Protocol for joint working between The Leeds Teaching Hospitals NHS Trust and The Leeds And York Partnerships NHS Foundation Trust

Publication: 20/12/2013  
Next review: 31/03/2023  
Clinical Protocol
ID: 3854 
Approved By: Executive Directors 
Copyright© Leeds Teaching Hospitals NHS Trust 2021  


This Clinical Protocol is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Protocol for joint working between the Leeds Teaching Hospitals NHS Trust and the Leeds and York Partnership NHS Foundation Trust

  1. Purpose
  2. Scope
  3. Definitions/abbreviation
  4. Procedure to be followed
  5. Roles and responsibilities
  6. Links to other documents

1. Purpose

This document sets out the formal protocol for joint working between the Leeds Teaching Hospitals NHS Trust (LTHT) and the Leeds and York Partnership NHS Foundation Trust (LYPFT) with regard to their responsibilities in relation to patients detained in a LTHT hospital under the Mental Health Act 1983 and treatment of their mental disorder.

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2. Scope

This protocol provides guidance to the Hospital Managers, medical staff and non-medical staff. It sets out the process of allocating approved clinicians to act as responsible clinicians and provision of care to patients that are or may become subject to compulsion under the Mental Health Act 1983, whilst an inpatient at a LTHT hospital. The protocol is derived in the greater part from the Mental Health Act and the code of practice to the Act. The protocol specifies how these provisions are to apply to the allocation of approved clinicians under the employ of LYPFT, but acting on behalf of LTHT. This procedure is reflective of the law and therefore any deviation from the protocol must be discussed and clarified with the head of Mental Health Legislation of both organisations.

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3. Definitions/abbreviation

Approved Clinician (AC): a mental health professional approved by the Secretary of State to act as an approved clinician for the purposes of the Mental Health Act. Some decisions can only be taken by an approved clinician. Responsible clinicians must be approved clinicians.

Approved Mental Health Professional (AMHP): a social worker or other professional approved by a local social services authority to act on behalf of a local social services authority in carrying out a variety of functions under the Mental Health Act.

Care Quality Commission (CQC): the regulator of all providers of regulated health and social care. This includes care provided under the Mental Health Act.

Leeds and York Partnership NHS Foundation Trust (LYPFT): is responsible for meeting the mental health needs of patients with a mental disorder who are detained to LTHT.

Leeds Teaching Hospitals NHS Trust (LTHT): is responsible for administering treatment for mental disorder as authorised and directed by the responsible clinician, for patients detained or on section 17 leave to LTHT.

Liaison Psychiatry (Hospital Mental Health Team): provides LTHT with 24 hour access to psychiatric assessment, opinion and support. The HMHT provide a specialist liaison psychiatry service to meet the specific mental health needs of patients admitted to St James Hospital Leeds (SJUH) and Leeds General Infirmary (LGI) and Chapel Allerton Hospital, as well as to patients accessing Accident and Emergency Departments. The service also provides named Responsible Clinician service to patients detained to LTHT under MHA. The process operating details for the HMHT are contained within Standard Operating Procedures for the service, agreed across the partnership and available to staff of both organisations.

Mental disorder: any disorder or disability of the mind. As well as mental illnesses, it includes conditions like personality disorders, autistic spectrum disorders and learning disabilities, but excludes a dependence on alcohol or drugs.

Mental Health Act 1983 (MHA): legislation concerning the care and treatment of patients with a mental health disorder. It covers detention in hospital for mental health treatment, as well as treatment in the community through community treatment orders and guardianship.

Mental Health Act Managers (Hospital Managers): Mental Health Act Managers are lay-people, not employed by an NHS trust or independent hospital, who have been authorised by the management of the NHS trust or independent hospital to review a patient’s detention or community treatment order. Mental Health Act Managers have the power to discharge a patient from detention or a community treatment order.

