Leave for inpatients policy and guidance including section 17

1 Introduction

For patients receiving care and treatment within mental health services periods of leave from the ward play an important part in their recovery particularly in relation to discharge planning. However, all decisions to grant a period of leave must be supported by a holistic assessment of the patients’ needs, circumstances, and presentation.

The service has a responsibility for preparing inpatients for a successful return to the community with periods of leave being an essential component to this. The decision to agree or grant leave of absence from hospital must balance the contribution that leave makes to the patient’s rehabilitation against considerations for the safety of both the patient and others.

This policy outlines the processes that should be followed when leave is being considered. It covers the steps to take where a patient is:

subject to detention under the Mental Health Act (MHA) 1983
an informal inpatient
sent to a general hospital ward as an informal patient or under section 17 of the MHA 1983

2 Purpose

The purpose of this policy is to guide employees in granting, reviewing, monitoring, and assessing leave ensuring that patients have access to appropriate, safe and meaningful leave where appropriate.

3 Scope

This policy applies to all mental health and learning disability wards within the Rotherham Doncaster and South Humber NHS Foundation Trust (the trust).

4 Responsibilities, accountabilities and duties

4.1 Mental health legislation operational group

The trust’s mental health legislation operational group is responsible for:

overseeing the implementation of the MHA 1983 within the trust
monitoring the trust’s compliance with the legal requirements of the MHA 1983
undertaking audits and agreeing action plans in relation to the MHA 1983
providing an annual report on MHA activity within the trust to the board of directors

4.2 Independent mental health advocates

The role of the independent mental health advocate is to help qualifying patients (those detained under the MHA 1983 conditionally discharged, subject to guardianship or community treatment orders but not those detained under section 4, section 5, section 135 or 136) understand the legal provision to which they are subject under the MHA 1983 and the rights and safeguards to which they are entitled.

This could include assistance in obtaining information about any conditions or restrictions the patient is subject to, for example, any arrangements made for section 17 MHA 1983 leave.

4.3 Responsible clinician

The responsible clinician (RC) is responsible for the granting of section 17 MHA 1983 leave of absence for any patient detained under the MHA 1983. In the absence of the patient’s RC (for example, if they are on leave) permission for a period of section 17 MHA 1983 leave can only be granted by the approved clinician who is for the time being acting as the patient’s RC.

When making any decision in relation to a patient having a period of leave from the inpatient ward the RC must in conjunction with the multi-disciplinary team (MDT) take account of the impact being away from the ward will have on the patient’s clinical risk profile. Whilst an identified increase in clinical risk will not necessarily prevent a patient from undertaking a period of leave, a plan must be in place to evidence what steps have been taken to manage or minimise the risk.

4.4 Consultant in charge

The consultant in charge of the patient’s episode of inpatient care has responsibility for overseeing the delivery of treatment for informal patients admitted under their care. This should include negotiating of ward activities and any leave with informal patients in consultation with the MDT and the patients’ carers or relatives.

4.5 On call managers

On call managers are required to ensure patients returning from s17 MHA 1983 leave effected as a transfer of care from another NHS hospital, are managed within working hours, or in exceptional circumstances is escalated and arranged with agreement of the on-call consultant in charge.

4.6 Registered mental health and learning disability clinical employees within inpatient services

In relation to this policy all registered mental health and learning disability clinical employees must be aware of and comply with the contents of the policy.

At any time when they are in charge of the ward, they will be responsible for providing:

assess any informal patient before leave, to consider risk and clinical need, before supporting the patient’s leave
the patient with a copy of the section 17 MHA 1983 leave form
the patient’s nearest relative with a copy of the section 17 MHA 1983 leave form
the patient’s care coordinator with a notification that there is a finalised section 17 MHA 1983 leave form
ongoing monitoring in relation to the date when the section 17 MHA 1983 leave authorisation is due to be reviewed
for applicable patients, the notification to the South Yorkshire or Humberside Multi Agency Public-Protection Arrangements (MAPPA) coordinator by completion of the MAPPA I notification form (refer to the trust’s MAPPA protocol (staff access only) (opens in new window))

Registered clinical employees should also:

in the event of a patient’s clinical presentation deteriorating immediately prior to a period of leave, take action to facilitate a review of the leave, or if the review is to be delayed revoke the leave subject to an MDT review
be aware of the site that they are working on and the boundaries in relation to patients being granted ground leave (see appendix A for site maps)
have consideration to the MHA 1983 for any patients who may be informal who may present with risks
attend any training which is provided in relation to this policy
bring to the attention of senior managers any concerns they may have under this policy.

4.7 Non-registered clinical employees within inpatient services

Any non-registered employees working within clinical services must:

be aware of this policy and its contents
direct any patient who has a query about leave to a member of registered employees
report any breaches to their line managers that they become aware of in relation to this policy.

