of the local
Haven@Millview hospital and the agreement of operational management of the role of an AMHP,
assure me that the confusion that was evident with some professionals involved in Miss Wells care
in March 2020 should not arise again.

Chief Executive
Brighton & Hove City Council

2|Page

2/2/2021

UK Parliament Acts/M/MA-MG/Mental Health Act 1983 (1983 c 20)/Part X Miscellaneous and Supplementary (ss [130A-
149)/[140 Notification of hospitals having arrangements for special cases]

[140 Notification of hospitals having arrangements for special cases]

It shall be the duty of [every clinical commissioning group and of] [. . .] every [Local Health Board] to give notice to
every local social services authority for an area wholly or partly comprised within the [area of the [clinical
commissioning group or] . . .] {Local Health Board] specifying the hospital or hospitals administered by [or otherwise
available [to the [clinical commissioning group or] [. . .] [Local Health Board]]] in which arrangements are from time to
time in force[—

(a) _ for the reception of patients in cases of special urgency;

(b) _ for the provision of accommodation or facilities designed so as to be specially suitable for patients who have
not attained the age of 18 years].

NOTES

Derivation

This section derived from the Mental Health Act 1959, s 132.

Initial Commencement

Specified date

Specified date: 30 September 1983: see s 149(2); for transitional provisions and savings see Sch 5 hereof.

Amendment

Section heading: substituted by the Mental Health Act 2007, s 31(1),.(4).

Date in force: 3 November 2008: see S$! 2008/1900, art 2(h); for transitional provisions and savings see art
3, Schedule, paras 1, 12 thereto.

Words “every clinical commissioning group and of” in square brackets inserted by the Health and Social Care Act
2012,$ 45(1){a).

https://www.lexisnexis.com/uk/legal/delivery/PreviewFrameDisplay.do?dnidFilePath=%2Fl-n%2Fshared%2Fprod%2Fdiscus%2Fqds%2Frepository%2... 1/3

Applications for detention in hospital

14

14.76

When making recommendations for detention under section 3, doctors are
required to state that appropriate medical treatment is available for the patient
(see chapter 23), Preferably, they should know in advance of making the
recommendation the name of the hospital to which the patient is to be admitted.
If that is not possible, their recommendation may state that appropriate medical
treatment will be available if the patient is admitted to one or more specific
hospitals (or units within a hospital).

Commissioning and section 140 of the Act

14.77

14.78

14.79

14.80

If the doctors reach the opinion that the patient needs to be admitted to hospital, it
is their responsibility to take the necessary steps to secure a suitable hospital bed;
it is not the responsibility of the applicant. In some cases, it could be agreed locally
between the local authority and the relevant NHS bodies and communicated to the
AMHP that this will be done by any AMHP involved in the assessment.

Clinical commissioning groups (CCGs) are responsible for commissioning mental
health services to meet the needs of their areas. Under section 140 of the Act,
CCGs have a duty to notify local authorities in their areas of arrangements which are
in force for the reception of patients in cases of special urgency or the provision of
appropriate accommodation or facilities specifically designed for patients under the
age of 18. The arrangements should include details of which providers in their area
can receive patients in cases of special urgency and provide accommodation or
facilities designed to be specifically suitable for patients under the age of 18. CCGs
should provide a list of hospitals and their specialisms to local authorities which will
help inform AMHPs as to where these hospitals are. This should in turn help inform
AMHPs as to where beds are available in these circumstances if they are needed.

The NHS Commissioning Board (known as NHS England) is responsible for the
commissioning of secure mental health services and other specialist services. NHS
commissioners should work with providers to ensure that procedures are in place
through which beds can be identified whenever required.

