Download Limited Community Treatment

Limited Community Treatment
Guideline
1.
Definitions
1. “Limited community treatment for a patient means undertaking some treatment or
rehabilitation in the community other than under the community category of an
involuntary treatment order”. (Definition, Schedule 2)
2.
2.
Absence – the patient may take authorised or unauthorised absence from the Authorised
Mental Health Service (AMHS). The Mental Health Act 2000 (MHA2000) does not include the
concept of leave of absence or absence without leave.
3.
Escorted absence – means under the supervision and authority of staff of the AMHS. Those
staff have authority to exercise powers under the MHA2000.
4.
Unescorted absence – means without any person accompanying the patient (i.e. the patient
does not require supervision) or where specified, in the company of a responsible adult.
Legislative Provision
An authorised doctor may, under the patient’s treatment plan, authorise Limited Community Treatment
(LCT) for the patient (section 129). For a forensic patient, the doctor may only authorise LCT with the
approval of the Tribunal or the Mental Health Court. For a classified patient, LCT may only be with the
written approval of the Director of Mental Health.
If the Tribunal orders that a patient has LCT, the administrator of the patient’s treating health service
must ensure that an authorised doctor for the health service changes the patient’s treatment plan to
give effect to the order (section 130). Further, under section 206 the administrator must ensure that
the Tribunal’s decision (e.g. authorising LCT) is given effect.
3.
Authority of the Tribunal
Under a review of an Involuntary Treatment Order (ITO), if the Tribunal confirms the ITO for the
patient, and the category of the ITO is inpatient, the Tribunal may decide to order that the patient
(other than a classified patient) have LCT subject to reasonable conditions the Tribunal considers
appropriate; or may revoke an order or authorisation for LCT (section 191(2)). A continuous period of
LCT for a patient other than a classified or forensic patient must not exceed seven (7) days (section
131).
Under a Forensic Order (FO) Review, if the order is confirmed, the Tribunal may decide to order or
approve that the patient have LCT subject to reasonable conditions the Tribunal considers
appropriate, or revoke LCT (section 203(2)).
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For a forensic patient, the Tribunal must not order or approve LCT unless it is satisfied that the patient
does not represent an unacceptable risk to the safety of the patient or others having regard to the
mental illness or intellectual disability (section 204(1)).
If the patient has been found not fit for trial and the relevant proceedings are not discontinued the
Tribunal must be satisfied that there is not an unacceptable risk the patient would, if the treatment
were undertaken in the community, not return to the AMHS; commit an offence; or endanger the
safety or welfare of the patient or others (section 204(4)). Note that LCT cannot be ordered on a
fitness for trial review, only on a FO review.
An approval by the Tribunal enables the authorised doctor for the patient’s treating health service to
arrange LCT for the patient at their discretion in accordance with the clinical status of the patient at the
time and the conditions set by the Tribunal (section 129).
4.
Information Requirements of the Tribunal
For the Tribunal to consider LCT, the following information will be required:
5.
1.
Comprehensive Clinical Report including details of the patient’s diagnosis, psychiatric history,
past and current risk factors, risk management strategies, including factors that mitigate risk.
2.
Treatment and LCT plan for the patient - the LCT plan must link the LCT being proposed with
the treatment and rehabilitation goals for the patient, and include details about how the team
proposes to implement, supervise and monitor the LCT, and to what extent breaches of the
conditions will constitute a risk to the safety of the patient or others.
3.
History of previous occurrences of LCT – including how successful or not the LCT has been,
compliance with the LCT conditions, and any incidents occurring during LCT.
4.
Queensland Health has implemented a standardised risk assessment tool that may provide
information about risk additional to the Clinical Report.
5.
A submission by a victim or concerned person made under section 464 may be relevant to the
question of LCT or the conditions for LCT.
Limited Community Treatment Review Committee
The LCT Review Committee is subject to the policy of the Director of Mental Health and is established
in the AMHS to review proposals for LCT in relation to forensic patients who are Special Notification
Forensic Patient (SNFP), and where it is proposed that a FO cease.
These committees review the LCT Plans and the Clinical Report prior to the FO review, and make
recommendations to the treating team regarding the quality of the information and the strategies in
place to manage the patient’s treatment in the community.
The recommendations of the Limited Community Treatment Review Committee (LCTRC), when
available, will be submitted to the Tribunal for consideration at the hearing.
In accordance with natural justice, if the Tribunal intends to have regard to the LCTRC report in the
hearing, the document should be brought to the attention of the patient when present at the hearing.