4.8 Care coordinator or lead professional

It is the responsibility of care coordinators or lead professionals to:

be aware of this policy and its contents
be involved in the planning of leave for patients they are working with:
- support patients whilst on leave from the wards
report back to inpatient employees as to the progress of the patient following any contact whilst leave is taking place.

4.9 Mental Health Act office

Within each of the trust localities, where there are inpatient services, there is a Mental Health Act office and in relation to this policy the employees working in these offices are responsible for:

the ongoing monitoring of the completion of the section 17 MHA 1983 leave forms where patients are taking leave at acute general hospitals

5 Procedure or implementation

5.1 Guidance on leave

Although informal patients have the right to leave the ward at any time, the trust has a duty of care towards them including the responsibility for their safety and wellbeing whilst on leave.

For detained patients, the trust must follow the legal guidance set out in the MHA. Employees should refer to section 5.3 of this policy for further guidance on responsibilities under the act.

The following guidance should be followed irrespective of the patient’s legal status with employees taking note of the relevant additional guidance set out for detained patents.

5.2 Planning, agreeing and granting leave

Wherever possible, any period of leave should be planned and agreed in consultation with all relevant people involved in the patient’s care and treatment, for example, family, carers etc.

In respect of detained patients, the RC can also make the section 17 MHA 1983 leave subject to any conditions, which they consider necessary in the interests of the patient or for the protection of other people. Periods of leave can be granted:

escorted (by employees) or unescorted in the hospital grounds
escorted (by employees) or unescorted in the community

For a specific occasion:

as recurring, for example, 2 hours per day to go out with employees.
as short leave, for example., for a day or overnight.
as extended leave, for example, 2 to 3 weeks at a time.
accompanied (with family or friends etc.)

Note, any period of leave cannot last longer than the duration of the authority to detain.

Any decision for a patient to have a period of leave from the ward will be informed by the ongoing assessment of clinical risk, taking account that a patient’s risk profile may change once they leave the ward and are no longer under the supervision and care of clinical employees. As part of the risk assessment the following factors should be considered:

any issues with treatment adherence
risk of absconding from the local area
risk of refusing to return to the ward.
any risks identified leading to the admission

Leave of an informal patient should be agreed by the MDT, whereas leave for a detained patient must be granted by the RC. The following should be considered when agreeing or granting all leave:

the patient’s response to their treatment and care
consider the potential benefits and any risks to the patient’s health and safety of granting or agreeing or refusing leave
consider the potential benefits of granting or agreeing leave for facilitating the patient’s recovery
balance these benefits against any risks that the leave may pose in terms of the protection of other people
be aware of any safeguarding issues in granting or agreeing leave
consider any risks identified leading to the admission
take account of the patient’s wishes and those of carers, friends and others who may be involved in any planned leave
feedback from any previous periods of leave
feedback from family or carers if consent is given
consider what support the patient would require during their leave and whether it can be provided
ensure that any community services which will need to provide support for the patient during the leave are involved in the planning and that they know the dates, times and any conditions where applicable
ensure that the patient is aware of any contingency plans in place for their support, including what they should do if they think they need to return to hospital early
ensure that any relatives or friends who are to be involved in the period of leave for the patient are aware that they are not taking any legal responsibility for the patient as they remain under the care of the service, for those patients granted escorted leave, the patient will remain in the custody of the escort who has powers to convey and restrain the patient
(in the case of mentally disordered offenders) whether there are any issues relating to victims which impact on whether leave should be granted and the conditions to which it should be subject
for detained patients, consider any conditions which should be attached to the leave
for informal patients, although conditions cannot be enforced, consider whether there are any conditions which we should be suggesting are attached to the leave
location of leave and who this will be with including confirming correct contact number and numbers for friends or relatives

A leave care plan must be developed which takes account of any identified risks and the management of these risks and includes any specific community-based support which is needed to safely facilitate the leave.

For patients having section 17 MHA 1983 leave, or incapacious patients managed under the MCA 2005 having leave, to a care home or supported living, then consideration should be given whether the patient will be under continuous supervision and control and not free to leave. Considerations need to be made and documented, regarding their valid consent, and where they lack capacity to consent Deprivation of Liberty Safeguards (DoLS) should be sought.

A DoLS standard authorisation should then be sought by the registered manager of the care home. Where possible this should be done before the person goes on leave. If there is insufficient time the registered manager should grant an urgent authorisation on the day of admission.

For patients in supported living who will be deprived of their liberty the funding authority (either the local authority or clinical commissioning group) will need to seek authorisation from the Court of Protection, prior to the leave being granted

Note, under normal circumstances leave should not be granted if the patient does not consent to relatives or friends who are to be involved in their care being consulted

5.2.1 Action immediately prior to a period of leave

Prior to leave each patient will be reviewed by a registered clinician who will carry out an assessment of the patient’s mental health presentation and clinical risk profile, and document this.

