Fillable UK Gov Department of Health & Social Care - Deprivation of Liberty Form 13 Supervisory Body's Decision Standard Authorisation Not Granted

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UK Gov Department of Health & Social Care - Deprivation of Liberty Form 13 Supervisory Body's Decision Standard Authorisation Not Granted

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1
Mental Capacity Act 2005
DEPRIVATION OF LIBERTY FORM No. 13
SUPERVISORY BODY’S DECISION
STANDARD AUTHORISATION NOT GRANTED
The following request for a standard authorisation has been refused
PART A — BASIC INFORMATION
Full name of the person being assessed
Their date of birth (or estimated age if unknown)
Name and address of the relevant hospital or
care home
Name and address of the supervisory body
Person to contact at the supervisory body
The present address of the person being
assessed
(If, for example, the person is currently living
at home and has not yet been admitted to the
hospital or care home, this will be their home
address. If they are currently living at a different
hospital or care home, this will be the hospital
or care home where they are at present.)
Name
DOB d d m m y y y y
Est. age Years
Name
Address
Name
Address
Name
Telephone
Email
As above (already living at the relevant
hospital or came home)
At a different address which is that given
immediately below:
Address
CASE
NUMBER
GFSB-Liberty Form 13.indd 1 16/2/09 12:27:43
2
PART B — THE SUPERVISORY BODY’S DECISION
A request for a standard authorisation was made by the relevant managing authority.
Enter the date below Ø
This request was received on:
The supervisory body is prohibited from giving a standard authorisation in relation to that request.
This is because the person was assessed not to meet the following qualifying requirement(s) for being
deprived of their liberty under the Mental Capacity Act 2005:
Note that there may be no completed assessment of some of the requirements. This is because when
a person fails one requirement, a standard authorisation may not be given and all other on-going
assessments must stop.
Place ONE cross in ONE column of each row (B1, B2, B3, B4, B5, B6) Ø
B1 Age requirement
B2 Mental health requirement
B3 Mental capacity requirement
B4 No refusals requirement
B5 Eligibility requirement
B6 Best interests requirement
PART C — REASONS WHY THE PERSON FAILED ONE OR MORE REQUIREMENTS
The reasons why the person failed the requirement(s) specifi ed above are as follows:
ddm
m
yyyy
REQUIREMENT MET NOT MET NOT ASSESSED
GFSB-Liberty Form 13.indd 2 16/2/09 12:27:43
Please Use Continuation Sheet
3
PART D — WHETHER THERE APPEARS TO BE AN UNAUTHORISED DEPRIVATION OF LIBERTY
Place a cross in either box D1 or D2 below Ø
D1 The best interests assessment report included a statement that it appeared to the assessor
that this person is, or is likely to be, subject to an unauthorised deprivation of liberty
D2 The best interests assessment report included a statement that it appeared to the assessor
that this person is not, or is not likely to be, subject to an unauthorised deprivation of liberty
PART E — PROVIDING COPIES OF THIS DECISION
As soon as practicable, the supervisory body must give a copy of this decision notice to the following:
(a) the managing authority of the hospital or care home
(b) the person in respect of whom the deprivation of liberty authorisation was requested
(c) any IMCA instructed for the person under section 39A of the Mental Capacity Act 2005 in relation to the
request for a standard authorisation
(d) every person named by the best interests assessor in their report as an interested person whom they
have consulted in carrying out their assessment.
This form is also your notice that any urgent authorisation previously in force now ceases to have effect. As
a result, there is now no authority to deprive this person of their liberty under the Mental Capacity Act 2005.
PART F — PROVIDING COPIES OF THE ASSESSMENTS
Copies of all the assessments in relation to the above person have been attached to this decision notice.
They will be sent as soon as practicable to all of the persons listed in paragraphs (a) to (c) of Part E above.
Unless they also fall within paragraphs (a) to (c) of Part E above, interested persons consulted by the best
interests assessor are entitled to receive a copy of this notice but not copies of the assessments.
Signed
(on behalf of the supervisory body)
Dated
NOTE TO THE MANAGING AUTHORITY OF THE HOSPITAL OR CARE HOME
Because your request has been refused on this occasion, you are not required to make a new request for
a standard authorisation unless it appears to you that there is a change in the person’s circumstances as a
result of which the supervisory body is likely to give a standard authorisation.
Signature
Print name
Position
Date
GFSB-Liberty Form 13.indd 3 16/2/09 12:27:43
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UK Gov Department of Health & Social Care - Deprivation of Liberty Form 13 Supervisory Body's Decision Standard Authorisation Not Granted

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Completed 27 May 2020

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