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Level of contact with professionals

The level of support and monitoring individuals require will vary depending on individual need and may change over time as the person's mental state and circumstances alter. It is important that individuals have adequate contact with their care team while on a short term detention certificate (STDC), to ensure that services can identify and respond to changes in individual need. Our previous themed visit reports have highlighted the value that individuals place on therapeutic time spent with members of their care team.

On these visits, we looked at the level of contact people had with their health and social care team members. There were several difficulties in measuring the frequency of contact. Firstly, while there may be no record of contact in nursing notes or medical files, we cannot be sure that contact has not taken place. Sometimes staff and individuals reported contact, but we could find nothing in notes to confirm this. Where we were unable to find records of contact with particular professionals, (and even if we were assured the contact had taken place) we raised this as an issue with staff and stressed the importance of accurate recording.Secondly, 18% of the people we saw had been in hospital for a week or less which may affect our findings.

Contact with doctors

The number of recorded Responsible Medical Officer (RMO) contacts with a patient during the first week after admission ranged from zero to four. The average contact was nearly once every four days. The average number of contacts with other types of psychiatrists (junior doctors/specialist registrars) during the first week ranged from none to seven contacts. On average, a patient would see a psychiatrist once every three days during the first week of admission

Those patients who had been in hospital for over a week and less than 28 days, had total recorded contacts with their RMO on average once every 10 days. The average number of contacts with other types of psychiatrists they had during this period was four. This finding suggests that, following the initial assessment period when a patient might on average expect to see one of these more junior doctors twice, this reduces to once a week on average over the first 28 days.

While we recognise that there are significant pressures on medical staff, and that new training arrangements for junior doctors and the European Working Time Directive have significantly reduced the amount of time available for face to face contact with patients, we believe that people who are on STDC should be seen more frequently than is indicated by this report. The 2003 Act is clear that people should be regularly reviewed to ensure that care and treatment is of benefit to the individual and that the grounds for compulsory treatment are still being met.

The very nature of acute episodes of mental disorder means that an individual's needs can change rapidly.Just as people may move from informal status to compulsion, then equally people can move in the other direction. We are concerned that a significant number of people on STDCs are subject to compulsion for longer than is necessary. For the people that we saw for this report 33% continued on their STDC until it lapsed, with only 19% being actively revoked; 48% progressed to a compulsory treatment order.

Contact with named nurse

Many NHS Boards have a system in place a system to allocate a named nurse to each patient soon after admission. Many of our previous visit programmes have highlighted the value that individuals place on therapeutic time spent with their named nurse and the benefits both to the patient and the service where this arrangement works well.

We found in records that this named nurse would see a patient on average three times in the first week following admission and six times during the first 28 days. However, on some wards there was no written record of when the named nurse sees an individual, perhaps devaluing how important this contact is as part of the overall assessment. In the following case for instance we found an excellent level of support available to the person but we were unable to count the number of named nurse contacts:

"Named nurse usually sees the patient many times a day, as and when required and at least twice a week on a 1:1 basis. When the named nurse is away on leave or on a different shift, another nurse is always backing up for him or her"

Elsewhere we found:

"Recording is on [an electronic] system which is not completed necessarily by the named nurse. So it is unclear where the named nurse would record any discussion or interaction"

It was also not routine for named nurses to write in the notes when they had offered to see an individual but the individual had refused.We would recommend that NHS Boards look at these issues to ensure full and proper recording in a way which facilitates assessment and care planning.

Contact with Mental Health Officer (MHO)

The MHO has specific responsibilities following the granting of an STDC. They have a duty to explain to the individual about their rights, about the role of the named person and about how to access independent advocacy services. The code of practice suggests that best practice would require the MHO to provide this information face to face, as well as in writing. The STDC also acts as a trigger for the completion of a social circumstances report. The social circumstances report should reflect the views of the individual in relation to their detention and should be based on an interview with the individual. The importance of a comprehensive up-to-date report to the health care team cannot be overstated. Our good practice guidance on Social Circumstances Reports aims to assist MHOs with this duty.

The MHO must also be involved, as part of the multi-disciplinary team, in the assessment and care planning for the individual, in particular when considering whether an application for a CTO will be made.

Whilst it was noted from interviews that MHOs are visiting more often than was routinely recorded in individual nursing and medical files, there was little evidence that individuals were being visited frequently enough to fulfil all of their functions to the full.

We found recorded MHO contact with patients within the first week of admission for barely half of the people we visited. By the 28th day they had visited on average once, usually in relation to a CTO application.But often the MHO had not been involved since the admission, or had visited and either had been refused an interview by the patient or no record of this interview existed in the notes.Sometimes we were told that although there had been no MHO contact another social worker had visited. Overall, it would appear that, once an individual is admitted to hospital, contact with social work, including MHOs, is infrequent.