Fillable UK Gov Department of Health & Social Care - Deprivation of Liberty Form 21

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UK Gov Department of Health & Social Care - Deprivation of Liberty Form 21

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1
Mental Capacity Act 2005
DEPRIVATION OF LIBERTY FORM No. 21
SUPERVISORY BODY’S DECISION AS TO WHETHER ANY
QUALIFYING REQUIREMENTS ARE REVIEWABLE
A person may only be deprived of their liberty under the Mental Capacity Act 2005 if they meet all of the six
‘qualifying requirements’.
In general terms, a review should be carried out if it is possible that the person no longer meets a particular
qualifying requirement.
With one exception, dealt with in Part D of this form, the supervisory body must arrange for assessments to
be carried out for each qualifying requirement that appears to be reviewable.
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 relevant hospital or
care home
Name and address of the supervisory body
Person to contact at the supervisory body
Name
DOB d d m m y y y y
Est. age
Name
Address
Name
Address
Name
Telephone
Email
CASE
NUMBER
GFSB-Liberty Form 21.indd 1 16/2/09 13:05:55
2
PART B — WHETHER ANY QUALIFYING REQUIREMENTS ARE REVIEWABLE
The supervisory body must decide whether it has evidence that the person may no longer meet one or more
of the qualifying requirements, or that they are entitled to a review on some other ground.
Place a cross next to any qualifying requirements that are reviewable (B1–B6).
If no requirements are reviewable, place a cross in row B7
B1 THE AGE REQUIREMENT
The age requirement is reviewable on the ground that:
A The person might not meet the age requirement.
B2 THE MENTAL HEALTH REQUIREMENT
The mental health requirement is reviewable on the ground that:
A The person might not meet the mental health requirement.
B The reason why the person meets the mental health requirement might be
different from the reason stated in the standard authorisation.
B3 THE MENTAL CAPACITY REQUIREMENT
The mental capacity requirement is reviewable on the ground that:
A The person might not meet the mental capacity requirement.
B The reason why the person meets the mental capacity requirement might be
different from the reason stated in the standard authorisation.
B4 THE NO REFUSALS REQUIREMENT
The no refusals requirement is reviewable on the ground that:
A The person might not meet the no refusals requirement.
B The reason why the person meets the no refusals requirement might be
different from the reason stated in the standard authorisation.
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3
B5 THE ELIGIBILITY REQUIREMENT
The eligibility requirement is 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
1
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 the 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.
B The reason why the person meets the eligibility requirement might be different
from the reason stated in the standard authorisation.
B6 THE BEST INTERESTS REQUIREMENT
The best interests requirement is reviewable on the ground that:
A The person might not meet the best interests requirement.
B The reason why the person meets the best interests requirement might be
different from the reason stated in the standard authorisation.
C There has been a change in the person’s case, as a result of which it might 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).
B7 NO REQUIREMENT IS REVIEWABLE
None of the qualifying requirements appear to be reviewable:
A The supervisory body has decided that none of the qualifying requirements
appear to be reviewable and that therefore the supervisory body is not required
to take any action in respect of the standard authorisation. This review is therefore
complete. (Give your reasons in Part C and then sign and date this form.
There is no need to complete Parts D and E.)
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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4
PART C — REASONS FOR REFUSING A REVIEW
Where a review was requested on a ground that the supervisory body has rejected, the supervisory body’s
reasons for rejecting the request, or that part of the request, are as follows:
PART D — VARYING THE CONDITIONS OF THE STANDARD AUTHORISATION
Note: there is one exception to the rule that the supervisory body must arrange a separate assessment (a
‘review assessment’) for each qualifying requirement it decides is reviewable.
This is where it has been decided that the best interests requirement (B6 above) is reviewable on the SOLE
ground that there has been A CHANGE IN THE PERSON’S CASE (ground C in B6), as a result of which
the conditions of the standard authorisation may need varying.
Part D of this form should be completed ONLY if this one situation applies. In all other cases, do not
complete it and proceed instead to Part E.
How to complete Part D
Part D should only be completed in the circumstances described in the note above.
If Part D requires completion, the supervisory body must decide whether the change in the person’s case is
signifi cant, having regard to its nature and the period for which it is likely to last.
If the change is signifi cant, you should place a cross in box D1 below, and then arrange a best interests
review assessment by also placing a cross in box E6. The best interests assessor will recommend any
appropriate variations of the conditions once they have completed their assessment.
If the change is not signifi cant, it is not necessary to arrange a best interests review assessment. You can
simply use this form to vary the conditions, whether by amending or omitting an existing condition, or by
adding a new condition. Place a cross in box D2 and then list the new, varied, conditions immediately below.
D1 There has been a signifi cant change in the person’s case and a best interests
review assessment is therefore required.
D2 Although there has been a change in the person’s case, as a result of which it is
appropriate to vary the conditions, the change is not signifi cant and a best interests
review assessment is not required. The new amended conditions are those set out below.
GFSB-Liberty Form 21.indd 4 16/2/09 13:05:55
Please Use Continuation Sheet
5
The standard authorisation is hereby varied to take account of the change in the person’s case. The person
is now subject to the following conditions:
PART E — DETAILS OF THE REVIEW ASSESSMENTS TO BE CARRIED OUT
Subject to the one exception mentioned in Part D, the supervisory body must arrange a separate review
assessment for each qualifying requirement that it decided in Part B is reviewable.
The usual assessment forms for a new standard authorisation should be used by the assessors. In general
terms, the assessor must follow the same assessment process, and comply with the same duties, as they
would if carrying out an assessment for a new standard authorisation.
Having regard to the decisions in Part B of this form as to which (if any) of the qualifying requirements are
reviewable, the supervisory body will now arrange for the following assessments to be carried out:
Place a cross in one or more box(es) below (E1–E6), or leave them all blank if you decided that no
review assessments are required.
E1 An age review assessment
E2 A mental health review assessment
E3 A mental capacity review assessment
E4 A no refusals review assessmen
E5 An eligibility review assessment
1
2
3
4
5
6
GFSB-Liberty Form 21.indd 5 16/2/09 13:05:55
6
E6 A best interests review assessment
Signed
(on behalf of the supervisory body)
Dated
Signature
Print name
Position
Date
GFSB-Liberty Form 21.indd 6 16/2/09 13:05:55
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UK Gov Department of Health & Social Care - Deprivation of Liberty Form 21

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Completed 27 May 2020

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