Memorandum of Procedure on Restricted Patients

• Cooperative and compliant.
• Participating in all therapeutic and occupational activity
• Listening to the advice of staff
• Coping with support and supervision without complaint
• No evasion of support and supervision
• Addressing problems directly with appropriate person or seeking help to do so

GREEN

• Continue with current care plan and agreed levels of supervision
• Continue to progress increasing levels of responsibility and community access while carefully considering risks and risk management strategies to ensure public safety

• Displaying an antiauthoritarian attitude periodically
• Making unfounded accusations against nursing staff ( e.g. bullying etc.)
• Suspicion of trying to evade supervision
• Arguing about level of support and supervision
• Arguing about security procedures
• Taking problems to another to solve rather than addressing directly or seeking help to do so.

AMBER

• Continue with current care plan but monitor carefully
• Attempt to address any expressed or observed concerns through discussion
• Do not resolve the issues for xxx but assist him to resolve the issues for himself
• Only progress community access at a slow pace while continuing to address any risk through robust risk management strategies

• Active evasion of supervision
• Rejection of advice from staff
• Threats to use his "ace card" or explicit threats towards staff
• Open aggression towards staff
• Total withdrawal of cooperation
• Actual physical assault

RED

• Abandon community access
• Review presentation and increase level of observation where necessary.
• Progression of Care plan suspended until sufficient level of cooperation and compliance is resumed
• Staff will actively pursue the origins of the deterioration of the therapeutic alliance with Damien

Symptoms of Mental illness

Green: No Symptoms of mental illness, compliant with medications

Continue current care and treatment

Amber: Increase in suspiciousness/ persecutory ideation, heightened state of arousal, disengagement from services

RMO and Clinical Team to review current treatment

Red: Persecutory delusions including those about the IRA, Auditory hallucinations, hostile - believing wife to be a double ( Capgras delusion)

Urgent review of care and treatment

Substance Misuse

Green: Abstinent from alcohol and substances, maintaining peer support via AA groups/ sponsor. Good insight evidenced into impact of substance use on offending behaviour/mental health.

Continue current care and treatment

Amber: Opportunities to use alcohol or substances, and suspicions that this may be the case. Perhaps seeking or acquiring alcohol/ substances in hospital setting. Associating with known users or negative influences from the past. Diminishing insight into impact of misuse.

Clinical team to monitor and review. Need for substance misuse input from services. RMO to be advised of current situation. Associations, grounds access and suspension of detention requests to be reviewed

Red: Clear evidence that alcohol/substances are being consumed/ acquired or supplied to. Noticeable impact on mental health, behaviours and attitudes. Potential for violence increased.

Urgent review of care and treatment

Engagement with treatment

Green: Fully engaged and compliant with treatment and services. Values input and open in communications with staff.

Continue current care and treatment

Amber: Evidence of some suspiciousness/persecutory beliefs or attitude to contact. Still engaging but concerns being noted by staff. Some evidence of selective disengagement from specific services.

RMO and Clinical Team to review current treatment

Engage in discussing the issues he may have with particular staff/services

Red: Disengagement from services and clear evidence of mental state deterioration. Open suspicions and reference to delusional material.

Urgent review of care and treatment

Violence to staff or patients

Green: Mental State stable, no signs of disengagement and compliant with care and treatment. Verbal responses appropriate to given situation.

Continue current care and treatment

Amber: Evidence of minor verbal hostility not in keeping with situation, or appropriate to interactions from others. Suspiciousness and feelings of persecution.

Becoming dissatisfied with his progress/ situation.

Previous history of fractious and difficult presentation in prison.

Clinical Team to review situation

Engage in work to address his attitude. Review mental state, compliance with medication

Red: Actual violence, threatened violence or verbal hostility of a serious nature.

Conversely, becoming more withdrawn, introspective and suspicious when interacting with others.

Urgent review of care and treatment

Consider risk to self (previous hanging attempt in prison environment - 1990) as well as high potential risk of violence to others

Other Relationship issues

Green: are both engaged in care and treatment. Insight evidenced by both into difficulties which they may encounter. Both have clear strategies in place to seek support and guide their choices. Insight is good on potential for risk should mental health become unstable.

Continue current care and treatment

Amber: sense of disgruntlement evident from both. Insight impaired into need for care and treatment - pressurising from to progress care.

Evidence that some pressure is being placed on by his wife i.e. stating that she will not visit after a certain date or anniversary. Reduction in her contact or visits.

Unreasonable expectations from both.

may show more evidence of suspicions with regard to actions i.e. questioning her whereabouts, seeking out telephone contact at different or unusual hours.

