Community treatment order policy

1 Introduction

Community treatment orders (CTO) were introduced with effect from 3 November 2008 through the 2007 amendments to the Mental Health Act 1983 (MHA 1983) for the purposes of:

allowing suitable patients to be safely treated in the community rather than under detention in hospital
providing a way to help prevent relapse and any harm to the patient or to others
helping patients to maintain stable mental health outside of hospital and to promote recovery
treating patients using the least restrictive option, maximising their independence and purpose and effectiveness

A CTO provides a framework for the management of patient care in the community and gives the responsible clinician the power to recall the patient to hospital for treatment if necessary.

2 Purpose

The purpose of this policy is to:

guide staff on the implementation of a CTO in accordance with the MHA 1983 and the Mental Health Act Code of Practice 2015
ensure that there is lawful and appropriate use of CTOs within the trust and that the legal rights of any patient subject to a CTO are upheld at all stages.

In the application of this policy staff should also refer to other relevant trust policies, as detailed in section 9 of this policy, and chapter 29 of the Mental Health Act: Code of Practice 2015.

3 Scope

This policy provides guidance for clinicians and practitioners within the care groups of the trust.

4 Responsibilities, accountabilities and duties

4.1 Mental health legislation sub committee

The trust’s mental health legislation sub committee is responsible for:

overseeing the implementation of the MHA 1983 within the organisation
the review and issuing of all policies and procedures which relate to the MHA 1983
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 Mental Health Act activity within the trust to the board of directors

4.2 Hospital managers

Whilst the MHA 1983 uses the term “hospital managers”, in NHS Foundation Trusts the trust themselves are defined as the “hospital managers”. They have certain statutory duties they must fulfil under the act and some of these duties including patients subject to CTO’s can be delegated by the hospital managers, but in delegating this responsibility they must be satisfied that:

patients understand what a CTO means for them and their rights to apply for discharge, and the role of the independent mental health advocacy (IMHA) Service. This means there should be systems in place for patients to be given information about their rights as soon
as is practicable after the patient goes onto a CTO. This information must be given both orally, and in writing (see 4.9 to 4.17 of the Code of Practice)
a copy of the written information be given to the Nearest Relative, unless either the patient requests otherwise, or it would be impractical for any reason (including the risk of breaching the patient’s rights under the Human Rights Act 1998. (see 4.31-4.36 of the Code or Practice)
there is a trust policy in place for the explanation of patients’ rights under section 132 MHA 1983 and staff should refer to this for full details
the duties placed on hospital managers under the Domestic Violence, Crime and Victims Act 2004 (DVCV Act) in relation to certain mentally disordered offenders detained in hospital are met.
This includes liaising with victims in order to:
- advise victims, who have been asked to be told, if the patient is to be discharged or go onto a CTO
- forward representations made by victims to people responsible for making decisions on discharge or a CTO and for passing information received from those people to the victim
- inform victims, who have been asked to be told:
  - if the patient is to go onto a CTO
  - of any conditions on the CTO relating to contact with them or their family
  - of any variation of the conditions
  - of the date on which the CTO will cease
- inform RCs of any representations made by the victim about the conditions attached to the CTO

4.3 Modern matrons and service managers within the care groups

The modern matrons or service managers are responsible for:

making staff aware of the contents of this policy
monitoring the implementation of this policy
bringing any issues which may affect implementation of the policy to the attention of the MHA manager

4.4 Registered clinical staff

In relation to this policy all registered clinical staff must be aware of and comply with the contents of this policy. They are responsible for:

giving appropriate consideration to the application of a CTO
implementation of the CTO in a manner that adheres to the legal framework and supports delivery of sensitive mental health care
having an awareness of their individual roles within this complex process