As part of this assessment the clinician should obtain the following information from the patient:

how they feel about the planned leave
that they clearly understand the arrangements including what to do in the event of them needing advice or assistance
the patient’s perception of any identified clinical risk issues and what coping strategies they can utilise

For any home leave employees should where possible, contact the patient’s carers or relatives to confirm:

there has been no change in circumstances which may have a direct impact on the planned leave
the address to which leave is to be taken
a contact number for the patient
any support which is to be provided by the services during the period of leave
that they are aware of action to take if they have any concerns

Where the patient is going on home leave, the inpatient team should also be satisfied:

the patient has access to the premises
the patient has (or will have) enough food and beverages for the period of leave
there are no immediate risks which could compromise the safety of the patient

Any medication required by the patient during leave will be issued immediately prior to the patient leaving the ward. The clinician must ensure that the patient understands how and when to take their medication, including any “as required” (PRN) medication if issued. The patient should be reminded of the purpose of the medication and of any side effects they might encounter.

All patients who are having a period of leave from the ward should be provided with a copy of the leave leaflet.

If employees have any concerns on the day of leave in relation to the patient’s clinical presentation or risk profile, they should suspend the planned leave subject to review by the patients consultant or RC. As part of this assessment the clinician should obtain and document from their immediate assessment:

is there a real (rather than remote) and immediate (meaning present and continuing) risk to their health, safety, or others, that means they need and deserve hospital in-patient care (so leave should not be supported at that time)?
if so, this must be discussed with the patient, and leave must be postponed (and appropriate legal frameworks then considered, see section 5.2.2)

Prior to the patient leaving the ward employees will provide a verbal handover to anyone who arrives to accompany the patient.

Note, all of the above must be recorded in the electronic patient record.

5.2.2 Action if a period of leave has been agreed, but there is a change in the patient’s clinical presentation or risk profile

If employees have any concerns in relation to a patient’s clinical presentation or risk profile, they are to suspend the planned leave subject to either a review by the patients RC or consultant or the MDT.

A full explanation is to be provided to the patient and where relevant their carers or relatives as to why this decision has been made and that arrangements are being made for a review to take place.

Should the patient insist on the leave taking place, but the risk of harm has increased, the patient should in the first instance be asked to remain on the ward until seen by one of the medical team.

For informal patients where the patient refuses to wait, employees should consider whether the criteria for detention under the MHA 1983 are met. If the patient meets the criteria for detention under the act employees should consider the use of section 5(4) or section 5(2) of the MHA 1983, as appropriate.

If the patient does not meet the criteria for detention under the act, and has not had any previous episodes of leave, it is essential that a full risk assessment is undertaken before they leave the ward and that a discussion is held with the Home-Based Treatment team or Community team in relation to any community support that may be required.

In these circumstances adequate communication with families and carers is key and there is to be a detailed record made in the patient’s clinical record of all action taken.

5.2.3 Action where an informal patient requests leave at short notice

Although patients who are not subject to detention under the MHA1983 are able to leave the ward area it is not unreasonable for them to be asked to inform a member of the team if they wish to go out for a short period and to give an approximate time of return. Any such request should then be considered in relation to the patient’s risk assessment, level of capacity and current presentation.

If the patient meets the criteria for detention under the act employees should consider the use of section 5(4) or section 5(2) of the MHA 1983, as appropriate.

Any nurse approached by an informal patient who wishes to leave the ward but is unwilling to provide full relevant details of the leave, or the nurse has concerns in relation to their clinical presentation should request that the patient remains on the ward until seen by a member of the medical team or treating consultant.

If the patient refuses to wait, employees should consider whether the criteria for detention under the MHA 1983 are met.

All queries and decision on leave directed towards non-registered employees must be escalated to the registered nurse on duty.

If the patient does not meet the criteria for detention under the act and is insisting on leaving the ward a detailed record is to be made in the patient’s clinical record of all action taken.

5.2.4 Support during leave

Any patients on leave are still subject to an episode of inpatient care and if ward employees receive communication from either the patient or their carer or relative expressing any concern they should in the first instance ascertain what the concern is and see if there is any advice or practical steps that can be taken to alleviate the concern.

If the call has been made by someone other than the patient, employees should also try to make direct contact with the patient to try and ascertain their perspective as to how they feel the leave is progressing. Following this discussion:

if it is not felt that the patient needs to immediately return to the ward, the named nurse or other allocated professional should contact the relevant community team and request that the patients care coordinator undertakes a visit. For patients not under the care of a care coordinator the local Access team should be asked to do an urgent visit. In some circumstances it may be that inpatient staff will carry out the visit, particularly where this approach would more appropriately support an ongoing discharge or rehabilitation or transition plan
if it is felt that the patient needs to return to the ward and they agree, the Named Nurse or other allocated professional should make sure that they have the means to return safely.