Responsible Clinician (RC) (LYPFT): is the approved clinician with overall responsibility for a patient’s care. Certain decisions (such as granting section 17 leave for an unrestricted patient, renewing a patient’s detention or placing a patient on a community treatment order) can only be taken by the responsible clinician. Therefore, where a patient has a mental disorder, but is also receiving treatment for a physical disorder at LTHT, the doctor in charge of the treatment can only be the responsible clinician, if he or she is an approved clinician. In such circumstances, it will be the consultant psychiatrist with responsibility for the treatment of a patient’s mental disorder, who would be the patient’s responsible clinician.

Second Opinion Appointed Doctor (SOAD): an independent doctor appointed by the CQC who gives a second opinion on whether certain types of medical treatment for mental disorder should be given without the patient’s consent or where they lack the capacity to consent. The responsibility for arranging a SOAD rests with the patient’s approved clinician (the approved clinician will usually also be the patient’s responsible clinician).

Treatment for Mental Disorder: part 4 of the Mental Health Act regulates treatment for mental disorder. Medication for mental disorder can be administered to a detained patient for up to 3 months before a formal review is required and a treatment certificate (T2/T3) needing to be in place. The responsibility for formally reviewing treatment is that of the patient’s approved clinician (the approved clinician will usually also be the patient’s responsible clinician).

Consent from the detained patient must always be sought before treatment is administered. Where the patient withholds or is unwilling to provide consent, consideration must be given to alternate treatments, which the patient might accept, before treatment is administered against their wishes.

Treatment for a physical condition cannot be provided under the authority of the Mental Health Act where the physical disorder is entirely unconnected with the patient’s pre-existing mental disorder. Where the physical condition is a manifestation or symptom of the mental disorder, treatment may be provided under the authority of the Mental Health Act. However, professionals are strongly advised to see further advice before proceeding.

Guidance on Mental Health Act treatment provisions can be found in the Mental Health Act Code of Practice, chapters 23, 24 and 25.

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4. Prodedure to be followed

4.1 Detaining general hospital inpatients:from time to time, an in-patient of a general hospital may require detention under Mental Health Act. Detention may be for assessment (section 2) or treatment (section 3). Whilst a Mental Health Act assessment is being undertaken it may be necessary to use short-term holding powers (section 5(2)).

  • Section 5(2) - use of section 5(2) holding power should be considered in an emergency where an inpatient wishes to leave hospital, where they appear to have a mental disorder and where there would be risks to their health or safety, and/or the protection of others, should they leave. The doctor in charge of the treatment or their nominated deputy can initiate a section 5(2). The purpose of the 72-hour ‘holding’ power to prevent the in-patient from leaving hospital, to allow a Mental Health Act assessment to be undertaken. In LTHT the nominated deputy is the duty/on-call doctor, excluding F1 and F2 doctors. The doctor must have personally seen/examined the patient before using section 5(2).

    The LTHT doctor using the powers should attempt to contact the relevant psychiatrist/psychiatry team for confirmation of their opinion, if possible prior to using the powers, or if not possible, immediately afterwards.

    If the doctor evoking the power is not the doctor in charge of the patient’s care then they should also, wherever possible, contact the doctor they are deputising for.

    The doctor using this power must follow LTHT Standard Operating Procedure for use of S5(2) by completing part 1 of Mental Health Act Form H1. On completion, the form must be handed to the nurse in charge who will complete part 2 of Form H1. The fully completed form must then be scanned and emailed to the LTHT MHA Administrator and the appropriate mental health team (LYPFT) informed. The mental health team will give clear information regarding on-going support and when they will be attending to review the patient. Clear information about the arrangements to consider a Mental Health Act assessment should be given to the ward’s senior nurse.

