COVID-19: Secure hospital and criminal justice settings

RCPsych, RCN, NHS England and Unite's Mental Health Nurses Association worked to develop this guidance for healthcare professionals working in low, medium and high secure hospital services, as well as those providing mental health in-reach services for prisoners and services to the courts or other agencies within the Criminal Justice System.

NHS England has published guidance on Prison transfers and remissions to and from mental health inpatient hospitals in relation to COVID-19 (28 April)

Secure hospital services in many areas will be able to draw upon general and mental health specific guidance, included those provided by the College, in terms of how it responds to COVID-19. However, secure hospitals (and especially so in high secure environments), there may need to be different approaches adopted in certain situations.

This section seeks to help services in responding appropriately.

It should be noted that safety advice and guidance in relation to COVID-19 is evolving all the time. Wherever decisions have to be taken that mean that significant extra restrictions have to be applied, every effort must be made to discuss these with at least one appropriately experienced colleague before continuing them beyond a few days, and the outcome of such discussion documented.

Secure hospitals

In prioritising services that must continue, the organisation must pay due regard to legal duties and also balance the impact of decisions on patient care against the risks associated with COVID-19. Please see further details in our COVID-19 ethical considerations page. NHS England/Improvement has published Legal guidance for mental health, learning disability and autism, and specialised commissioning services supporting people of all ages during the coronavirus pandemic

Staff must ensure that patients and their families have as much accurate, accessible information as possible about COVID-19 and are engaged as much as they can be with staff in providing the safest possible services.

Patients who test positive should be isolated. As far as possible this should be with the patient’s agreement and cooperation. If a patient lacks the capacity to understand the need for isolation, or declines to comply, then isolation may need to be enforced in the broader best interests of the patient as well as others. This is likely to be under the Common Law doctrine of necessity. The patient will require regular medical reviews whilst in isolation.

Please refer to guidance from National Association of Psychiatric Intensive Care & Low Secure Units on Managing acute disturbance in the context of COVID-19.

Every secure hospital setting should have a simple social distancing policy in place which is compliant with public health guidance and preferably drafted with the knowledge and acceptance of the patients and preferably co produced.

In secure forensic hospital settings the responsible clinician (or deputy) should ensure that there is a review of each patient’s pre-existing physical health vulnerability and consider any particular vulnerabilities for the circumstances as a result of their mental disorder. This will help to make patient level decisions when required. An example of the risk assessment is as follows:

  • Refer to national guidance on shielding and protecting people defined on medical grounds as extremely vulnerable from COVID-19.
  • Refer to the updates on the changed processes of the Mental Health Casework Section in response to COVID
  • Does the patient have an underlying physical illness or anything causing them to be immunocompromised? If so, there should be a clear plan in place to provide extra protections and contingencies for that patient as far as possible.
  • If the patient’s discharge were pending, is it still safe to send them home, taking account of the risks of covid-19 being in the secure hospital setting and risks of transmitting this at home/next placement and the potential risks of the next placement to the patient. If there is to be any deferral of discharge, this will have to be discussed sensitively with the patient and their family or significant others.
  • If a patient’s discharge were not pending, is there any case for bringing this forward? This is unlikely, but should be formally considered in the interests of everyone’s physical health safety
  • Should the patient require isolating, to what extent will s/he be able to cooperate voluntarily? What measures are in place to ensure cooperation for the few cases where there are difficulties in this respect?
  • Is the patient on clozapine? What is the frequency of blood tests? When is the next one due? Which service can do clozapine blood tests in house?
  • Can the patient have visits with family by Skype or by other interactive media? Can patients make free (or cheap) phone calls to family and friends? Where such communication possibilities do not exist, units must prioritise setting up facilities for such communication as soon as basic safety precautions have been implemented.
  • It is really important that patients continue to have activities to occupy and divert them, and to stay fit or improve their physical fitness. It is unlikely that off-ward activities like OT can continue, but, as far as possible, occupational therapists should ensure an on-ward activity plan is available for each patient, which includes minimisation of any interpersonal interactions. Access to secure gardens must be planned to be compliant with public health guidance.
  • All leave outside the secure perimeter must be reviewed with each patient who already has permissions for this in place, and a new plan formulated to ensure patient and unit safety. Any decisions about leave will need to be taken based on latest government advice at the time and analysis of benefits and risks for that individual patient’s recover. Please also refer to the guidance on this provided on the section on patient leave here.