4.5 Responsible clinician (RC)

The RC will have overall responsibility for the patient and will be responsible for the patient’s treatment in the community. A CTO will be one of the options considered by the RC when reviewing treatment. It is the RC responsibility to:

establish whether the criteria for a CTO is met and seek the agreement of the approved mental health professional (AMHP)
consider the Code of Practices’ principles, in particular the least restrictive option and maximising independence principle
consider whether the power to recall is necessary and whether the patient can be treated in the community without that power
consult, at an early stage, with the patient, including family and carers their views on the use of a CTO
be satisfied that the patient requires medical treatment for mental disorder for their own health or safety or for the protection of others, and that appropriate treatment is, or would be, available for the patient in the community
assess what risk there would be of the patient’s condition deteriorating after discharge, for example, as a result of refusing or neglecting to receive treatment
assess the patient’s current mental state
assess the patient’s capacity to make decisions about their care and treatment and attitude to treatment and risk of relapse
assess the circumstances into which the patient would be discharged and the willingness and ability of family or carers to provide support (especially where aspects of the care plan depend on them)
ensure that a copy of the CTO11 or CTO12 is issued to the patients GP
consider a CTO when the first tier tribunal suggests it

4.6 General practitioner (GP)

The GP will be notified in the usual way about the patient’s medication and, where it has been agreed, that the GP will assume responsibility for the ongoing prescribing. They should not prescribe anything for the patient’s mental disorder which is not covered by the certificate (CTO11 or CTO12). If the certificate needs to be changed, they should discuss this with the RC prior to making any changes. GP’s can of course treat the patient as they see appropriate for any condition not relating to the patients mental disorder.

4.7 Approved mental health professional (AMHP)

The AMHP’s formal role in setting up a CTO involves:

determining with the RC whether the criteria is met and that it is appropriate to make a CTO
meeting with the patient before deciding whether to agree that the CTO should be made
if the AMHP does not agree with the RC that the patient should go onto a CTO, ensuring that a record is made of their decision, with the full reasons for it, in the patient’s notes (see 29.25 of the code of practice)
agreeing the conditions of the CTO and completing Form CTO1, where the AMHP agrees the criteria is met
the agreement of an AMHP before a CTO being extended
the agreement of an AMHP before a CTO is revoked

5 Procedure or implementation

5.3 CTOs children and young people

Whilst there is no lower age limit for a CTO it is likely that there will only be a small number of children and young people whose circumstances are suitable for a CTO to be a possible option for their treatment following a period of detention. However, where it is appropriate it should be used.

Guidance on assessing competence in children and young people is included in the code of practice chapter 19 of the Code of Practice (19.26 to 19.30).

5.4 When can a CTO be applied

Only patients who are detained in hospital for treatment under section 3 of the MHA 1983, or are unrestricted part 3 patients, can be considered for a CTO.

Patients who are subject to detention under the MHA 1983 for assessment, such as, section 2, are not eligible for a CTO, nor is anyone who is subject to a restriction order.

A CTO is an option only for patients who meet the following criteria:

the patient is suffering from a mental disorder of a nature or degree which makes it appropriate for them to receive medical treatment
it is necessary for the patient’s health or safety or the protection of others that they should receive such treatment
subject to the patient being liable to be recalled as mentioned below, such treatment can be provided without the patient continuing to be detained in a hospital
it is necessary that the RC should be able to exercise the power under section 17E(1) of the MHA 1983 to recall the patient to hospital
appropriate medical treatment is available for the patient

Patients who might be suitable for a CTO are individuals who have a history of non-compliance, relapse and readmission cycles, for example:

patients who are well known to local teams and caught in a long term cycle of relapse and readmission
patients who, during a period of detention in hospital are identified by their RC as needing the support and structure which a CTO offers, to pre-empt relapse in the community and avoid further lengthy admissions to hospital under the Mental Health Act

5.5 Patients agreement

Patients do not have to give formal consent to a CTO. However in practice patients should be involved in decisions about the treatment to be provided in the community and how and where it is to be given and be prepared to co-operate with the proposed treatment.

5.6 Process

The decision about a patient’s suitability for a CTO is taken by the responsible clinician (RC) and requires the agreement of an approved mental health professional (AMHP). A CTO may be used only if it would not be possible to achieve the desired objectives for the patient’s care and treatment without it. The RC should consider whether the power to recall the patient is necessary and whether the patient can be treated in the community without that power.

Consultation at an early stage with the patient and those involved in the patient’s care should take place, including:

patient
family or carers
nearest relative
approved mental health professional
ward named nurse
care coordinator

The patients GP and any other appropriate community and primary care workers should also be included, where possible.

