9.4 Visits by Children to Psychiatric Wards, to High Security Psychiatric Hospitals and to Medium Secure Units
- General Principles
- Visiting Patients in Psychiatric Wards
- Visiting High Security Psychiatric Hospitals – Ashworth, Broadmoor and Rampton
- Visiting Medium Secure Hospitals
This chapter sets out the procedures for managing risks and safeguarding the wellbeing of children and young people, who may be visiting or having contact with adults or other young people who are in a psychiatric ward or high security psychiatric hospital.
The legislation and guidance that relate to this procedure are:
- Directions under Section 17 of the National Health Service Act are set out in HSC1999/160 as amended by LAC 2000 (18). These refer specifically to visits to Ashworth, Broadmoor and Rampton Hospitals;
- The revised Mental Health Act Code of Practice 1999 (26.3), which gives guidance on the visiting of psychiatric patients by children. It states that Hospitals should have written policies on the arrangements about the visiting of patients by children, which should be drawn up in consultation with Children’s Specialist Services. A visit by a child should only take place following a decision that such a visit would be in the child’s best interests. Decisions to allow such visits should be regularly reviewed. HSC 1999/222: LAC (99) 32 which contains guidance to Health and Children’s Social Care on the visiting of psychiatric patients by children.
- General Principles
- Safe and regular contact for children should be promoted with patients in psychiatric facilities, whenever it is appropriate to maintain relationships which are of importance to the child;
- The child’s interests must remain paramount and take precedence over the interests of the adults involved when decisions are made about whether visits are appropriate;
- Any risks to the child should be identified and managed. These may be from the patient or from the environment in which visiting will take place;
- High security hospitals contain detained patients who are considered very disturbed and should be seen as potentially dangerous. Patients may remain in the setting for considerable periods of time. The setting is also potentially frightening for a child. Specific procedures guide professionals considering visits by children in these circumstances (see Section 3, Visiting Patients in Psychiatric Wards).
- Visiting Patients in Psychiatric Wards
When children visit adult patients, all psychiatric in-patient settings should:
- Place child welfare at the heart of professional practice for all staff involved in the assessment, treatment and care of patients;
- Take account of the needs and wishes of children as well as patients;
- Consider the issue of contact visits throughout the whole process, including preadmission assessment, admission, care planning, discharge and after care;
- Assess the desirability of contact between the child and patient, identify concerns and assess the potential risks of harm to the child in a timely manner;
- Establish an efficient procedure for dealing with requests for child visits in those cases where concerns exist;
- Establish a process for child visits which is:
- Not bureaucratic;
- Supportive of both the child and the adult;
- Does not cause delay in arranging contact;
- Maximises the therapeutic value of the visit; and
- Ensures the child’s welfare is safeguarded.
- Set and maintain standards for the provision of facilities for child visiting;
- Ensure that staff are competent to manage the process of child visiting.
3.1 Pre-Visit Arrangements
When a compulsory admission is planned for an adult who is a parent, the approved mental health professional must assess the children’s needs and the suitability of arrangements for their care. If there are any concerns, Children’s Specialist Services for the area where the child lives should undertake an assessment and make recommendations to the hospital about the children visiting and present the views of those with Parental Responsibility about the child visiting.
When a patient has been admitted informally, nursing staff should seek out information about children who may be visiting. If there is a Children’s Specialist Services worker or an adult mental health care coordinator involved, the nursing staff must discuss the arrangements for any child visiting. This discussion must be clearly recorded.
Where the ward manager has concerns about visiting arrangements but there is no social worker involved, the ward manager must request that Children’s Specialist Services for the area where the child lives undertake an assessment in order to determine whether it is in the best interests of the child for a visit to take place and to make recommendations to the hospital about the suitability of the child visiting.
Where Children’s Specialist Services have been asked to undertake an assessment, their report should be sent back within one month of receipt of the written request/referral from the ward manager in order to avoid delay in arrangements for the child.
3.2 The Decision about Visits
The ward manager is responsible for the decision to allow a visit by a child.
When a visit by a child is expected, the ward manager should consider the available information about the child alongside the assessment of the patient’s needs for treatment and care and of the current state of the patient’s mental health. The ward manager should make the decision in consultation with other members of the multi- disciplinary hospital team.
The ward manager must make their decision on the basis of the interests of the child being paramount.
Where a child visits unexpectedly, the visit may be refused if it is not feasible to make a proper assessment while they wait.
A decision to refuse or prohibit visiting by a child may be taken by the ward manager if they have reason to believe that it is not in the child’s or patient’s best interest for visits to take place.
