Care Programme Approach Guidance for Restricted Patients

1. Care Programme Approach Guidance for Restricted Patients Dr John Crichton, Consultant Psychiatrist, Orchard Clinic Peter Clarke, Social Work Team Leader, South Lanarkshire Council (The State Hospital) The Forensic Network

2. Official Guidance • Scottish Office Circular SWSG 16/96 • Care Programme Approach for people with severe and enduring mental illness including Dementia • Supplementary Guidance & Policy • MEL (1999) 5 • 2002 Early Discharge Protocol • 2005 Memorandum of Procedure for Restricted patients • 2006 Delivering for Mental Health The Forensic Network

3. CPA in Scotland Current Characterisation • Targeted – focus on transitions • Patient and carer involvement. • Multi-agency • Explicit roles of each professional • Identification of care co-ordinator. • Care Plan – SMART and patient centred • Review Cycles The Forensic Network

4. ACPOS Scottish Independent Advocacy Alliance Caldicot Guardian Social Work Forensic Network Forensic Psychiatry Crown Office SE Criminal Justice SE Health Risk Management Authority Community Nursing Scottish Care Programme Approach Network Mental Welfare Commission Scottish Prison Service ADSW Community Justice Working Group Membership Group had large membership that did not stay static throughout the process. Representation from: The Forensic Network

5. Drivers for Change • Management of Offenders Act section 10 & 11 • Forensic Network Standards Report • High Profile CIR results • Homicide Inquiries • MAPPA • MOP • Mr L & Mr M The Forensic Network

6. Remit of the group • “To review and revise the Care Programme Approach Guidance to ensure that the protection of the public is at the core of the decision making in respect of restricted patients’ rehabilitation.   To establish joint arrangements for effective risk management requiring that all those engaged in a restricted patient’s care have an understanding of the risks presented by the patient and of the factors that might suggest a relapse in the patient’s conditions and be prepared to act where those factors appear to be manifest.  The revised guidance will give clarity to the roles and responsibilities of the professionals involved in the care and treatment of the patient and the role of the agencies included in the information sharing process in order to enable the successful, safe rehabilitation of the restricted patient. To share the guidance with the Scottish Executive chaired Tripartite Group[1] and present guidance to Scottish Ministers for approval” [1] Tripartite Group involved local authorities, SPS, ACPOS and Justice Department and worked with the Scottish Executive to develop legislation and develop MAPPA. The Forensic Network

7. CPA Report • Current CPA Practice • Review of Restricted Patient Cases • Information Sharing • Assessment and management of Risk • Recommended guidance and documentation • Recommendations The Forensic Network

8. Current CPA Guidance • CPA or equivalent required for all Restricted Patients (source MOP) • Practice varies considerably between services • Some area have specific policies • In other areas CPA included within service operational policies • Implemented at point patient considered for transfer • Used for regular patient reviews • Not used routinely in some services • Different paperwork The Forensic Network

9. Review of Current Restricted Patient Cases • 50 cases of conditionally discharged patients (50% of RMO not within forensic service) • 28 had CPA paperwork, others information from other sources • Disappointing results • No recorded statement of risk • No identified risk factors • No contingency plan • Little multi-agency working The Forensic Network

10. Information Sharing • Under MOO Act Health is a Responsible Authority for patients under restriction orders • For other cases (non-restricted patients) Health has a “duty to cooperate” under MAPPA guidelines • Links with ViSOR (Violent and Sexual Offender Register) • Implications for non Restricted Patients subject to Criminal Procedures Act The Forensic Network

11. Assessment and Management of Risk • RMA tasked with review of Risk Assessment and Management of Restricted Patients (completed) • Integrated working vital via CPA • Risk Assessment Documentation should be prepared prior to CPA with contribution from all relevant agencies • Risk Management/ Contingency Plan Flowchart for information sharing • Patient engagement • Risk Assessment Tools and understanding between agencies of the tools each use • More than just High, Medium or Low risk • Risk Assessments should be ongoing • Planning and Contingency Planning vital The Forensic Network

12. Guidance • Should be adopted for all Restricted Patients in Scotland • Initial CPA 4 – 10 weeks after admission and then at least every 6 months • Care Co-ordinator role in CPA • Pre-CPA and CPA Meetings • Competencies for Chair • Structure of Meetings • Traffic light approach to contingency planning The Forensic Network

13. Documentation • Number of support documents • Historical summary, risk assessment, multidisciplinary reports, professional care plan, minutes of third party discussions • Recommended proforma • Key demographic information, legal status, MAPPA status, compulsory treatment details, parties involved in CPA, identified needs, review of previous objectives, contingency plan, risk summary • Living document including information for part 9 care plan The Forensic Network

14. Further Recommendations • Suitable for any patient requiring similar risk assessment • Following implementation further Scottish Executive Audit • SEHD should satisfy itself that local services have a system of clinical governance in place. SEHD should develop system for collating red and amber alerts • CPA will fit within MAPPA arrangements including sharing of information • Local services should develop protocols to facilitate integrated working between agencies linking with MAPPA arrangements The Forensic Network

15. Traffic Lights • Aid contingency planning not replace Risk Assessment • Give clear practice protocols for action given certain circumstances • Green status: In most cases reflects monitoring of risk factor • Amber status: In most cases reflects urgent clinical review • Red status: In most cases indicated need for emergency action The Forensic Network

16. Traffic Lights • Advantages • Clarity of approach especially for those not familiar with sophisticated Risk Assessment tools or forensic settings • Flexibility • Disadvantages • May appear too simplistic • Not exhaustive The Forensic Network

17. Box 3.1 – Traffic Light Approach to Contingency Planning (This replicates the Contingency Planning section of the CPA Documentation and provides an example of what the risk indicators and relevant traffic lights might be for an in-patient, it is important to note that these should be tailored to individual circumstances for each case) This table provides examples of possible entries and is not proposed as a standard to be adopted. The Forensic Network

18. Box 3.2 – Traffic Light Approach to Contingency Planning (This replicates the Contingency Planning section of the CPA Documentation and provides an example of what the risk indicators and relevant traffic lights might be for an in-patient, it is important to note that these should be tailored to individual circumstances for each case) This table provides examples of possible entries and is not proposed as a standard to be adopted. The Forensic Network

19. Case Scenario • David, 38 years old man on CORO • Convicted 12 years ago of attempted homicide with knife • Paranoid ideation towards victim, delusional system, active schizophrenic symptoms; alcohol and illicit drug use • The State Hospital 6 years; Orchard Clinic 3 years; Hostel 1 year; Independent tenancy 2 years • Risk Assessment highlighted features of disadvantaged childhood: broken family, excluded from school, features of anti-social personality disorder • In the past has uncorroborated allegations of violence in a domestic setting (no weapons) • Particular de-stabiliser = Press Attention • Victim continues to believe David fooled the system and got out early and contacted the press The Forensic Network

20. Questions • Assuming MAPPA is fully in place what level of MAPPA co-ordination is required and why? • Normally have comprehensive Risk Assessment; but from these details identify the Key Risk Factors. • How would you construct traffic light contingencies to manage the risk in this case. The Forensic Network