Following a multidisciplinary review the RC and the AMHP then have to agree that a CTO is appropriate in order for the application to be made.

The RC should inform the patient of the essential legal and factual grounds for the CTO and other information about the CTO, both orally and in writing.

The RC must complete part one of the statutory CTO, (form CTO1) and on it specify:

the date and time when the CTO comes into effect
the reason why the patient meets the criteria
the conditions
attach a copy of the care plan to the completed form (a copy of the care plan is also to be sent to the patient’s GP)

The AMHP must complete part two of the statutory CTO (form CTO1).

Once this has been completed the RC may then complete part three, formally suspending the detention and placing the patient under the CTO.

When the CTO1 is completed and signed by both the RC and AMHP it must be sent to the MHA office.

5.7 CTO, conditions

A CTO includes conditions with which the patient is required to comply.

There are 2 conditions which must be included in all cases. Patients are required to make themselves available for medical examination:

when needed for consideration of extension of the CTO
if necessary, to allow a second opinion appointed doctor (SOAD) to provide a part 4A certificate authorising treatment

The RC and AMHP may also, following discussion with the patient, set other conditions which are identified as being necessary or appropriate to:

ensure that the patient receives medical treatment for mental disorder
prevent a risk of harm to the patient’s health or safety as a result of mental disorder
protect other people from a similar risk of harm

Conditions may be set for any or all of these purposes, but not for any other reason. (see 29.27 to 29.33 of the Code of Practice).

The conditions must not deprive the person of their liberty and should:

be kept to a minimum number consistent with achieving their purpose
restrict the patient’s liberty as little as possible while being consistent with their care plan and recovery goal
have a clear rationale, linked to one or more of the purposes, as detailed above
be clearly and precisely expressed, so that the patient can readily understand what is expected

The reasons for any condition should be explained to the patient and other, as appropriate, and recorded in the patient’s notes.

5.8 Information to patients and nearest relatives

As soon as the decision is made to discharge a patient onto a CTO, the RC should inform the patient and other consulted of the decision, the conditions to be applied to the CTO and the services which will be available to the patient in the community.

Once this has been done a form 14A is to be completed by the named nurse or care coordinator and forwarded to the local Mental Health Act office.

The explanation of the patient’s legal rights should be revisited periodically, by the care coordinator, but at least at each CPA review and once read a form 14B should be completed by the care coordinator and kept within the patient’s clinical records.

On notifying the MHA Office, they will give the patient information, in writing, the reasons for the CTO, the conditions, how it works, their rights to apply to the first tier tribunal and about the availability of the independent mental health advocate (IMHA) with the same information being given to the nearest relative, unless there is an objection.

5.9 Right of appeal against a CTO

Any patient, who is subject to a CTO, and their nearest relative, has the same rights of appeal as a patient detained on a section 3. This means they may appeal to both the hospital managers and the first tier tribunal.

The nearest relative can make an application to discharge the patient from a CTO and the procedure for this is outlined in the “trust procedure for the discharge of a patient by their nearest relative.”

5.10 Care planning and CTO

A care plan must be prepared and include details of who is responsible for prescribing medication and who has clinical responsibility for the patient’s physical health. The care plan must include:

a statement of the patient’s needs for future treatment in the community and any conditions
details of how and where the patient is to receive treatment. This will include medication (included on part 4A certificate, CTO11 or CTO12)

Note, force cannot be used to give a treatment if the patient objects to it, except in an emergency.

details of a crisis support plan and a 24 hour mental health crisis helpline number
details of day care services, training and where appropriate personal support and any other therapeutic interventions
carer and family support
particular cultural requirements, for example linguistic or religious factors that may affect a patient’s needs
information on how to contact the out of hours services for physical health care or emergency GP care
the name and telephone number of the patient’s RC, their care coordinator, or other named team member and a written appointment for their first visit

The following parties should also be consulted, subject to the usual considerations of patient confidentiality, to enable the delivery of a seamless transfer of care from hospital to community:

nearest relative
any carers
where appropriate, an attorney (authorised by lasting power of attorney, personal welfare) or court appointed deputy under the MCA 2005
members of the multidisciplinary team involved in the patients care
the care coordinator under CPA arrangements

5.11 Treatment under a CTO

Part 4A of the Mental Health Act sets out different rules for the treatment of patients subject to a CTO who have not been recalled to hospital.