Decisions to refuse visits should be given verbally and confirmed in writing and must be supported by clear evidence of concern and the difficulties of managing them.
The decision must be communicated to the patient, the child and those with Parental Responsibility.
Information about procedures to review any decision or to make representations about what has been decided must be made available; including access to assistance and independent advocacy.
3.3 The Arrangements for Visits
The hospital or mental health trust providing the service must ensure that the facilities for contact are conducive to the child’s safety and promotes good quality contact for both child and patient.
Children should have appropriate supervision when they are visiting mental health service users. They should normally be accompanied by someone who has Parental Responsibility.
In some cases it may be better for visiting to take place away from the hospital. In the case of detained patients, this will require due consideration of the need for leave. Staff must be aware of protection and child welfare issues in granting leave of absence under Section 17 of the Mental Health Act 1983.
- Visiting High Security Psychiatric Hospitals – Ashworth, Broadmoor and Rampton
4.1 Key Points
Assessments by the local authority will be carried out in response to a hospital request for a child visit.
The assessment must state whether it is in the child’s best interest to visit a patient and should be conveyed in writing to the hospital within one month of receiving the referral letter from the hospital.
The hospital authority must nominate a senior manager to manage the request and decide if a visit is to be approved or not. The senior manager must take account of the advice of Children’s Specialist Services where the child resides.
The request for a child to visit must be in respect of a child within the permitted categories of relationship as set out in the Directions and associated guidance to Ashworth, Broadmoor and Rampton Hospital Authorities (HSC 1999/160 as amended by LAC 2000 (18)), that is:
- The patient is a parent or relative of the child; or
- He/she has parental responsibility for the child; or
- He/she was cohabiting with the parent of the child immediately prior to their detention under the Mental Health Act (1983) and the child was treated as a member of the household.
Hospital staff may not allow a visit to any patient in hospital unless the nominated senior manager has approved the visit and, in particular, is satisfied that the visit is in the child’s best interest.
The only exception is where there is a Contact Order made under the Children Act 1989, which specifies that the child may visit the patient in the high security hospital. In such cases, visits should be allowed except where there are concerns about the patient’s mental state at the time of the proposed visit, such that the nominated officer decides the visit would not be in the child’s best interest.
Assessments will be conducted under Section 17 of the Children’s Act (1989) or Section 47 where appropriate.
Assessment will be conducted speedily and be concluded within one month of request of referral letter from the hospital.
Children’s Social Care will only receive requests for an assessment once the nominated officer to the hospital considers that there is a case for considering a visit by a child.
4.2 The Request for a Visit
The Directions impose a duty on the Hospital to appoint a nominated officer to consider a request by a patient for a child to visit. The nominated manager should determine whether the child is within the permitted categories of relationship.
The nominated officer must arrange for the patient’s clinical team to carry out an assessment as to whether, in their view, it would be appropriate for the visit to take place having regard to the patient’s offending history (if any), their clinical history and present mental state and in the event a visit is recommended, any particular arrangements which would need to be made for a visit by that child to take place safely.
If these conditions are met, the nominated officer should obtain written permission from the patient to contact those with Parental Responsibility for the child. The nominated officer designated by the hospital authority is responsible for contacting those with Parental Responsibility for the child explaining the request for a visit.
Those with Parental Responsibility should be asked to confirm the relationship between the patient and the child and to state whether they agree or not to the child visiting. The nominated officer is then required to contact Children’s Social Care for advice as to whether a visit is in the child’s best interests.
If more than one person has Parental Responsibility, it is the person with Parental Responsibility with whom the child lives who is required to give consent.
Those with Parental Responsibility should also be asked to decide who will accompany the child on a visit. If not the parent with Parental Responsibility, this should be a parent or a relative who knows the child well and is able to ensure the child’s safety and wellbeing during and after the visits.
Where the child lives with someone who does not have Parental Responsibility for him or her (for example a grandparent), the nominated manager should write to the child’s carer explaining that a request for a visit has been made and that the person with Parental Responsibility will be contacted.
If the person with Parental Responsibility responds to the nominated officer stating they do not agree to the visit, the nominated officer must refuse the visit. The decisions and the reasons for the decision must be put in writing to the patient by the nominated officer to the patient and if appropriate the child.
If a child is Looked After and is subject to a Care Order, Children’s Specialist Services has responsibility for providing consent but the decision should be taken following consultation with those others who also have Parental Responsibility.
