Memorandum of Procedure on Restricted Patients

11 MANAGEMENT WHILST ON CONDITIONAL DISCHARGE ( CORO PATIENTS ONLY)

11.1 This chapter is for the guidance of:

• Responsible Medical Officer (" RMO") supervisors; consultant psychiatrists who take on the role of RMO supervisor to a CORO patient who, having been made subject to conditions of discharge, is conditionally discharged from hospital by the Tribunal under section 193(7) of the Mental Health (Care and Treatment) (Scotland) Act ("the 2003 Act").
• Community Psychiatric Nurses (" CPNs"), who become involved with the supervision of such patients.
• Mental Health Officer (" MHO") supervisors; mental health officers who have responsibility to supervise and report to the Scottish Ministers on the progress in the community of such patients.

11.2 The chapter covers the responsibilities of those involved with the CORO patient after discharge from hospital and the action to be taken in some of the circumstances which may arise while the patient is in the community. Those aspects of the work which may not be familiar are described and examples are given of procedures and practices which have been found, over the years, to be most effective.

11.3 At any time, there are around 50 CORO patients on conditional discharge and under supervision in the community.

Reports to the Scottish Ministers

11.4 In addition to the RMOsupervisor and MHOsupervisor, the CPN Supervisor will also be asked to provide reports on a CORO patient's progress in the community. CPNs often form a key part of the multidisciplinary team and have a good knowledge of the patient. All supervisors will be asked to complete report forms at specified intervals, initially on a monthly basis. All of the supervisors should provide copies of the reports that they send to the PMO ( FP) to each other.

11.5 In some cases, the Scottish Ministers may ask for more frequent reports in the initial period after discharge. This would be made clear at the beginning of supervision.

11.6 Supervisors should naturally take the initiative in contacting SGHD quickly should the patient be involved in any unusual or serious incidents and/or should the patient's mental condition deteriorate sufficiently to give cause for concern. When completing reports supervisors should consider the following, although not exhaustive, list of issues:

• any change in mental state;
• any concerning behaviour;
• failure to attend appointments with supervisors or other members of the multidisciplinary team;
• non-compliance with medication or proposed change to medication;
• abuse of drugs/alcohol;
• any change of address; and
• any changes to the level of supervision/support or other aspects of the care plan.

Changes to Reporting intervals

11.7 After a period of at least 12 months in the community, when a conditionally discharged CORO patient has settled down and is maintaining a steady pattern of life , the RMO, CPN or MHO supervisor may consider it appropriate to submit reports to the SGHD at longer intervals, reflecting a belief that the patient can manage well with supervision. The RMO, MHO and/or CPN supervisor may write to the Scottish Government's Principal Medical Officer (Forensic Psychiatry) ("the PMO ( FP)") recommending that his or her reports be made at three monthly intervals (the maximum interval permissible). It would normally be expected that all supervisors in a patient's case would be reporting at the same intervals. In circumstances where it was felt appropriate for one or more supervisor to report at a different interval, the reasons for this must be clearly outlined in a letter to the PMO ( FP).

11.8 Besides reporting to the Scottish Ministers on a regular basis, the RMO, MHO and CPN supervisor should keep in touch with each other (and other social care agents in the community) about the patient and copy their reports to each other. In addition to supplying the more frequent reports mentioned earlier, the RMO, in consultation with the MHO, will be required to provide an annual report on the patient's condition and progress, .The patient will remain on the Care Programme Approach (" CPA") and subject to MAPPA for the duration of their conditional discharge.

11.9 Conditions of discharge must be stringently adhered to by the patient and monitored closely by the supervising team. Where there is a breach of any of the conditions of discharge, this will automatically trigger a formal consideration of whether recall is appropriate via a CPA meeting ⁷⁶. If recall is not considered to be appropriate, the justification for not recalling the patient and what steps the team are taking to monitor the patient following the breach must be clearly set out and reported to officials in SGHD immediately. The RMO must advise the appropriate senior manager at the Health Board of any breaches in conditional discharge in order that they can fulfil their responsibilities in relation to the collation of statistical information in respect of the operation of CPA for inclusion in the MAPPA Annual Report. A formal breach of conditional discharge is counted for MAPPA recording purposes as one where the SGHD has written directly to the patient copied to the managers of the Health Board, RMO, MHO and CPN.