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6.
Factors for Consideration by the Tribunal
Section 203(6) of the MHA2000 directs the Tribunal in making an LCT decision for a forensic patient,
to have regard to:
 The patient’s mental state and psychiatric history;
 Each offence leading to the patient becoming a forensic patient;
 The patient’s social circumstances;
 The patient’s response to treatment and willingness to continue treatment.
In considering an order for LCT, the Tribunal will generally need to also consider:
 The relationship between the LCT and the treatment and rehabilitation goals for the patient;
 The appropriateness of the location of the LCT;
 The effectiveness of risk management strategies;
 The timing of the LCT in the context of the patient’s illness, offence, behaviour, reportable
incidents involving the patient, risks presented by the patient, and the likely public perception of
the safety and suitability of the proposed LCT;
 Potential impact of the LCT on victims and concerned persons.
7.
“Unacceptable risk”
The term “unacceptable risk” is not defined in the MHA2000 nor is there a definition in case law.
Appeal cases decided by the Mental Health Court indicate that:
a. unacceptable risk referred to in section 204 must arise from a current mental illness or
intellectual disability (Re AKB [2005] QMHC 005 Holmes J 17/06/2005);
b. slight risks with potentially catastrophic results are unacceptable (Re KAC [2005] QMHC 007
Holmes J 21/04/2005).
The Tribunal must determine whether the risk is unacceptable, by balancing the clinical opinion on risk
with other factors including the likely community perception of risk. This is a determination to be made
by the Tribunal on the day of the review depending on the facts of the particular case. An example of
this process in a particular case can be found in Re Wright [2010] QMHC 001 Ann Lyons J 25/03/2010
at paragraphs [6] – [15], [37].
8.
Application of the Purpose and Principles of the Act
In accordance with the principles for administration of the Act (section 8), LCT should occur in an
environment that recognises the person’s cultural, social and emotional needs, maximises the
person’s participation in community life and the maintenance of supportive relationships, and is the
least restrictive option appropriate to the person’s treatment and rehabilitation needs and the safety of
others. Decisions regarding LCT must achieve a balance between the rights and freedoms of the
patient and the rights and freedoms of others (section 4). When making a decision about a forensic
patient in relation to LCT, the Tribunal must take into account the protection of the community and the
needs of the victim of the alleged offence to which the applicable FO relates.
9.
Conditions
The LCT decision should specify the conditions that apply. It is not sufficient to refer to the conditions
proposed in the LCT plan put forward by the clinical team on a particular date, or to refer to a previous
decision of the Tribunal. Upon each review, a new set of LCT conditions will be generated as part of
the Tribunal’s decision.
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The Tribunal must be satisfied that the plans for LCT provide appropriate risk management. The
conditions may be framed in terms of the following variables –
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Purpose – the LCT may be defined in terms of being for a particular purpose (for example to
attend specific group or individual rehabilitation activities).
Duration and Frequency – the LCT may be limited to day or overnight absence from the
AMHS, or defined in terms of a period of absence encompassing a number of day and
overnight stays (for example a weekend including Friday and Saturday nights).
Level of Supervision – where the LCT approved is escorted, the escort may only be provided
by members of staff of the AMHS, as only these staff has the authority to ensure the LCT
conditions are complied with and to intervene to detain the patient if required. In exceptional
circumstances the LCT may specify the number and skill level of escort staff, otherwise this
should be determined at the discretion of the authorising doctor. Other LCT may be approved
on the basis that the patient remains in the company of a responsible adult while on LCT.
The accompanying adult has no authority in respect of the patient, and should not be
expected to take any action to ensure the conditions of LCT are adhered to.
Gradation – the LCT may be approved to progress in stages (for example from supervised
absence during the day progressing to unsupervised absences including day and overnight,
over a period).
Location – the Tribunal may prescribe the place where the LCT is to occur (for example,
where the patient must reside while undertaking LCT, or the specific venue where the patient
may attend rehabilitation activities).
Compliance with treatment – the Tribunal may require the patient to attend certain follow up or
case management appointments either at the mental health service, or at home, and take
certain prescribed medication in accordance with the treatment plan.
Restrictions – the Tribunal may make the LCT conditional upon restriction on certain
behaviours (for example, the patient not having contact with certain persons where the history
of contact with the person has been adverse or dangerous, or controlling his/her use of certain
substances).
