Memorandum of Procedure on Restricted Patients

MENTAL HEALTH OFFICER MOCK REPORT

Basis of Report

This report is based on numerous contacts with Mr XX since the writer became involved with his care in September 2004. These contacts have been in the ward and most recently in his flat when Mr XX has been out on suspension of detention.

I have also interviewed Mr XX sister in one occasion (11/3/05), when I was carrying out a Community Care Assessment of Mr XX needs. I have had regular contact with ward staff in the XX ward and have spoken to his Responsible Medical Officer. Dr X, on several occasions. I have attended multi-disciplinary Care Programme Approach meetings (4/10/04; 10/1/05; 21/3/05; 25/7/05; 29/8/05; 14/11/05; 16/1/06; 13/3/06; 16/6/06; 3/8/06; 14/9/06; 12/10/06; 30/11/06; 22/2/07; 25/4/07; 29/6/07; 10/8/07; 27/9/07; 5/11/07; 17/12/07).

For the purpose of this report I have had sight of medical notes and a Psychological Risk Assessment report prepared/updated on Mr XX by Clinical Psychologist Ms X on 2/5/06. I have also spoken to nursing staff on various occasions when visiting Mr XX in the ward.

I have attended Social Work Planning meetings with the purpose of discussing Mr XX social care needs and the provision of services required for his rehabilitation in the community.

I have further maintained contact first of all with our XX housing officer in relation to finding Mr XX appropriate accommodation in XX through the homeless team. I have also made contact with different housing associations also in XX as Mr XX wishes were to live in the XX area. I have contacted and maintained this contact with XX care provider regarding support services for Mr XX also with Occupational Therapist, in order to assess the current level of functioning and support, Mr XX needs with personal, domestic and community living skills.

Purpose of the Report

Mr XX is a Restricted Patient on a Compulsion Order Section 58/59 of the Criminal Procedure (Scotland) Act ("the 1995 Act") who is working towards a conditional discharge to the community through the use of the Care Programme Approach. Mr XX is in the 'severely at risk' category. A multi-disciplinary risk assessment and multi-disciplinary care plan is incorporated with this report which focuses on the management of Mr XX care in the community in the event the Tribunal orders his conditional discharge.

I was verbally advised by Dr X, Mr XX's Responsible Medical Officer ( RMO) on the 22/10/07, that Mr XX continues to meet the criteria of having a mental disorder as defined in the Mental Health (Care and Treatment) (Scotland) Act 2003 "the 2003 Act", this being a mental illness and his diagnosis being schizo-affective disorder. The current medical treatment is alleviating the symptoms he first presented and this medical treatment will continue being available to him as well as monitoring by medical and nursing community staff in the community.

This report is prepared under Section 191(b) of the Act in relation to Mr XX's preparation towards a conditional discharge into the community.

Summary of Personal History/circumstances leading to his admission into hospital

a. Childhood and family siblings

Mr XX was born in the XX area of Xx. He moved with his parents to XX when he was aged 7. His mother died in 1986 of a brain tumour. Mr XX, following his mother's death, began drinking alcohol excessively and had an admission into hospital for 6 months following an overdose of Paracetamol tablets. His diagnosis was then endogenous depression. Notes indicate that Mr XX was close to his mother. Mr XX father died in 1990 (Index Offence).

When the family moved to XX, Mr XX being 6 at the time attended XX Primary and XX Schools respectively. Mr XX left school at the age of 16 with 3 standard grades. On leaving school he had various jobs as well as periods of unemployment. He worked as a store man in an Industrial Estate and worked in the Council in Xx. Mr XX was on sick leave from his job at the time of the index offence.

Mr XX sister XX informed the writer that they both related quite well with each other when they were younger but they were not particularly close. They had their own friends and socially they led their own lives.

Medical notes indicate that Mr XX sister used to visit him in hospital many years ago and had been observed their relationship to be a superficial one. These visits had stopped and Mr XX tends to write to his sister at the end of each CPA Meetings. Mr XX does not get a reply. However, his sister sends him greeting cards and gifts for birthdays and Christmas.

b. Schools/Adulthood prior to index offence

As said earlier in this report, Mr XX attended the local schools in XX Primary and XX High). Reports suggested that he was an average pupil and played truancy. He left at 16 with 3 standard grades in English, Geography and Arithmetic. Mr XX had various employments. Reports suggest that Mr XX knew a lot of people and socialised more visiting local pubs. The writer is not aware of Mr XX having had a formal, serious relationship with any female.

