Memorandum of Procedure on Restricted Patients

10 PLANNING FOR CONDITIONAL DISCHARGE ( CORO PATIENTS ONLY)

10.1 This Chapter (and Chapter 11 which follows) applies to CORO patients only as there is no possibility of a patient subject to a transfer for treatment direction or Hospital Direction being conditionally discharged from hospital under the Mental Health (Care and Treatment) (Scotland) Act ("the 2003 ").

10.2 The Tribunal is empowered to order the conditional discharge of a CORO patient who no longer requires to be detained in hospital for treatment or for the protection of others from harm but in respect of whom the continuation of a restriction order is still deemed to be necessary. A patient granted conditional discharge will therefore remain subject to the CORO, and so subject to Part 10 of the 2003 Act, which means that the Scottish Ministers' supervisory role continues. When the Tribunal first grants conditional discharge, it may impose such conditions as it sees fit ( for variation of conditions see paragraph 10.27). See the Compulsion Order and Restriction Order flowchart.

10.3 Multidisciplinary teams should make any plans for Conditional Discharge via the normal Care Programme Approach (" CPA") procedures and in response to needs assessment and risk assessment (including the risk of harm to others). See information provided in Chapter 3.

10.4 In general, a CORO patient's discharge from hospital is subject to certain conditions set by the Tribunal, the exception being those restricted patients who are also life sentence prisoners. The conditions usually imposed are those of residence at a stated address, supervision by a Responsible Medical Officer (" RMO") and designated Mental Health Officer (" MHO"). However, additional conditions may be recommended either for the protection of the public or of the patient.

10.5 Under the 2003 Act, Scottish Ministers may vary these conditions at any time, and Scottish Ministers have power to do so if they consider variation is necessary.

10.6 The purpose of formal supervision resulting from conditional discharge, and the restriction order remaining in place throughout that discharge, is to protect the public from harm in two ways:

• by assisting the CORO patient's successful reintegration into the community after what may have been a long period of detention in hospital under conditions of security; and
• by closely monitoring the CORO patient's mental health for any perceived increase in the risk of danger to the public so that steps can be taken to assist the patient and protect the public.

10.7 Conditional discharge also allows a period of assessment of the patient in the community before a final decision is taken on whether to remove the control otherwise imposed by continuation of the restriction order. It is important to stress the need for the multidisciplinary team to work closely together, and with the community team, to ensure that effective and thorough pre-discharge planning takes place through the CPA and that each agency is aware of its respective procedures and protocols. Prior to accommodation being confirmed to the patient, the police's views should be sought on the proposed accommodation.

10.8 Once a CORO patient has reached the stage of overnight suspension of detention from hospital (granted under section 224 of the 2003 Act for restricted patients) (" SUS") to accommodation where it is anticipated they will ultimately reside on conditional discharge, a MAPPA referral should be made by the RMO on the appropriate form. The consideration by the MAPPA will help inform the Scottish Ministers' Position Statement to the Tribunal following a recommendation by the RMO for conditional discharge.

When Conditional Discharge may be appropriate

10.9 On admission of a CORO patient to hospital, the RMO will, together with the rest of the multidisciplinary clinical team and the designated MHO, seek not only to treat the patient's mental disorder but to understand the relationship, if any, between the disorder and the patient's behaviour. The aim will be to understand what led to the dangerous behaviour that resulted in the patient's detention and, as the mental disorder is treated, to assess the extent to which that treatment has reduced the risk of the patient behaving in a dangerous manner if returned to the community.

10.10 In some cases, this period of assessment and treatment may take several years. Only when the CORO patient's condition has so improved that the level of risk to the public is reduced to the extent that detention within hospital is no longer considered necessary, should the RMO, after consulting with the designated MHO, recommend the patient's conditional discharge. The PMO ( FP) would usually assess the patient when plans for discharge are well underway and flag up to the RMO and designated MHO any issues which may need to be addressed.

10.11 When the RMO considers it appropriate, he should make a recommendation to the Scottish Ministers who will automatically refer the case to the Tribunal. If the Tribunal are satisfied a conditional discharge order should be made, it can then go on to consider making a deferred conditional discharge order,. The conditional discharge may be deferred when the patient has been fully tested out and conditional discharge is considered appropriate but the full care package is not yet in place. It will be for the Tribunal to determine the sufficiency of evidence in each case.

