Deprivation of Liberty Safeguard Adult Critical Care

Publication: 24/05/2017  
Next review: 18/08/2023  
Standard Operating Procedure
ID: 5041 
Approved By: Adult Critical Care Governance Group 
Copyright© Leeds Teaching Hospitals NHS Trust 2017  


This Standard Operating Procedure 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.

Deprivation of Liberty Safeguard Adult Critical Care

Background and indications for standard operating procedure/protocol

Conflicting and unclear legal direction following initial publication of the statute for deprivation of liberty with regard to use of restraint and deprivation of liberty for patents on critical care.

This SOP seeks to aid the clinical teams in determining if a patient has capacity and f the Dols procedure needs to be sought and applied to ensure patients safety.

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Procedure method (step by step)

Deprivation of Liberty Safeguards;
The 2014 Supreme Court Judgement in the Cheshire West Case clarified what constitutes ‘deprivation of liberty’ for the purposes of article 5 of the European Convention on Human Rights. The judgement clarified an ‘acid test’ (as follows). An individual is deprived of their liberty if all 3 elements below are satisfied:

  • They lack capacity to consent to the restrictions placed upon them
  • They are under continuous supervision and control
  • They are not free to leave.

Following concerns about the implication for critically ill patients in intensive care, the DOH stated in a letter dated 22nd October 2015 that ‘the department does not consider that unconsciousness in itself constitutes a mental disorder for the purposes of schedule A1 of the mental capacity act’.  ‘The implications are that an individual who is unconscious under anaesthetic - but does not have a mental disorder is not eligible for DoLs.’

The following flow chart provides guidance on when DolS should be considered for critically ill patients in LTHT:

To make a DOLS referral,   complete the DOLS application form available on trust intranet at  http://lthweb/sites/safeguarding/deprivation-of-liberty-safeguards/deprivation-of-liberty-safeguards-dols

Then Fax   to: 66541  or email to

See over for additional information:
Patients may be deprived of their liberty if:

  • They have a mental disorder* such that they lack capacity to consent to restrictions placed on them by their admission or treatment.
  • They are over 18 years of age.
  • They are not detained under the mental health act.

*Mental disorder can be considered as any disorder of mind or brain

Patients are not deprived of their liberty if:

  • They have provided prior valid consent to intensive care
  • They currently have capacity to consent to the restrictions placed upon them and do so
  • They require lifesaving treatment in a true emergency or require a vital act to prevent serious deterioration

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Record: 5041

To ensure best practice in application of legislation DOLs for patient whilst on ACC.

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

Evidence base

Further information is available on the trust intranet safeguarding pages;

Approved By

Adult Critical Care Governance Group

Document history

LHP version 1.0

Related information

Not supplied

Equity and Diversity

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