Multi-Agency Public Protection Arrangements (MAPPA): national guidance

10. Restricted Patients (Managed within the Health System)

Statutory Basis

10.1 Section 10 (1) of the Management of Offenders etc. (Scotland) Act 2005 sets out the distinct categories of individuals who can be subject to MAPPA. In April 2008, relevant parts to that section in relation to Restricted Patients were enacted by virtue of a Scottish Statutory Instrument (SSI).

Identification

10.2 Restricted Patients mean patients subject to a compulsion order with restriction order, a hospital direction or a transfer for treatment direction; that is patients who are subject to special restrictions under the Mental Health (Care and Treatment) (Scotland) Act 2003. All such patients are subject to MAPPA. These are:

• Patients who are detained following conviction under section 57A and section 59 of the Criminal Procedure (Scotland) Act 1995;
• Patients who are detained under section 57(2)(a) and (b) of the Criminal Procedure (Scotland) Act 1995 Compulsion order with a Restriction Order following a finding of unfitness for trial or acquittal by reason of mental disorder; and
• Prisoners detained in hospital on a Hospital Direction under section 59A of the Criminal Procedure (Scotland) Act 1995 or a transferred prisoner on a Transfer for Treatment Direction under section 136 of the Mental Health (Care and Treatment) (Scotland) Act 2003.

10.3 The legislative provisions requiring the use of MAPPA procedures in relation to these patients can be found at sections 10 and 11 of the Management Offenders etc. (Scotland) Act 2005.

10.4 Scottish Ministers also have a statutory role in relation to certain patients subject to other types of mental health orders, such as interim compulsion orders, assessment orders and treatment orders. They are not 'restricted patients' and are not subject to MAPPA.

MAPPA and the Care Programme Approach

10.5 Although the same underlying principles of gathering and sharing of relevant information in relation to risk apply, the Care Programme Approach (CPA) focuses on a patient's care and treatment including that likely to minimise the risk posed to other persons, whilst MAPPA focuses on multi-agency review and scrutiny of the risk management plan produced through the CPA process. Within the MAPPA framework, the CPA process will remain the vehicle for planning a person's care and treatment and for risk assessment and management planning.

10.6 The underlying concept of MAPPA is to provide systems and processes for relevant agencies to share information about individuals who represent a risk to the community. Where appropriate, the agencies will co-operate to put together plans to assess and manage these risks. It is important to emphasise that the MAPPA meeting's remit is scrutiny of risk assessment, information sharing and risk management plans and not direct case management or an opportunity to have a case conference.

NHS Boards and State Hospital Board

10.7 All regional NHS Boards and the State Hospital Board for Scotland should identify a senior manager responsible for providing the assurances on the quality of the operation of the CPA and to provide the statistical information for contributing to the MAPPA Annual Report. As detailed in the Memorandum of Procedure for Restricted Patients (MOP) it is recommended that an audit be carried out on the quality of the operation of CPA on an annual basis. Further information on data required for the MAPPA Annual Report can be found at Annex 3 of this guidance.

Liaison with Police Scotland

10.8 The local MAPPA Co-ordinator should help identify police link staff to be invited to a pre-CPA meeting and for liaison about any police issues of relevance to the case including when a MAPPA Level 2 or 3 referral is appropriate. The aim is that the police link should be in place from the start of the CPA process and not simply introduced when the patient is moving towards the community. The police role should include invitation to CPA meetings in the following circumstances:

• On the admission of the patient to hospital an appropriate police liaison officer is identified who will assist with the gathering and sharing of information to assist the risk assessment process. This person should be invited to the pre-CPA meeting which takes place shortly after admission and does not normally involve the patient;
• When unescorted leave within hospital grounds is being considered;
• If the patient is high risk or high profile and escorted leave is being considered;
• Prior to accommodation being identified for a patient progressing towards conditional discharge;
• When a breach of condition occurs or if a patient is recalled; or
• Any other occasion when it can be demonstrated that a police representative at the meeting is essential.

Notification to MAPPA Co-ordinator

10.9 A notification should be completed and sent to the MAPPA Co-ordinator in the area where the patient is located when a restricted patient is admitted to hospital; any transfer between hospitals or hospital units or back to prison. A MAPPA Restricted Patient Notification Form can be found within the MAPPA document set of this guidance Further detail on the notification process for Restricted Patients can be found in CEL 19 (2008).

Referral to MAPPA Co-ordinator

10.10 There are three key stages at which a MAPPA referral should take place, using the MAPPA Restricted Patients Referral Form:

• when the patient is being considered for unescorted hospital grounds access or unescorted suspension of detention for the first time - following scrutiny of the risk assessment and management plans, MAPPA partners will indicate whether or not they are content with the plans. Once agreement is reached the Responsible Medical Officer (RMO) should submit the request for suspension of detention to the Scottish Ministers in the usual way;
• when suitable accommodation has been identified in the community as part of the planning for conditional discharge - suspension of detention may continue as usual whilst this process is underway; and
• when the RMO is considering recommending the revocation of the compulsion order or the revocation of the restriction order.