    If the reviewing LYPFT clinician decides that a Mental Health Act assessment is not needed, they must clearly inform the patient and ward’s senior nurse of this decision and its implications. The reviewing clinician must complete a LTHT Form H2 and record the time and date of the decision in the patient’s medical records.
  • Section 2/3: where a Mental Health Act assessment is undertaken and it is decided the patient requires detention under section 2 or section 3 of the Mental Health Act, the application for detention will usually be made by an Approved Mental Health Practitioner (AMHP) and must be supported by two medical recommendations from two different doctors. One medical recommendation must be provided by a doctor approved under section 12(2) of the Mental Health Act.

    Detention under section 2 can last for up to 28 days.
    Detention under section 3 can last for up to six months and be renewed for a further period of six months, and then annual thereafter.

    The ward’s Nurse in Charge at the time must record the start of detention by completing Mental Health Act Form H3.
    All clinicians involved in use of Section 2/3 at LTHT must follow LTHT MHA detention Procedure

4.2 Admission from the community: there may be circumstances where a patient is admitted from the community under section 2 or 3 of the Mental Health Act. On receipt of the section papers (application and two medical recommendations), the ward’s Nurse in charge must complete Mental Health Act Form H3.

4.3 Patients transferred to LTHT from LYPFT for medical treatment on section 17 leave
Leeds Teaching Hospitals NHS Trust may be asked to admit patients who are detained by LYPFT, but also need treatment for their physical health that cannot be provided in a mental health hospital. In such cases, it will usually be appropriate for LYPFT to remain the detaining authority and for the patient to be granted leave of absence from the mental health hospital (using powers under section 17 of the Mental Health Act) to be admitted to the general hospital.

Any patient who is subject to section 17 leave for medical treatment will, in terms of the Mental Health Act, remain the responsibility of LYPFT and LTHT will be responsible for any medical treatment for a physical condition. The responsibility for the treatment of the patient’s mental disorder will remain under the authority of the responsible clinician at LYPFT. For example, a patient transferred from ward 1, Becklin Centre will remain under the care of the responsible clinician for that ward for any treatment of the patient’s mental disorder.

When admitting patients to LTHT under section 17 leave, the Responsible Clinician (LYPFT) is accountable for ensuring that a local section 17 leave form is completed and contains:

  • clear details of who to contact for advice and their contact numbers,
  • details of any escort arrangements (this should ordinarily be provided by LYPFT staff unless otherwise discussed and expressly stated)
  • information about any current risk assessment and treatment certificate.

Handover from the detaining (psychiatric) ward to the receiving ward should happen by Nurse-in-charge to Nurse-in-charge. This may be completed by telephone but should be recorded on the patient record.
The handover must include:

  • any conditions attached to the Leave
  • agreed escort arrangements.
  • Who to contact for psychiatric input

The section 17 leave Form should be handed in person to the Nurse in Charge on the receiving ward (LTHT) by LYPFT escorting the patient. Nurse in Charge will then scan the Form into the patient’s LTHT electronic record (PPM+) and contact LTHT MCA/MHA Team with the patient’s details by telephone (ext 65011) or email (

There should be regular consultant to consultant review of section 17 leave. If leave is to continue beyond 7 days, consideration needs to be given to formally transferring responsibility under section 19 of the Mental Health Act to LTHT.

4.4 Patients transferred under section 19 for medical treatment from LYPFT to LTHT
Occasionally, a patient requiring physical health care is formally transferred from LYPFT to LTHT, using powers under section 19 of the Mental Health Act. In such cases LTHT becomes the ‘detaining authority’ and is responsible for compliance with all aspects of the Act, whilst the patient remains detained under its authority. A transfer under section 19 to LTHT must be with the agreement of an approved clinician in the relevant Liaison service, who is willing to act as responsible clinician for the detained patient. This should only happen after clear discussion between LYPFT and LTHT doctors in charge of the patient’s care.

The transferring authority (in most cases LYPFT) would facilitate a transfer and liaise with the approved clinician within Liaison Psychiatry to ensure that the patient has a nominated responsible clinician.