11.10 Supervisors should also report to the SGHD any concerns regarding any aspect of management of the patient, irrespective of whether a report is due. After the completion of initial summary data, the report itself should convey sufficient information to enable the Scottish Ministers to consider whether the patient may remain in the community or whether, for the protection of the public, steps should be taken to return him to hospital. The report should include a detailed account of the issues outlined, as well as any other issues which supervisors feel may be of relevance.

Post-Discharge Contact with the Discharging Hospital

11.11 The practice of copying supervisors' reports to the discharging hospital for a period of about a year after discharge can have practical benefits for both the hospital and the supervisors. It is clearly helpful for the hospital staff to know how their former patient is progressing in the community and their knowledge and experience of the patient at close quarters may enable them to make helpful suggestions about the patient's management during the early stages of his discharge. A RMO supervisor needing further background information about a patient or to discuss the patient's behaviour should make direct contact with the previous RMO. All hospitals will expect and welcome such approaches.

The Role of the Supervisors

11.12 It is the Scottish Ministers' aim that, by means of conditional discharge of a CORO patient, any risk should be minimised by effective supervision, by appropriate support in the community or by recall to hospital if need be. It is recognised that this places great reliance on the personal skills and dedication of individual supervisors ( i.e.RMO, CPN and MHO supervisors). While it will not always be possible to predict and thus prevent dangerous behaviour, it is important that the supervisor sets out to provide more than just crisis intervention. This is underpinned by good risk assessment prior to the CORO patient leaving hospital.

11.13 The protection of the public is enhanced by the successful reintegration into the community of the CORO patient. Supervisors should, therefore, have a positive and constructive approach towards the patient's rehabilitation rather than simply monitoring progress.

11.14 The specific requirements of supervision will vary from case to case and an individual patient's needs vary over time. It is impossible, therefore, to draw up a blueprint for successful supervision. However, there are some elements in the roles of a RMO, CPN and MHO supervisor which are important if supervision is to be effective in achieving its purpose.

11.15 Important elements in effective supervision include the development of a close relationship with the patient and partnership working between the RMO, CPN and MHO supervisors. The frequency of supervision should be such as to detect any deterioration in the CORO patient's mental health or behaviour at an early stage. It is understood that the professional/patient relationship may be made more difficult by the fear or resentment of a conditionally discharged patient of being "policed" by the supervisors.

RMOSupervisor

11.16 The RMO supervisor, in any case, is ultimately responsible for all matters relating to the mental health of the CORO patient, including the regular assessment of the patient's condition, the monitoring of any necessary medication and the consideration of action in the event of deterioration in the patient's mental disorder.

11.17 The RMO supervisor will be expected to indicate prior to discharge the appropriate manner and frequency of psychiatric supervision and treatment, in any particular case. The minimum frequency of contact is determined by the interval which the Tribunal directs that reports on the patient's progress should be made to the Scottish Ministers. However there will, of course, be many cases in which the RMO supervisor considers more frequent contact appropriate. A template for reports to the Scottish Ministers is offered.

11.18 The RMO supervisor should be prepared to be directly involved in the treatment and rehabilitation of the CORO patient and to offer constructive support to the patient's progress in the community, rather than simply checking that the patient is free from symptoms and 'staying out of trouble'. The RMO supervisor should also be prepared to work with other professionals involved in the patient's care, including the MHO supervisor and possibly the general practitioner, CPN and other support staff. This is placed in the context of a multidisciplinary team and CPA. In addition, the principles of the Integrated Care Pathway Framework for Mentally Disordered Offenders ⁷⁷ should be applied (see NHSHDL (2001) 9).

11.19 The Scottish Ministers recognise that many RMO supervisors have had little or no experience of restricted patients and the legislation and procedures entailed. However, there is a great deal of support available from various sources. Scottish Government Health Directorate ( SGHD) officials and the PMO ( FP) can provide information about an individual case or advice on any aspect of supervision, including the legal framework. [ RMO's can also obtain independent legal advice from solicitors based at the Central Legal Offiice who provide advice to Health Boards.]

