When Can a Detained Patient be Subject to Seclusion

Hello. Welcome to this session from Data Law relating to mental Health law. My name's Steph Baba. Andi. I'm a retired solicitor from Law Hound Limited on formally, I was a member off the Law Society's Accreditation Mental Health Review Tribunal panel. In this session, we're going to be looking at when a patient who's detained under the Mental Health Act 1983 as amended can be subject to seclusion. Seclusion is one of the restrictive interventions which can be used to deal with disturbed behaviour. AST's part of medical treatment for disorder seclusion is thes supervised confinements and isolation of a patient away from other patients in an area which the patient is prevented from leaving where it is off. Immediate necessity for the containment off severe behavioural disturbance, which is likely to cause harm to others. Restrictive intervention should be a last resort on. There are safeguards in place to help avoid abuse. The Department of Health, its code of practice to the Mental Health Act, which are referred to as the code, requires mental health providers and those involved in their care on social care to have a restrictive intervention reduction program in place. So what is a restrictive intervention program. Well, it's a Siris of policies and guidance, the aim of which is to provide a clear definition about restrictive invention on guidance on how it's to be used, including the use of seclusion. It needs to include the fact that there should be an assessment of the individual. Andi, the immediate and potential risks off behavioral dispute disturbance on that needs to be regularly reviewed before a system of support that meets the injury jewels needs is actually put into place. And so a restrictive intervention reduction program for an individual needs to be very much based on the assessment off that individual and plans would normally involve a three tier strategy, firstly, the primary preventative strategy. And that should be a strategy which aims to enhance the patient's quality of life and meet their unique needs by reducing the likelihood off behavioral disturbances in the first place. There were then the secondary preventive strategies, which should focus on the recognition of early signs of impending behavioral disturbance on how to respond to that. In order to encourage the patient to be calm, that would include things like de escalation strategies and finally, tertiary strategies so that if restrictive interventions are unavoidable, then the code requires they should be planned evidence space lawful in the patient's interest, proportionate and dignified. And that means that they need to be medically necessary in all circumstances of the case. Restrictive interventions need to be a necessary and proportionate response to behavioral disturbance on aiming to minimize distress and risk of harm to the patient on never be used to deliberately punish or humiliate on. This includes staff not causing deliberate pain in an attempt to force compliance with their instructions except in the most exceptional circumstances to mitigate on immediate risk. The life restricted intervention needs to be pre planned on with one single member of stuff assuming control of the instant on DSO that it's only used in a way that respects human rights. On consistent with current national policy. On DOF course, Best practice, guidance and so restrictive intervention is based very much on individualized assessments, but obviously needs to take into account care plans and treatment plans. Andi, in some services care plans, are referred to as positive behavioral support or PBS plans, and that means everything being very much recorded in what the code describes as an open and transparent manner, detailing the nature and manner of application of any restrictive intervention. The reasons for its use on the consequences or outcome on any restrictive intervention must always be part of restrictive intervention reduction program. On behalf of the health care provider on DSO, there needs to be the policies and guidance and training, which takes a very robust approach to ensuring that restrictive intervention is only used in the safest possible manner. Andi is regularly reviewed. Andi updated. So let's examine the seclusion guidelines. Whenever a patient is confined in any way that meets the definition of seclusion, even if it's at the patient's own request, the procedural safeguards off the code must be followed on. That means seclusion shouldn't be used as a punishment or threat or because of a shortage of staff. It should form part of a treatment program. Andi, it should be you solely as a means of managing self harming behaviour. If a patient poses a risk of self harm as well as harm to others, then seclusion should only be used when the professionals involved a satisfied that the need to protect to the people outweighs any increased risk. The patients healthful safety arising from the own self harm on that any such risk can be properly managed. And that means that the code reinforces that mental health care providers must have detailed guidance on the use of seclusion, which are consistent with the guiding principles of the code on. That means that their policies should ensure the physical and emotional safety and well being of the patients on short patient receives the care and support rendered necessary by their seclusion both during it and after it's taken place. And it means designating a suitable environment that takes into account the patients dignity and physical well being and clearly sets out roles and responsibilities of stuff on