Local authorities, providers, NHS commissioners, police forces and ambulance
services should ensure that they have in place a clear joint policy for the safe and
appropriate admission of people in their local area agreed at board or board-
equivalent level by each party and each party should appoint a named senior lead
(‘senior lead’). It is good practice for the parties to the local policy to meet regularly
to discuss its effectiveness in the light of experience and review the policy where
necessary, and to decide when information about specific cases can be shared
between relevant parties for the purposes of protecting the person or others, in line
with the law. Persons carrying out functions for these parties should understand
the policies and their purpose, the roles and responsibilities of other agencies
involved, and follow the local policy and receive the necessary training to be able to
carry out fully their functions.’

7 Local crisis care policies and agreements should already in place through the Mental Health Crisis Care Concordat: Improving outcomes for people
experiencing mental health crisis, Department of Health and Concordat signatories. 2014. https://www.gov.uk/government/uploads/system/uploads/
attachment_data/file/28 1242/36353_Mental_ Health_Crisis_accessible.pdf

126

Applications for detention in hospital

14.81 In order to promote a patient's recovery, NHS commissioners and providers should
work together to take steps, with appropriate input from section 12 doctors
and AMHPs, to place individuals as close as is reasonably possible to a location
that the patient identifies they would like to be close to (eg their home or close 14
to a family member or carer}. This should take account of any risk assessment
undertaken, the availability of services which can meet the patient’s individual
needs, any assessment in respect of the likely duration of the patient's stay,
and any other factors raised by the patient and their family. The location of the
placement, and considerations relevant to that decision, should be monitored and
reviewed regularly. Where secure care is needed further issues become relevant
(see paragraph 14.82). This will help to facilitate effective discharge and after-care
planning (see chapters 32 and 33).

14.82 For individuals who require low and medium secure mental health services,
consideration should be given, through clinical and risk assessment, to the type
of care required, especially where this includes specialist care. Steps should be
taken to place individuals as close as is reasonably possible to a location that
the patient identifies they would like to be close to that is suitable for their needs.
If an individual is assessed as requiring high secure mental health services, they
will be placed in a high security hospital according to the defined catchment
areas of these hospitals. Rampton Hospital is the provider of national services for
women, deaf people and people with learning disabilities who require high secure
mental health services. Decisions regarding the location and type of facility where
restricted patients are placed will be determined by appropriate clinical and risk
assessment of the type of care required to meet the needs of the patient and to
protect public safety.

14.83 In cases where the patient lacks capacity to make a decision about the location
they would like to be close to, a best interests decision on the location should be
taken.

14.84 Having regard to the empowerment and involvement principle, commissioners
should ensure as far as is possible that carers are involved in the decision about
where to locate an individual, and are informed of the reasons for the decision
taken. Commissioners should have in place a policy so that the patient and/or the
patient's carers are able to challenge a decision.®

14.85 When a patient's carer informs the commissioner of difficulties in visiting the
patient because of the distance that they need to travel, the commissioner should
consider whether they can provide any assistance to support the patient's carer
to visit and maintain contact with the patient. The commissioner should inform the
carer that they can request a carer's assessment from the local authority. CCGs
should work with the relevant NHS Commissioning Board regional team under
these circumstances to seek to move the patient closer to their preferred location.

® The Department of Health and NHS Commissioning Board (NHS England} will work together to develop guidance for commissioners as to what should
be included in such a policy.

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Applications for detention in hospital

14

14.86

Local recording and reporting mechanisms should be in place to ensure the details
of any delays in placing patients, and the impacts on patients, their carers, provider
staff and other professionals are reported to commissioning and local authority
senior leads. These details should feed into local demand planning. AMHPs should
be supported by their local authority in these circumstances and should not be
expected by commissioners and providers to address the delay themselves. In

the meantime, commissioners should, in partnership with providers, ensure that
alternative arrangements to meet the person's needs pending the availability

of a bed are accessible, eg crisis houses, and should communicate those
arrangements to the local authority. The local authority should ensure that AMHPs
are aware of these arrangements.