Part 1 of the MHA Form 4 will be completed by the transferring ward and must be given in person to the nurse in charge of the receiving ward (LTHT), who will then complete Part 2, scan into the patient’s PPM record and contact the LTHT MHA Administrator.
The responsible clinician is responsible for appraising the patient’s mental state and providing the authority for any treatment for the patient’s mental disorder. A medical practitioner on the LTHT ward will take responsibility for treatment of the patient’s physical health condition.

It is the responsibility of LYPFT Legislation team to ensure that all relevant MHA papers are shared in a timely manner with the Mental Health Legislation team in LTHT. LTHT legislation team will subsequently ensure that MHA papers are uploaded to the patient’s electronic record and will communicate relevant actions and instructions to receiving ward staff through notifications on PPM

4.5 Patients detained to LTHT under section 2 or section 3 or other relevant section for treatment for mental disorder

Patients detained within LTHT whilst an inpatient or from the community to LTHT will be under the responsibility of an approved clinician within Liaison Psychiatry.
Clinicians attending in order to make recommendations for detention under the Act (Pink) will ensure that the Nurse-in-charge is aware of their assessment and where it is located; and will contact the LTHT MHA office with the details of the patient.
The Approved Mental Health Professional (AMHP) and the Nurse-in-charge will complete first scrutiny of the Papers and identify themselves on the short AMHP report prior to the AMHP leaving the ward.

4.6 Out of hours arrangements
Leeds and York Partnership NHS Foundation Trust has an out-of-hours consultant psychiatrist rota operating between the hours of 5pm and 9am, Monday to Friday and 24 hours at weekends and bank holidays. Out-of-hours the on call approved clinician (consultant psychiatrist) is the nominated responsible clinician for all detained patients. In an emergency, the on-call consultant psychiatrist can be contacted via the LYPFT Switchboard - tel: 55000. The out of hours arrangement are in place in order to provide responsible clinician cover for all detained patients at LTHT throughout the year and therefore ensuring that a responsible clinician is always available.

4.7 Other requirements under the Act
For all patients detained to LTHT under the Act, the responsible clinician will adhere to LTHT’s MHA Standard Operating Procedures and keep in contact with the LTHT MHA/MCA team.

4.8 Escalation and advice.
This Protocol is not designed to provide specific solutions to the variety of complex MHA/MCA interface issues which can arise when transferring patients across organisational boundaries. If there are concerns or advice required regarding such matters clinicians should contact their relevant legislation leads for support:

Office hours:
LTHT MHA administrator/ Mental Capacity and Mental Health Act Team: (20)65011
Secure email:
LYPFT MH Legislation Team (85) 56847 / 56739 / 56854

On-call / out of hours:
LTHT Clinical Site Managers:
SJUH Bleep 5242 07776 230473 / LGI Bleep 2928 07776 228723
LYPFT switchboard (85) 55000 and ask for the on-call manager .

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5. Roles and responsibilities

Hospital Managers: they have primary responsibility for ensuring that the requirements of the Mental Health Act are followed. However, the enactment of the Act is an operational matter. The trust must ensure that patients are detained only as the Act allows, that their treatment and care accord fully with its provisions, and that a local protocol is in place for allocating responsible clinicians to patients. This is particularly important when patients move between hospitals, or from hospital to the community and vice versa. The protocols should:

  • ensure that the patient’s responsible clinician is the available approved clinician with the most appropriate expertise to meet the patient’s main assessment and treatment needs;
  • ensure that it can be easily determined who a particular patient’s responsible clinician is;
  • ensure that cover arrangements are in place when the responsible clinician is not available (e.g. during nonworking hours, annual leave etc.);
  • include a system for keeping the appropriateness of the responsible clinician under review.

Chief Nurse: the Chief Nurse (LTHT) has responsibility for ensuring that Clinical Services are suitably established to provide treatment under the Mental Capacity Act and the Mental Health Act, and to ensure that clinical staff understand and comply with the service provision and are able to identify the patient’s responsible clinician.