If the patient refuses to speak with employees and the situation is felt to warrant the patient returning to the ward employees must:

ascertain the patients’ location
assess the level of risk posed to either the patient, and, or others. Establish if the patient is willing to return to the ward, and if yes make any necessary arrangements to facilitate their safe return
in the event of the patient refusing to return, liaise with the patient’s ward consultant in charge in relation to the need for possibly organising an assessment under the MHA 1983

5.2.5 Return from leave

Adequate feedback of progress whilst on leave is crucial for informing future clinical decision-making, review of clinical risk and timing of discharge. In view of this after the patient returns from leave the named nurse should meet with the patient and their carer where appropriate at the earliest opportunity to discuss how the leave went. The outcome should be:

summarised in the post leave nursing notes in the patient’s electronic record
feedback given to the care coordinator or lead professional where one is allocated
a discussion held within the MDT
the care plan reviewed and updated as necessary

5.2.6 Failure to return from leave and missing patients

Where a patient fails to return from leave at the specified time the ward employees should attempt to contact the patient via the phone and establish the reason for the failed return. Any requests from the patient for an extension of leave should normally be discussed with the medical team before being allowed. However, nursing employees should exercise judgement when members of the appropriate medical team are unavailable, for example, over the weekend.

Where the ward employees are unable to make contact or have any concerns regarding the safety of the patient or others then direct contact must be attempted with the patient. The situation must be discussed with a member of the medical team and consideration given to a visit to the patient’s address by ward employees or community team employees.

If a detained patient fails to return to the ward at the agreed time they are classed as absent without leave (AWOL) and must be returned under section 18 of the MHA 1983. Employees should refer to the trust policy for patients who are missing or absent without leave (AWOL) for detailed guidance.

5.2.7 Involvement of carers or relatives

As indicated throughout this policy any carers or relatives who are supporting the patient should be involved in the care planning process throughout the episode of inpatient care, including planning of leave. Agreement for this involvement should be sought from the patient at the time of their admission to the ward and revisited at regular intervals throughout their stay.

Ensure that information in relation to their care and treatment is considered and shared with their relatives or carers. Employees must discuss this with patient, so they are aware of what information is necessary to be shared to support their leave and their ongoing treatment or safety. However, they need to be mindful of the fact that sharing information from the carer or relative and listening to any concerns they may have does not breach patient confidentiality.

However, in circumstances where a patient states they do not want to share information with their relative or carer it may not be possible to support the period of leave.

Where further considerations are required with the sharing of information, please contact the Information Governance team or the data protection officer (DPO).

5.3 Requirements for granting leave to patients detained under the MHA 1983

5.3.1 What is section 17 MHA 1983 leave of absence?

In respect of patients who are detained under the MHA 1983 the MHA Code of Practice 2015 states:

27.3 “In general while patients are detained in a hospital they can leave lawfully, even for a very short period, only if they are given leave of absence by their responsible clinician under section 17 of the act”.

It must be remembered that any period of leave cannot last longer than the duration of the authority to detain which was current when the leave was granted.

27.5 “Except for certain restricted patients no formal procedure is required to allow patients to move within a hospital or its grounds. Such ‘ground leave’ within a hospital may be encouraged or, where necessary, restricted, as part of each patient’s care plan”.

27.7 “What constitutes a particular hospital for the purpose of leave is a matter of fact which can be determined only in the light of the particular case. Where one building, or set of buildings, includes accommodation under the management of different bodies (for example, 2 different NHS Trusts), the accommodation used by each body should be treated as forming separate hospitals. Facilities and grounds shared by both can be regarded as part of both hospitals”.

However, where hospitals comprise a number of buildings which are not on the same site, leave of absence will be required for any period of absence involved in moving between those buildings.

5.3.2 Under which sections of the MHA 1983 can section 17 leave of absence be given?

Leave of absence can be granted to any patient detained under the MHA 1983 except for those detained under sections 35, 36, 38. However, leave of absence would not normally be granted to patients detained under section 4, 5(4), 5(2) or 136.

Where the courts or the Secretary of State for Justice have decided that restricted patients are to be detained in a particular unit of a hospital, those patients require leave of absence (authorised via the Ministry of Justice) to go to any other part of that hospital as well as outside the hospital.

5.3.3 Who can grant leave of absence under section 17?

Only the patient’s RC has the authority to grant leave of absence under section 17 and in the case of restricted patients this has to be with the approval of the Ministry of Justice.

RC’s cannot delegate the decision to grant leave of absence to anyone else. In the absence of the usual RC (for example, if they are on leave or off sick) permission can be granted only by the approved clinician who is for the time being acting as the patient’s RC.