Patient isolation because of COVID-19

Services should ensure they have made adequate arrangements in place to isolate patients where necessary because of covid-19 infection or suspected infection

Screening

All units should have access to COVID-19 testing on demand (if tests are available) and there should be testing for patients who are presenting with symptoms now

Protection

  • Patients who test positive should be isolated. As far as possible this should be with the patient’s agreement and cooperation. Those who do not comply with isolation should be secluded and the seclusion pathway be followed.
  • Consideration should be given at that stage to what that means for the need for additional staffing on the relevant ward to reflect the need to care for both the isolated patient and those who remain on the ward.
  • Any approach to staffing needs to be seen as a system wide prioritisation exercise. Secure services with need to be high priority and therefore in some situations be able to call on staff from outside their own services if there are significant workforce pressures. This will need to for part of organisation-wide contingency planning.
  • Pretension and Management of Violence Physical Training, may need to be adapted to include social distancing where possible.
  • Staff should ensure that they have access to and use appropriate PPE. (PDF)
  • Where patients in isolation show signs of deterioration, an urgent medical review should be undertaken to establish whether additional treatment support is needed
  • If additional medical support is needed and it is deemed safe to transfer them to a general hospital setting, this should be done via the normal 999 arrangements in place for COVID-19 referrals.
  • If additional medical support is required but the patient’s mental health condition means they are not deemed suitable for treatment within a general hospital setting, arrangements, including appropriate ventilation if needed, should be put in place. Where this happens, Aerosol Generating Procedure (AGP) is likely to be necessary

As of April 2019, the Ministry of Justice decided to provide all responsible clinicians at any hospital with general consent to exercise their power to grant leave for medical treatment. (PDF) The terms of this consent differ, depending on the type of patient (whether the patient is a transferred prisoner or whether they have been diverted to hospital for treatment by way of a hospital order).

This does not apply to those restricted patients that the Mental Health Casework Section (MHCS) has classified as “high profile” cases.

Please note that this does not change the arrangements in relation for emergency medical leave, which responsible clinicians may continue to use at their discretion for any restricted patient, as necessary.

For further information on this, please refer to the letter from the Ministry of Justice to all hospitals detaining Restricted Patients. (PDF)

Managing behavioural crises

The nature of the secure hospital unit population is that, from time to time, a particularly distressed patient may threaten or enact violence towards themselves or others and staff must intervene. New protocols must be drawn up in each unit (or hospital0 for the possibility that patients who are infected with covid-19 who may require physical restraint.

Plans must be in place to manage such eventualities as safely as possible.

Although all secure hospital units should be provided with personal protective equipment for this eventuality, it is already clear that supplies are slow reaching hospitals. Plans must therefore take account of this with guidance on interim protection and cleaning arrangements.

Staff will need to plan for how the practice of safe control and restraint will be affected when wearing protective clothing – interim or purpose designed. It is likely that such gear will restrict movement and could even create dangers in restraint situations. Staff should practice with each other to test out the changed situation. Plans should be agreed at the hospital, trust or the unit’s clinical reference group (or similar) as part of contingency planning.

General management responsibilities

Plans must be in place for the eventuality of staffing falling below safe levels. These may include:

  • Movement of staff within and between units; when doing this, competencies of the staff coming in needs to be considered
  • Role sharing between disciplines
  • Confinement of patients in their rooms for periods of time when staffing is at its lowest
  • Withdrawal of non-essential activities
  • Consider medical or psychiatric emergency response teams

Ensure continuing supply of food, fluids and essentials during the pandemic period.