There have not been any concerns of Mr XX had experimented with illicit drugs, apart from him admitting trying cannabis in 1992 (Psychological Risk Report 2/5/06). In the days prior to the Index Offence, (1 April 1991), Mr XX abused alcohol to excess around 1985 to 1992. Notes indicate that he began binge drinking after the death of his mother. He had been feeling depressed and had been to see his GP with his complaint. He had an admission to XX Hospital in 1986 and was treated for psychotic depression. Medical notes also indicate that after the death of his mother, his father became depressed, withdrawn and unwell. Mr XX and his father seemed to have argued a lot. Mr XX began to experience the beliefs that his father was Hitler and became afraid of him. He developed persecutory delusions that seem to have led to him stabbing his father with a knife. He then contacted the police and told them what he had done. Mr XX seems to have drunk to reduce his symptoms. He developed depressive symptoms around 2/3 months prior to the time of the offence developing a number of delusional beliefs which involved the belief that his father had killed his mother and intended to kill him. Mr XX lived with his father at the time of the Index Offence which took place on the XX, XX was charged with murder of his father, (patricide) then 75 years old. At first Mr XX went to XX Prison while the trial was progressing. He was then admitted into the State Hospital under a Hospital Order, Restriction Order Section 58/59 of the 1995 Act.

While in hospital

Mr XX was transferred from the State Hospital to XX on the 26/2/2001 . The staff's impression at the time was that Mr XX mental state and his general behaviour appeared settled and initially staff did not think that Mr XX would need to be in the Forensic Ward for any extended length of time. At the time he was treated with Clozapine, the writer understands that he stated he was unhappy with the side effects of this particular medication ie flu symptoms, weight gain. It appears that Mr XX spoke to nursing staff who recommended he had been very well on the medication and the side effects were minimal. After discussion he had agreed to remain on this medication. However, he wrote to his Solicitor and the Mental Welfare Commission, who in turn asked for the RMO to review his medication resulting in it being changed. This incident appears to have occurred in September 2001 and according to notes Mr XX within a matter of days became seriously unwell. His mind was racing, there was an increase of paranoia, he was not sleeping and sweating profusely. He had a serious fixation about staff being spies. Notes indicate that after 3~4 weeks he was put back on the same medication and dosage. It was observed that his positive symptoms declined very quickly, he was more settled, showed some insight into his diagnosis and the need for treatment.

The writer understands from medical and nursing staff that Mr XX does not present any of the above issues at present. He appears to have some understanding of his need for taking his medication, he has been self medicated for about three years and has informed me him taking his medication is well established in his routine and he faithfully takes it. However, the writer foresees this as an issue which should be closely monitored by the clinical staff, because this presents as a risk factor. The clinical team is fully aware of close monitoring is required when in the community.

While in the ward Mr XX was found to have a good residual pool of skills and had been able to go out escorted by nursing staff to XX and go around shops. However, he had also been observed he can be unmotivated in getting involved in activities available to him needing encouragement to make use of his free time. At present he attends XX 3 times a week. This is his only structured activity. He participates in recreational activities in with his Support Worker. It would appear Mr XX will benefit in obtaining gradually other purposeful and structured activities.

Preparation and Response to Rehabilitation into the Community

Mr XX have been an in-patient in the XX Ward, rehab ward since Feb 2001. Mr XX has been subject to Care Programme Approach meetings. Planning towards conditional discharge commenced on 4 October 2004 to prepare Mr XX for the stage of him spending overnight passes at his new home. The writer understands while Mr XX being in hospital his medication had been reviewed regularly and monitored with the purpose of improving his mental state. Prior to accommodation being identified the police were involved and confirmed from a risk perspective that the accommodation was appropriate situated.