Note the following decisions re LCT by the Mental Health Court (these decisions may be viewed on
the Tribunal website using your member login):
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Alcohol to excess – LCT approved JMLP 2/4/09 – reference to the NHMRC Guidelines in
limiting the patient’s alcohol use to not more than two standard drinks over a 24 hour period
on those days when he/she drinks.
Positive Urine Drug Screen – compulsory inpatient assessment not required – LS 9/6/09.
Internet history check – CGP 2 13/10/09.
Specify stages in LCT conditions – JFL 8/5/09.
24 hour supervision to manage risk to children – CD 13/4/05.
Impact of LCT usage on subsequent order – PRA 30/11/09.
In determining the conditions to be placed on the LCT, the conditions should link directly to
appropriate clinical management and risk factors. For example, where the Tribunal requires a person
to submit to urine drug testing, there must be a clear connection with drug taking as an identified risk
factor. Where the Tribunal seeks to limit a person from driving a motor vehicle, there should be a clear
relationship with a dangerous driving offence, or clear evidence that the person needs a medical
clearance for driving (refer to the LCT Decision Forms).
The issues that have been considered in determining the stated conditions on LCT are to be recorded
on the Record of Proceedings.
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10.
Enforceability of Conditions
With reference to sections 130 and 206 of the MHA2000, it is the expectation that mental health
services will give effect to the LCT in accordance with the conditions.
The Tribunal should set out in the order which conditions, if breached, will result in cancellation of the
LCT. The threshold should be sufficiently robust that the patient and the mental health service can
realistically anticipate successful compliance with the conditions. For example, in the case of a patient
who regularly uses drugs and/or alcohol, and therefore breaches the no drugs/alcohol condition, the
expectations of the Tribunal should be clear as to whether the patient is to have their LCT cancelled
on the basis of one breach, or whether there is discretion as to the consequences of the breach.
The order/approval for LCT must be practical and take account of the capacity of the mental health
service to implement the LCT.
11. Treating Psychiatrist’s Exercise of Discretion and the Circumstances in
which the matter should come back before the Tribunal
The Tribunal’s standard approach is to approve LCT subject to the discretion of the treating
psychiatrist. The psychiatrist may exercise his/her discretion through ceasing the LCT (during
periods when the patient requires inpatient care) and the reinstatement of LCT (when the patient no
longer requires inpatient treatment and can continue the treatment in the community on the existing
set of conditions). By requiring the patient to return to the AMHS, the LCT approval is not
automatically revoked. LCT is suspended pending the treating psychiatrist’s exercise of discretion to
place the patient back in the community.
In a small number of cases, the Tribunal may see fit to include as part of the conditions, that a breach
of a particular condition of LCT will result in revocation of the LCT approval (for example, where use of
illicit drugs is identified as a major risk factor and the patient’s use of drugs would result in an
unacceptable risk). Under these circumstances, if the patient were to breach the stated condition, the
LCT must cease, and the treating psychiatrist must require the patient to return to the AMHS. Then the
matter would need to come back before the Tribunal for LCT to be reinstated. It is anticipated that
such an order would be made infrequently; as such a lack of flexibility can create a major impediment
to responsive management of the patient’s illness, and an infringement of liberty if the patient must be
detained in hospital unnecessarily while awaiting a Tribunal hearing to review the LCT.
12. Order/approval for Limited Community Treatment for a Patient on an
Involuntary Treatment Order
In relation to an ITO review, if the Tribunal decides to confirm the ITO, and the category of the ITO is
inpatient, the Tribunal may order that the patient have LCT, subject to reasonable conditions the
Tribunal considers appropriate; or revoke an order or authorisation for LCT (section 191(2)(b)).
Normally though, the Tribunal would regard the approval of LCT under an ITO as a matter for
the treating psychiatrist.
If the Tribunal makes such an order, the authorised doctor can change the order when and as
appropriate. Where the Tribunal has placed some specific condition on the LCT, the authorised doctor
should be satisfied that there has been a change in the patient’s mental condition to warrant altering
the LCT arrangements. However, the doctor is empowered to change the conditions in accordance
with the patient’s treatment plan. An order by the Tribunal does not overtake the doctor’s authority,
and it is not necessary to apply to the Tribunal to alter the LCT conditions as required.
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Because the authority to approve LCT is given to the authorised doctor to enable management at the
local level, it is not envisaged that the making of LCT orders for patients on an ITO will be common
practice for the Tribunal, but would most likely occur in the context of an application for review. The
Tribunal’s order for LCT should take into account the treatment team’s treatment plan for the patient.
LCT for a patient on an ITO (other than a classified patient) may not exceed seven (7) days.
