Fill - Free fillable UK Gov - Deprivation of Liberty Form 9 DH-113207 PDF form

Mental Capacity Act 2005

DEPRIVATION OF LIBERTY FORM No. 9

ELIGIBILITY ASSESSMENT

PART A — WHY THIS FORM IS BEING COMPLETED

Place a cross in ONE of the boxes below Ø

A1 This form is being completed in relation to a request for a standard authorisation.

A2 This form is being completed in relation to a review of an existing standard

authorisation under Part 8 of Schedule A1 to the Mental Capacity Act 2005.

PART B — BASIC INFORMATION

Name, address and profession of the assessor

Full name of the person being assessed

Name of the hospital or care home in which the

person is, or may become, deprived of their liberty

Name of the PCT or local authority that is the

supervisory body

The present address of the person being

assessed

(Place a cross in the relevant box and, where

applicable, state the address)

Address of the hospital or care home in which the

person is, or may become, deprived of their liberty

(Place a cross in the relevant box and, where

applicable, state the address)

CASE

NUMBER

Name

Address

Profession

Name

As stated on the request for a standard

authorisation

As stated immediately below

Address

As stated on the request for a standard

authorisation

As stated immediately below

Address

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PART C — STATUTORY CONSULTATION

In carrying out this assessment, I have taken into account any information given to me, or submissions

made, by any of the following:

(a) any relevant person’s representative appointed for the person

(b) any IMCA instructed for the person in relation to their deprivation of liberty.

C1 REQUIREMENT TO SEEK ELIGIBILITY INFORMATION FROM THE BEST INTERESTS ASSESSOR.

Place a cross in ONE of the following boxes (A, B, C) Ø

A I also carried out the best interests assessment.

B The requested standard authorisation relates to the person’s deprivation of liberty

in a care home.

C The requested standard authorisation relates to the person’s deprivation of liberty

in a hospital.

I have, to the extent that I am required to do so by the regulations

made under

paragraph 47 of Schedule A1 to the Mental Capacity Act 2005, asked the best interests

assessor for any information s/he has relevant to my making a decision about whether

or not the person is ineligible to be deprived of liberty by virtue of paragraph 5 of

Schedule 1A to the Mental Capacity Act 2005.

Please now complete:

• Part D of the form if the authorisation relates to a care home; OR

• Part E of the form if the authorisation relates to a hospital.

PART D — CARE HOME CASES ONLY

Answer ALL of the following questions Yes or No, by placing a cross in the relevant box.

Note: if the answer to ANY of the following questions is ‘Yes’ then the person is NOT eligible to be deprived

of their liberty under a standard authorisation. Only if the answer to ALL of the questions is ‘No’ is the

eligibility requirement met.

Give answers to questions based on what you expect the person’s circumstances to be if and when the

requested standard authorisation comes into force. For example, if the person is currently detained under

section 3 of the Mental Health Act 1983

, but will not be when any standard authorisation comes into force,

for these purposes they are not detained under section 3.

1 The relevant regulation is regulation 15 of the Mental Capacity (Deprivation of Liberty: Standard Authorisations,

Assessments and Ordinary Residence) Regulations 2008, accessible via: http://www.dh.gov.uk/en/SocialCare/Delivering

adultsocialcare/MentalCapacity/MentalCapacityActDeprivationofLibertySafeguards/DH_084948

2 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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D1 PERSONS CURRENTLY LIABLE TO DETENTION UNDER THE MENTAL HEALTH ACT 1983

A (i) The person is liable to be detained under one of the following sections Yes No

of the Mental Health Act 1983: sections 2, 3, 4, 35–38, 44, 45A, 47,

48 or 51; AND

(ii) accommodating them in this care home would conﬂ ict with a requirement

imposed on them in connection with their liability to detention under the

Mental Health Act 1983, for example as a condition of a leave of absence or

conditional discharge from hospital.

D2 PERSONS ON A COMMUNITY TREATMENT ORDER UNDER THE MENTAL HEALTH ACT 1983

A The person is on a community treatment order and accommodating Yes No

them in this care home would conﬂ ict with a requirement imposed on them

under their community treatment order, for example because they are being

recalled to hospital or because a condition of their community treatment order is

that they should reside elsewhere.

