Fillable Dh 124845 GFMA-Liberty Form 1.indd

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Dh 124845 GFMA-Liberty Form 1.indd

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The Dh 124845 GFMA-Liberty Form 1.indd form is 6 pages long and contains:

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  • 10 check-boxes
  • 29 other fields

Country of origin: UK
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1
Mental Capacity Act 2005
DEPRIVATION OF LIBERTY FORM No. 1
URGENT AUTHORISATION
PART A — BASIC INFORMATION
Full name of the person being deprived of their
liberty
Their date of birth (or estimated age if
unknown)
Name and address of the hospital or care home
where the person is being deprived of their
liberty
Person to contact at the hospital or care home
Name
DOB d d m m y y y y
Est. age Years
Name
Address
Name
Telephone
Email
Name
Address
CASE
NUMBER
Name and address of the person registered,
or required to be registered, under Chapter
2 of Part 1 of the Health and Social Care Act
2008 in respect of the provision of residential
accommodation, together with nursing or
personal care, in the care home and in
relation to an independent hospital, the person
registered, or required to be registered, under
Chapter 2 of Part 1 of the Health and Social
Care Act 2008 in respect of regulated activities
(within the meaning of that Part) carried on
in the hospital, or the NHS Trust that manages
the hospital
Name of the PCT or local authority to whom
this form is being sent (‘the supervisory body’)
PART B — THE MANAGING AUTHORITY’S DECISION
It appears to the managing authority that ALL of the following conditions are met.
An urgent authorisation may only be given if the person appears to meet ALL of the conditions
below (B1–B10). Place a cross in EACH box to confi rm that the person appears to meet the particular
condition.
Name
2
B1 The person is aged 18 or over.
B2 The person is suffering from mental disorder.
B3 The purpose of accommodating the person here is to give them care or treatment.
B4 The person lacks capacity to make their own decision about whether to be accommodated
here for the purpose of being given the proposed care or treatment.
B5 The person has not, as far as the managing authority is aware, made a valid advance
decision that prevents them from being given any proposed treatment.
B6 Accommodating the person here, and giving them the proposed care or treatment, does
not, as far as the managing authority is aware, confl ict with a valid decision made by a
donee of a lasting power of attorney or deputy appointed by the Court of Protection under
the Mental Capacity Act 2005.
B7 Even though the circumstances amount to depriving the person of their liberty, it is in
their best interests to be accommodated here so that they may be given the proposed
care or treatment.
B8 This is necessary in order to prevent harm to them, and is a proportionate response to the
harm they are likely to suffer if they are not so deprived of liberty, and the seriousness
of that harm.
B9 The need for the person to be deprived of their liberty here is so urgent that it is appropriate
for that deprivation to begin immediately.
B10 The person concerned is not, as far as the managing authority is aware, subject to an
application or order under the Mental Health Act 1983
1
or, if they are, that order or
application does not prevent an urgent authorisation being given.
PART C — DETAILS OF THIS URGENT AUTHORISATION
This urgent authorisation permits the managing authority to deprive the person of their liberty here, but only
for the purpose of enabling them to be given the care or treatment specifi ed below in section C2 of this form.
C1 THE DURATION OF THIS URGENT AUTHORISATION
This urgent authorisation comes into force immediately.
It is to be in force for a period of: DAYS
The maximum period allowed is seven days.
Enter number of days in the box above ×
This urgent authorisation will expire at the end of the day on:
Enter date in boxes above ×
Important note: the day on which the urgent authorisation is given counts as the fi rst of the days.
For example, if an urgent authorisation is given for seven days at 11.30pm on Monday, it will expire
at the end of the day on the following Sunday.
ddm
m
yyyy
1 References in this form to provisions of the Mental Health Act 1983 include provisions of other enactments that have the same effect.
GFMA-Liberty Form 1.indd 2 26/2/09 11:59:32
3
C2 THE PURPOSE OF THIS URGENT AUTHORISATION
The purpose for which this urgent authorisation is given should be described here.
Note: there is a legal requirement that the giving of a Mental Capacity Act 2005 deprivation of liberty