The writer also understands that Mr XX mental state has been stable for the past three years. A nursing summary dated 19/12105 indicates that Mr XX since his initial transfer to the XX Ward (July 2004), Mr XX's mental state appeared stable and there had been no overt signs or symptoms or psychosis and his mood and manner were settled and appropriate. He is regularly tested for drugs and alcohol use and results had been negative.

With regard to his medication this nursing summary indicates that Mr XX self medicates and he appears to be coping well. He regularly has blood samples taken to test his Clozapine levels and they have always been within an acceptable range and caused no concern, at present Dr X is negotiating for blood tests to be done in his local health centre where his flat is situated.

While in hospital Mr XX had at first been introduced to the day services at XX Clinic with the aim for him joining in activities. He was initially escorted and this progressed to the stage where he was travelling unescorted. He had also attended XX one day per week. He was also being escorted at first and progressed to the unescorted stage. He commenced attending XX House 2001 in where he engaged in computing course. He also engaged well in other social activities like going to the cinema, library, shopping etc. I understand that permission from the Scottish Government was sought to allow Mr XX to attend to all these recreational, social and educational programmes which have assisted him in the rehabilitative process.

Mr XX was subsequently referred to Social Work with the purpose of carrying a community care assessment of his needs and finding suitable accommodation (to be risk assessed by the police) and support resources to meet his needs. The writer while being in the process of completing his Community Care Assessment met with Mr XX sister (11/2/05) at the social work office in the XX Resource Centre. I understand his RMO, had tried to make contact with Mr XX sister but had been unsuccessful.

When the writer saw Mr XX's sister she said there is no contact between them and she was then clearly anxious about Mr XX possible discharge into the community. She was extremely anxious with the prospect and possibility of Mr XX presenting himself to her house. His nephews do not know of Mr XX existence. His sister was clear in expressing that she and her family would not be able to support him although at the same time not wishing for Mr XX to stop his rehabilitation into the community. The Psychological Risk Assessment Report (2/5/06) indicates that Mr XX had a belief that his sister may socialise with him following discharge and did not recognise that communication between them was and is "one sided", ie Mr XX writes to her after each CPA meeting and does not obtain a reply. This report also comments that in 2004 Mr XX seemed to have spoken on the phone to his brother in law, this initiated by him. His sister had not returned the phone call as requested and Mr XX was observed to have been upset.

The writer's observations in this issue are that Mr XX internally wishes for some family contact however, he appears to respect his sister's wishes and claims not to have the intention in contacting her in any other form apart from writing letters. My other observation is that Mr XX on 20 August 2007, learnt from a family member of his father's side (cousin), that 'his sister has separated from her husband'. Mr XX although was observed to have coped well with this unconfirmed news he was somehow concerned for his sister's well being and required support and reassurance in this matter. The writer feels Mr XX requires support and reassurance with respect of family issues/rejection and this will need close monitoring in the community for Mr XX benefit considering the family concerns.

Mr XX nominated named person is, by default, his sister. However, Mr XX has decided to complete a declaration (27/6/06) that his sister should not be his named person under section 253 of the 2003 Act. He has not nominated anyone else and he feels there is no-one he could nominate.

A Community Care Assessment on Mr XX was completed in April 2005 indicating that Mr X required to reside in Supported Accommodation outside XX as his sister resides in this Local Authority area. Mr XX primarily wished to reside in the XX part of XX. He had no access to supported accommodation in XX. He completed several applications for Housing for different Housing Associations in XX where he had a preference to live. Mr XX eventually obtained a 2 bedroom flat from the XXs Housing Association. He signed the tenancy agreement on 4/12/06. Support from XX care provider commenced around the same time. He started to spend time with them in preparation to have his flat decorated and furnished for commencing his first overnight pass at his flat, (9/3/07). At the time of writing this report he has a 24 hour care package provided by XX. It is envisaged that soon after Mr XX is conditionally discharged this care package will be according to his needs and progress be reviewed and subsequently reduced where necessary.

Mr XX has been well supported and work has been done to his own pace, introducing him to his new environment. He commenced his 1st overnight pass on the 01/04/07 and he is now on 4 overnight passes to his flat. Requests to permit these passes have been made by his RMO, Dr X and authorised by Scottish Government.