4.3 Action by Nominated Officer to consider a Visit
If the previous steps have been taken and the hospital’s assessment of risk of harm posed by the patient to the child does not rule out a visit, the nominated officer must:
- Contact the Head of Children’s Specialist Services where the child resides to request advice on whether the visit is in the child’s best interest;
- Include in the request a copy of the hospital’s assessment and any other relevant information about the patient, to assist Children’s Specialist Services to carry out the assessment;
- Include in the request any information about other local authorities which have relevant information about the child and the family;
- Inform the parents that Children’s Specialist Services have been asked to make contact with them.
All requests from the hospitals should be sent to the Safeguarding Unit.
4.4 Children’s Specialist Services Responsibilities
The Children’s Specialist Services branch where the child resides, will be expected to respond to the assessment request if the child is:
- Looked after by the Local Authority; or
- A child in need and being provided with Part III Services; or
- The Subject of a Child Protection Plan or has been the subject of Section 47 Enquiries; or
- A closed case but known to Children’s Specialist Services as being formerly Looked After, having had a Child Protection Plan or having been provided with services under Part III (Section 17) of the Children Act (1989).
If a child was not known previously to Children’s Specialist Services, and the person(s) with Parental Responsibility has indicated they will cooperate with the assessment, Children’s Specialist Services should consider this as a request under section 17.
However if the parent requesting a visit is a sex offender or, poses a risk of Significant Harm, Children’s Specialist Services should conduct a risk assessment under section 47 of the Children Act (1989).
If the person with Parental Responsibility refuses to co-operate with the Children’s Specialist Services assessment, and Children’s Specialist Services believes it has the statutory powers to undertake the assessment, advice must be sought from the legal department, on the most appropriate way of conducting this assessment.
If Children’s Specialist Services concludes that a visit is not in the child’s interest, the nominated officer must be notified and a visit will not be permitted.
4.5 Looked After Children
Where a child is Looked After by the Local Authority and subject to a Care Order, Children’s Specialist Services has the responsibility for providing consent but their decision should be taken following consultation with those with Parental Responsibility.
The Local Authority should also decide, following consultation with those with Parental Responsibility, who will accompany the child. It may be a parent or relative, a foster parent, or employee of the Local Authority who knows the child and is able to ensure their safety and wellbeing during and after the visits.
Where a child is Looked After but not subject to a Care Order, the person with Parental Responsibility is required to give their consent. The person with Parental Responsibility should decide, with Local Authority consent, who may accompany the child. It may be a parent, relative, foster parent, or employee who knows the child well and is able to ensure their safety and wellbeing during and after the visits.
4.6 The Assessment Process
All requests from the hospitals should be sent to the Quality Assurance Service Manager, Safeguarding Unit. If the request has not proceeded through this route the Service Manager should be notified immediately. On receipt of the request from the hospital the Safeguarding Service Manager will:
- Evaluate the information;
- Check any information across electronic and manual records held by the Children’s Specialist Services to see if the child is known;
- Contact the relevant Children’s Social Care team who nominate a key social worker to contact those with Parental Responsibility, to undertake the assessment and to prepare a report for the nominated officer at the hospital.
The assessment must establish, within one month:
- The child’s legal relationship to the named patient;
- The quality of the relationship currently and prior to hospitalization;
- Whether there has been past, alleged or confirmed abuse of the child by the patient;
- Future risks of Significant Harm if the visit took place;
- The child’s view of a visit, taking into account age and understanding;
- The view of those with Parental Responsibility and those with day to day care for the child;
- Background information in respect of the family;
- The frequency of contact that would, if at all, be appropriate;
- Whether the visit would be in the child’s best interests;
- Views of other professionals who may have contact with the child;
- Details as to who will accompany the child and the nature and quality of their relationship with the child.
The report must be concluded with a recommendation based on the above indicating whether a visit should take place, the frequency and duration of such proposed visit. The report should be sent to the Quality Assurance Service Manager at the Safeguarding Unit who will be responsible for assessing and monitoring this procedure and who will consider whether recommendations are consistent with overall protection of the child.
The report must be provided for the QA Service Manager within 25 days of the request being received from the hospital which will allow for an agreed response within 28 days of receipt of the initial request.
4.7 The Decision
The completed assessment report must be sent within a month to the nominated officer at the hospital, who will discuss the recommendations with Children’s Specialist Services and make a decision about the visit taking into account any potential risk posed by the patient and the potential risk of Significant Harm being suffered by the child.
The decision should take account of:
- The nature (for example, quality and duration) of the child’s attachment to the patient;
- Past abuse and/or risk of Significant Harm to the child from the named patient;
- The views of the child, taking account of his age and understanding, and of those with Parental Responsibility and, if different, those with day to day care for the child;
- The opinions of professionals who have knowledge of the child;
- The hospital assessment.
