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Mental Capacity Act 2005
DEPRIVATION OF LIBERTY FORM No. 19
REQUEST FOR A REVIEW BY THE MANAGING AUTHORITY
Note: a deprivation of liberty can be ended before a formal review. If a managing authority decides that a
deprivation of liberty is no longer necessary then they must end it immediately, by adjusting the care regime
or implementing whatever other change is appropriate. The managing authority should then apply to the
supervisory body to review the 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 and address of the PCT or local
authority to whom the form is being sent
(‘the supervisory body’)
Name
DOB d d m m y y y y
Est. age Years
Name
Address
Name
Telephone
Email
Name
Address
CASE
NUMBER
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PART B — GROUNDS FOR REQUESTING A REVIEW
It appears to us (the managing authority) that the following qualifying requirement(s) is/are reviewable on
the stated ground(s):
Place a cross in the relevant box(es) below (B1–B6) Ø
B1 THE AGE REQUIREMENT
The age requirement appears to be reviewable on the ground that:
A The person does not meet the age requirement.
B2 THE MENTAL HEALTH REQUIREMENT
The mental health requirement appears to be reviewable on the ground that:
A The person does not meet the mental health requirement.
B The reason why the person meets the mental health requirement is not the reason
stated in the standard authorisation.
B3 THE MENTAL CAPACITY REQUIREMENT
The mental capacity requirement appears to be reviewable on the ground that:
A The person does not meet the mental capacity requirement.
B The reason why the person meets the mental capacity requirement is not the reason
stated in the standard authorisation.
B4 THE NO REFUSALS REQUIREMENT
The no refusals requirement appears to be reviewable on the ground that:
A The person does not meet the no refusals requirement.
B The reason why the person meets the no refusals requirement is not the reason
stated in the standard authorisation.
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B5 THE ELIGIBILITY REQUIREMENT
The eligibility requirement appears to be reviewable on the ground that:
A (a) the standard authorisation authorises the person’s deprivation of liberty in hospital; AND
(b) the person is subject to guardianship under the Mental Health Act 1983
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OR
meets the statutory criteria for being detained under section 2 or 3 of the
Mental Health Act 1983; AND
(c) the person objects to being accommodated in this hospital for the purpose
of being given some or all of the proposed medical treatment for their mental
disorder; AND
(d) no donee of a lasting power of attorney or deputy appointed by the Court of Protection has
consented to each matter to which the person objects.
B6 THE BEST INTERESTS REQUIREMENT
The best interests requirement appears to be reviewable on the ground that:
A The person does not meet the best interests requirement.
B The reason why the person meets the best interests requirement is not the reason
stated in the standard authorisation.
C There has been a change in the person’s case, as a result of which it would be
appropriate to vary the conditions to which the standard authorisation is subject
(whether by amending or omitting an existing condition, or by adding a new condition).
PART C — REASONS FOR OPINION THAT ONE OR MORE REQUIREMENTS IS REVIEWABLE
The reasons why it appears to the managing authority that one or more of the qualifying requirements is
reviewable are as follows:
Signed
(on behalf of the managing authority)
Dated
Signature
Print name
Position
Date
1 References in this form to provisions of the Mental Health Act 1983 include provisions of other enactments that have the same effect.
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