5.3.4 Granting leave of absence for more than seven consecutive days

When considering whether to grant leave for more than 7 consecutive days or extending leave so that the total period is more than 7 consecutive days the RC must first consider whether the patient should go onto a CTO instead. (This does not apply to restricted patients or to patients detained under section 2 MHA 1983).

This does not mean that the RC cannot use longer-term leave if that is the more suitable option, but they will need to be able to show that both options have been duly considered. Therefore, the decision and the reasons for it should be fully documented in the patient’s electronic patient record.

For further guidance on CTO’s refer to the trust community treatment order policy.

5.3.5 Granting of leave for restricted patients

Any proposed period of leave for a restricted patient must be approved by the Secretary of State for Justice.

Where the Courts or Secretary of State have decided that restricted patients are to be detained in a particular unit of a hospital, those patients will require the Secretary of State’s permission to take leave to go to any other part of that hospital as well as outside the hospital.

It is the responsibility of the patients RC to request approval from the Secretary of State via the Ministry of Justice for leave for restricted patients. Employees should refer to appendix B of this policy for the MHCS Guidance on section 17 leave (dated March 2015).

For patients who are also subject to MAPPA, the MAPPA I notification form should be completed and forwarded to the appropriate MAPPA coordinator (refer to the trust MAPPA protocol).

5.3.6 The recording of section 17 MHA 1983 leave

The granting of leave under section 17 and any specific conditions attached to it should be recorded by the RC in SystmOne on the leave template.

Nursing employees should also ensure that section 17 leave is recorded for all periods of leave over 1 hour in the inpatient functionality of SystmOne and that pre-section 17 and post-section 17 leave reviews are completed on the leave template.

Copies of the authorisation should be given to:

the patient
any carers
professionals involved in their care and treatment
and other people in the community who need to know

Note, the section 17 form must be finalised on SystmOne by the responsible clinician otherwise leave cannot proceed

5.3.7 Who can revoke a period of leave?

The patients RC can revoke leave at any time if they consider it necessary in the interests of the patient’s health or safety or for the protection of others. If it is the case that the patient is on leave and concerns are expressed then serious consideration must be given to the reasons for recalling the patient and the effect recall would have on the patient, as well as how best to return the patient to the ward.

Also, any concerns from relatives or carers about how the leave is progressing and any concerns they may have must be taken seriously, and fully documented.

5.3.8 Action if leave is revoked

In all cases the reasons for revoking the leave are to be explained to the patient and the discussions should be recorded in their electronic patient record. For patients returned early from leave the MHA Code of Practice 2015 at chapter 27.33 makes it a requirement for the revoking of the leave to be put in writing to the patient by their RC.

All other relevant persons should be notified of the patient’s leave being revoked.

5.4 Leave for patients requiring a stay in another hospital

There may be times when due to physical care needs, a patient may require treatment on a general hospital ward which cannot be appropriately provided on a mental health inpatient ward within the trust.

In these circumstances the patient will be classed as being on leave to allow them to attend the medical ward for treatment. Detained patients will be granted section 17 MHA 1983 leave Wherever possible, except in emergency situations, such transfers should be planned and what follows are guidance to ensure that the transfers are undertaken in a safe and consistent manner.

5.4.1 Urgent treatment

If a detained patient needs to be moved to a general hospital as a matter of urgency for treatment for a physical disorder or an injury, employees will have the legal authority to move the patient if either:

leave has been granted by the RC in anticipation of such an event
the RC has granted leave over the phone at the time of the emergency

However, if the urgency is such that there is no time to phone the RC and employees do not have anticipatory leave granted, then the Mental Capacity Act 2005 provides the authority for the patient to be moved to the general hospital.

The RC will then be required to grant the patient leave of absence at the earliest opportunity.

For restricted patients it is accepted that there will be times of acute medical emergency (such as heart attack, stroke or penetrative wounds or burns) where the patient requires emergency treatment. There may also be acute situations which, while not life threatening still require urgent treatment, for example, fractures. In these situations, the RC may use their discretion, having due regard to the emergency or urgency being presented and the management of any risks to have the patient taken to hospital.

The Secretary of State should be informed as soon as possible:

that the patient has been taken to hospital
what risk management arrangements are in place
be kept informed of developments and notified when the patient has been returned to the secure hospital.

5.4.2 Process

A decision to send a patient on leave to receive care or treatment on a general hospital ward will normally be made when it is felt by the multi-disciplinary team that their physical care needs can only be safely met on a general hospital ward.

Wherever possible, except in medical emergency situations, these should be planned, particularly if the patient is to be sent for a pre-booked medical or surgical procedure, including day surgery, or is to undergo an investigation which requires them to be in a more appropriate environment.

