Memorandum of Procedure on Restricted Patients

ANNEX B INCIDENT RECORDING AND NOTIFICATION

It is the RMO's responsibility to report all incidents to the Scottish Government and the Mental Welfare Commission, and best practice would indicate also informing the designated MHO. A checklist of information required when reporting an incident is given below ¹²⁵

Hospital authorities must advise the police immediately of an escape, serious assault, abscond or other serious incident ¹²⁶ involving a restricted patient. Immediately thereafter, the Responsible Medical Officer (" RMO") (or duty RMO) should make a telephone report to the Scotland Government Health Directorate (" SGHD").

Out of hours' telephone and pager numbers for SGHD officials are given¹²⁷. These should be used to contact officials between the hours of 5pm and 8.30am and on weekends and on public holidays¹²⁸.

Where, exceptionally, no contact can be made with an official, a message may be left with the Security Guards at the Scottish Government, Victoria Quay (by dialling the main Scottish Government phone number - 0131 556 8400). Security will relay the message to an official as soon as possible. Please note that on no account should patient details be left as part of such a message.

Definition of serious incident

A serious incident involving a patient can be defined as one which:

• results in serious injury or death to the patient or to another person involved in the incident;
• requires a formal critical incident review by the hospital management (whether internal or external) as result of a disturbance or other event occurring;
• results in serious damage to the unit;

or involves:

• concerted indiscipline by a number of patients involving violence;
• the use of seclusion;
• the taking of a person hostage;
• making a protest in a public place, for example, following unauthorised access to a rooftop;
• escapes from the hospital building;
• absconds while on suspension of detention from hospital (" SUS") (escorted or unescorted) outwith the hospital building.

A serious injury can be defined as any that results in:

• injury to the patient or another person requiring treatment in hospital; or
• any of the following injuries whether or not hospitalisation is required:
• fractures;
• concussion;
• internal injuries;
• crushing;
• severe cuts or lacerations;
• severe bruising, scalds or burns; or
• severe shock requiring medical treatment.

The aim where any restricted patient absconds or escapes is to ensure that the patient is found and returned to the hospital as soon as possible with no harm to the patient or others. Where an incident occurs within the hospital, it should be resolved with minimum force necessary, to prevent injury to the patient and others wherever possible.

There will be occasions when an incident has the potential to result in media interest. In the event of a serious incident involving a restricted patient, arrangements for providing the media (including the radio and television companies) with information about the incident must be handled sensitively. Further information is given in Annex C.

Escape

The hospital authorities should notify police and the RMO (or duty RMO) should notify the SGHD immediately in all instances of escape.

The definition of an escape is distinct from an abscond, in that the restricted patient has breached a physical barrier, (for example, breaking out of a locked ward).

If either of the following apply:

the most recent risk assessment indicates that the patient is "high risk"; or

the patient's recent conduct indicates that there may be some risk to the public,

SGHD officials will contact Communication Health to arrange the issue of a short statement to the media. Unless the restricted patient is considered as "high risk", the statement will give the patient's name and age, the hospital concerned and a brief physical description. Other information may be included as appropriate.

The media will not automatically be notified of the crime for which the restricted patient has been sentenced. Scottish Criminal Records Office is the holder of this information and it is a breach of the Data Protection Act to disclose this information. The Crown Office will be consulted on any occasion when a photograph is to be used.

In the case of an untried prisoner on transfer to hospital who escapes, no details will be volunteered and in response to enquiries care will be taken to ensure that no information that may be prejudicial to any future proceedings is revealed. For example, it is unlikely that the escapee would be described as 'dangerous'. This would only be done on the basis of advice from the Crown Office.

Abscond

An abscond is defined as an occasion when a restricted patient:

is absent without authority

• from a ward;
• work placement; or
• open supervision ( i.e. supervision which does not require the use of physical restraints nor continued oversight);or
• exceeds his or her authorised suspension of detention form hospital (" SUS"); or
• flees from an escort.

The hospital authorities should notify police and the RMO (or duty RMO) should notify the SGHD immediately in all instances of abscond.

If neither of the following apply:

• the most recent risk assessment indicates that the patient is "high risk"; or
• the patient's recent conduct indicates that there may be some risk to the public;

then no immediate press statement is necessary.

Once 24 hours have elapsed and the patient has not returned, a short Press Release may be issued. Communication Health will be informed of the absconding to hold against any enquiries but will not volunteer information to the media in these cases.

Where the patient's recent conduct indicates that they may present some danger to the public, the procedure for an escape will be followed.

