Discharge or transfer of patients from forensic services procedure

1 Aim

The aim of this document is to provide additional guidance to the trust’s policy for discharge and transfer of patients when preparing for and completing discharge and transfer of patients from the forensic service. The document offers guidance based on best practice and should be used for all transfers and discharges from Amber lodge.

2 Scope

This document applies specifically to the forensic service and provides procedural guidance for use of colleagues working in this service including agency, bank and students during the process of transfer and discharge of patients.

3 Link to overarching policy

This document is overarched by the forensic service manual and should be read in conjunction with the following trust documents:

Personalised easy-read discharge pathway booklets prepared for each patient, “L:drive/Doncaster/Amber lodge/discharge booklets”.

4 Procedure

A transfer from the forensic service would result in the patient moving to another hospital of either a lesser or greater level of security.
Discharge from the forensic service involves the patient being discharged from Amber Lodge into a community service placement.

4.1 Responsibilities of the MDT

4.1.1 9 to 12 months prior to planned transfer or discharge

Revisit treatment outcomes and milestones to give confidence that treatment will be completed in 9-12 months. Consider who can or should advocate for the patient at this time, for example IMCA, family member, general advocate.
Develop and agree an integrated, person-centred plan for discharge, considering the views and wishes of the patient and their advocates and carers (if applicable).
Allocate a social worker or care manager to undertake the patient’s needs assessment.
Assess the patient’s capacity to make decisions in specific areas if indicated, for example, regarding future residence, care and treatment, contact with others, finances, tenancy, shopping, internet access, social media, phone access.
Develop a person specification identifying the type of accommodation, care requirements, colleagues’ requirements (for example, how many, training, skills and experience required), number of people in the accommodation (including no others) and location of accommodation.
Undertake risk assessments capturing the risks posed to and by the patient in a potential discharge environment.
Develop a positive behavioural support (PBS) plan for discharge.
Make necessary referrals for discharge, for example, community responsible clinician, social supervisor, community support, occupational therapy (OT).
Arrange a care and treatment review (CTR) to be held within recommended timescales and MDT processes to review progress.
Identify funding stream (section 117, joint funding) and responsible funding authority.

4.1.2 6 to 9 months prior to planned transfer or discharge

Ensure the responsible funding authority has agreed the funding in principle based on the pen picture and service specification to allow the procurement process to commence.
Develop detailed practical transition plan and identify all steps required for successful discharge. Ensure the transition plan includes contingency, crisis and risk management plan.
Prepare a personalised easy-read booklet, outlining the steps required for successful discharge, for the patient’s own use and support them to access it.
Make best interests decision where required in relation to tenancy. LA to ensure Court of Protection (CoP) process underway once home address is identified, if this is needed.
Ensure appropriate is property found, tenancy agreed, adaptations identified and works planned with agreed timescales. Confirm placement or provision and ensure the contract is awarded.
Arrange additional professionals or MDT meetings to foresee potential barriers.
Hold CTR to assure planning if concerns that discharge delay is a risk.

4.1.3 3 to 6 months prior to planned transfer or discharge

Confirm funding for the individual person-centred support plan from the responsible funding authority and confirm its route of delivery, for example, personal health budget (PHB), direct payment or commissioned service.
Where applicable, notify the finance appointee of the intention of transfer or discharge and the planned date.
Include the patient and their family, where appropriate, for co-production.
Make best interests decision where required for accommodation, care and treatment, plus any restrictions. Make CoP application, if required.
Finalise care colleagues recruitment and training where required (for example, by forensic outreach liaison service (FOLS), in line with the person centred plan and PBS plan.
Hold MDT review and CTR to agree that treatment goals are achieved and confirm transition plan.
Where the placement is subject to section 37 or 41 of Mental Health Act (MHA), determine when the tribunal hearing should be applied for.