The RDaSH medical employees will have undertaken a medical assessment to determine that such a move is appropriate and will have sought advice from the general hospitals medical team.

Note, any decision to proceed with any medical treatment for a physical condition on a patient who lacks capacity will need to be assessed, and a best interest decision made by the treating clinical team at the general hospital, not the RDaSH clinical team.

5.4.3 Capacity to consent

The Mental Capacity Act (2005) applies to all adults who may lack capacity. All professionals must therefore work within the provisions of the act and its associated Code of Practice (2007), where there are concerns that the patient is unable to consent to the transfer.

However, in a medical emergency, a best interest decision may have to be made based on the balance of probability that the person lacks capacity to consent.

Staff should refer to the Mental Capacity Act (2005) and carry out an assessment of the patient’s capacity. For further guidance staff should refer to the trusts MCA Mental Capacity Act 2005 policy.

Whenever an assessment of capacity is undertaken it should be recorded on MCA1 and in the patient’s clinical records.

If the outcome of the assessment of capacity is that the patient has capacity to make this decision, then their wishes should be respected. If the refusal of the care or treatment presents risk of serious harm to the patient staff should complete an informed refusal form (can be found the consent to care and treatment policy) in accordance with the consent to care and treatment policy to evidence that they have discussed the person’s condition with them and explained the proposed care and, or treatment with the patient.

Consent is the voluntary and continuing permission of a patient to the intervention or decision in question. It is based on adequate knowledge and understanding of the purpose, nature, likely effect and risks of that intervention or decision, including the likelihood of its success of that intervention and any alternatives to it. Permission given under any unfair or undue pressure is not consent. Patients who lack capacity to consent cannot consent. Compliant acceptance of any intervention is not consent.

To transfer a detained patient to the general hospital trust for treatment of their physical condition employees need to be clear that:

the patient has capacity to consent to the treatment of their physical condition and if so, proceed sending under section 17 leave
if the patient lacks capacity to consent to the treatment of their physical condition ensure that a capacity assessment has been undertaken (to evidence the lack of capacity to consent) and that a best interest decision has been made

5.4.4 Best interest decisions

If the patient is assessed as lacking capacity to consent, then a best interest’s decision will need to be made.

When determining what is in a patient’s best interest, the clinician making the decision must not make it merely on the basis of the person’s age, appearance, or behaviour.

For further guidance staff should refer to the trusts MCA Mental Capacity Act 2005 policy.

Whenever a best interest decision is made, a full record of the staff involved and the process of how the decision was made is to be made on MCA2 in the patient’s clinical records.

5.4.5 Prior to sending the patient on section 17 leave

Wherever possible, agreement will be reached with the patient and consent obtained.
The patients risk assessment is to be updated by the multi-disciplinary team considering any new risk factors which may arise from moving the patient into a different environment.
For detained patients a section 17 leave form is to be completed by the patients RC or consultant in charge on-call, if the patient is to be transferred off site, to cover for the duration of their stay. However, if the patient is expected to need a prolonged period of stay on the general hospital ward or is going out of area, the need for continued detention under the MHA 1983 should be reviewed.
For any patients who are to be transferred any distance for a prolonged period of treatment on a general hospital ward consideration should be given to the need for their care to be transferred to a local mental health provider (under section 19 for detained patients). Such a transfer will allow for a quick response to their mental health needs by the local mental health service.
The RDaSH nurse in charge is to contact the nurse in charge of the general hospital ward that the patient is to be transferred to, to discuss any specific risk or safety issues, and the restrictions of the patient’s detention where applicable, and whether the patient will require one-to-one nursing observations. (Please refer to section 5.4.8 of this procedure).

Note, the decision on the level of observation the patient requires is made by the medical and nursing employees on the mental health unit as part of the risk assessment and is determined by clinical need.

For areas which use the integrated care pathway for the transfer of patients, this is to be completed and will accompany the patient. Within all other areas a brief written summary is to be prepared by the nurse in charge detailing all the discussion as above and this report will accompany the patient at the time they are sent on leave.
Ascertain if the patient wishes their nearest relative or carer or friend to be notified of the planned leave to the general hospital. If so, ensure that the nearest relative or carer or friend has details of which ward and a contact number.
Where a patient is unable to give consent a best interest decision will be undertaken.
In all cases, except where the patient is physically too unwell, the patient is to be given information about why the leave is taking place, where they are to be sent on leave to, what treatment they are to receive, and what support or contact they will have from the mental health services.
With the patients consent the above information is also to be provided to their nearest relative or carer or friend.
For any patient who is unable to express a preference their nearest relative or carer or friend must be informed of the planned leave arrangements.