A part 4A patient who has the capacity to consent to, or refuse treatment, may not be given that treatment unless they consent. There are no exceptions to this rule, even in emergencies. The effect is that treatment can be given without their consent only if they are recalled to hospital.

For a part 4A patient, aged 18 and over, who lacks the capacity to consent to or refuse treatment, it may be given if someone who has lasting power of attorney or a court of protection appointed deputy consents on their behalf.

Similarly it may be given in the case of those aged 16 and over if a deputy consents to the treatment on their behalf.

Part 4A patients who lack capacity to consent, or refuse treatment may also be given it, without anyone’s consent by or under the direction of the RC in charge of their treatment unless:

patient aged 18 or over, the treatment would be contrary to a valid and applicable advance decision made by the patient
patient aged 18 or over, the treatment would be against the decision of someone with the authority under the MCA 2005 to refuse it on the patient’s behalf (for example, an attorney, a deputy or the court of protection)
patient aged 16 or over, the treatment would be against the decision of someone with the authority under the MCA 2005 to refuse it on the patient’s behalf (for example, an attorney, a deputy or the court of protection)
patient aged 16 or over, the treatment would be against the decision of a deputy who has authority to refuse it on the patient’s behalf, or force needs to be used in order to administer the treatment and the patient objects to the treatment

For further information on issues relating to capacity to consent see The Mental Capacity Act 2005 Policy and the Mental Capacity Act Code of Practice.

5.11.1 Part 4A treatment

When a patient is subject to a CTO, treatment prescribed for their mental disorder must be certified by either a SOAD on a part 4A certificate (CTO 11) or by their responsible clinician on a part 4A consent certificate (CTO12).

5.11.1.1 Second opinion appointed doctor (SOAD) certificate (CTO11)

The SOAD must specify on this certificate the forms of treatment to which it applies, and any conditions to which the approval of any or all of these forms of treatment is subject. They may also specify which, if any, of the treatments approved on the certificate can be
administered, should the patient become subject to a recall to hospital.

Before issuing a certificate, the SOAD must consult with other clinicians who have been professionally concerned with the patient’s medical treatment, one of whom must be a nurse and the other a person who is neither a nurse nor a doctor. In addition neither of the consulted may be the patients RC, or another AC in charge of any of the treatments to be specified on certificate. The suitable second consultee could be the patient’s care coordinator, a pharmacist, occupational therapist, clinical psychologist or social worker. The procedure for arranging and obtaining a second opinion part 4A certificate is outlined in the trust procedure for when a SOAD attends.

Where a patient subject to a CTO is receiving their medication in the community by depot injection, the depot card must be marked with the date of the review by the second opinion appointed doctor (SOAD). A copy of the form CTO 11 authorising treatments by the SOAD is to be attached to the depot card.

5.11.1.2 Part 4A consent certificate (CTO12)

Treatment may be authorised by the patient’s RC and they must certify that the patient has the capacity or is competent to consent and has consented to the treatment. They must also specify on this certificate (CTO12) the forms of treatment to which it applies and any conditions to which the approval of any or all of these forms of treatment is subject.

Where a patient subject to a CTO is receiving their medication in the community by depot injection, the depot card must be marked with the date of the review. A copy of the Form CTO12 authorising treatments by the RC is to be attached to the depot card.

5.12 Treatment in an emergency (section 64G)

In an emergency, treatment may be given to a CTO patient who lacks the capacity to consent to the treatment in question, if the treatment is immediately necessary to:

save the patient’s life
prevent a serious deterioration of the patient’s condition, and the treatment does not have unfavourable physical or psychological consequences which cannot be reversed
alleviate serious suffering by the patient and the treatment does not have unfavourable physical or psychological consequences which cannot be reversed and does not entail significant physical hazard
prevent patients behaving violently or being a danger to themselves or others, and the treatment represents the minimum interference necessary for that purpose, does not have
unfavourable physical or psychological consequences which cannot be reversed and does not entail significant physical hazard

Where treatment is immediately necessary it can be given even though it may be in conflict with an advanced decision or the decision of someone who has authority under the Mental Capacity Act to refuse it on the patient’s behalf. In addition force may be used (whether or not the patient objects) provided that:

the treatment is necessary to prevent harm to the patient
the force used is proportionate to the likelihood of the patient suffering harm and to the seriousness of the harm

Note, this is the only circumstance in which force may be used in the treatment of a patient subject to a CTO who is objecting without recalling the patient to hospital.