D3 PERSONS SUBJECT TO GUARDIANSHIP UNDER THE MENTAL HEALTH ACT 1983

A The person is subject to guardianship and accommodating them in this care Yes No

home would conﬂ ict with a requirement imposed on them by their guardian,

for example a requirement that they should reside elsewhere.

Please now sign and date the form. You do not need to complete Part E.

PART E — HOSPITAL CASES ONLY

Answer ALL of the following questions Yes or No, by placing a cross in the relevant box.

Note: if the answer to ANY of the following questions is ‘Yes’ then the person is NOT eligible to be deprived

of their liberty under a standard authorisation. Only if the answer to ALL of the questions is ‘No’ is the

eligibility requirement met.

Give answers to questions based on what you expect the person’s circumstances to be if and when the

requested standard authorisation comes into force. For example, if the person is currently detained under

section 3 of the Mental Health Act 1983, but will not be when any standard authorisation comes into force,

for these purposes they are not detained under section 3.

E1 PERSONS CURRENTLY LIABLE TO DETENTION UNDER THE MENTAL HEALTH ACT 1983

A The person is detained in a hospital under one of the following sections Yes No

of the Mental Health Act 1983: 2, 3, 4, 35–38, 44, 45A, 47, 48 or 51.

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E2 PERSONS WHO ARE SUBJECT TO ONE OF THE ABOVE SECTIONS BUT WHO ARE NOT

CURRENTLY DETAINED (FOR EXAMPLE BECAUSE THEY HAVE LEAVE TO BE ABSENT FROM

THE HOSPITAL WHERE THEY ARE LIABLE TO DETENTION OR BECAUSE THEY HAVE BEEN

CONDITIONALLY DISCHARGED)

A The purpose for which the requested standard authorisation would be given Yes No

consists wholly or partly of medical treatment for mental disorder in a hospital.

B Accommodating the person in this hospital under the requested standard Yes No

authorisation would conﬂ ict with a requirement imposed on them in connection

with their liability to detention under the Mental Health Act 1983, for example as

a condition of a leave of absence or conditional discharge from hospital.

E3 PERSONS ON A COMMUNITY TREATMENT ORDER UNDER THE MENTAL HEALTH ACT

1983

A The person is on a community treatment order and the purpose for Yes No

which the requested standard authorisation would be given consists wholly or

partly of medical treatment for mental disorder in a hospital.

B The person is on a community treatment order and accommodating Yes No

them in the hospital under the requested standard authorisation would conﬂ ict

with a requirement imposed on them under the community treatment order.

E4 PERSONS SUBJECT TO GUARDIANSHIP UNDER THE MENTAL HEALTH ACT 1983

A The person is on guardianship and accommodating them in the Yes No

hospital under the requested standard authorisation would conﬂ ict with a

requirement imposed on them by their guardian.

B The person is subject to guardianship and objects to being accommodated Yes No

in the hospital for the purpose of being given some or all of the medical

treatment proposed for their mental disorder. No donee of a lasting power of

attorney or deputy appointed by the Court of Protection has made a valid decision

to consent to the matters to which they object.

E5 PERSONS WHO COULD BE DETAINED UNDER THE MENTAL HEALTH ACT 1983

• The person objects to being in this hospital in order to be given medical

treatment for their mental disorder or to being given some or all of the Yes No

mental health treatment; AND

• no donee or deputy has made a valid decision to consent to each matter to

which the person objects; AND

• the person meets the criteria for being detained under section 2 or 3 of the

Mental Health Act 1983.

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Please now sign and date the form.

Signed

Dated

WHAT TO DO NOW

It is essential that you give a copy of this assessment to the supervisory body as soon as you have

completed it. This is because the supervisory body may not give a standard authorisation unless and until it

has written copies of all the assessments.

If the person does not meet the eligibility qualifying requirement, a standard authorisation may not be given

and all other on-going assessments should stop. You should immediately notify the supervisory body, and

then provide them with a copy of this assessment as soon as practicable. You must keep a written record of

the assessment.

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