10.12 The clinical team in the detaining hospital and the designated MHO will begin preparations for a CORO patient's conditional discharge before authority for discharge is sought. These preparations include the patient's personal preparation for life outside the hospital, consideration and choice of suitable accommodation, employment or other daytime occupation and identification of a MHO supervisor (usually the designated MHO) and a supervising RMO.

10.13 Where a nursing home is proposed as accommodation, the Scotland Government Health Directorate (" SGHD") will consult the Care Commission following notification of the care home name and address.

10.14 The supervisors should ensure that the CORO patient has adequate support and monitoring to make a successful transition to life in the community. They should ensure that the CPA is adopted and which is mandatory for all restricted patients. The CPA care plan forms the basis for admission, through-care, discharge and aftercare arrangements and specifies individual and agency responsibilities. Examples of risk management traffic lights within the community are contained at Annex H. The arrangements for future contact with the CORO patient's supervisors should be discussed, and the patient should be assured that his supervisors are there to help. The patient should be advised how to get in touch with his supervisors should any difficulty arise between the times of formal visits.

Pre-discharge procedures

10.15 As outlined above, the clinical team in the detaining hospital must consider a number of issues when making preparations for a CORO patient's conditional discharge. However, prior to identifying such things as suitable accommodation, employment or other daytime occupation, the multidisciplinary team must consider where they intend to discharge the patient. In some exceptional cases there may be reasons why the patient should be discharged out of the area in which the hospital is located and, in such cases, the multidisciplinary team must make a thorough assessment of all of the factors involved. These might include:

• support from the patient's family and friends, if appropriate, and whether this would be available out of area;
• the patient's care needs and whether an appropriate package and care team, knowledgeable in the needs of the patient, could be organised out of area;
• the views and location of the victim and/or victim's family;
• the views of the patient on the resettlement plan and their attitude to moving to a new area;
• is such a resettlement in the best interests of the patient, e.g. because of risk to or from the victim or because of a detrimental influence from peers who may lead the patient astray?;
• what are the risks of a change of area and care at such a vulnerable stage in the patient's rehabilitation and do these outweigh the benefits of such a move?;
• possible adverse media interest.

10.16 In summary, the rights and wishes of the CORO patient have to be balanced against those of the victim with due consideration being given to effect of the added complexities of an out of area discharge and change of multidisciplinary team at a vulnerable transition in the patient's care. Where the clinical team are in any doubt, they may seek advice from the Scottish Government's PMO ( FP) or other officials at the SGHD.

Identification of Accommodation

10.17 A carefully thought out programme of SUS will also form part of the essential pre-discharge procedures. Prior to accommodation being identified the police should be invited to a pre- CPA to share information about the prospective accommodation and for any police intelligence about the area to be shared with the clinical team. Overnight stays in the patient's identified accommodation are a key part of the programme and will enable the clinical team to appropriately assess how well the CORO patient is adapting to their new lifestyle. It is expected that a CORO patient will complete at least 4 months of overnight stays, building from one night per week to the maximum of four nights per week on monthly increments prior to conditional discharge taking place.

Supervising Team

10.18 As soon as the prospective RMO, MHO and CPN supervisor are known, they should discuss the CORO patient's after-care and supervision arrangements, with each other and the referring team. A CPA meeting should be arranged at least three months prior to the proposed discharge date, and a MAPPA referral should be made using the standard referral form once accommodation has been identified.

10.19 These discussions are important both as a means of combining hospital and community expertise in the setting up of practical arrangements most suited to the patient and also in enabling the prospective supervisors to familiarise themselves with the patient before discharge.

10.20 The multidisciplinary team should consider, where appropriate, including representatives from the housing association or local council housing department in the planning process. The team should also ensure that copies of the minutes of each CPA meeting and the CPAdocumentation are sent to the PMO ( FP) for information. The police role is outlined in Chapter 2.