Chief Medical Officer: the Chief Medical Officer (LTHT) is responsible for ensuring that policies and the process for the care and treatment of patients are implemented and complied with, and that all professional staff understand and adhere to their requirements.

Medical Director: the Medical Director (LYPFT) is responsible for ensuring that the approved clinician allocation protocol (MHL-0006, LYPFT) is adhered to and that consultant psychiatrists are approved to act as approved clinicians.

Approved Clinician: the approved clinician with overall responsibility for managing the patient’s case. The approved clinician will be involved in the medical scrutiny of medical recommendations.
Leeds and York Partnership NHS Foundation Trust (LYPFT): has a process for the identification of approved clinicians and management of their approved clinician registration, which is undertaken by the Medical Directorate. Leeds Teaching Hospitals NHS Trust has adopted the approved clinician list of LYPFT. This means that:

  • patients detained under the Mental Health Act, whilst in LTHT have a responsible clinician, who will be an approved clinician from Liaison Psychiatry
  • on call responsible clinician duties (for example, the granting of section 17 leave or advice about psychiatric medical treatment) is lawfully discharged by the appropriate duty psychiatrist on call for LYPFT
  • Leeds Teaching Hospitals NHS Trust can be assured that the responsible clinicians on the on-call rota are suitably qualified and up-to-date with the approved clinician registration.

Mental Health Legislation Department (LYPFT): to ensure the scrutiny, safe keeping and secure transmission of legal documentation for patients subject to compulsory powers who are transferred between detaining authorities/hospitals.

Mental Health Act Administrator (LTHT): has responsibility for receiving and scrutinising all Mental Health Act documentation for LTHT, ensuring appropriate action is taken and documentation related issues are resolved.

Lead Professional MCA/MHA (LTHT): to work with all professional groups throughout LTHT, all stakeholders and partner agencies across traditional inter-agency and professional boundaries to provide robust clinical leadership, expert specialist advice and support to a comprehensive range of multi-disciplinary professionals dealing with patients subject to consideration under the Mental Health Act.

Head of Mental Health Legislation (LTHT): author, reviewer of this Protocol. Responsible for consultation across the partnership regarding aspects of this protocol; monitoring its effectiveness; providing assurance through LTHT Governance and representing LTHT at relevant LYPFT Governance meetings. Providing overall leadership and advice relating to this Protocol and other aspects of Mental Health legislation across LTHT and in partnership with LYPFT. Receive and co-ordinate any escalations regarding this Protocol’s use.

Ward Nurse in Charge (LTHT): must be aware of and comply with the contents of this protocol by ensuring:

  • They liaise with Nurse in Charge from transferring wards (LYPFT) when a patient is transferred under section 19 or section 17
  • that Part 2 of Forms H4 (section 19 transfer) and Form H1 (Section 5(2) Doctor’s holding power) are completed.
  • All papers are kept securely together,

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6. Links to other documents

Mental Health Act 1983, Scheme of Delegation
Mental Health Act 1983, Standard Operating Procedure


Record: 3854
Clinical condition:
Target patient group:
Target professional group(s): Secondary Care Doctors
Secondary Care Nurses
Adapted from:

Evidence base

Mental Health Act 1983
Mental Health Act, Code of Practice (2015)
Reference Guide to the Mental Health Act (2015)
Mental Capacity Act Code of Practice (2008)
Deprivation of Liberty Code of Practice (2009)
Care Quality Commission (Registration) Regulations 2009

Approved By

Executive Directors

Document history

LHP version 1.0

Related information

Not supplied

Equity and Diversity

The Leeds Teaching Hospitals NHS Trust is committed to ensuring that the way that we provide services and the way we recruit and treat staff reflects individual needs, promotes equality and does not discriminate unfairly against any particular individual or group.