5.13 Varying conditions

The RC has the power to vary the conditions of the CTO or suspend part of them. The RC does not need to agree any variation or suspension with the AMHP. However, good practice dictates, that the RC should have discussed any changes to a recently agreed CTO with both the AMHP and the care coordinator prior to making any variations. It will also be appropriate to discuss the proposed changes with the patient and ensure that the patient and anyone else affected by the changes (for example, family and carers) knows that they are being consulted and why.

A record of the reasons for any varying of conditions should be recorded, by the RC, in the patient’s notes. A copy of the variation should also be placed with the care plan.

Any variation of conditions should be recorded on the Form CTO2 and sent to the MHA Office.

5.14 Monitoring CTOs

It is important that close contact is maintained with patients on CTO’s so that there can be ongoing monitoring of their mental health. The type and scope of these monitoring arrangements will depend on the individual needs and circumstances of each patient and should be set out in the patient’s care plan.

Appropriate action will need to be taken if the patient becomes:

mentally unwell
engages in high risk behaviour as a result of mental disorder
withdraws consent to treatment (or begins to object to it)
becomes non-compliant with any of the conditions attached to the CTO

In the event of any of the above, an urgent review of the situation will be required, and a recall to hospital may be needed if it is no longer safe and appropriate to the patient to remain in the community.

5.15 Voluntary admission

A patient subject to a CTO may agree to come into hospital voluntarily and in these circumstances the RC for the patient will transfer to the inpatient RC on the inpatient ward. It is to be noted that if they subsequently meet the criteria for recall (see 5.18 below) they may then be formally recalled to hospital and detained there for up to 72 hours, even though they are already a voluntary inpatient.

5.16 Recall of a CTO patient to hospital

5.16.1 When to consider recall

Patients subject to CTO’s will require regular monitoring via their care coordinator and RC in order that any evidence of a deterioration, relapse, or failure to comply with conditions of the order may be discussed by the team at an early stage. Regular monitoring should,
therefore, avoid the need to issue a recall notice outside normal hours, when the patients RC may not be easily contactable.

To ensure compliance with the Code of Practice, recall should only be considered if the following criteria are met:

the patient needs to receive treatment for mental disorder in hospital (either as an inpatient or as an outpatient)
there would be a risk of harm to the health and safety of the patient or to other people if the patient were not recalled

Or:

the patient has broken one of the two mandatory conditions outlined above without a valid reason

Patients should be given the opportunity to comply with the conditions before recall is considered.

If access cannot be gained to the patient, consideration should be given to obtaining a warrant under section 135 (2) of the MHA 1983.

5.16.2 Voluntary admission recall

A patient subject to a CTO may agree to come into hospital voluntarily. However, if they subsequently meet the criteria as stated above, they may then be formally recalled to hospital and detained there for up to 72 hours, even though they are already a voluntary inpatient.

Note, the use of section 5(4) and section 5(2) to prevent a voluntary CTO patient from leaving a ward in an emergency is not permitted under the MHA.

5.16.3 When is a recall notice served

Whatever the circumstances of the recall, the RC must complete a written notice of recall to the hospital on a Form CTO3 which is effective only when served on the patient.

Where ever possible, this notice should be:

handed to the patient personally and will be deemed to immediately be served
delivered by hand to the patient’s usual or last known address, in which case the notice is deemed to be served the day after it has been delivered
sent by first class post, it is not deemed to be served until the second business day after posting (clearly this would only be appropriate when recall was not considered to be urgent)

Responsibility for the issuing of the recall notice is the RC’s but the delivery of the recall notice can be delegated to the care coordinator or other professional staff.