13. Limited Community Treatment in Relation to Patients in a Community
Care Unit
Places that are designated Community Care Units (CCUs) are not part of the AMHS, even though
they are part of the inpatient services of a health service that includes an AMHS. CCUs differ from
Extended Treatment and Rehabilitation Units (ET&RU) in that ET&RU are inpatient units within the
AMHS. Although the facilities may appear similar, the model of treatment and the applicability of
restrictive practices authorised under the Act differ between the two types of services.
CCUs are community-based facilities that offer 24-hour staff supervision to assist patients’
rehabilitation in the community. They are generally designed to provide a long-term or permanent
community living option for patients who are unlikely (because of severe impacts of their mental
illness) to be able to live in a less supportive community placement.
Staff of a CCU are not authorised to give involuntary treatment. For example, a patient may not be
detained within a CCU, nor secluded or given treatment by force. Once a person is placed in a CCU,
they are essentially on full community LCT.
The Tribunal’s LCT decision must appropriately reflect the status of the CCU as separate from the
AMHS, and as in all cases, uphold the basic principle of least restriction on rights and liberty.
Terminology that is used in relation to inpatient services within the AMHS is not relevant to a CCU.
For example, patients are residents of the CCU and are allowed to come and go, have their own
belongings there, have friends visit, stay away overnight if they choose, prepare their own food etc.
Hospital care notions of detention and escorted and unescorted leave are not applicable for a patient
in a CCU.
If the Tribunal seeks to impose restriction on the movements of a patient in a CCU for the purposes of
managing unacceptable risk, this may be done in terms of describing the circumstances under which
the patient may be absent from the unit, or the level of supervision (e.g. by a staff member or other
responsible adult) that is required during such absence.
The conditions must be stated in such a way that the LCT is being approved from the AMHS for the
patient to reside in their own home (albeit that the person’s home in this case is an “inpatient” facility of
a health service). The patient should understand the status of the unit where they are to reside and the
boundaries of the authority of staff within the unit, and that their LCT is from the AMHS inpatient unit,
and not from the CCU. Nothing in the LCT conditions should imply that CCU staff has authority to
detain the patient at the facility. The conditions of the LCT should also not be inconsistent with any
“rules” or behavioural contract that the patient has agreed to in relation to tenure in the CCU.
14. LCT in Relation to Patients who have Moved out of Queensland
Where a patient is granted approval to move out of Queensland under section 173 of the MHA2000,
the FO or ITO continues in Queensland, to come into effect if the patient returns to Queensland. For a
forensic patient, the Tribunal will continue to periodically review the order, and where the FO is
confirmed upon the review, the Tribunal must decide whether to approve LCT.
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Where it is necessary for the patient to have available to them an LCT regime to be in effect upon their
return, the Tribunal should put in place relevant arrangements. This prevents the patient being subject
to being absent without authority or having to be readmitted to hospital until such time as a Tribunal
review can be arranged. If there are no suitable arrangements that can be made (for example, the
patient has an intellectual disability and would require assistance to find a suitable place of residence)
then it may be appropriate to make no LCT order in this case so that the patient is required to attend
an AMHS upon their return.
The LCT decision is only effective within Queensland. Where the patient is moving out of Queensland
the Tribunal does not have power to frame the conditions of LCT in such a way as to impose
requirements on interstate authorities (for example, make LCT conditional upon a mental health
service in another state providing involuntary mental health treatment). The arrangements for the
patient in the other state should be considered in relation to the application to move, and not in relation
to LCT (refer guidelines for interstate moves).
15. Temporary Absence outside Queensland
A forensic patient may need to be temporarily absent from Queensland (for example for holiday, family
or work-related reasons). There is no provision that precludes an involuntary patient from travelling
outside the State, although the Tribunal could restrict travel interstate and/or overseas as a special
condition of LCT if that were appropriate, for example, where a temporary absence outside
Queensland would represent an unacceptable risk.
Where the Tribunal has approved full community LCT at the discretion of the treating psychiatrist,
there is no specific need for the matter to come back before the Tribunal when a patient wants to be
temporarily absent. The treating psychiatrist may exercise his/her discretion regarding the place where
the patient resides, to allow a temporary absence from the usual place of residence, having regard to
all the other conditions of the LCT and being satisfied that by allowing the patient to be absent, the
LCT and the patient’s treatment generally will not be compromised. In the exercise of discretion, the
treating psychiatrist is taking responsibility for the judgement that the patient will comply with the
conditions of the LCT and will return to Queensland for continuing treatment.