Drug and alcohol misuse while in hospital

In the case of many restricted patients, their mental illness may be adversely affected by drug and alcohol misuse and in some cases may have led, albeit indirectly, to their admission to hospital. Misuse of alcohol and/or drugs either while in hospital or while on SUS can have a detrimental effect on a patient's rehabilitation and can increase the risks to staff and other patients within the hospital. The RMO should ensure that all incidents of this type are reported urgently to the Scottish Government's Principal Medical Officer (Forensic Psychiatry) along with details of the action taken, and copied to the designated Mental Health Officer (" MHO"). Circular NHSHDL (2002) 41¹²⁹ provides guidance on safe care approaches for staff, patients and visitors and on the management of those with a drug misuse or alcohol problem in mental health care settings.

Patients on Conditional Discharge

In setting conditions of discharge, there is an expectation that the patient will adhere to those conditions and that any breach of conditions will trigger consideration of recall, or other appropriate action by the multidisciplinary team.

When any breach takes place, it must be reported to the SGHD quickly, certainly within a few days of the breach in question. If the breach constitutes a serious incident, including testing positive for illicit substances, the reporting conditions for such incidents will apply.

A statement from the RMO should follow the initial report indicating what action has been taken and if recall is considered appropriate. In some cases, it will be appropriate for the RMO to convene a CPA meeting and in those cases; the RMO should provide an interim report to SGHD.

Transferred Prisoners

Prisoners do not become the responsibility of the Health Service until they are received into hospital, and a warrant/receipt handed over to those transferring the patient by the hospital managers after reception.

Similarly, they cease to be the lead responsibility of the Health Service while under escort from hospital to court or prison. Reliance Prisoner Custody Officers, as part of Reliance Custody Services, will normally provide such escort and they have responsibility for the prisoner while attending court. Good practice suggests that hospital staff should also accompany the patient.

Enquiries concerning any prisoner, who absconds from escort going to or from hospital before or after trial, or from police custody or a police cell, should be referred to the police force in the area in which the incident has taken place. See Annex C for further guidance.

Reports to the Scottish Government Health Directorate

Once the incident has been resolved, the RMO should make a formal report to the SGHD and copy it to the designated MHO. Where the incident involved the patient being absent without permission, full details of what occurred while the patient was absent should be provided, including any misdemeanours or suspected misdemeanours.

Incident Review

Following an incident involving a restricted patient, Scottish Ministers may seek an Incident Review ( IR). In addition, the NHS Board, hospital managers or lead clinician involved in the case, may consider it appropriate to initiate an IR. In such circumstances, the RMO should advise SGHD officials of the likelihood of an IR when submitting their report on the incident

'Critical' incidents are defined in the Mental Health & Well Being Support Group - Risk Management Report ¹³⁰ as follows:

• death of a resident, in-patient or outpatient which is sudden or unexpected or where suicide is the most likely cause;
• homicide allegedly committed by the in-patient or outpatient;
• "incidents" including those which might have resulted in suicide or homicide, episodes where there is evidence of serious intent of self-harm, violence to others or which led to injury or disability; and
• an event where an important policy, procedure, or practice was not followed by staff leading to a detriment or potential detriment of care - so called "near misses".

The Risk Management Report ¹³¹, describes a method of 'critical' Incident Review which is intended to be seen as part of the NHS Board's wider risk management processes to link all levels of the organisation - ward, clinical managers and Board managers - into a system which takes the opportunity to learn from incidents and enact any changes in practice necessary to forestall a similar incident in future. It should not be seen as a disciplinary process ¹³².

NOTIFICATION OF INCIDENTS - INFORMATION REQUIRED AND RECORDED

Details of the notification:

• Date and time of call to SGHD:
• Name of caller and designation ( i.e. Doctor, Nurse, etc):
• Name of Hospital, Telephone Number and Extension:

Details of the incident being reported, including:

• events leading up to it;
• what happened;
• when;
• where; and
• how.
• If an escape or abscond, what is known about money the patient has with them

Details of the patient involved:

• Name:
• Date of Birth:
• Home Address:
• Index Offence and Section:
• Restricted status ( i.e. if Life Sentence Prisoner, transferred prisoner, on remand, originally held in State Hospital and, if so, date of transfer):

RMO's view on perceived level of risk patient poses to himself and the public (This is of great importance particularly if Index Offence involved culpable homicide, murder or rape, and patient has escaped or absconded). In cases where it is not possible to get the RMO's view out of hours SGHD staff will consult the most recent risk assessment and seek the view of staff on duty.

Summary of patient's presentation:

• Summary of patient's recent conduct i.e. any worrying incidents
• Mental state on day of incident
• Medication ( i.e. when last received, when next due and whether recent compliance with medication has been good)

Who has been informed:

• Have the Police been informed? If so, when? Contact name and telephone number of police to be obtained:
• Is there a victim at risk? Has consideration been given to breaching medical confidentiality to inform victim of escape or abscond?
• In the case of abscond or escape, have relatives been informed?
• Has the Mental Welfare Commission been informed?
• Has the designated MHO been informed?