Once a recall notice has been served, the patient can, if necessary, be treated as absent without leave, and taken and transported to hospital (and a patient who leaves hospital without permission can be returned there). The time at which the notice is deemed to be served will vary according to the method of delivery (as stated above).

5.16.4 Who is responsible for coordinating the recall process

The RC has the responsibility for coordinating the recall process, however, within the trust is has been locally agreed that:

during daytime hours, this will be coordinated by the RC and the care coordinator, and or other members of the clinical team, as delegated
out of hours, the consultant on call will be responsible for co-ordinating the recall process with the assistance of a Crisis team practitioner, this may on occasions be an AMHP on call however it is to be noted this will not be in every case, and legally an AMHP is not required for the recall process

Note, the RC must identify an appropriate hospital for the patient to be recalled to and should ensure that the hospital to which the patient is being recalled to is ready to receive him or her and to provide treatment, although this may be given on an outpatient
basis if appropriate. Return to that hospital should be in the least restrictive manner possible. The RC must also contact the relevant AMHP, to inform them of the recall and the possibility of a revocation in order that an assessment can be coordinated if required.

5.16.5 Who is responsible for the patient until the recall notice is served

Until the patient presents themselves in response to the recall notice the patient remains the responsibility of the community team and any notice of recall issued to a patient should be notified to the inpatient ward.

5.16.6 Failure to comply with the recall notice

Failure on the part of the patient to return voluntarily to the hospital named in the recall notice will render the patient absent without leave (AWOL) and once again liable to be detained and subject to the powers of section 18 of the MHA 1983 (refer to the trust AWOL policy).

5.17 Effect of recall

When the patient arrives at hospital, or is formally recalled from informal inpatient status, a form CTO 4 should be completed on behalf of the hospital managers and sent to the MHA office, along with a copy of the recall notice (form CTO3).

The patient may then be detained for up to 72 hours and treated, once again under part 4A provisions unless the SOAD has explicitly stated the treatment authorised on recall on the form CTO11, in which case treatment can be carried out on that basis.

The 72 hours commences from the time indicated on the form CTO 4.

As soon as is practicable, the patient is to be given information both verbally and in writing about their rights following recall and the impact, if any on their treatment provisions. The giving of information to a patient in respect of their CTO rights must be recorded in the same manner used for other detained patients. Staff should refer to the trust procedure for informing detained patients of their legal rights under section 132 MHA 1983.

On recall to hospital as an inpatient, the patient’s designated RC will be the inpatient RC. This will only change to the community RC if the patient is discharged back into the community subject to the CTO.

During the recall period (up to 72 hours) when the patient is detained and treated the RC must make a decision on whether the treatment has been sufficient for the patient to return home. If so, the patient may return to the community at any time within the 72 hours and still be subject to a CTO, however, if the RC feels that a longer period in hospital is required then the CTO may be revoked with the agreement of the AMHP. (Where the AMHP disagrees, they are to record their reasons in the AMHP report).

If no decision is made, for example, neither the patient should return to the community, or that the CTO should be revoked, the default position at the expiration of 72 hours is that the patient remains on the CTO.

This means they can no longer be detained or given treatment under part 4A of the MHA 1983 and must be allowed to leave if they so wish.

5.18 Part 4 treatment of patients recalled to hospital

On recall to hospital, whether as an inpatient or an outpatient, the patient is subject to the provisions set out in part 4 of the MHA 1983.

However, patients may be given treatment under the authority of a part 4A certificate issued by the SOAD whilst the patient was in the community, provided that the SOAD has authorised the administration of specific treatment(s) on recall to hospital, using the form CTO 11. In
the absence of authority from a SOAD, the patient may be given treatment as if they had remained liable to be detained since the application of the CTO.

If the CTO is revoked, the patient becomes subject to detention under the original detaining order and the normal provisions within part 4 of the MHA 1983 for consent to treatment will apply.

