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DOLS FORMS

By John Reynolds,2014-05-19 14:13
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DOLS FORMS

     Mental Capacity Act 2005

     CASE

    DEPRIVATION OF LIBERTY FORM No. 1 NUMBER

    URGENT AUTHORISATION

PART A BASIC INFORMATION

    Full name of the person being deprived of their Name

    liberty

    Their date of birth (or estimated age if unknown) d d M m y y y y DOB

    Est. age Years

     Name Name and address of the hospital or care home where the person is being deprived of their liberty

    Address

     Name Person to contact at the hospital or care home

     Telephone

     Email

     Name Name and address of the managing authority

    responsible for the hospital or care home (the person registered under Part 2 of the Care Address Standards Act 2000, or the NHS trust that manages the hospital)

    Name of the PCT or local authority to whom this Name 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 confirm that the person appears to meet the particular condition.

    Page 1 of 6

    If using electronically, just double click the box that needs a X and select checked

    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

    The person lacks capacity to make their own decision about whether to be accommodated here for B4 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, conflict 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 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.

    The person concerned is not, as far as the managing authority is aware, subject to an application or under the 1B10 Mental Health Act 1983or, 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 specified 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 x

This urgent authorisation will expire at the end of the day on: d d m m y y y y

     Enter date in boxes above

    Important note: the day on which the urgent authorisation is given counts as the first 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.

    1 References in this form to provisions of the Mental Health Act 1983 include provisions of other enactments that have the same effect.

    Page 2 of 6

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:

    Page 3 of 6

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 a follows:

    Page 4 of 6

PART E NEED FOR AN INDEPENDENT MENTAL CAPACITY ADVOCATE (IMCA)

    Place a cross in ONE of the boxes below

    If using electronically, just double click the box that needs a X and select checked

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 boxes below

    If using electronically, just double click the box that needs a X and select checked 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).

    Page 5 of 6

    Signature Signed

    (on behalf of the managing authority) Print name

    Position Dated Date PART H RECORD THAT THE DURATION OF THIS URGENT AUTHORISATION HAS BEEN EXTENDED

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 specified must not exceed seven days.

This urgent authorisation will now expire at the end of the day on: d d m m y y y y

    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 Signed

     Print name (on behalf of the managing authority)

    Position Dated Date

    Page 6 of 6

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