10.21 In the case where the CORO patient is being discharged to a different team in the community, the RMO, MHO and the Community Psychiatric Nurse (" CPN") supervisors must visit the hospital at least once to meet the patient before discharge. In addition, the new RMO supervisor should peruse all the patient's notes and make their own assessment and take part in at least one multidisciplinary case conference. By doing so, they will be able to discuss the case with the outgoing RMO and the staff of all disciplines who know the patient. On this visit contact must also be made with the MHO supervisor if they are transferring the case to another social worker. If it should happen that the RMO supervisor is not invited by the discharging hospital to take part in pre-discharge discussions and preparations, the RMO supervisor should ask, in the first place directly, for a suitable contact with the hospital multidisciplinary team. In the unlikely event of no response (or of an inadequate response), officials in the SGHD may be able to help.

Provision of written information by the discharging hospital

10.22 In addition to pre-discharge contact, it is essential that the RMO, MHO and CPN supervisors, should receive, as early as possible before discharge, detailed written information about the patient which can be retained for reference.

10.23 Discharging hospitals are advised that the full package of information provided to the supervisors for retention should be based on the CPAdocumentation⁷⁵, and must cover the following aspects of the CORO patient's case:

• a pen-picture of the patient including his diagnosis and current mental state, present medication and reported effects and any side-effects;
• admission, social and medical history including any use of drugs and alcohol;
• psychiatric history;
• forensic history including its relationship to illness and other problem areas and a detailed note of the index offence (if the patient is a sex offender, it should refer to his statutory requirement to register with the police following discharge);
• summary of progress in hospital;
• a report on present home circumstances;
• a risk assessment and risk management plan, including any warning signs which might indicate a relapse of his mental state or a repetition of offending behaviour together with the time lapse in which this could occur; and
• supervision and after-care arrangements that the hospital considers both appropriate and inappropriate in the particular case.

10.24 Where there are difficulties in obtaining details of the index offence, e.g. summary of court proceedings, the RMO should contact officials in the SGHD who may be able to assist in obtaining this information.

10.25 The RMO supervisor should receive this information from the discharging hospital before agreeing to accept the patient into his care and should inform SGHD officials if this information is not received within a reasonable time to enable them to assist in obtaining this necessary information.

10.26 In addition, the discharging hospital should provide details of the circumstances of the offence which led to the CORO patient's admission to hospital and of the legal authority for that admission. Again if this information is not received, SGHD officials should, if notified, be able to assist in obtaining this.

Variation of Conditions of Discharge

10.27 when conditional discharge is first granted, the conditions of discharge are set by the Tribunal. These may be varied, if necessary, from time to time by the Scottish Ministers. If supervisors wish to recommend a change in any of the formal conditions of discharge they must consult with the Scottish Ministers who may vary the conditions , e.g. the patient's address,.

EXAMPLES OF SPECIFIC CONDITIONS OF DISCHARGE

• address; and access to this address for the clinical team
• compliance with medication
• compliance with agreed structured activities
• regular psychiatric and MHO contact
• regular contact with CPN and/or care workers
• compliance with any exclusion zone or excluded contacts
• compliance with conditions of abstinence from drugs and/or abstinence from or limits on alcohol and associated testing
• psychological interventions

10.28 This list is by no means exhaustive. Conditions are designed to meet the needs and manage the risks posed by individual CORO patients. A patient may appeal to the Tribunal against any variation in their conditions made by the Scottish Ministers.

Right of Appeal

10.29 When the Tribunal orders conditional discharge of a CORO patient, they will advise the patient of their appeal rights. Patients should continue to be reminded of these rights, and of their right to approach the Mental Welfare Commission on any aspects of their care about which they might feel aggrieved. In addition, each CORO patient's case will automatically be referred to the Tribunal after 2 years, where no other reference or application has been made during that period.

10.30 Where the Tribunal orders conditional discharge, the order does not come into effect until 21 days after the patient requested or was informed of the decision. The RMO may request that the Scottish Ministers grant unescorted SUS to cover the period until the conditional discharge order takes effect. Where the Scottish Ministers do not oppose conditional discharge, they may grant up to 7 nights of SUS - Rule 2 of the Mental Health (Period for Appeals) (Scotland) (No 2) Regulations 2005 SSI 2005/441 refers.