Care Planning for the Mentally Disordered Offender “The changes in legislation aim to provide more flexible procedures for the assessment and treatment of persons pre-trial and pre-sentence; to make the status of persons detained in hospital pre-trial and pre-sentence similar to that of persons detained under civil proceedings; to allow compulsory measures to be authorised in the community as well as in hospital in line with the compulsory treatment order in cases; and to allow for a thorough assessment of mental disorder, needs and risks in cases where serious offenders have been committed.” Mental Health (Care and Treatment) Scotland Act 2003 Code of Practice

Summary of Principles of the Act The principles place a requirement on those people who have a formal role to have regard for: 1.The present and past wishes and feelings of the patient. 2.In so far as is practicable, the views of the patient’s named person, carer and any guardian or welfare attorney. 3.The importance of the patient participating as fully as possible in the discharge of the function. 4.The importance of providing information and support for the patient in a form that is most likely to be understood, to enable the patient to participate. 5.The importance of a range of options available in the patient’s case.

Summary Principles of the Act cont. 6.The importance of providing the maximum benefit to the patient. 7.The importance of the patient’s abilities, background and characteristics including age, sex, sexual orientation, religious persuasion, racial origin, cultural and linguistic background and membership of any ethnic group. 8.The importance of providing appropriate services and continuing care to the patient. 9.The needs and circumstances of the patient’s carer, providing such information as might be needed to assist in the care of the patient. 10.The function must be discharged in a manner that involves the minimum restriction on the freedom of the patient that appears to be necessary in the circumstances, encourages equal opportunities and if the patient is a child (under 18 years old), best secures his or her welfare.

Principle of Reciprocity “ Where society imposes an obligation on an individual to comply with a programme of treatment and care, it should impose a parallel obligation on the health and social care authorities to provide safe and appropriate services, including on-going care following discharge from compulsion.” Scottish Executive 2001

Role of the MHO Medical colleagues still retain a lead role in presenting reports to the court, but the ethos behind such assessments and recommendations is now significantly changed, reflecting the expectation that multi-disciplinary joint work underpins such formulations, combined with the expectation and requirement to take into account the opinion of the designated MHO. The MHO role in criminal justice is largely new and expanded and is targeted on: 1.The preparation of SCRs for orders made by the Court at any stage of criminal procedures. 2.A substantial Mental Health Officer Report to the Court in consideration of Compulsion Orders. 3.A continuing role for the designated MHO, who has a duty to be consulted in the continuance, extension and variation of past conviction orders.

S.C.R. Required whenever ‘a relevant event occurs’ within 21 days of event occurring. Relevant event: 1.An assessment order. 2.A treatment order. 3.An interim compulsion order. 4.A compulsion order. 5.A hospital direction. 6.A transfer for treatment direction. Unless it serves “little or no practical purpose”. Purpose of an SCR 1.Informing the RMO of social circumstances in order to facilitate decision making. 2.A tool to enable the RMO to make appropriate recommendations to the Court. 3.To ensure that health and social care services are alerted to and pay proper regard to the assessed needs of the patient, irrespective of the outcome of the criminal proceedings. 4.To inform the Mental Welfare Commission in its monitoring of the Act and promoting best practice.

MHO Report for a Compulsion Order Must include: 1.Details of offender - name and address. 2.Name and address of primary carer and named person. 3.Details of personal circumstances. 4.Any other relevant information. Report should also discuss: 1.The MHO: views of the suitability of the measures being sought by the medical reports. 2.A description of the proposed care plan as agreed by the multi-disciplinary team. 3.Confirmation on behalf of the local authority of availability of community services that are to be delivered by compulsion. 4.A description of any alternative mental health disposals that the Court may wish to consider. 5.If the MHO does not consider that a compulsion order is the appropriate mental health disposal, he/she should draw the Court’s attention to any alternative considered feasible. The MHO may suggest that consideration is given by the Court to request an SER to further inform the suitability and viability of other alternatives.

Risk Assessments 1.Based on information from as many sources as possible. 2.Use protocols or assessment tools that have proven validity. 3.Look at past history/clinical concerns/ personal family history/assessment of personality/contextual issues. 4.More specialist risk assessments may be needed for particular groups (e.g. sex offenders). Such an assessment should involve the multi-disciplinary team. The team should then meet to formulate a risk management plan. This meeting should form a formal part of any care planning process.

Care Plan Although the procedures prior to the imposition of a compulsion order by a Court do not include a statutory requirement for the preparation of a proposed care plan, it would be expected that the patient’s future Part 9 Care Plan would be considered by the RMO and MHO and drawn up prior to the recommendation for compulsion order being made to the Court. This should involve the multi-disciplinary team. This plan would include: 1.The objectives of the medical treatment. 2.Details of community services or other relevant services and the objectives of these services. 3.Details of any other treatment, care or service and the objectives of this service.

Process of Care Planning Person CentredRisk Planning Assessment Risk Management Plan Care Plan Review Positive Risk Taking

Person Centred Risk Assessment Planning What is the risk? Who is at risk? Hopes and AspirationsLikelihood of it happening Impact and consequences Strengthsof it happening Circumstances in which Likes/dislikesit might happen balance empowerment and public safety

Risks - originates from ‘Rhiza’ - Greek for cliff Risks to: Individual Staff Relatives Members of Public

Risk Management Limit opportunities to carry out risky behaviours Restrict access to victims Reduce triggers, stressors and situational factors associated with the risk behaviour Change risky behaviours and promote self risk management Adopt the most effective intervention methods Recognise where greater levels of control and intrusion are required Carry out appropriate monitoring

Why do people change risky behaviours? Costs outweigh benefits Risks and harms to others are recognised Motivation to change is established Desirability of change is accepted Risky behaviour is limited by external constraints

Care Plan - Areas to Consider Accommodation Staffing/support Staff skills Housing/care support Structured day - employment, education Psycho/social Family contact Mental/physical health Legal issues Monitoring/reviewing

Positive Risk Taking Taking risks involves deciding that the potential benefits of a proposed action outweigh the potential drawbacks. Acceptable and unacceptable risks may vary over time. Perceptions of risk will vary from person to person. Total safety can only exist in an environment of total control.

“There will unfortunately sometimes be cases which go wrong. We have to accept this in the uncertain environment of risk assessment. But when this happens, the public needs the reassurance that everything that could reasonably have been done to prevent it was done and the highest standards of management and practice must continue to apply”

Important Factors 1.Involve service user throughout process. 2.Ensure all assessments are multi- agency and holistic. 3.Ensure multi-agency sign up to risk management and care plans. 4.Identify a care manager/co-ordinator. 5.Ensure any care providers have protocols to manage risk both proactively and reactively. 6.Ensure all agencies have a clarity re their role. 7.Ensure clear reporting procedures. 8.Review regularly.