safeguards authorisation must be for the purpose of giving care or treatment to the person to whom the
authorisation relates. The entry below should therefore identify the care and/or treatment that constitutes
the purpose for which the authorisation is given. It should be borne in mind, however, that the deprivation of
liberty authorisation does not itself authorise the care or treatment concerned, the giving of which is subject
to the wider provisions of the Mental Capacity Act 2005.
The purpose of this urgent authorisation is to enable the person to be given the following care and/or
treatment in this hospital or care home:
GFMA-Liberty Form 1.indd 3 26/2/09 11:59:32
4
PART D — THE MANAGING AUTHORITY’S REASONS
Explain here:
(a) the nature of the restrictions on the person’s liberty that lead to the conclusion that they are
deprived of their liberty
(b) why the care and/or treatment described above cannot be provided in a way that is less
restrictive of the person’s rights and freedom of action
(c) to the extent that the managing authority is aware, what alternatives to deprivation of liberty
have been considered
(d) what harm the person is likely to come to if they are not immediately deprived of their liberty
in this hospital or care home
(e) why the need to deprive the person of their liberty is so urgent that it is appropriate for the
deprivation to begin immediately.
The managing authority’s reasons for giving an urgent authorisation are as follows:
GFMA-Liberty Form 1.indd 4 26/2/09 11:59:32
5
PART E — NEED FOR AN INDEPENDENT MENTAL CAPACITY ADVOCATE (IMCA)
Place a cross in ONE of the boxes below Ø
E1 As far as the managing authority is aware, apart from professionals and other people who
are paid to provide care or treatment, this person has no one whom it is appropriate to
consult about what is in their best interests.
We will therefore immediately inform the supervisory body via Form 4 (managing
authority request for a standard authorisation) that it needs to instruct an IMCA to
assist the person.
E2 The managing authority believes that there is someone it is appropriate to consult
about what is in this person’s best interests who is neither a professional nor is being
paid to provide care or treatment.
PART F — PROVIDING COPIES OF THIS URGENT AUTHORISATION AND RIGHTS INFORMATION
As soon as practicable after this form is signed, the managing authority will give copies of it to:
(a) the person to whom the urgent authorisation relates; and
(b) any section 39A IMCA acting for them.
The managing authority will also, as soon as possible, take all practicable steps to ensure that the person to
whom the urgent authorisation relates understands:
(a) the effect of the authorisation
(b) their right to make application to the Court of Protection, challenging the urgent authorisation.
This information will be given both orally and in writing.
PART G — DETAILS OF THE STANDARD AUTHORISATION REQUESTED
Place a cross in ONE of the two boxes below Ø
G1 The managing authority has already completed and sent off Form 4 (managing
authority request for a standard authorisation).
G2 The managing authority will now immediately complete and send off Form 4
(managing authority request for a standard authorisation).
If you placed a cross in box G2, you should now also complete and send off Form 4 immediately
(managing authority request for a standard authorisation).
GFMA-Liberty Form 1.indd 5 26/2/09 11:59:32
6
Signed
(on behalf of the managing authority)
Dated
This part of the form must be completed if the duration of the urgent authorisation is extended by the
supervisory body. Do not complete this part of the form in any other circumstances. Simply leave it blank.
H1 DETAILS OF ANY EXTENSION
The duration of this urgent authorisation has been extended by the supervisory body.
It is now in force for a FURTHER: DAYS
Enter number of days in the box above ×
The period specifi ed must not exceed seven days.
This urgent authorisation will now expire at the end of the day on:
Enter new date on which it will expire above ×
H2 PROVIDING COPIES OF ANY EXTENSION
As soon as practicable after signing this form below, the managing authority will give copies of this amended
form to:
(a) the person to whom the urgent authorisation relates; and
(b) any section 39A IMCA acting for them.
Signature
Print name
Position
Date
ddm
m
yyyy
Signed
(on behalf of the managing authority)
Dated
PART H — RECORD THAT THE DURATION OF THIS URGENT AUTHORISATION HAS BEEN EXTENDED
Signature
Print name
Position
Date
GFMA-Liberty Form 1.indd 6 26/2/09 11:59:32
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Completed 9 February 2020

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