CTO Conditions

All CTOs must include conditions requiring patients to make themselves available for examination so that:
(a) The RC can decide whether to make a report extending the CTO under S20a and
(b) A SOAD can decide whether to give a certificate authorising certain kinds of treatment for the patient

The CTO may include other conditions which the RC (with the AMHP’s consent) think are necessary or appropriate for one or more of the following reasons:

• Ensuring that the patient receives medical treatment
• Preventing harm to the patient’s health or safety
• Protecting other people

The conditions (with the exception of the two mandatory conditions above) are not directly enforceable.
The RC and AMHP should ensure the conditions of a CTO :

• Be kept to a minimum consistent with achieving their purpose
• Restrict the patient’s liberty as little as possible while being consistent with their care plan and recovery goal
• Be clearly and precisely expressed, so that the patient can readily understand what is expected (CoP 29.31)

CTO Criteria

• The patient is suffering from a mental disorder of a nature or degree which makes it appropriate for the patient to receive medical treatment
• It is necessary for the patient’s health and safety, or for the protection of others that the patient should receive such treatment
• Subject to the patient being liable to be recalled, such treatment can be provided without the patient continuing to be detained in hospital
• It is necessary that the RC should be able to exercise the power to recall the patient
• Appropriate medical treatment is available

An AMHP needs to endorse the RC’s opinion that all the above criteria are met and agree that it is appropriate for the patient to be subject to a CTO.

S17a Community Treatment Order

• The purpose of a CTO is to allow suitable patients to be safely treated in the community rather than under detention in hospital, and to provide a way to help prevent relapse and any harm – to the patient and others – that this might cause. It is intended to help patients maintain stable mental health outside hospital and promote recovery (CoP 29.5)
• The Guiding Principles of the MHA 1983, in particular, treating patients using the least restrictive option and maximising their independence, and purpose and effectiveness should always be considered when deciding if a CTO is necessary.
• A CTO does not bring an admission for treatment to an end. It merely suspends the hospital power to detain the patient for as long as the CTO is in force.
• Patients detained under s3 and s37 can be considered for discharge under a CTO.

Renew Detention – Section 20

Responsible Clinician (Medic vs Non-Medic)

Important cases to read – Winterwerp v Netherland (1979) EHRR 387/ Varbanov v Bulgaria (2000) MHLR 263 (issues with the term ‘Medical expertise’)

Absence Without Leave – S 18 / 21 / 21A + B

• AWOL Section 18
• Patient leaves hospital without S17 Leave (18(1)a)
• Patient fails to return from escorted / unescorted leave (18(1)b)
• Patient fails to return on being recalled to hospital (18(2A))
• Patient fails to reside at an agreed address (18(1)c / 18(3))
• If patient returns or taken into custody within 28 days of going AWOL (Section 3, 37, CTO & Guardianship)
• RC renews order – simple
• If patient returns or taken into custody after 28 days of going AWOL (Section 3, 37, CTO & Guardianship)
• RC must examine within 7 days; Consult an AMHP and one more professional to reinstate order (order extended by 6 or 12 months from the date of going AWOL)
• If Original Order (3,37,CTO & Guardianship) expires on the day or patient returns within 7 days preceding that day – order extended by 7 days / For CTO Recall Period (S 17F) – extended by 72 Hours
• No liability for detention after expiry of Sections 2 / 5(2) / 5(4)
• No Restriction on detention of Restricted patients (41 & 49)

Community Treatment Order – Section’s 17A – 17F

Leave – Section 17

• RC only (or AC acting as RC)
• Indefinite or specified occasions
• Could be conditional
• Should consider SCT if leave > 7 days (consecutive)
• Risk assessment to be carried out and care plan implemented
• Recording system has to be in place
• Leave can be in custody
• Recall – anytime if considered necessary by RC
• Copy of leave should be shared with patient, carers, escort

Roles of Responsible Clinician (RC)

Other Roles of Approved Clinician (AC)

• Detention under section 5(2)
• Examine Detained patients following referral by Secretary of State under:
  • Section 67 (Re: Section 37 Hospital Order / Guardianship/ CTO)
  • Section 76 (Re: Section 37 & Section 41)
• Give evidence in court (Section 35 – 36)
• Extend remand (Section 35)
• Assure court of bed availability (Section 35 – 36) (hospital managers can also do this)

Reporting Responsibilities of Approved Clinician (AC)

• An Approved Clinician (AC) must:
• Submit periodic reports under section 61 to the Mental Health Act Commission regarding treatment under section 57.
• Submit periodic reports under section 61 to the Mental Health Act Commission regarding medication and ECT supported by a SOAD certificate under section 58 or 58A.
• Submit reports to MHAC as required on treatment given to SCT patients on the basis of a SOAD’s “Part 4A certificate” (62A).
• An Approved Clinician (AC) can sign a certificate under section 58 or 58A of the Act certifying that the patient has consented to medication or ECT (respectively).