10.11 There may be other circumstances when a MAPPA level 2/3 referral is appropriate.

These include:

• the restricted patient is also subject to the Sex Offender Notification Requirements (SONR) and an environmental scan requires to be carried out on the new address;
• involving transfer or escorted suspension of detention from the State Hospital when the risk is considered to be high or there are significant victim sensitivities;
• first occasion of escorted suspension of detention, where risk is high or patient is high profile;
• if a patient is approaching their Earliest Date of Liberation (EDL) and the care team consider the risks presented by the patient are significant enough to be managed through a risk management plan managed at MAPPA level 2 or 3;
• if a patient is already on unescorted suspension of detention or unescorted ground leave and the care team considers the risk presented by the patient might be best managed at MAPPA Level 2 or 3; or
• if a patient is on conditional discharge and the clinical team and others involved through the CPA process consider the risk presented by the patient might be best managed at MAPPA Level 2 or 3.

10.12 All referrals should be completed and sent to the MAPPA Co-ordinator in the area of hospital sending the referral. A copy of a MAPPA Restricted Patient Referral Form found within the MAPPA document set of this guidance.

MAPPA Meeting

10.13 A request for a Health case (Restricted Patients) to be discussed at a MAPPA Level 2/3 meeting may be arranged upon referral to Level 2 or 3, or when a 'significant change' is likely. It is the responsibility of the RMO to request a Health case to be added to the MAPPA meeting agenda when a significant change is being considered.

10.14 To assist and help clarify about what may constitute as a significant change in circumstances and avoid confusion over whether a MAPPA meeting for a Health case is necessary, this is a decision left to the discretion of the clinical team around the Restricted Patient. The aim is to allow the clinical team to make decisions on a case-by-case basis, subject to following the guidance given in this document and relevant consultation with risk management partners.

10.15 Paras 10.10 and 10.11 detail at what points a referral to the MAPPA Co-ordinator should be made. In those instances, or where a significant change is being considered and the clinical team has decided that it requires a MAPPA referral, no changes should be made to an existing care/risk management plan until it has been explored at a CPA meeting and the Scottish Government (Restricted Patient Team) has approved the subsequent recommendation.

10.16 The MAPPA Chair should clearly establish what action NHS staff will take in the event a patient absconds and how Police Scotland will respond in the event they are called. The relevant Health Board(s) should be aware of what action they expect Police Scotland to take in such situations and Police Scotland should explain the legal boundaries that define their ability to respond. This should be clearly recorded in the MAPPA minute.

MAPPA information relayed to the Mental Health Tribunal (MHT) for Scotland

10.17 In the event of a request for disclosure of MAPPA minutes for submission to the Mental Health Tribunal, the following information will be shared by the Health Directorate: A MAPPA meeting was held on [date]. MAPPA level is [state level]. The MAPPA group support the recommendation by the RMO for unescorted suspension of detention. When considering unescorted suspension of detention, the RMO should share with MAPPA the plan for the proposed Suspension of Detention (SUS) including where appropriate victim sensitivities. This information will be reflected in the Position Statement when relevant.

10.18 For those Tribunals considering conditional discharge, revocation of the compulsion order or revocation of the restriction order the Scottish Government's Restricted Patient Team will e-mail the relevant MAPPA Co-ordinator to request that a Minutes Executive Summary be prepared by the Chair of the MAPPA meeting for lodging at the MHT (which in turn will be copied to the patient and other parties). The Restricted Patient Team should be advised of all MAPPA meetings and will consider whether or not they should be represented.

The wider role of the NHS in MAPPA

10.19 The NHS has a duty to co-operate for all individuals subject to MAPPA (not just Restricted Patients). Further information on duty to co-operate can be found at Chapter 3 of this guidance. The role and remit of the NHS as a Responsible Authority can be found at Chapter 2 of this guidance.

Further information and supplementary guidance - Restricted Patients within the MAPPA Framework

10.20 Scottish Government Circular - CEL 19 (2008) provides guidance on the immediate actions to be taken by health boards in relation to restricted patients, and explained both how restricted patients would be assessed and managed within the MAPPA framework as well as the on-going responsibilities of health boards and patient care teams under the 2005 Act.

10.21 CEL 19 (2008) also provides guidance on:

• Health responsibilities for restricted patients under MAPPA (paras 15-19)
• Application to restricted patients (paras 20-27)
• CPA for restricted patients (paras 28-33)
• Risk assessment and management of restricted patients (paras 34-38)
• NHS Boards and Clinical Governance (paras 29-41)
• Role of the Responsible Medical Officer (paras 42-44)
• Role of the Mental Health Officer (para 45)
• Procedures for MAPPA Stage 1 (paras 50-56)
• Transfer to conditions of lower security or otherwise (paras 57-60)
• Planning for Suspension of Detention (SUS) (paras 61-67)
• Planning for Conditional Discharge (CD) (paras 68-75)
• Procedures for referral to MAPPA stage 2 and 3 (paras 76-81)
• Transferred prisoners (paras 82-85)
• Absconding by patient on leave (paras 86-88)
• Breaches of conditions of discharge (paras 89-92)
• Revocation of Compulsion Order (Absolute Discharge) or Revocation of Restriction Order (paras 93-99)
• Early Discharge Protocol (para 100)
• Transfer out of Scotland (para 101)
• ViSOR (paras 102-104)

NHSHDL (2007)19

NHSCEL (2007) 7

NHSCEL (2007) 13

NHSHDL (2002)85

Memorandum of Procedure for restricted patients