4.1.4. Less than 3 months prior to planned transfer or discharge

Ensure necessary legal frameworks in place to facilitate transfer or discharge.
Ensure transition plan in place and being actively followed. Colleagues from the intended placement should attend Amber Lodge to meet, understand the needs of, and develop a therapeutic relationship with the patient prior to the patient using Section 17 leave to attend the placement.
Ensure risk management, crisis or contingency plans are agreed and well understood by all, including the patient and their family, and that all of the resources for those plans are in place.
Ensure that a best interest decision or consent has been given for inclusion on dynamic risk register at the point of discharge.
Ensure Welfare Benefits have been applied for, where appropriate.
Liaise with the receiving responsible clinician, Mental Health Act office, and the Ministry of Justice (MoJ) to arrange the transfer.
Ensure that all relevant paperwork is in place prior to transfer or discharge, such as MoJ authorisation and Section 17 leave, if applicable.
Confirm details of the general practitioner (GP) doctor service in the receiving area and identify an allocated GP for the patient.
For transfers, ensure a professionals meeting is arranged and held with the receiving responsible clinician (RC) in attendance alongside the service, care coordinators and patient’s family or carers.
For discharges, ensure that a section 117 aftercare meeting has been held with the community responsible clinician, support services involved in the care, and the patient’s family or carers in attendance.

4.1.5 Immediately prior to and on the day of discharge

To ensure that:

transport required is agreed and arranged, plus escorting colleagues are identified, at least 7 days prior to transfer or discharge
to take out (TTO) medication is ordered at least 5 days prior to the agreed date of transfer or discharge. TTO medication must be available and sent with the patient along with a copy of the patient’s prescriptions
all Mental Health Act paperwork is readily available and transferred with the patient. These must be original documents. Liaison with the trust Mental Health Act office is essential to prepare this documentation and to notify them of decisions to transfer or discharge the patient
appropriate professionals are involved in the transfer, so effective handover can be provided to the receiving service. This must include ReSPECT forms (if applicable) and DNA CPR status
all patient belongings and personal items inventory are transferred with the patient
all valuables (if applicable) which are stored in the Trust valuables safe are retrieved in a timely manner for the date of transfer, so that they can go with the patient
support is provided (if applicable) with packing patient belongings and personal items prior to the moving day
where appropriate, the MoJ are informed of the confirmed transfer of the patient

4.1.6 Immediately following transfer or discharge

Once the patient has left Amber lodge, it is to be documented on the patient electronic record (SystmOne) and the patient is to be removed from the bed states and fire board.
A confirmation email is to be sent to the Mental Health Act office, responsible clinician, finance department and any other relevant professionals involved, such as care coordinator and police public protection unit (PPU) officer, where appropriate.
The patient room is to be cleaned in line with the infection, prevention and control manual.
If consent was given by the patient, a phone call is to be made to their family or carers to confirm transfer of the patient.
Ensure follow up by the social worker or care manager in the new placement, within one week of transfer or discharge.
Hold a CPA Meeting within four weeks of transfer or discharge.
Ensure that contingency arrangements are still in place if required after four weeks. FOLS practitioners to continue to visit.
Ensure that a review mechanism via MDT and CTR is in place for the medium term.

4.2 Transition planning

As stated in section 4.1, a personalised transition plan must be developed for each patient and provided to them in an individualised format.

4.2.1 Transition plan easy-read booklet

Each patient transition plan booklet must include:

an explanation of the technical terms and acronyms appropriate to that patients discharge or transfer for example, MoJ, Integrated Care Board (ICB), Deprivation of Liberty Safeguarding (DoLS), conditional discharge, capacity assessment
the steps patients must take to engage with their treatment to demonstrate that it is appropriate to progress with the transition plan for example, taking medications, attending OT sessions, utilising Section 17 leave appropriately, attending psychology sessions, attending MDT meetings
an explanation of the steps required to identify a suitable placement as outlined in section 4.1.1
the key individuals involved in the transition plan for example, placement colleagues, social supervisor, social worker, care co-ordinator, probation officer, responsible clinician, GP, FOLS practitioner
an explanation of the incremental increase in day visits, and later night visits, to the new placement, and the required applications.
an outline of the potential conditions that may be included in a conditional discharge or release on licence for example, restrictions on address, medications, appointments, jobs, relationships, travel, alcohol, illicit substances, internet access, leave

4.2.3 Unplanned or emergency transfer

Any unplanned or emergency transferred required will be led by the provider collaborative in conjunction with the ward and led by the RC.

Document control

Version: 3
Unique reference number: 527
Date ratified: 5 March 2024
Ratified by: Clinical policies review and approval group
Name of originator: Forensic ward manager
Name of responsible individual: Executive director or nursing and allied health professionals
Date issued: 2 April 2024
Review date: 30 May 2027
Target audience: All colleagues working in forensic services.
Description of change: Full review and update.

Page last reviewed: September 13, 2024
Next review due: September 13, 2025

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