requirements. Recording monitoring on reviewing the use of seclusion on, of course, any follow up action. What about when, where seclusion should take place? Well, it should only be used in hospitals and in relation to patients detained under the act. So if an emergency situation rose, for example, involving an informal patient, Andi, it's the last resort that seclusion is necessary. Prevent harm to others than an assessment for an emergency application for detention, and the act should be undertaken immediately. Seclusion should have a minimal impact on a patient's autonomy on DSO needs to be flexible. So, for example, allowing patients to receive visitors on facilitating brief periods of access to secure areas outside the seclusion area. For example, taking meals in the usual ward areas can help when evaluating the patient's mood on degree of agitation that should take place without determinate ing the seclusion episode, so seclusion needs to be applied in the least restrictive manner possible. Taking into account the patient circumstances and regularly reviewed on seclusion should only be undertaken in a room or suite of rooms that have bean specifically designed and designated for the purposes of seclusion, on which serves no other function on the ward. Seclusion does not include locking people in their rooms night. It's in accordance with the high security psychiatric services, arrangements for safety and security directions on when designing rooms or areas where seclusion is going to be taken out. Some of the following factors need to be taken into account. The area needs to be capable of being within constant sight and sound of stuff, members Andi. It should allow for communication with the patient when the patients in the room on the door is locked, for example, fire and into calm. The room should include limited furnishings, but should include a bed, pillow, mattress and blanket or other covering. Their obviously needs to be no apparent safety hazards on rooms should have rib bust reinforced windows. The provide natural light where possible. Andi, where possible, enable a view outside to take place. Rooms should have externally controlled lighting, including a main light and subdued lighting for nighttime with a robust door, which opens outwards. Room should have externally controlled heating and conditioning, which enables those observing the patient to monitor the room. Temperature on room shouldn't have blind spots, and alternative viewing panels should be available where required. Ah, cock should always be visible to the patient from within. The room on the rooms should have access to toilet and washing facilities. And finally, a patient should never be deprived of clothing while stare in seclusion. So can north rise? Seclusion Well, seclusion can be authorized by any psychiatrist, however, if they're not the Patients Responsible Commission or R C, nor Unapproved Commission or a C than the RC or Duty Doctor or equivalent needs to be informed of the seclusion assumes is possible. Seclusion can also be authorized by an approved condition who's not a doctor all over mental health providers. Policy should determine the appropriateness off, enabling people who are not doctors to authorize seclusion. In any event, the patients are see or duty doctor or equivalent at least to again be informed of seclusion a soon as is practicable on. Seclusion can also be authorized that by the professional in charge reward, for example, a nurse. But again, the patients are see or duty doctor or equivalent must be informed of seclusion as soon as it's practical. Whoever authorizes seclusion, I must have seen the patient immediately prior to the commencement off that seclusion and in most circumstances, family members should be notified off. Significant behavioral disturbances on the use of restrictive interventions has agreed within the care plan and during any seclusion that needs to be both. Monitoring on observation observation should be conducted by a suitably skilled professional staff member who is within constant sight and sound of the seclusion area. Andi. They must also always be able to summon urgent assistance from any other staff members appointed to observe when appointing the stuff member for observation. Consideration needs to be given to the patient trauma history on whether a male or female would be more appropriates. However, if the secluded patient has received sedation than a skill, professional needs to be actually outside the door at all times. There should be a documented observation record provided every 15 minutes reported by the person. Monitoring on the record should include, where applicable, the patient's appearance, what they're doing and saying they're mood, the level of awareness, any of evidence of physical ill health, especially with regard to breathing or power. If the patient pays to be sleeping seclusion, then the person observing should be alert to and assess the levels off consciousness on respites vibrations off the patient as appropriate on where there's any concern whatsoever regarding the patient's condition, Then this should be immediately brought to the attention off the patients responsible clinician or the duty doctor. And there needs to be a clearly documented Siri's off reviews of seclusion on where agreed family members should be advised off the outcomes of reviews on one patients in seclusion or asleep. Provided policies could allow reviews to be undertaken in accordance with the revised stretchable, which should be recorded in the care plan in order to avoid working the patient's. Otherwise, we need to have reviewing as follows firstly, no