PG37. Psychiatric Ward Visits

1.1

Visits by children to psychiatric wards or hospitals should be undertaken to maintain a positive relationship for the child with the patient, who will usually be their parent or more rarely a family member such as a sibling. A visit by a child should only take place if it is in their best interest, which 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.

1.2

When a child visits a psychiatric ward or hospital, they could suffer significant harm through physical, sexual and/or emotional harm (see Recognising Abuse and Neglect Procedure).

1.3

This section applies to children visiting all patients receiving in-patient treatment and care from specialist psychiatric services, whether or not they are detained under the Mental Health Act 1983. This includes children visiting detained adolescent patients and adolescents who are being cared for in adult facilities.

2.1

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;
• Address the whole process, including preadmission assessment, admission, care planning, discharge and aftercare;
• 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 way;
• 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;
  • 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 visits.

2.2

See the legislation and guidance that relate to children's visits:

The revised Mental Health Act Code of Practice January 2015 chapter 11 (implemented April 2015), 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 Social Care 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.

• [Local Authority Circular LAC(99)23] refers to the specific tasks to be undertaken by local social service authorities in receipt of a request from the hospital for advice on whether it is in the best interests of a child to visit a named patient. Local Authority [Circular LAC (2000)18] refers to who can accompany a child on a visit to a named patient. It is issued as statutory guidance under section 7 of the Local Authority Social Services Act 1970;
• The High Security Psychiatric Services (Arrangements for Safety and Security) Directions, 2013;
• The High Security Psychiatric Services (Arrangements for Visits by Children) Directions. 2013.

Compulsory admission

3.1

When a compulsory admission is planned for an adult who is a parent, the approved mental health professional must assess the child/ren's needs and the suitability of arrangements for their care. If there are concerns (see Mental Illness (Parenting Capacity) Procedure) about the safety or care arrangements of the child/ren, the approved mental health professional must request that local authority children's social care undertakes an assessment (see Referral and Assessment Procedure). Local authority children's social care should make a recommendation to the hospital about the suitability of the children visiting their parent.

3.2

The approved mental health professional should, wherever possible, provide the hospital with the child/ren's assessment information. This may, as appropriate, include the recommendation made by local authority children's social care when the patient was admitted, together with the views of those with parental responsibility about the child/ren visiting the patient in hospital.

Expected visit by a child

3.3

The ward manager/nurse in charge is responsible for the decision to allow a visit by a child. When a visit by a child is expected, the ward manager/nurse in charge should consider the available information about the child (as outlined in Pre-visit Arrangements), alongside the assessment of the patient's needs for treatment and care and an assessment of the current state of the patient's mental health. The ward manager/nurse in charge should then make the decision in consultation with other members of the multi-disciplinary hospital team.

3.4

The ward manager/nurse in charge must make their decision on the basis of the interests of the child being paramount, superseding those of the adult patient.

Unexpected visit by a child

3.5

If a child visits unexpectedly, the ward manager/nurse in charge is responsible for deciding whether it is feasible, whilst they wait, to consider the available information about the child (as outlined in Pre-visit Arrangements), alongside the assessment of the patient's needs for treatment and care and an assessment of the current state of the patient's mental health. The ward manager/nurse in charge should then make the decision in consultation with other members of the multi-disciplinary hospital team. If this is not feasible, the visit must be refused.

Patients admitted informally

3.6

Most patients are admitted informally. When a patient has been admitted on an informal basis, nursing staff should seek out information about children who may be visiting. When nursing staff are aware that a patient has a child, and there is a local authority children's social worker or adult mental health care co-ordinator working with the patient, nursing staff should check with the social worker / care co-ordinator about the desirability of children visiting and the arrangements which have been made. Such discussions should be clearly documented.

3.7

If there are concerns about the safety or care arrangements of the child/ren (see Identifying concerns below, and Mental Illness (Parenting Capacity) Procedure) and there is no local authority children's social worker involved, the ward manager/nurse in charge must request that local authority children's social care undertake an assessment (see Referral and Assessment Procedure). local authority children's social care should make a recommendation to the hospital about the suitability of the child/ren visiting the patient.

3.8

Where local authority children's social care has been asked to undertake such an assessment, their report should be sent back within one week of receipt of the written request / referral from the ward manager/nurse in charge (see section 3.7, above) in order to avoid delay in arrangements for the child.

3.9

The ward manager/nurse in charge is responsible for the decision to allow a visit by a child, and must follow the same decision making process for informal admissions and for compulsory admission (see Expected visit by a child above).

3.10

In the vast majority of cases where no concerns have been identified, arrangements should be made to support the patient and child and to facilitate contact.