11.20 While requests for change in status and reports require to be made in writing, telephone contact for discussion and updating is encouraged and SGHD officials and the PMO( FP) will make themselves available, where possible, to meet multidisciplinary teams and discuss care plans and related issues. RMOs are encouraged to use this resource.

11.21 Hospital-based RMOs may choose to supervise their own CORO patients after conditional discharge. This is an obvious course if the patient is to be discharged into the immediate vicinity of the discharging hospital. In other cases a RMO supervisor should be chosen who is within easy travelling distance of the patient and can easily keep in touch with the other professionals involved in the case, particularly the MHO supervisor. It may be appropriate, in some cases, for the RMO to supervise the patient for an initial period of several months and then to make arrangements for a local consultant psychiatrist to take over as RMO supervisor. Whenever such a handover occurs, the change of RMO should be notified to the SGHD and the supervising MHO and the hospital- based RMO should ensure that the new RMO and the MHO supervisor are given all necessary information on the patient, through a CPA meeting.

11.22 Should the CORO patient's mental health deteriorate, the RMO supervisor will consider whether steps are necessary to arrange for the patient to receive additional out-patient treatment or to be admitted to hospital for treatment either voluntarily or by recall (see paragraphs 11.55 - 11.62 below). Any decision to admit the CORO patient for short-term treatment on a voluntary basis will generally be taken with the knowledge of, and often in consultation with, the MHO and CPN supervisors as part of the regular review process. In all cases he should be advised when the patient is admitted or discharged in these circumstances.

11.23 If the CORO patient will be taking medication, the RMO supervisor should inform the general practitioner and the MHO supervisor of the nature of the medication, its effects on the patient's condition and behaviour and any possible side effects. The psychiatrist should also inform the MHO supervisor of the arrangements to be made for the medication to be given, including when, where and by whom, and of any changes in those arrangements. With this information the MHO supervisor, while not primarily concerned with the patient's mental health, may identify changes in the patient's state of mind during his or her regular contact with the patient which may be helpful to the psychiatrist.

MHOsupervisor

11.24 A MHO supervisor may have many difficult decisions to make when working with a conditionally discharged CORO patient. The patient should consult the supervisor when considering any significant change in circumstances, for example, a new job, new home, financial matters or a holiday. Careful consideration of risk should precede any decisions about such proposed changes and the supervisor should advise the patient against taking any step which, in the supervisor's view, would involve an unacceptable degree of risk. Some proposals will involve the MHO supervisor making a special report to the SGHD for example in the case of change of address or holidays.

11.25 A sound knowledge of the case and the establishment of a close working relationship with the patient are essential if the MHO supervisor is to be able to spot warning signs before dangerous behaviour occurs. If the patient is in close contact with, or living with, friends or relatives the MHO supervisor should also see them regularly, sometimes separately from the patient.

11.26 It is recommended that meetings with the patient should take place at least once a week for at least the first month after discharge reducing to once each fortnight and then once each month as the MHO supervisor judges appropriate. These are considered to be minimum periods. Sometimes the SGHD will request that more frequent meetings take place. Generally, individual supervisors will consider more frequent meetings appropriate, particularly for the initial period of the first year during which the patient settles down to life in the community. Meetings may take place at the supervisor's office, in the patient's home or other venues. The MHO supervisor's visits to the "home territory" should be in accordance with good practice and local risk management protocols. A template for reports to Scottish Ministers is offered.

11.27 The MHO supervisor will provide practical support to the patient in his everyday life, especially in matters relating to accommodation, relationships and employment. As well as the importance of a close and informed relationship between the MHO supervisor and the patient, the most valuable element in successful supervision is liaison with other professionals involved in the case. This is placed in the context of a multidisciplinary team and CPA.

11.28` The MHO supervisor may be the key worker in the necessary liaison between all those involved with a CORO patient in the community, having contact with those providing accommodation, employers or day care staff, relations, general medical practitioners and the RMO supervisor. However, provisions vary from area to area and this key worker role may also be taken by the CPN.