Staff should continue to offer re-assurance and engagement with to patients during any interaction (while working with social distancing).

Wherever more restrictive practices are introduced, it must be explicit that they are to cover only the period of crisis secondary to the pandemic and to ensure that the unit can comply with good public health principles, and must be reduced and abolished as soon as conditions allow.

Patients and their relatives must be kept informed of all restrictive practices and the reasons for them.

NHS England/Improvement has published Legal guidance for mental health, learning disability and autism, and specialised commissioning services supporting people of all ages during the coronavirus pandemic (PDF) (30 March) which includes specific considerations for mental health services and the criminal justice system including restraint and restrictive practice.

 

Legal responsibilities

All patients in secure hospital units will be subject to detention under mental health legislation and most patients in other closed units or units with restricted egress will be under some kind of legislative containment.

It is important that such patients have their legal rights respected throughout the crisis.

It should be noted that the emergency Coronavirus legislation makes changes to UK mental health legislation, including that which covers secure care.

These changes have not yet been enacted, however information on the emergency changes is available here. These pages will be updated as soon as changes are made. All units should be aware of the changes which apply and help ensure that patients are aware of these too.

It should also be noted that the operation of Mental Health Tribunals will be changed for a period of 6 months (starting March 23rd 2020) meaning that pre-hearing examinations will no longer be carried out and that where possible hearings will be carried out by a single judge. Further information on these changes is available here:

Services in prisons

Prisons are run by HM Prisons and Probation Service and, as such, not their management not the responsibility of healthcare staff. Healthcare staff do, however, have a responsibility to advise and to protect themselves and others as far as possible within such a framework.

COVID-19: prisons and other prescribed places of detention guidance states that any prisoner or detainee with a new, continuous cough or a high temperature should be placed in protective isolation for 7 days.

Prisoners or detainees who have a new, continuous cough or a high temperature but are clinically well enough to remain in prison or prescribed places of detention (PPDs) do not need to be transferred to hospital. Regular observations are not required unless indicated for other clinical reasons.

Suspected cases of coronavirus (COVID-19) should be notified by prison or immigration removal centre (IRC) healthcare teams as soon as possible to local Public Health England (PHE) Health Protection Teams (HPT)

People who are severely unwell must be transferred to appropriate healthcare facilities according to need, but it is the prison’s responsibility to organise escorts and follow advice on safe transfers

In-reach mental health staff follow PPE guidance for mental health: (PDF)

  • Guidance on PPE for staff and managers, including a helpline number to request supplies and training resources, is here.
  • All clinical mental health, learning disability and autism staff are to be bare below the elbow, with hair tied back, wearing no false nails, jewellery etc.
  • For treating a patient with suspected or confirmed COVID-19 symptoms – a fluid resistant surgical mask (FRSM) and apron and gloves must be worn when working in close contact (within 2 metres) of a patient with COVID-19 symptoms
  • In-reach mental health staff should encourage prisons to facilitate remote consultations with patients.

In-reach mental health staff should check with the prison governor that there is a plan in place for identifying an appropriate place to isolate patients with symptoms, preferably with input from an infection control specialist and to ensure that current infection prevention and control practices have been reviewed to ensure they follow national infection prevention and control guidance for PPDs.

HPTs will contact PHE’s National Health and Justice Team and Centre Health and Justice leads in response to cases in prisons and PPDs. The HPT and the National Health and Justice Team will decide whether to declare a formal incident and respond accordingly. This will support efforts across organisations to achieve infection prevention and control following the national contingency plan for outbreaks in PPD (PDF).

Court Liaison and Diversion Services

Almost all courts in the UK have access to mental health liaison and diversion services. These may become particularly important as courts strive to lower rates of new imprisonment. As most cases referred are likely to be unknown to the mental health services standard NHS guidance on personal protection of health workers as applied in A&E departments should apply.

Healthcare staff seeing people in this context should ensure that they and all relevant court staff have the most up-to-date accurate information on virus management in such circumstances.

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