5.4.6 Sending the patient on leave to a general hospital

The leave is to take place at a time which is mutually agreed between the mental health ward and general hospital ward. Unless it is a medical emergency which requires the patient to be immediately moved.
If needed, transport appropriate to the needs of the patient is to be arranged and employees should refer to the trust safe transportation of patients AMH IPS policy for further guidance.
An appropriate employee escort (in line with the risk assessment) is to be arranged, the nurse in charge of the ward must:
- ensure that the accompanying employee has all the relevant written information with them to hand over
- phone the nurse in charge of the ward or service to which the patient is to be sent, to give a verbal handover and answer any queries in respect of the patient’s legal status
- provide a contact number for the receiving ward to use in the event of any further queries
Where patients are being sent unplanned a letter from the medical team (as directed by the consultant in charge or RC) will be sent with the patient (unless the move has been requested by the general hospital medical team following their assessment of the patient).
The clinical records from mental health services are not to be sent with the patient, but employees should provide photocopies or printouts of any relevant information which may be needed by the general hospital ward as per admissions to adult and older persons MHS IP wards procedure.
Copies of the section papers are to be provided to the general hospital ward where applicable.
Contact details for the mental health ward are to be provided to the general hospital ward so that they know who to contact if they have any concerns or need advice.
Details of the current medication is to be sent with the patient as well as any copies of consent to treatment forms under the MHA (for example, T2 or T3 or S62 Forms). Personalised medication they may be taking must also be sent with the patient.
If consent has been given (or a best interest decision made) the patients nearest relative or carer or friend are to be notified that the patient has moved, to which ward, and a contact number for the ward provided.

5.4.7 Contact whilst on the medical ward

Any patient who is on a general ward remains the responsibility of the mental health service (MHS) in respect of treatment for their mental disorder, so contact must be maintained throughout their stay.

For patients who are not being cared for on one-to-one observations this contact is to be at agreed intervals of no less than daily for a conscious patient and weekly for an unconscious patient.

Following each visit or phone call an entry is to be made in the patient’s clinical records detailing both the patient’s mental state and progress in response to their medical treatment.

Any concerns are to be immediately reported to the patient’s consultant in charge or RC.

It is important that the patient continues to receive the appropriate treatment to address their mental health needs whilst receiving medical care, there should also be agreement as to the frequency of any reviews by their consultant in charge or RC. Medical reviews should be at intervals of no less than twice weekly. Consideration may need to be given by the inpatient consultant in charge or RC whether the care, treatment and RC status should be transferred to the Hospital Liaison team consultant whilst the patient is in the general hospital. This should be decided on a case-by-case basis between the two consultants.

5.4.8 One-to-one nursing observation of detained patients on a general hospital ward

Due to the restrictive nature of one-to-one care, it would not normally be instigated in respect of an informal patient. However, if it is felt by the MHS that the patient will benefit from one-to-one nursing it is important that:

an environmental risk assessment is undertaken for the area in which the patient is to be nursed, with particular attention to any equipment the patient may have access to, open windows, ligature points and risk posed to others
if possible, arrangements should be made for the patient to be nursed in a single room as this will make it easier to control the safety of the environment and offer more privacy to the patient
a one-to-one care plan is to be completed as per policy which will give details of any requirement for the one-to-one to be provided by a specific gender of employees, how long employees are to spend with the patient on one-to-one and how the handover of the one-to-one observation will be arranged

Note, for patients who are being nursed on one-to-one observations on a general ward, the staff are there to monitor the patient’s mental state and are not there to provide physical care and treatment. The only exception to this will be where it is felt to be in the patient’s best interest to receive some basic care such as washing and assistance with food from staff they know.

5.4.9 Consultant responsibilities

Whilst it is expected that for the duration of their stay on the general hospital ward there will be close collaboration between the mental health and physical health care teams, the physical health care needs of the patient will be the responsibility of the appropriate physician or surgeon and their consultant in charge or RC will retain responsibility for their mental health or learning disability needs.

5.4.10 Legal duties under section 132

Employees must be mindful of the fact that their obligations in respect of section 132 of the MHA continue whilst any detained patient is receiving care and treatment on a general ward. For full guidance, employees are to refer to the trust procedure for section 132 informing detained patients of their legal rights procedure.

5.4.11 Return of patients back to the mental health ward

Any transfer back to the mental health services should only take place if it has been decided that the patient no longer requires the medical care which had been provided by the general hospital ward and would have been discharged home had they not been detained, for example, they are medically fit for discharge.
The return of the patient should be planned and arranged doctor to consultant in charge or RC.
The consultant in charge or RC will notify the ward of the agreed date and time for the patient to be returned.
The move should not take place outside normal working hours unless in exceptional circumstances and with agreement by the on-call manager or on-call consultant.
If the patient has been identified as having any long-term physical care needs, discussion needs to take place as to:
- how these can be met on a mental health ward
- if there are any employee training needs which need to be addressed to allow the patient’s health care needs to be met
- what support can be provided from physical health services, for example, district nursing, chronic obstructive pulmonary disease (COPD) services etc.
Copies of the patient’s medical notes from the general hospital are to be sent with them so that in the event of a relapse they are available for medical employees to view, and, for services which use the transfer integrated care pathway this will be completed by the general hospital employees and returned with the patient.
Nearest relative or carers or friends are to be notified of the patients return to the mental health ward (subject to the patients’ consent).