Risk Assessment and Care Plan

This has been discussed at multi disciplinary care programme approach meetings. Psychologist Ms X in the Psychological Risk Assessment dated 02/05/06 offers the opinion that Mr XX presents "with a low moderate risk of future violent offending in the community". I enclose page 10 of Ms X report with key conclusions and recommendations for risk management.

The writer has further discussed with the RMO on the 17/12/07 a risk management plan for Mr XX and this is also attached to this report. The writer further understands the following risks are well covered in the risk management plan and staff as well as Mr XX co-operate with the plan. Mr XX is supported in the following areas:

Maintenance of mental health in the community

This is to be monitored by RMO who sees Mr XX monthly and (F) the Community Psychiatric Nurse ( CPN) weekly.

• Maintenance of compliance with prescribed medication

This is to be monitored by (F) CPN, RMO and local health centre for blood tests.

• Continue monitoring abstinence from alcohol and support his abstinence

This is to be monitored by RMO, FCPN, observations from all team and communicate to RMO.

• Physical health

Mr XX general health to be monitored by health staff

• Relationship with his sister/cousin

This to be observed by all the team especially XX workers who will see Mr XX on a daily basis. Observations to be communicated to the whole team. Mr XX may find it upsetting not to have family contact.

• Structured activities

Mr XX to continue structured activities in the community. Support and motivate him to engage in activities he enjoys.

• Housing/advice of financial matters/benefits

Mr XX has functioned well with assistance in this area. However he has been in hospital for many years and will continue to need support from XX to alleviate issues and assist to increase independency.

Present Circumstances

Mr XX is currently spending 4 overnights at his flat situated in the Xx. This consists of him spending overnights at his flat on Monday to Thursday. He is supported by XX workers who stay in through the nights with him. Mr XX has familiarised himself with the local area finding out where amenities are. He is close to the shops and he had participated in a cycling club in the area. Mr XX with the assistance of the Occupational Therapist has prepared in relation to domestic, practical matters, building up self confidence and independency for living in the community. Mr XX is much more confident and attends to house chores independently.

Mr XX from the professional point of views continues seeing his CPN Mr X, once a week, normally on a Friday. He also sees her RMO Dr X also every week and attends all CPA meetings. Mr XX is visited by the writer ( MHO) every 4 weeks at his flat.

Views of Current Support Providers

Mr XX is supported by XX. They have commented that the patient engages well with the workers and other clients. He is co-operative and motivated. His flat is kept reasonably tidy.

Engagement with Addiction Services

Mr XX will meet with the Addiction Services initially following conditional discharge to carry out some booster work in addressing alcohol abuse.

Views Nominated Named Person/Advance Statement

The writer has assisted in explaining and providing information about named persons and advance statements to Mr XX. As stated above Mr XX completed a declaration (27/6/06) that his sister XX should not be his named person, Mental Health (Care and Treatment) (Scotland) Act 2003. Mr XX has preferred for the writer not to contact his sister to discuss this and his possible forthcoming conditional discharge to the community. The writer therefore cannot offer any views of a named person. Mr XX has not nominated anyone else.

Mr XX has made use of Advocacy services. Ms XX is his advocacy worker and can be contacted at XX. She attends all CPA meetings with Mr XX.

Mr XX has not completed an advance statement.

Views of Mental Health Officer

Mr XX is currently detained under section 58 and 59 1995 Act. I am informed by Mr XX Medical Responsible Officer, Dr X, that Mr XX suffers from a mental disorder as defined in the Mental Health Care and Treatment Scotland Act 2003, this being a mental illness and his diagnosis being schizo-affective disorder, that he has been in the XX, following the Index Offence. Mr XX medication had been reviewed regularly and he has been mentally stable for a long period of time, his present medication is as follows:

Lithium 600mg (once per day),
Simvastatin 40mg (once per day),
Clozapine 475mg (once per day),
Lansoprazole 30mg (once per day),
Tetracycline 500mg (twice per day)

Mr XX self medicates and the writer understands that he has no problems in complying with taking his medication. He sees this being part of his routine in the morning and night times. He seems to appreciate the importance of him needing medication. The writer is only aware of an incident when he wanted a change of medication this issue is explicit in another part of this report.