Action when it is decided to make an application

14.87

14.88

14.89

128

Most compulsory admissions require prompt action. Applicants have up to 14
days (depending on when the patient was last examined by a doctor as part of the
assessment) in which to decide whether to make the application, starting with

the day they personally last saw the patient. There may be cases where AMHPs
conclude that they should delay taking a final decision in order to see whether the
patient's condition changes, or whether successful alternatives to detention can be
put in place in the interim.

Before making an application, AMHPs should ensure that appropriate
arrangemenis are in place for the immediate care of any dependent children the
patient may have and any adults who rely on the patient for care. Their needs
should already have been considered as part of the assessment. Where relevant,
AMHPs should also ensure that practical arrangements are made for the care of
any pets and for the local authority to carry out its other duties under the Care Act
2014 to secure the patient’s home and protect their property.

Applications for detention must be addressed to the managers of the hospital
where the patient is to be detained. An application must state a specific

hospital. An application cannot, for example, be made to a multi-site provider
without specifying which of the provider's sites the patient is to be admitted to.
Providers should identify a bed manager or other single point of contact who

will be responsible for finding a suitable bed as soon as possible and telling the
applicant the name of the site at which it is situated. Effective systems of bed
management including discharge planning, possible alternatives to admission and
demand planning should be in place. The bed manager should work closely with
commissioners to proactively identify local need, and with assessing doctors and
AMHPs to secure a bed. AMHPs should be adequately supported by their local
authority in establishing working partnerships with other local agencies listed at
paragraph 14.80.

Applications for detention in hospital

14,90 Where units under the management of different bodies exist on the same site (or
even in the same building), they will be separate hospitals for the purposes of the
Act, because one hospital cannot be under the control of two sets of managers.
Where there is potential for confusion, the respective hospital managers should 14.
ensure that there are distinct names for the units. In collaboration with local
authorities, they should take steps to ensure that information is available to AMHPs
who are likely to be making relevant applications to enable them effectively to
distinguish the different hospitals on the site and to describe them correctly in
applications.

14.91 Once an application has been completed, the patient should be transported to
hospital as soon as possible, if they are not already in the hospital. However,

patients should not be moved until it is known that the hospital is willing to accept
them.

14.92 A properly completed application supported by the necessary medical
recommendations provides the applicant with the authority to transport the patient
to hospital even if the patient does not wish to go. That authority lasts for 14 days
from the date when the patient was last examined by one of the doctors with a
view to making a recommendation to support the application. See chapter 17 for
further guidance on transport.

14.93 The AMHP should provide an outline report for the hospital at the time the patient
is first admitted or detained, giving reasons for the application and any practical
matters about the patient's circumstances which the hospital should know. Where
possible, the report should include the name and telephone number of the AMHP
Or a Care co-ordinator who can give further information. Local authorities should
use a standard form on which AMHPs can make this outline report.

14.94 Where it is not realistic for the AMHP to accompany the patient to the hospital, it
is acceptable for them to provide the information outlined above by telephone, fax
or other electronic means compatible with transferring confidential information. If
providing the information by telephone, the AMHP should ensure that a written
report is sent to the admitting hospital as soon as possible.

14.95 An outline report does not take the place of the full report which AMHPs are
expected to complete for their employer (or the local authority on whose behalf
they are acting — if different).

14.96 If the patient is a restricted patient, the AMHP should ensure that the MHCS of the
Ministry of Justice is notified of the detention as soon as possible. This information
should be left during office hours, although a duty officer is available at all times for
urgent queries.®

° At the time of publication, contact details are available at wwwjustice.gov.uk/contacts/noms/mental-health-unit, and the Ministry of Justice switchboard
is contactable on 020 3334 3555. For urgent queries out of office hours the telephone number (operated by the Home Office) is 020 7035 4848: select
option 5.

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Applications for detention in hospital

14

14.97

14.98

14.99

If the patient is a looked after child under the Children Act 1989, AMHPs should
inform the local authority's children’s services as soon as possible. If this patient is
placed out of the area of the local authority that looks after the child (‘responsible
authority’), AMHPs should inform the children’s services in both the responsible
authority and the local authority in which the child is placed.