11.29 The RMO supervisor should inform the MHO supervisor of the nature of any medication, its effects on the patient's condition and behaviour and any possible side-effects. The RMO should also inform the MHO supervisor of the arrangements to be made for the medication to be given, including when, where and by whom, and of any changes in those arrangements. With this information, the MHO, whilst not primarily concerned with the patient's mental health during his or her regular contact with the CORO patient, may identify indicators of medication difficulties (and, possibly, indicators of other problems arising) which are helpful to the psychiatrist.

11.30 Should the MHO supervisor become aware of an incident or detect a deterioration in the CORO patient's mental health or behaviour, he should immediately alert the RMO and CPN supervisors to any concerns and discuss appropriate action. It may be necessary to arrange for the patient to receive additional out-patient treatment or to be admitted to hospital for treatment either voluntarily or by recall. The MHO supervisor should also contact officials in SGHD by telephone to advise them of the situation and the steps that are being taken. This should be followed up by a full report in writing, which may form part of the regular supervisor report.

CPNSupervisor

11.31 Where CPNs have been involved in the after-care and supervision of CORO patients, they have proved extremely helpful. The CPN supervisor has a key role in monitoring the mental health of the CORO patient, including the regular assessment of the patient's condition and the monitoring and administration of medication.

11.32 The CPN, like the MHO, provides practical support to the patient in his everyday life. Depending on the arrangements in a particular local area, the CPN may be the key worker in the necessary liaison between all those involved with a CORO patient in the community, having contact with those providing accommodation, employers or day care staff, relations, general medical practitioners and the RMO and MHO supervisors.

11.33 The minimum frequency of contact is determined by the interval which the Tribunal directs that reports on the patient's progress should be made to the Scottish Ministers. However there will, of course, be many cases in which the CPN supervisor considers more frequent contact appropriate. A template for reports to the Scottish Ministers is offered.

11.34 The CPN supervisor should also be prepared to work closely with other professionals involved in the patient's care, including the RMO and MHO supervisors and possibly the general practitioner and other support staff. This is placed in the context of a multidisciplinary team and CPA.

11.35 Should the CPN supervisor become aware of an incident or detect a deterioration in the CORO patient's mental health or behaviour, he should immediately alert the RMO and MHO supervisors to his concerns and discuss appropriate action. It may be necessary to arrange for the patient to receive additional out-patient treatment or to be admitted to hospital for treatment either voluntarily or by recall. The CPN supervisor should also contact officials in SGHD by telephone to advise them of the situation and the steps that are being taken. This should be followed up by a full report in writing, which may form part of the regular supervisor report.

Medication

11.36 For many conditionally discharged CORO patients, continuation of medication is crucial to avoid a relapse and the attendant possibility of increased risk. It is important, therefore, that the RMO, MHO and CPN supervisors are fully informed of the CORO patient's medical history, including details of current medication and what is known of its effects, side-effects and the effect on the patient's condition and behaviour if medication is stopped. The patient's general practitioner and, where appropriate, other support staff will also need to have basic information about medication.

11.37 Medication issues should be covered in periodic discussions about a patient between the RMO and MHO supervisors. Immediately after discharge and again when any change or cessation of medication has been made, the RMO supervisor should inform other members of the multidisciplinary team of the arrangements made, including when, where and by whom medication is to be given. Unless this information is clearly understood by all concerned, there is potential for confusion resulting in adverse consequences for the patient and for others.

11.38 Under the provisions of the 2003 Act, compliance with medication can be made a compulsory condition of discharge.

Sharing Of Information

11.39 This is covered briefly in Annex A of this Memorandum. Except where medical information is concerned, it will usually be the MHO supervisor who has to make decisions. Those to whom it may be appropriate to disclose information about a CORO patient's background include hostel staff, landladies or landlords, employers, those providing voluntary work or placements and, in some circumstances, partners. In all cases information should only be disclosed on a "need to know" basis and only of the essential details.

11.40 Decisions about sharing of information should be taken by the MHO supervisor in the light of their knowledge of the case, their professional judgement and in cases of doubt they are advised to consult managers or other members of the clinical team. In general, information about the CORO patient should be disclosed only on a "need to know" basis and only with the full knowledge and agreement of the patient. Information should only be given against the patient's wishes when there are strong overriding reasons for doing so. Such reasons include the patient's known propensity for offending in circumstances to which the accommodation, or job, may give rise. For example, the supervisor of a CORO patient with a history of offending against a child should be particularly conscious of the fact in discussions with those providing accommodation which does or may also contain children or those providing employment or voluntary work which may bring the patient into contact with children.

