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Quick reference guide to identifying a deprivation of liberty in the psychiatric setting
The following are examples of potentially liberty-restricting measures that may apply in psychiatric hospitals generally (this includes acute and rehabilitation or ‘step down’ wards):
- wards are busy places where there may be a high turnover of patients and significant pressure on staff time. This can result in blanket restrictions. These include: limited access to bedrooms during the day; restrictions on access to parts of the ward such as kitchen areas
- setting of observation and monitoring levels
- requirements for patients to be escorted in certain parts of the ward or site
- the physical environment (e.g. wards not on ground level) may limit patients’ access to the outdoors
- the prescription and administration of medication to a patient who lacks capacity to consent to it, in particular medication to sedate and/or to control the behaviour of the patient
- the extent to which the patient is required to adhere to a timetable
- locked doors, or use of “baffle locks”, unless patients have the code and are able to come and go as they please
- the concept of “protected time” is a valuable means of ensuring that patients have quiet periods during the day but also represents control over the activities of patients
- limited visiting time
- lack of easy access to telephones, internet, equipment for hobbies and interests such as art or music materials, possibly on safety or availability grounds
- use of seclusion, especially where such seclusion is regular and/or prolonged
- use of physical restraint, especially where such restraint is regular
- sanctions, such as time out, for behaviour that causes concern
- restriction of access to finances
In addition to the measures described above that apply in psychiatric hospitals generally the following are examples of potentially liberty restricting measures which may apply in an assessment and treatment unit (ATU):
- physical restraint
- seclusion (often described in misleading terms, not recognized as such and thus not reviewed in accordance with the Code of Practice to the MHA 1983)
- blanket rules which are rarely justified by the needs of the individual patient. This can be exacerbated by pressure on staff through low numbers
- routine and clear boundaries, which can be beneficial and a source of reassurance, but can also entail assuming control over what the individual does with their time
In addition to measures described above that apply in psychiatric hospitals generally the following additional measures may apply in a dementia specialist unit:
- the need for restraint and other physical interventions, in the patient’s best interests, to deliver personal care
- blanket restrictions to avoid risks such as falls
Questions for front-line staff
These questions may help establish whether an individual is deprived of their liberty in this context:
- is the door to the ward or unit locked? Does the patient either know the Code or have a swipe, and is he or she able to make use of it to come and go as he or she pleases?
- can the patient leave the ward at any time or are there any conditions the person is required to adhere to?
- how easy is it for the patient to go outside and get access to fresh air?
- what if any steps would be taken by staff if the patient were to announce their intention to leave the ward a) temporarily or b) permanently?
- is the patient able to access all areas of the ward when they wish to?
- can the patient prepare any refreshments for themselves?
- is the patient able to access items for leisure activities when they wish, such as: games consoles, books, means of listening to music, art, craft or writing equipment, the internet?
- what observation levels is the patient on and how are they monitored?
- is the patient prescribed medication? If so, can they consent to such medication, and what is its purpose? Is it to control their behaviour?
- to what extent is the patient required to adhere to a timetable?
- does the ward have a period of “protected time” when visitors cannot come onto the ward?
- how easy is it for the patient to use the phone in private?
- what are the visiting hours?
- is the patient ever nursed alone and if so in what circumstances?
- is the patient ever secluded? If so, why and for how long on each occasion? Is seclusion regularly used?
- is restraint ever used and in what circumstances? How often is it used?
- are there any sanctions used if the patient’s behaviour is cause for concern? If so what are they and why?
- does the patient manage his or her own finances? If not, who does, why, and under what authority?
- could any of the liberty- restricting measures be dispensed with and if so how?