An application cannot be used to admit a patient to any hospital other than the one
stated in the application (although once admitted a patient may be transferred to
another hospital - see paragraphs 37.16 — 37.27),

In exceptional circumstances, if patients are transported to a hospital which has
agreed to accept them, but there is no longer a bed available, the managers and
Staff of that hospital should assist in finding a suitable alternative for the patient.
This may involve making a new application to a different hospital. If the application
is under section 3, new medical recommendations will be required, unless the
original recommendations already state that appropriate medical treatment is
available in the proposed new hospital. The hospital to which the original
application was made should assist in securing new medical recommendations if
they are needed. A situation of this sort should be considered a serious failure and
should be recorded and investigated accordingly.

Communicating the outcome of the assessment

14.100 Having decided whether or not to make an application for admission,

AMHPs should inform the patient, giving their reasons. Subject to the normal
considerations of patient confidentiality, AMHPs should also give their decision and
the reasons for it to:

® the patient's nearest relative

the doctors involved in the assessment

« the patient's care co-ordinator (if they have one), and

® the patient's GP, if they were not one of the doctors involved in the assessment.

14.101 An AMHP should, when informing the nearest relative that they not do intend to

make an application, advise the nearest relative of their right to do so instead.
If the nearest relative wishes to pursue this, the AMHP should suggest that
they consult with the doctors to see if they would be prepared to provide
recommendations.

14.102 Where the AMHP has considered a patient's case at the request of the nearest

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relative, the reasons for not applying for the patient’s admission must be given

to the nearest relative in writing. Such a letter should contain, as far as possible,
sufficient details to enable the nearest relative to understand the decision while at
the same time preserving the patient's right to confidentiality.

Applications for detention in hospital

Action when it is decided not to apply for admission

14.103 There is no obligation on an AMHP or nearest relative to make an application for
admission just because the statutory criteria are met.

14.104 Where AMHPs decide not to apply for a patient’s detention they should record the
reasons for their decision. The decision should be supported, where necessary,
by an alternative framework of care or treatment (ar both). AMHPs should decide
how to pursue any actions which their assessment indicates are necessary to
meet the needs of the patient. That might include, for example, referring the
patient to social, health or other services.

14.105 The steps to be taken to put in place any new arrangements for the patient's care
and treatment, and any plans for reviewing them, should be recorded in writing
and copies made available to all those who need them (subject to the normal
considerations of patient confidentiality).

14.106 It is particularly important that the patient's care co-ordinator (where they require
support under the care programme approach (CPA) - see chapter 34) is fully
involved in decisions about meeting the patient’s needs.

14.107 Arrangements should be made to ensure that information about assessments and
their outcome is passed to professional colleagues where appropriate, eg where
an application for admission is not immediately necessary but might be in the
future. This information will need to be available at short notice at any time of day
or night.

14.108 More generally, making out-of-hours services aware of situations that are ongoing
— such as when there is concern for an individual but no assessment has begun
or when a person has absconded before an assessment could start or be
completed ~— assists out-of-hours services in responding accordingly.

Resolving disagreements

14.109 Sometimes there will be differences of opinion between professionals involved in
the assessment. There is nothing wrong with disagreements: handled properly
these offer an opportunity to safeguard the interests of the patient by widening the
discussion about the best way of meeting their needs. Doctors and AMHPs should
be ready to consult other professionals, especially care co-ordinators and others
involved with the patient’s current care, and to consult carers and family, while
retaining for themselves the final responsibility for their decision. Where disagreements
do occur, professionals should ensure that they discuss these with each other.

14.110 Where there is an unresolved dispute about an application for detention, it is
essential that the professionals do not abandon the patient. Instead, they should
explore and agree an alternative plan — if necessary on a temporary basis. Such a

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