Mr XX was transferred to the XX and Rehabilitation ward in July 2004 he has participated in all based activities and others like attending XX in preparation towards his conditional discharge. Mr XX's history indicates that he has presented a risk to others (index offence), he had been charged with the murder of his father and being in hospital on a compulsion order and restriction order ( CORO) he has undergone intensive and extensive psychiatric treatment over the years.

A psychiatric Risk Assessment completed by Psychologist Ms X dated 2/5/06 indicates that Mr X presents with a low moderate risk of future violent offending in the community. Dr X also indicates in her last care and treatment plan (7/6/07) that he requires close monitoring of his mental state by all professionals involved and maintain this with a rehabilitative programme as motivation seems to be one of his negative symptoms. It has also being indicated that Mr XX offence was linked to psychosis and alcohol consumption appeared to have increased at index offence and this requires to be closely monitored regularly and at random.

A Community Care Assessment of Mr XX needs was completed identifying he required supported accommodation in the XX area. He did not wish to return to XX as Mr XX is well known in the XX area. Mr XX sister also resides in XX and as explained earlier in this report Mr XX sister had concern of him approaching her and her family who do not know of his existence.

It is the writer's impression that Mr XX appears to seek involvement with his sister although he rationalises and accepts that he respects his sister's decision.

Mr XX had no access to supported accommodation in XX. He obtained a 2 bedroom flat in the XX and 24 hour support care package has been contracted from XX provider. This care package will be regularly reviewed and reduced as Mr XX increases his confidence, involvement with structured activities and settling in the community once he is conditionally discharged.

Opinions and Recommendations

Mr XX has a mental disorder as defined in the Mental Health (Care and Treatment) (Scotland) Act 2003, this being a mental illness and his diagnosis being schizo-affective disorder.

As a result of Mr XX mental disorder, it not necessary, in order to protect any other person from serious harm for the patient to be detained in hospital, whether or not for medical treatment.

Mr XX's history indicates that he has presented a serious risk to others (index offence) and the risk of serious harm is still present should he stop taking his medication and relapse. Mr XX displayed lack of insight into the need to take his medication in September 2001 when he wrote to his solicitor and Mental Welfare Commission suffering a serious relapse within a matter of days displaying an increase in paranoia. He has undergone intensive and extensive psychiatric treatment over the years. However, the writer's opinion is that it is not necessary for Mr XX to be detained in hospital.

Medical treatment is available for Mr XX which would be likely to:

(i) prevent the mental disorder worsening; or

(ii) alleviate any of the symptoms, or effects, of the disorder.

The current medical treatment is alleviating the symptoms and this medical treatment will continue to be available to him as well as continued monitoring by medical and nursing staff in the community

If Mr XX was not provided with such medical treatment there would be a significant risk -

(i) to the health, safety or welfare of the patient; or

(ii) to the safety of any other person.

Mr XX index offence was an act of violence committed in the context of deteriorating mental illness. Without medical treatment there would be a significant risk of violence recurring.

It does continue to be necessary for X to be subject to the compulsion order.

It does continue to be necessary for the patient to be subject to a restriction order.

Mr XX history indicates that he has presented a serious risk to others (index offence) and the risk of serious harm is still present should he stop taking his medication and relapse.. Mr XX displayed lack of insight into the need to take his medication in September 2001 when he wrote to his solicitor and Mental Welfare Commission suffering a serious relapse within a matter of days displaying an increase of paranoia. He has undergone intensive and extensive psychiatric treatment over the years. The nature and effect of a restriction order is to give a supervising and monitoring role to the RMO and to the Scottish Ministers in the public interest because of the circumstances in which the original order was made. Mr XX requires the restriction order to remain with the resultant safeguards this provides. However, conditional discharge allows supervision, assessment and monitoring which is in the public interest at a time when Mr XX will be coming into increasing contact with the wider community.

It is not necessary for Mr XX to be detained in hospital. Mr XX is stable on medication, he is self medication and has good insight into the need to take medication. He has successfully completed a period of extensive testing out building up to 4 overnights a week without incident.

Mental Health Officer

Date