5.19 Transfer of a recalled patient

Where a patient subject to a CTO is recalled to hospital, they may, if necessary, be transferred to a different hospital, provided such a transfer takes place within the 72 hour period allowed for in the recall. Where the transfer is to a hospital under the same managers, for example, a different hospital in the same trust, there is no specific authorisation required to allow the transfer to go ahead, however, if the transfer is to a hospital under different managers a form CTO 6 must be completed to authorise the transfer. The completion of this form is the responsibility of the hospital managers but they are able to delegate this responsibility to a suitable person whom they have authorised to act on their behalf, (for example, nurse in charge).

Authority may also be given to the responsible hospital for a patient, who has not been recalled, to be assigned a different hospital under different managers using the form CTO 10, with the agreement of the hospital to which responsibility is transferred.

5.20 Revocation of the CTO

If the RC is of the opinion that a 72 hour period provides insufficient time in which to treat the patient and prepare them for a return to the community they should recommend that the CTO be revoked and the patient readmitted under their original detaining section (for example, section 3 or section 37).

The RC must request an assessment from an AMHP as to whether they agree that it is appropriate to revoke the CTO and that the criteria for readmission are met.

If the AMHP agrees that the CTO should be revoked a form CTO 5 is to be completed. The revocation takes immediate effect once the form CTO 5 is signed, and the patient reverts back to the detention under whichever section of the Mental Health Act they were subject to at the time of the CTO being made. In all cases for renewal of detention purposes they become liable to a new period of detention for up to six months beginning with the date of the revocation.

The completed form CTO 5 must be forwarded to the Mental Health Act office, and they, on behalf of the hospital managers, will make an automatic referral to the first tier tribunal. (The patient also has the right to appeal directly to the first tier tribunal).

5.21 Expiry and Extension of the CTO

A CTO can be extended for a second six month period and then for a year at a time.

If no extension is made, the CTO will expire at the end of the six month period (starting from the day on which it was originally made).

During the final two months of the first, and each subsequent period for which a CTO is in force, the RC must examine the patient and decide whether the patient meets the criteria for an extension. If appropriate, the RC may recall the patient to hospital for the purpose of this assessment, as the patient making himself available for this examination is a mandatory condition of the CTO.

At this examination the RC must determine if the criteria, as detailed in section 5.5, are still met. It is only if they are that the RC can proceed with an application to extend the CTO.

Once satisfied that the criteria is met the RC must:

consult with a clinician involved in the patient’s care, who is from a different profession to themselves
hold a multi disciplinary team meeting where discussion should take place, and consideration given to the views of the patient, and their nearest relative or carer. The discussion and decision of this meeting are to be fully documented
obtain the written agreement of an AMHP that the conditions for extending the CTO are met and that the extension is appropriate. (This need not be the AMHP who was involved when the form CTO1 was originally completed)
complete and sign part 1 of the form CTO7
the AMHP will then complete part 2 of the form CTO7
complete and sign part 3 of the Form CTO7

The completed document will be effective once it has been sent to the MHA Office and Part 4 of the CTO7 is completed on behalf of the hospital managers.

Following the extension of the CTO the patient and the patients’ nearest relative will be informed of the effect of the extension and the patient’s right of appeal to the first tier tribunal. The patient’s full rights will also be read in line with the trust procedure for informing detained patients of their legal rights under section 132 of the MHA 1983.

Note, in the event that the AMHP or the second Professional does not agree that the extension is appropriate then the RC should review whether the patient should be discharged from the CTO

5.22 Discharge from a CTO

The planning for discharge of a patient from a CTO by their RC should begin from the time they are first considered to require treatment under this section. It is also good practice to review the need for a CTO to continue as part of every CPA or section 117 review meeting, and any patient who no longer meets the criteria for a CTO must be discharged.

5.22.1 Discharge by responsible clinician

The reasons for discharge should be explained to the patient and any concerns that the patient has, or which their relatives or carers express, should be considered and dealt with as far as possible. The patient will be entitled to any section 117 after care services they may be assessed as needing and are to be informed of this.

The RC may discharge a patient subject to a CTO at any time by notifying the hospital managers in writing.

5.22.2 Discharge by hospital managers (under section 23 MHA)

The hospital managers have the power to discharge a patient from a CTO if:

any of the essential criteria no longer apply
three or more members of the panel (who between them make up a majority) are satisfied that the answer to any of the questions set out is “no” the patient should be discharged (see 38.22 of the Code of Practice)

Hospital managers have discretion to discharge patients even if the criteria for continued detention under a CTO are met. Hospital managers’ panels should always consider whether there are other reasons why the patient should be discharged despite the answers to the questions.