Liaison with other professionals

11.41 Supported accommodation projects, hostels, centres providing day care and other community settings are likely to have several members of staff involved with the patient on a day-to-day basis. The work of other clinical personnel involved with the patient, such as psychiatric nurses or psychologists, should be under the general direction of the RMO supervisor who should consult them periodically about the patient's progress.

11.42 Whichever supervisor is designated the key worker in liaison between those involved in the CORO patient's care, should discuss with them the broad approach to the patient's care and invite them to contact him or her if there is any cause for concern about the patient's condition or behaviour. Attendance at regular CPA meetings will also offer those involved in the care of the patient to discuss progress and any concerns.

11.43 All conditionally discharged CORO patients should be registered with a general medical practitioner and arrangements for this should be made before discharge by the discharging hospital. The discharging hospital should inform the general practitioner of the names and addresses of the patient's RMO supervisor, MHO and CPN supervisor. The RMO supervisor should, at least, contact the general practitioner to give him brief details of the patient's background and current status as a conditionally discharged patient, to explain his or her role as RMO supervisor and to provide the general practitioner with a point of contact in the event of any concern about the patient's mental condition. It is understood that in some circumstances, the general practitioner may appropriately be an active participant in the CPA and should, at least, receive copies of the CPA minutes.

11.44 The 'traffic light' section of the CPAdocumentation should be produced such that it may be shared with all those who may have contact with the patient. In particular, it should share important contingency information and as well as health and social care arrangements this section should be stored in the patient's Vi SOR record.

Changes in address

11.45 If the CORO patient wishes to change his address or to be away from the address for more than a short absence, and the MHO supervisor agrees that the new accommodation proposed is suitable, the RMO supervisor or MHO supervisor MUST write to the PMO ( FP) to seek agreement to the change. (Although, in an emergency the MHO supervisor may have to agree to a change of address without prior reference to the SGHD in which case he should contact the PMO ( FP) as soon as possible thereafter.) Agreement to routine changes of address may be sought at any time before the proposed change and need not await the next report. It would be helpful if details were given of the new accommodation proposed and the reasons for the change. The whole of the supervising team should be kept informed. The MAPPA coordinator should also be notified of such a change.

Change in Supervisors

11.46 When a RMO, MHO or CPN supervisor is absent from his or her post even for a short period, for example when on leave, it is important that responsibility for the case should be transferred to a colleague and that the patient and other supervisors know whom to contact. If absences are to be for longer than two months, the Medical Director of the NHS Board/Chief Social Work Officer of the Local Authority and SGHD should be informed. When changes in supervisors occur, it is important that the outgoing supervisor passes to his successor full information about the case and supplements this with oral briefing. A change of supervisor may be upsetting for a patient and care should be taken to ease the transition.

11.47 It is important that the SGHD are notified as soon as possible of any change of RMO, MHO or CPN supervisor. The supervising RMO, MHO or CPN should also be informed of any impending change of other supervisors.

Patient Holidays

11.48 A conditionally discharged CORO patient is not precluded by his status from having holidays away from home. However, the patient should always discuss plans for such holidays with his supervisors so that the suitability of the arrangements can be considered, and the PMO ( FP) should be informed.

11.49 During the first six months after discharge, for absences from home of two weeks or more, the MHO supervisor should notify the Social Work Department in the holiday area and should inform the patient whom to contact there in case of problems arising.

11.50 The RMO and CPN supervisors should be informed of any of the above proposals. In the case of proposed absences from the patient's home, consideration of special medication arrangements to cover the absence may be necessary.

11.51 Holidays abroad do not allow any form of supervision to continue and should be considered very carefully. Any proposals for a CORO patient to leave the country should be put to the PMO ( FP) for approval. These proposals should include details of the patient's plans, any perceived risk attached to the holiday proposals, and any work which has been done to reduce these should be put to SGHD officials for their observations. However, it is worth noting that a request for a CORO patient to go abroad would not normally be considered until they had been on conditional discharge for at least a year.