A clear judgement should be made whether the visit is, overall, in the child’s best interests and if so, the frequency of contact that would be appropriate
The suitability of the adult or adults who are to accompany the child on a hospital visit should also be considered.
4.8 The Visit
Where visits are agreed, the hospital remains responsible for maintaining an overview of the risks, which may vary according to the health of the patient, other environmental factors and the impact on the child if visiting is allowed. This may involve further liaison with Children’s Specialist Services.
All visits must be properly supervised and all unauthorised contacts are to be prevented.
No children are to visit on ward areas.
The nominated officer must ensure that a child’s contact with a patient within the hospital takes place at a frequency which is in the child’s best interest.
All visits by children shall be specifically authorised by the nominated officer and clear records must be kept.
4.9 Duration of Approval
Any approval for a visit is valid for a period of 12 months from the date on which it is given and may only be withdrawn in that period if the nominated officer is satisfied that there has been a relevant change of circumstances. If the period of 12 months has elapsed and the patient wishes to continue to have visits, the nominated officer must review the permission in accordance with their responsibilities.
4.10 Refusing a Visit
There are five circumstances in which the nominated officer must refuse to allow a child to visit.
These are if:
- The relationship between the child and the patient is not within the permitted categories of relationship as set out in the Directions. The nominated officer must notify the patient of the decision and reasons for it in writing. However the patient has no right to make representations against this decision;
- The person/s with Parental Responsibility responds to the nominated officer stating that they do not agree to the child visiting the patient. The decision and the reasons for the decision must be put in writing to the patient;
- The hospital’s assessment indicates that the patient’s mental health state and /or risk to children is such (in the immediate or longer term) that it would not be appropriate for the child to visit the patient. The decision to refuse the visit must be put in writing to the patient and the person with Parental Responsibility and include details of the complaints procedure;
- The relevant Children’s Specialist Services concludes that a visit is not or may not be in the child’s best interests. The decision to refuse the visit must be put in writing to the patient, the child (if appropriate), those with Parental Responsibility, person/s with day-to-day care of the child if different and Children’s Specialist Services. Details of the review procedure should be given;
- There are concerns about the patient’s mental state at the time of the visit. The reasons for the refusal should be explained to the patient, those with Parental Responsibility, person/s with day to day care of the child, if different, and, if appropriate, the child.
4.11 Monitoring the Process
When there are active arrangements for Wirral children visiting patients in a high-security hospital, the Safeguarding Service Manager will maintain contact with the relevant nominated manager in hospital to monitor the progress of the contact plan. A record of discussions between the two managers should be made in the child’s electronic file. The Safeguarding Service Manager should, in addition, provide a brief report to the LSCB annually when the arrangements are current or have been active in the preceding 12 months.
- Visiting Medium Secure Hospitals
Medium secure hospitals have patients who are detained under the Mental Health Act who are significantly disturbed and may be in hospital for lengthier periods of time, often in excess of a year. The process for agreeing visits operates with a similar degree of formality as those for high-security hospitals.
Medium secure units also have a nominated officer who administers all requests for children to visit. Where the hospital clinical team concludes, from its own assessments, that a visit is not in the interests of the child, the visit is refused.
Where the hospital clinical team supports the application for a child to visit, a specific member of the clinical team, usually the forensic social worker, will liaise with Children’s Specialist Services which has responsibility for the child if the child is Looked After or Children’s Specialist Services for the area in which the child resides.
The written request from the hospital will ask whether the local authority has information which would suggest that a visit to the named patient would be against the best interests of the child.
Any subsequent assessment carried out by Children’s Specialist Services should cover the same considerations as outlined above in relation to high security hospitals.
Where the conclusion of the assessment by Children’s Specialist Services is that the visit is not in the best interests of the child, then the visit will not be allowed. It is the social worker’s responsibility to advise the child and family. The hospital will advise the patient.
If visiting is agreed, it remains the responsibility of the clinical team to oversee that the visit remains safe and appropriate for the child, and to take action if the assessment of risk changes. Previous risk assessments from other institutions may not take account of changes in the patient’s current risk assessment and/or a child’s current circumstances.
It is the nominated officer who authorises visits when the assessments have been completed and who will ensure that the child’s best interests will remain paramount.
All medium secure units will have systems in place to oversee that visits by a child are conducted in a safe and appropriate environment and that there are records maintained of all visits. This will include a record of the patient’s behaviour, any problems which occurred, any concerns regarding the behaviour of the parent and the response of the child.
The decision to refuse visits to children in these facilities should be a rare exception and one which identifies clear risk to the child, either physically or emotionally, which would negate the value of the visit for the child.