In the event that the hospital managers agree to discharge the patient they have a duty to inform the nearest relative that the CTO has been discharged.

5.22.3 Discharge by first tier tribunal

Patients who are subject to a CTO may also have the CTO discharged by the first tier tribunal. The hospital managers have a duty to refer patients to the tribunal (see 37.39 of the Code of Practice) they may also request the Secretary of State to refer a patient (see 37.44 to 37.46 of the Code of Practice) and for children and young people (see 19.107 to 19.110).

5.22.4 Discharge by nearest relative

As stated in section 5.10 the nearest relative can make an application to discharge the patient from a CTO and the procedure for this is outlined in the “trust procedure for the discharge of a patient by their nearest relative.”

However, where a patient is subject to a CTO under part III of the MHA 1983 the nearest relative cannot request discharge, but can in certain circumstances apply to the first tier tribunal.

5.23 Record keeping

The local MHA Office will be responsible for documenting, recording and storing copies of all statutory documentation involved with the use of a CTO. All staff taking action under the CTO provisions must inform their local MHA Office of actions taken and notices issued so that use of a CTO can be monitored and made available for the purposes of audit.

6 Training implications

Staff training in relation to the contents of this policy is included in the trust Mental Health Act training.

It is also included in the local induction for new staff and staff will also be made aware of the review and reissuing of this policy in the following ways:

team meetings
Weekly news bulletin
copy of the policy will be available on the trust web site

7 Monitoring arrangements

7.1 The number of patients within the trust who are subject to a CTO

How: Review.
Who by: MHA office.
Reported to: Local mental health legislation monitoring groups, who in turn report to the trust mental health legislation sub committee (which has delegated power from the board).
Frequency: Monthly at the local mental health legislation monitoring groups and quarterly at the trust mental health legislation sub committee.

7.2 Compliance with the contents of this policy

How: Audit.
Who by: Modern matrons and service managers in conjunction with the trust Clinical Effectiveness team.
Reported to: The trust mental health legislation sub committee.
Frequency: Yearly.

7.3 Any serious incident reviews which identify issues and concerns in relation to this policy

How: Review of the outcome of any relevant serious incident reviews and the recommendations made by the panel.
Who by: The chair of the trust mental health legislation committee.
Reported to: Summary to be included in the annual report provided to the board of directors.
Frequency: As and when required.

8 Equality impact assessment screening

To download the equality impact assessment for this policy, please follow this link: Equality impact assessment.

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’.

Consequently, 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 Indicate how this will be met

All individuals involved in the implementation of this policy should do so in accordance with the Mental Health Act Code of Practice Statement of Guiding Principle of (Chapter One)

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 individual’s 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 colleagues 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 Indicate how this will be achieved

All individuals involved in the implementation of this policy should do so in accordance with the guiding principles of the Mental Capacity Act 2005. (Section 1)

9 Associated documents

10 References

Jones R (2015) Mental Health Act Manual, Eighteenth Edition, Sweet and Maxwell.
Jones R (2016) Mental Capacity Act Manual, Seventh Edition, Sweet and Maxwell.
Department of Health: Mental Health Act Code of Practice 2015.
Department of Health: Mental Capacity Act Code of Practice 2007.
The Human Rights Act, 1998.
Supervised community treatment: A guide for practitioners (NIMHE).

Document control

Version: 7.1.
Unique reference number: 78.
Ratified by: Covid-19 gold command.
Date ratified: 7 April 2020.
Name of originator or author: Mental health act manager.
Name of responsible individual: Executive medical director.
Date issued: 14 May 2020.
Review date: January 2021.
Target audience: Responsible and approved clinicians, qualified mental health and LD inpatient staff, qualified mental health and LD community staff, Mental Health Act offices.
Description change: Due to the Covid 19 pandemic gold command agreed a review extension from July 2020 to January 2021.

Page last reviewed: April 24, 2024
Next review due: April 24, 2025

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