Action in the Event of a Breach of Conditions or Concern about a Patient

11.52 Conditions of discharge must be stringently adhered to by the CORO patient and monitored closely by the supervising team. In the event of a breach of any of the conditions of discharge, this should trigger automatically formal consideration of whether recall is appropriate. This should be carried out as part of the CPA processes. If recall is not considered to be appropriate, the justification for not recalling the patient and what steps the team are taking to monitor the patient following the breach must be clearly set out and reported to officials in SGHD immediately.

11.53 If a RMO supervisor is concerned about a conditionally discharged CORO patient's mental state or behaviour or has reason to fear for the safety of the patient or of others, he may decide to take immediate local action to admit the patient to hospital for a short period with the patient's consent. Similarly, if the MHO or CPN supervisor has reason to fear for the safety of the patient or of others, he should contact the RMO supervisor immediately to consider such an action. Supervisors with such concerns should report to the SGHD at once.

11.54 Telephone discussion in such circumstances is welcomed by the PMO ( FP) or officials in the SGHD. In normal office hours an officer should be contacted at the Scottish Government Health Directorate, St Andrew's House, Regent Road, Edinburgh EH1 3DG. Officials may also be contacted out of office hours, if required. (See Annex E.)

Recall to Hospital

11.55 Under section 202 of the 2003 Act, the Scottish Ministers have the power to recall a CORO patient from conditional discharge where they are satisfied that it is necessary for the patient to be detained in hospital. In practice, a formal warrant of recall is issued by SGHD officials following a recommendation from the RMO supervisor and consultation with the PMO ( FP). In cases of urgency, the warrant can be faxed to the RMO. Formal recall cannot take place without a warrant issued by the Scottish Ministers. It is not possible to specify all the circumstances in which the Scottish Ministers may decide to exercise their powers to recall to hospital a conditionally discharged CORO patient, but in considering the recall of a patient they will always have regard to the safety of the public. Accordingly, a report to the SGHD must always be made in a case in which:

• there appears to be an actual or potential risk to the public;
• contact with the patient is lost or the patient is unwilling to co-operate with supervision;
• the patient's behaviour or condition suggest a need for further in-patient treatment in hospital;
• the patient is charged with or convicted of an offence;
• the patient breaches any of the conditions of discharge; or
• the patient takes illicit drugs.

11.56 Consideration of a case for recall will take into account any steps taken locally to remove the CORO patient from the situation in which he presents a danger. Where the RMO supervisor decides not to formally recall the patient, they should provide a brief report to the SGHD outlining the reasons for their decision. They should always try to discuss the situation with the MHO and CPN supervisors and in any case copy the report to them.

11.57 The Scottish Ministers have no objection to a conditionally discharged CORO patient being admitted to a hospital, informally for a short period of observation or treatment. The SGHD should be kept informed in these circumstances since the patient will again be subject to the formal conditions of his earlier discharge when he leaves hospital. However, it is generally inappropriate for a conditionally discharged patient to remain in hospital for more than a short time informally.

11.58 This is partly because such a patient will not be "detained" in that hospital, and partly as it raises questions of whether the patient does in fact require a further period of detention back in hospital. The Scottish Ministers would therefore usually wish to consider the issue of a warrant of recall if the period of in-patient treatment seemed likely to be protracted. However, each case is considered on its individual circumstances and there may be occasions where a longer, informal admission is considered appropriate. The RMO supervisor is encouraged to discuss such cases with the PMO ( FP), and a decision is reached after consultation with the doctor(s) concerned and with the MHO supervisor.

11.59 Where a conditionally discharged CORO patient is admitted to hospital informally, the RMO supervisor should consider whether the patient is able to consent to treatment. The RMO should also consider whether, if the patient chose to discharge themselves, they would allow them to do so. If they would not, the RMO supervisor should give consideration to formal recall (so that the patient is formally detained once again, with the statutory protections that this brings) to prevent any possibility of breaching the patient's rights under the European Convention on Human Rights [ HL v UK (Bournewood) 5 October 2004, with reference to article 5 ECHR]. Where there is any doubt about the appropriateness of continued informal admission, the RMO supervisor is encouraged to contact the PMO ( FP) for further advice.

