10. Restricted Patients (Mentally Disordered Offenders Managed Within The Health System)
10.1 Arrangements to ensure appropriate multi-agency assessment and management of the risk posed by certain offenders came into effect in relation to all restricted patients on 30 April 2008.
10.2 This guidance is intended to explain how restricted patients should be assessed and managed within the MAPPA framework. Multi-disciplinary teams caring for restricted patients should ensure that they are familiar with the MAPPA guidance and also the guidance contained in the Memorandum of Procedure: http://www.gov.scot/Publications/2010/06/04095331/0.
10.3 The term 'restricted patient' is used in this guidance. For clarity any patient subject to any of the following orders or directions comes within the remit of MAPPA legislation and procedures:
- 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.
10.4 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.
10.5 While patients on remand are detained in hospital for treatment or assessment they are managed as restricted patients. However, such patients are not subject to MAPPA management by NHS boards (though of course they may be subject to such management by other agencies as a result of prior offences).
10.6 While patients on Interim Compulsion Orders are not subject to MAPPA they are included in the CPA process for their risk assessment and management in anticipation of them becoming a restricted patient and subject to MAPPA in due course.
NHS Health Boards
10.7 All NHS Boards and the State Hospitals 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.
Notification or Referral to MAPPA Coordinator
10.8 There are three key stages at which a MAPPA referral must take place, using the relevant MAPPA Referral Form contained in the document set accompanying this guidance:
- when the patient is being considered for unescorted ground parole or unescorted suspension of detention for the first time - following scrutiny of the risk assessment and management plans MAPPA 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.
10.9 There may be circumstances when a MAPPA level 2 referral is appropriate.
- the restricted patient is also a sex offender 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 very 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;
- 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 above; 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 above.
10.10 A police view should be sought before a decision is made to make a MAPPA 2 referral.
Actions, Assessment and Management of Restricted Patients within the MAPPA Framework
10.11 CEL 19 (2008) provided 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.
10.12 CEL 19 (2008) 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 of 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)
Care Programme Approach ( CPA)
10.13 Guidance on the operation of CPA for restricted patients was circulated in October 2007 ( CEL13 (2007). Although the same underlying principles of gathering and sharing of relevant information in relation to risk apply, CPA focuses on the care and treatment likely to minimise the risk posed, 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.
10.14 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 cooperate to put together plans to assess and manage these risks. It is important to emphasise that 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.
Liaison with the police
10.15 Local MAPPA Coordinators 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 whether a MAPPA Level 2 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 patients are 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.
MAPPA information relayed to the Mental Health Tribunal ( MHT) for Scotland
10.16 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 considered 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.
10.17 For those Tribunals considering conditional discharge, revocation of the compulsion order or revocation of the restriction order the restricted patient team will e-mail the relevant MAPPA Coordinator to request that a Minutes Executive Summary be prepared for lodging at the MHT (which in turn will be copied to the patient and other parties). Restricted Patient team will on receipt of a recommendation for Conditional Discharge, revocation of Compulsion order or Restriction Order, e-mail the relevant MAPPA Coordinator to request that a Minutes Executive Summary be prepared for lodging at the Mental Health Tribunal. The restricted patient team should be advised of all MAPPA meetings and will consider whether or not they should be represented.
10.18 The following further guidance on MAPPA and CPA in relation to restricted patients has been issued:
Note this has been superseded by NHSCEL (2007)8
Memorandum of Procedure for restricted patients
The wider role of the NHS in MAPPA
10.19 Reference should be made to the guidance contained within Chapter 3 of this guidance, which sets out the legal position of the NHS in respect of those subject to the SONR.
10.20 The role of the NHS in MAPPA can be summarised as follows:
- Mentally disordered offenders ( MDO) (restricted patients) - health boards and Special Health Boards are the lead responsible authority;
- Health Boards and Special Health Boards have a duty to cooperate with other agencies for non-restricted MDO sex offenders;
- Sharing information with other agencies - receiving and giving information so as to help protect the public (including NHS staff and patients) from serious harm;
- Representation and points of contact - there must be involvement of senior staff who can cover both management and clinical issues;
- Involvement in strategic management of MAPPA; and
- Providing clinical knowledge and resources, where appropriate, to help other agencies in the assessment and management of risk of serious harm posed by sexual (and violent) offenders.