Clinical team/ RMO to work with both to achieve resolution and achievable goals identified

Situation to be monitored

Red: Increase in all behaviours' in green and amber section to disproportionate levels.

y has, when extremely unwell ( and prior to the second homicide), suffered from Capgras Delusions in relation to his wife - expression of this type of material should be seen as a significant violence risk factor to or others.

Urgent review of care and treatment

Sexual Relationship

Green: are accepting of impact of prescribed medications on (impotency).

Recognition exists that risk of violence increases significantly when non-compliant with medication.

Realistic choices are considered and treatment outcomes accepted.

Continue current care and treatment

Amber: Significant pressure exerted by both for medication change or decrease in order to alleviate symptoms of erectile dysfunction.

Clinical Team/ RMO to discuss alternatives - risk discussed and balance sought from both

Red: Decrease in compliance with prescribed medications to achieve sexual relations.

Full non-compliance with medications. No discussion with RMO or clinical team. Evidence of deteriorating mental state and function.

Unrealistic expectations from both and disengagement from services in response to advice.

Urgent review of care and treatment

Symptoms of Mental Illness

Green: Compliant with prescribed medication, fully engaged in care package and mood and mental state stable.

Amber: Reduction in engagement with support staff and other professionals, reduction in self care and home care; brittle on interaction and poor motivation to attend planned activities.

Red: Elation in mood and flight of speech and thought, Florid psychotic symptoms and thought disorder. Non-compliant with prescribed medication and agreed support package

• Weekly from FCPN, monthly out-patient contact with Dr Smith Fortnightly contact with social worker and daily support from Support provider.
• Increased frequency of FCPN contact, liaison with support staff. Urgent medical assessment of mood and mental state and testing procedures - alcohol breath testing and drug urine testing. CPA meeting to discuss intervention and package. Update Scottish Government.
• Immediate Medical review of mood and mental state; review of legal status, level of observation, level of security and level of risk. Referral to appropriate in-patient environment (Rowanbank Clinic unless otherwise agreed).

Alcohol misuse

Green: Compliant with testing procedures - providing negative random breath tests. No issues with alcohol and stable mental state.

Amber: signs in presentation or environment, no firm evidence of alcohol misuse, but concern raised by staff.

Red: Evidence of alcohol use, unwilling to respond to advice and intervention. Non-engagement with support package.

• Random breath testing, observation by all staff for evidence of substance misuse in home environment and presentation. 3 monthly liver function tests ( LFTs) at GP surgery.
• Increase levels of support from FCPN and support staff, assessment of mood and mental state, CPA to discuss intervention and support. Consider increasing frequency of LFTs. Update Scottish Government.
• Immediate Medical assessment of mood and mental state and review of legal status. Consider re-call to hospital.

Engagement with treatment

Green : Fully engaged with agreed care package, attending structured activities and professional appointments

Amber: occasionally misses planned appointments - but responds to intervention and advice. Increased complaining and attempts to negotiate interventions or plans.

Red: dis-engaged from agreed support package. Non - attendance at planned appointments or activities. Avoiding professionals. Deterioration in mood and mental state.

• Continue care package as planned and monthly contact with O.T staff
• Increased contact and support from support staff to attend appointments. Assess reason why appointments missed. Visit next day if misses appointment. Update Scottish Government
• Urgent CPA to discuss intervention and placement. Urgent Medical assessment of mood and mental state and review of legal status, consider re-call to hospital.

Offending Behaviour

Green: No concerns or issues. Compliant with prescribed medication and support package and stable in mood and mental state

Amber : Change in mood and mental state, alcohol use, decrease in

Engagement with agreed package. Involvement in new relationship.

Red: Offending behaviour - index offence: 1999 - assault to severe injury and permanent disfigurement.

• Continue care package as planned.
• Increased contact with FCPN and Support staff. CPA meeting to discuss package with multi-agency team and explore any stressors. Discuss how best to manage information-sharing with new partner
• Medical assessment of mood and mental state and review of legal status. Re-call to hospital.

Non-Compliance with medication

Green: No issues or concerns.

Amber: Ongoing complaints about medication or side effect profile and seeking to negotiate medication. Evidence of changes in clinical presentation

Red: Non-compliance with prescribed medication and not responding to advice or intervention. Deterioration in mood and mental state.

• Continue with agreed care package.
• Increased contact with FCPN, liaison with support staff and CPA. Introduce supervised medication administration and blister packs to aid monitoring.
• Immediate medical assessment of mood and mental state, review of placement and legal status and consider re-call to hospital.