Identifying concerns

3.11

Concerns about the desirability of a child visiting may arise in a number of areas.  These could relate to:

• Consideration of the child's best interests;
• The patient's history and family situation;
• The patient's current mental state (which may differ from an assessment made immediately prior to or on admission);
• The response by the child to the patient's illness;
• The wishes and feelings of the child;
• The developmental age and emotional needs of the child;
• The views of those with parental responsibility;
• The nature of the service and the patient population as a whole;
• Availability of a suitable environment for contact.

See also Mental Illness (Parenting Capacity) Procedure.

3.12

The hospital multi-disciplinary team may use the Framework for Assessing Children in Need and their Families (now archived) (see Appendix 4: Triangle chart for the Assessment of Children in Need and their Families) to consider the best interests of the child in these situations.

3.13

A range of options may present themselves when concerns are identified in any of the areas above, and the concerns need not automatically result in a refusal of visiting. The hospital multi-disciplinary team must obtain a balance between the management of risk of harm and the interests of the child/ren and patients.

3.14

It may be helpful for the Hospital Trust and / or Local Safeguarding Children Partnership to consider whether or not to provide a service to facilitate contact. Research has highlighted the dangers of loss of contact with children for people who are psychiatric in-patients in hospital

Decisions to refuse a child's visits

3.15

The ward manager/nurse in charge may refuse to allow a child to visit if they have reason to believe it is not in the best interest of the child or patient.

3.16

The decision to prohibit a visit should be regarded as a serious interference with the rights of the patient and should only be taken in exceptional circumstances.

3.17

Decisions to refuse visits should be given verbally and confirmed in writing. They must be supported by clear evidence of concerns and the difficulties of managing them.

3.18

Policies should clearly set out the steps to be taken in making the decision to refuse visiting, including the process for:

• Consulting with the patient, the child (depending on age and understanding), those with parental responsibility and, if different, person/s with day to day care for the child, advocates and, where relevant, the local authority children's social care;
• Communicating the decision to the patient, other family members, the child and those with parental responsibility;
• Reviewing any decision and the means of communicating this to the patient, advocate or other person or agency involved in the decision;
• Enabling a patient and others with parental responsibility to make representation against any decision not to visit, including access to assistance and independent advocacy. Such a system should be consistent with the Trust's overall complaints procedure and should contain an independent element.

Making arrangements for visits

3.19

The hospital or mental health trust providing the service must ensure that the hospital contains facilities for all patients to have contact with their children in a venue which is conducive to the child's safety and good quality contact for both child and patient.

3.20

Children should have appropriate supervision according to their age and need when they are visiting mental health service users. They should normally be accompanied by someone who has parental responsibility for their care and well being.

3.21

In some cases, it may be better for arrangements to be made for visiting 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 the child protection and child welfare issues in granting leave of absence under s.17 of the Mental Health Act 1983.

4.1

Specialist hospitals must have procedures for child visiting that have been developed specifically for that service.  Decisions about whether to permit a child to visit a unit must always be based on:

• The interests of the child;
• The service user's offending history;
• The clinical history of the service user;
• The conditions under which the visit will take place.

4.2

A hospital may not allow a child to visit any patient unless the hospital's authority has approved the visit in accordance with the directions pertaining to the patient's admission see Guidance on the High Security Psychiatric Services (Arrangements for Visits by Children) Directions 2013 (and in particular is satisfied that the visit is in the child's best interests.

The only exception to this is where there is a Child Arrangement order or for a Looked After Child a contact order made under the Children Act 1989 which specifies that the child may visit the patient in the special 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 interests (see Refusing a visit).

5.1

There may be cases where the patient has been:

• Convicted of murder or manslaughter, or an offence which leads to them being identified (by probation / youth offending services, police or health services, individually or via the Multi-Agency Public Protection Arrangements) as posing an ongoing risk to a child; or
• Found unfit to be tried or not guilty by reason of insanity, in respect of a charge of murder or manslaughter or an offence which leads to them being identified (by probation / youth offending services, police or health services, individually or via the Multi-Agency Public Protection Arrangements) as posing an ongoing risk to a child.

In these circumstance, the child must be within the permitted categories of relationship set out in Guidance on the High Security Psychiatric Services (Arrangements for Visits by Children) Directions 2013.

5.2

If the patient's circumstances are not those in section above or the child is within the permitted categories of relationship, the nominated officer should:

• Obtain written permission from the patient to contact those with parental responsibility for the child;
• Write to the person/s with parental responsibility for the child:
  • Explaining that a request for a visit has been made;
  • Asking for confirmation of the relationship between the patient and the child;
  • Requesting consent for the child to visit the patient;
  • Explaining that before a visit can proceed, local authority children's social care will be asked to assess whether the visit is in the child's best interests.
• Write to any person/s without parental responsibility but with day-to-day care for the child (e.g. a grandparent), explaining that a request for a visit has been made and that the person with parental responsibility will be contacted.