5.4.12 Patients who are transferred back with “do not attempt cardiopulmonary resuscitation order” (DNACPR or ReSPECT) in place

In cases where a patient is transferred back with a DNACPR or ReSPECT order this will remain in place until the review date. This order will have been reviewed on discharge from the previous service and all lead clinicians informed of its existence. A copy of the DNACPR or ReSPECT paperwork should be received by the receiving ward; scanned into the patient’s electronic record and a record made on SystmOne.

If the consultant from our services raises issues with the order following the transfer of the patient back to mental health or learning disability services, it must be immediately reviewed. Staff should refer to the resuscitation manual for full details.

6 Training implications

There are no separate identified training needs in respect of the contents of this policy as an explanation of section 17 leave of absence is included in the trust Mental Health Act training, and a programme of clinical risk assessment training is delivered to clinical employees.

Clinical employees will also be made aware of the review and reissuing of the policy in the following ways:

review and reissue of the policy to be included in the trust weekly news bulletin
local induction for inpatient clinical employees
copy of the policy will be issued on the trust Intranet

7 Monitoring arrangements

7.1 Compliance with the standards set out in this policy and the requirements of the Mental Health Act 1983 in respect of detained service users

How: Clinical records audit.
Who by: Modern matrons and ward managers.
Reported to: Care group leadership and quality groups.
Frequency: To be agreed by each care group as part of their audit cycle.

7.2 Any complaints received in respect of leave arrangements for inpatients

How: Monitoring of complaints themes, trends and action plans.
Who by: Complaints manager.
Reported to: Care group leadership and quality groups.
Frequency: Quarterly.

8 Equality impact assessment screening

To access the equality impact assessment for this policy, please email rdash.equalityanddiversity@nhs.net to request the document.

8.1 Privacy, dignity and respect

The NHS Constitution states that all patients should feel that their privacy and dignity are respected while they are in hospital. High Quality Care for All (2008), Lord Darzi’s review of the NHS, identifies the need to organise care around the individual, ‘not just clinically but in terms of dignity and respect’.

As a consequence the trust is required to articulate its intent to deliver care with privacy and dignity that treats all service users with respect. Therefore, all procedural documents will be considered, if relevant, to reflect the requirement to treat everyone with privacy, dignity and respect, (when appropriate this should also include how same sex accommodation is provided).

8.1.1 How this will be met

No issues have been identified in relation to this policy.

8.2 Mental Capacity Act

Central to any aspect of care delivered to adults and young people aged 16 years or over will be the consideration of the individuals’ capacity to participate in the decision-making process. Consequently, no intervention should be carried out without either the individual’s informed consent, or the powers included in a legal framework, or by order of the court.

Therefore, the trust is required to make sure that all staff working with individuals who use our service are familiar with the provisions within the Mental Capacity Act (2005). For this reason all procedural documents will be considered, if relevant to reflect the provisions of the Mental Capacity Act (2005) to ensure that the rights of individual are protected and they are supported to make their own decisions where possible and that any decisions made on their behalf when they lack capacity are made in their best interests and least restrictive of their rights and freedoms.

8.2.1 How this will be met

All individuals involved in the implementation of this policy should do so in accordance with the guiding principles of the Mental Capacity Act (2005).

9 Links to any other associated documents

10 References

CQC Guidance Note, Leave of Absence and transfer under the Mental Health Act 1983, March 2010.
Mental Health Act 1983 Code of Practice (2015).
Mental Health Act Commission-Tenth Biennial Report 2001 to 2003; Mental Health Act Manual 17th Edition (Richard Jones).
Ministry of Justice, Mental Health Casework Section: Section 17 Leave of Absence (March 2015).

11 Appendices

11.1 Appendix A Tickhill Road and Woodfield Park site boundaries

Appendix A Tickhill Road and Woodfield Park site boundaries

11.2 Appendix B Mental health casework section 17

Appendix B Mental health casework section 17 (staff access only) (opens in new window)

Document control

Version: 1.3.
Unique reference number: 632.
Approved by: Mental health legislation operational group.
Date approved: 28 July 2023.
Name of originator or author: Mental health act manager.
Name of responsible individual: Executive medical director.
Date issued: 17 August 2023.
Review date: 30 June 2025.
Target audience: Mental health and learning disability clinical employees.

Page last reviewed: November 15, 2024
Next review due: November 15, 2025

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