Multi-Agency Public Protection Arrangements (MAPPA):national guidance 2016

Details from restricted patient Care Plan Dated:

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Patient Name: Date of Birth:

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Restricted patient referral to MAPPA

MAPPA Local Office

MAPPA Coordinator

Name

Contact
Number

Suggested Level

MANAGEMENT STAGE

Notifiable under part 2, Sexual Offences Act 2003 (2) Yes / No *

If yes to above - Detail offence(s) and period of order *

Schedule 1 Notification Yes/ No *

Patient Details

Name

Date of Birth

Permanent Address

Previous significant address

CHI number

Prison number

PNC number

SCRO number

ViSOR number

Sex

Ethnic Origin (Standard Codes)

Referring Service Details

Hospital

Ward

Phone No

Responsible Local Authority

Responsible Health Board

Clinical Team

Useful Contacts

Designation:

Name:

Office Hours Contact Number

Out of Hours Contact Number

Key Worker/
Care Coordinator

RMO

MHO

General Practitioner

CPA Coordinator

Scottish Government

Legal Details

Legal Status & Section

Sentencing court

Date of Conviction/Insanity Acquittal *

Date order began *

Date of previous annual review*

Date of next annual review *

RMO details *

MHO details *

For Determinate Sentences

Earliest Liberation date/ Parole Qualifying date

For Life Sentences

Punishment part

Offending History

Index Offence

Other Offences

Highlight all violent/sexual offences

Highlight all offences or concerns
relating to children young persons.
Detail any children within or outside
the family who may be at risk with
names and dates of birth

History of …

Yes/No

Brief Details

Violence

Include a list of all known
incidents of violence to staff of
any agency

please select

Sexual Aggression

please select

Fire Raising

please select

Hostage Taking

please select

Use of Weapons

please select

Alcohol or Substance misuse

please select

Absconding/Escape

please select

Self Harm

please select

Other factors of relevance

( e.g. past child protection referral
or vulnerable adult referral)

please select

Current Risk Status

Setting

Likelihood, imminence, frequency & severity of harmful behaviour towards whom & under what circumstances

In Hospital

List all known concerning incidents whilst in an institution ( e.g. prison or hospital)

Escorted in Community

Unescorted in Community

Other

Conditional Discharge Conditions

Medication

Yes/No/not applicable

Comment

Is the patient prescribed medication without which his/her risk may be increased?

Is the patient compliant with this medication?

Victim Considerations

Yes/No

Details

Is/are there specific person(s) whom the patient poses a risk to?

Does the patient pose a potential risk to certain types of people? ( e.g. children, women, adults at risk of harm)

Monitoring & Supervision Requirements

In Hospital

Nursing observation level

Restrictions regarding contact with staff

Restrictions regarding access to indoor areas

Restrictions regarding access to outdoor areas

Restrictions on telephone use and letters

Room searches

Personal searches

Alcohol/drug testing

Access to sharps & other utensils

Visitors

Other hospital requirements

In the Community

Escort requirements

Special considerations for staff visiting patient

Special consideration for out-patient appointments

Alcohol/drug testing

Other community requirements

Additional Comments

Please give details of any other information held which may assist with public protection ( e.g. details of any known violent/sexual behaviour, previous allegations, domestic abuse incidents)