5.3

In the case of a child who is looked after by the local authority and subject to a care order (with parental responsibility shared by the local authority and the parent/s), local authority children's social care has responsibility for providing consent (following consultation with those with parental responsibility). Where a child is looked after by the local authority but not subject to a care order, the person with parental responsibility is required to give their consent.

5.4

If those with parental responsibility state that they are prepared to allow their child to visit the patient, the nominated officer should arrange for the patient's clinical team to undertake an assessment. This assessment is to judge the level of risk, if any, presented by the patient to children and to the particular child for whom the visit request has been made. Procedures for undertaking this type of assessment should be agreed with both the relevant local authority children's social care service and Local Safeguarding Children Partnership for the hospital.

5.5

If the hospital's assessment of the risk of harm posed by the patient to the child does not rule out a visit, the nominated officer must:

• Contact the Director of Children's Services for the local authority children's social care service where the child resides to request advice on whether the visit is in the best interests of the child;
• Include in the request a copy of the hospital's assessment and any other any relevant information about the patient, to assist local authority children's social care to assess whether the proposed visit is in the child's best interests;
• Include in the request any information about other local authority children's social care services which have relevant information about the child or the child's family;
• Inform the parents of the child that local authority children's social care have been asked to make contact with the family.

local authority children's social care response

5.6

On receipt of the request from the hospital (see section above), local authority children's social care should contact those with parental responsibility (and those caring for the child if they are different) to arrange to undertake an assessment to establish:

• The child's legal relationship with the named patient;
• The quality of the child's relationship with the named patient, prior to hospitalisation and currently;
• Whether there has been past abuse of the child, alleged or confirmed, by the patient;
• The likelihood of future risks of significant harm to the child if the visits took place;
• The child's wishes and feelings about the visit, taking account of their age and understanding;
• The views of those with parental responsibility and, if different, person/s with day-to-day care for the child;
• If it is known the child has lived in other local authority children's social care areas, what other relevant information is known about the child and family;
• The frequency of contact that would be appropriate.

5.7

Local authority children's social care should send the completed assessment report to the nominated officer, advising whether the visit would be in the best interests of the child.

5.8

If local authority children's social care advises that a visit would be in the child's best interests, the nominated officer should discuss this with local authority children's social care and make a decision about the visit, taking account of any potential risk posed by the patient and the potential of significant harm being suffered by the child.

5.9

If the person/s with parental responsibility refuses to co-operate with the local authority children's social care assessment, local authority children's social care should consider its legal position:

• If the child is known to local authority children's social care, it could make its report on the basis of the information it has already but make clear that the information is not up to date and does not take account of the wishes and feelings of the child;
• If local authority children's social care holds no information about the child, it should inform the hospital that it is unable to make any report.

The visit

5.10

Any visits by children must:

• Take place in an appropriate atmosphere and setting (i.e. child-centred and child-friendly), taking account of the age of the children (as advised by the local authority children's social care service local to the hospital) whilst maintaining the required level of security;
• Be properly supervised throughout the visit, with sufficient staff present (of an appropriate grade and with requisite knowledge and understanding and enhanced Disclosure and Barring Service checks - for children, not just vulnerable adults) to supervise the children's visits at all times and to prevent unauthorised contacts;
• Allow the child contact with only the named patient for whom a visit has been approved. No children are to visit on the ward areas.

5.11

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 interests, taking account of advice from local authority children's social care. All visits by children shall be specifically authorised by the nominated officer.

Refusing a visit

5.12

There are five circumstances in which the nominated officer must refuse to allow a child to visit. These are if:

• The relationship between the patient and the child is not within the permitted categories of relationship. 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 local authority children's social care service 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 for the child, if different, and local authority children's social care. 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 for the child, if different, and, if appropriate, the child.

5.13

Guidance on the High Security Psychiatric Services (Arrangements for Visits by Children) Directions, 2013 sets out the assessment process to be followed when deciding whether a child can visit a named patient in these hospitals; and  Local Authority Circular LAC(99)23 which refers to the specific tasks to be undertaken by local social service authorities in receipt of a request from the hospital for advice on whether it is in the best interests of a child to visit a named patient. Local Authority Circular LAC (2000)18 which refers to who can accompany a child on a visit to a named patient. It is issued as statutory guidance under section 7 of the Local Authority Social Services Act 1970.