later than one hour after the seclusion starts. So if seclusion was authorized by consultant psychiatrists, whether or not they are the patients are sea or on a C. The first view is the one undertaken immediately bought before seclusion was authorized. However, although authorization for seclusion can be provided by someone other than a psychiatrist, where this happens, there must be a medical review within one hour or without delay if the individual is newly minted, not known, or there's a significant change from the usual presentation and after that review, where it's agreed that seclusion needs to continue, then a seclusion care plan needs to be agreed on prepared, which identifies how the patients presenting it ongoing needs whilst in seclusion can be properly met. Medical reviews would normally be carried out by the R. C. But where the RC is unavailable than the providers policy needs to make provision for duty doctor to deputize for the RC on, that person needs to be competent to carry out a medical review. If the duties not unapproved permission, then they must always have access to an on call doctor who is an approved permission. Medical review should be carried out in person so that they provide an opportunity to determine whether seclusion needs to be continued or stopped, and so that the patient's mental and physical health Converium viewed on that could be a reassessment of the medication prescribed and to assess any at first effect of the medication. Andi. It's also review of observations and to assess the risk posed by in patients to others and to assess any risk to the patient from deliberate or accidental self harm. On finally, to assess need for continuing seclusion on whether it's possible for seclusion measures to be applied more flexibly or in a less restrictive manner on when there's any concern regarding the patient's condition, then that should be immediately brought to the attention off the patients responsible commission or duty doctor. There needs to be nursing of use by two nurses every two hours throughout seclusion. Continuing medical review should take place every four hours until first internal multi disciplinary team review the first internal month multi disciplinary team review should take place as soon as is practicable. Onda after period off eight consecutive hours or 12 hours, intermittent seclusion within a 48 hour period That needs to be a review by the Inter Dependent Multi disciplinary team on their after at least twice daily lives, you'd expect there needs to be a record relating to conclusion, which needs to be kept. There's no prescribed system or former for that record, which could be Elektronik or paper based or a combination of both. Provided that they meet the recognised professional recordkeeping standards. A seclusion record should at least provide the following details. Who authorized the seclusion? The date and time of the commencements off the seclusion? The reason for the seclusion? What the patient took into the seclusion room if and when a family member, carer and or advocate was informed of the use of seclusion? The 15 minute recordings by the person undertaking continuous direct observation details of who undertook the scheduled nursing reviews, the medical reviews. The independent M D T. On the scheduled MDT reviews and including their assessment, a record of the patient's condition on recommendations and finally, the date and time that seclusion ended and details of who determined that that seclusion should come to an end under suspension. There needs to be a seclusion care plan on that needs to set out how the individual care needs of the patient will be met whilst there in seclusion and recalled the steps that should be taken in order to bring the need for seclusion to an end as quickly as it's possible on the seclusion care plan must at least include a statement of clinical needs, including any physical or mental health problems, risks and treatment object sifs A plan as to how on individuals needs are to be met. How de escalation attempts will continue on how risks will be managed. Details of bedding and clothing to be provided. Details as to how the patient's dietary needs are to be provided for on finally details of any family or Keira contact or communication, which will be maintained during the period off seclusion. Wherever it's possible, patients should be supported to contribute to this seclusion INS care plan on step should in fact be taken to ensure patient is aware of what they need to do for the seclusion to come to an end in view of the potentially traumatic effective seclusion care plan should provide details of support that's also going to be divided when seclusion actually comes to an end. So much about bringing an end to seclusion. Well, seclusion should immediately end when any of the following decide seclusion is no longer warranted. So when a medical review decides, ah, multi disciplinary team review an independent multi disciplinary team review or the professional in charge of the ward provided that that professional has consulted the patients are see or duty doctor in person or by telephone, and that they agree. And seclusion actually physically ends when a patient is allowed free on unrestricted access to the normal ward environment or transfers or returns to conditions of long term segregation. Simply opening a door for toilet off food breaks or the medical review does not actually physically constitute the end of a period off seclusion that now brings this current mental health session to an end. Thank you very much for joining me, Steph Barber on this Data Law mental health session