11.60 Whether the Scottish Ministers decide to recall a CORO patient depends largely on the degree of danger which the particular patient might present in relation to his mental disorder. Where the patient has a history of serious violence, comparatively minor irregularities in behaviour or failure of co-operation would be sufficient to raise the question of the possible need for recall. On the other hand, if the patient's history does not suggest that he is likely to present a serious risk, the Scottish Ministers may not wish to take the initiative unless there are indications of a probable physical danger to other persons. There are cases in which recall to hospital for a period of observation can be seen as a necessary step in continuing psychiatric treatment. Each case is assessed on its merits by SGHD and a decision is reached after consultation with the doctor(s) concerned and with the MHO and CPN supervisors.

11.61 Where recall is considered by the Scottish Ministers to be necessary and a warrant is signed to that effect, the CORO patient may be returned in the most appropriate manner to the hospital specified on the warrant. If the patient will not return to hospital willingly, on being told of his recall, then the police should be informed. There is a general duty to inform a patient, within 72 hours of his recall to hospital, of the reasons for that recall. Where an MHO supervisor is involved in returning the patient to hospital, this duty should be borne in mind. The SGHD (and MHO and CPN supervisor if they were not involved in the return) should be informed as soon as a recalled patient is back in hospital, or in case of any difficulty.

11.62 After recall, a CORO patient is once again detained as a restricted patient in pursuance of the legal authority which was operating immediately before the conditional discharge. In some cases the RMO supervisor may be able to recommend the patient's further discharge after only a short while, but in other cases what has been learned about him in the community or slow response to treatment may point to a need for a longer period of compulsory detention in hospital. The CORO patient, or the patient's named person, has the right of appeal to the Tribunal within 28 days of formal recall.

Absconding patients

11.63 On occasion, a conditionally discharged CORO patient might leave the approved address without approval and break off contact with both supervisors. In such cases, the MHO supervisor should report to the SGHD immediately and make every reasonable effort to locate the patient, contacting colleagues in other areas if there is reason to believe that the patient may have gone to a particular place in a different locality. The SGHD may decide to monitor the situation whilst taking no immediate action, perhaps until patient's whereabouts are known.

11.64 However, if necessary, the Scottish Ministers will issue a warrant for the recall of the patient for breaching conditions of discharge, thus providing the police with the statutory powers to bring the patient into custody and return the patient to hospital.

11.65 The MAPPA coordinator and the police should also be informed that the patient's whereabouts are unknown. The patient may be reported as a 'missing person'. Police involvement in finding the patient may be based on concern for the patient's own safety.

11.66 If a conditionally discharged CORO patient is suspected of having left his approved address to go abroad the Scottish Ministers may decide to issue a recall warrant and alert the immigration authorities who would detain the patient on re-entry to the country. Any ensuing publicity which may arise as a result of a patient returning from abroad should be dealt with in accordance with the guidance issued in Annex C.

Further offending

11.67 Where a CORO patient has committed a criminal offence whilst on conditional discharge, if the patient is in custody and he is no danger to himself, the Scottish Ministers will usually await the outcome of the prosecution. In that event, the criminal court will be able to decide whether the patient needs a fresh medical disposal, whether some other non-medical disposal is called for, or whether the most appropriate course would be for the patient to be recalled to hospital. In this last event, the court may, for example, convict the patient but impose no penalty or only a nominal penalty in the knowledge that the Scottish Ministers have in mind to recall the patient at once to hospital.

11.68 If a conditionally discharged CORO patient is convicted of a further offence and the court imposes a non-custodial sentence, and recall to hospital is not considered appropriate, the terms of the previous conditional discharge will continue and the supervisors should resume their roles.

11.69 If a conditionally discharged CORO patient is convicted of a further offence and the court imposes a new sentence of imprisonment, the Scottish Ministers often reserves judgement on the patient's restricted status until towards the end of his prison sentence. The Scottish Ministers will make a reference to the Tribunal and based on the medical recommendation, will recommend either revocation of the compulsion order, the continuation the conditional discharge, or the recall to hospital on release from prison. This will depend largely on the length of the prison sentence imposed, the nature of the offence, the patient's mental state, both at the time of the offence and during the sentence of imprisonment, and the risk of danger to the public.