Where the matter is specifically brought before the Tribunal, an important issue for the Tribunal to
consider is whether such an approval will disrupt the patient’s involuntary treatment. For example, will
the person require treatment while they are away? How will the treatment be provided? If they do need
to receive treatment in the other place, will the patient obtain treatment on a voluntary basis? How
stable is the person’s mental condition? What is the risk that the patient’s condition will deteriorate
while he/she is away? What is proposed if this should occur?
LCT can only be managed from within Queensland. If the patient deteriorates in their mental condition
while temporarily out of Queensland, there is no mechanism available to return the patient to
Queensland, unless there is a Forensic Apprehension and Return Agreement in place in that relevant
state.
Therefore, if an approval is to be given by the Tribunal it must be with certainty that a temporary
absence will not represent an unacceptable risk, and will not cut across the patient’s treatment. If a
Tribunal, in approving LCT at the discretion of the treating psychiatrist, considers that such discretion
should not extend so far as to allow the patient temporary absence from Queensland, conditions
should be framed in such a way as to specifically exclude the possibility of a temporary absence.
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16. Limited Community Treatment and Classified Patients
LCT for a classified patient may only be with the written approval of the Director of Mental Health
(MHA2000 section 129(2)(b) - refer to the Classified Patient Guidelines). Ordinarily the Tribunal would
not consider LCT in relation to a classified patient, unless the classified patient is also under a FO.
The patient may be on full community LCT and is remanded in relation to a new charge, then
subsequently is transferred to an AMHS as a classified patient. Then the existing LCT decision of the
Tribunal may only be given effect to the extent that the Director‘s approval is not more restrictive than
the Tribunal’s. Otherwise, the more restrictive conditions will apply.
Upon review of the FO for a forensic patient who is also a classified patient, if the Tribunal confirms
the FO the Tribunal must consider LCT. Any LCT decision of the Tribunal will in effect be subject to
the Director’s concurrence. If the Tribunal makes no order for LCT the patient will have no LCT even if
the Director approves it. Further, if the patient’s classified status ends in a way that means the patient
is no longer subject to custody (for example expiry of sentence or granting of parole; granting bail or
discontinuation of prosecution) the patient will be detained at the AMHS until such time as a review
can be scheduled. The preferable approach is that the Tribunal makes a LCT decision in appropriate
cases, that can be given effect with the concurrence of the Director or when the classified status ends.
This provides greater flexibility for the AMHS to manage the patient in the least restrictive manner, and
prevents the need for urgent review when a person ceases to be a classified patient. Appropriate
wording should be incorporated in the LCT approval conditions to recognise that authorisation of the
LCT while the patient is a classified patient will be subject also to the approval of the Director of
Mental Health.
17. Limited Community Treatment for Patients on Multiple Forensic Orders
Under section 203(5) of the MHA2000 if two (2) or more FOs for the patient is being reviewed, the
Tribunal must make one decision that applies to all of the FOs.
If a FO is made by the Mental Health Court in relation to a patient for whom a FO was already in
place, to the extent that there is any inconsistency between the FOs (for example, the conditions of
LCT differ), the new FO prevails over the old FO (section 288A).
18. Caution in the Use of a Condition Imposing Non-Contact
It might be reasonable from time to time to include a condition preventing the patient from having
contact of any kind with another person, where contact is known to represent a risk to the safety of
that person (for example, a victim of an offence committed by a forensic patient; a family member
where there is a history of violence in the relationship). The Tribunal should first consider whether the
patient is likely to come into contact with the person.
For example, where non-contact is being considered in relation to a victim of an offence, does the
patient know the identity of the victim and where the victim is to be contacted? The condition will not
be meaningful if the patient does not know the victim and is unlikely to come into contact with the
person or seek out contact. Naming the victim in an order when the patient was not previously aware
of their identity may even be detrimental.
Where a non-contact condition is to be made, it will be necessary to name the person specifically (in
preference to stating non-contact with “the victim of the index offence” for example) so that the LCT
conditions can be administered by the mental health service and the patient is clear as to whom the
condition refers.
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If the person is named, the Tribunal will then need to consider the privacy implications for the named
person. For example, how the person can be made aware that they are so named, and that the
information will be held by certain recipients of the decision. This is not an issue where the person is
subject to a Forensic Information Information Order and can be advised of the decision.
It is anticipated that the use of non-contact conditions will occur infrequently and only in cases where
such a condition is necessary to protect the safety of the person.
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