Children Visiting Psychiatric Wards and Facilities
AMENDMENT
In May 2021, this chapter was refreshed throughout and terminology updated, and additional information was added in to Section 3, Visiting Patients in the Special Hospitals: Ashworth, Broadmoor and Rampton, in line with the High Security Psychiatric Services (Arrangements for Safety and Security) Directions 2019 and associated Guidance.
Contents
- Introduction
- Visiting Patients in Psychiatric Wards
- Visiting Patients in the Special Hospitals: Ashworth, Broadmoor and Rampton
1. Introduction
Visits by children to psychiatric wards or hospitals should be undertaken to maintain a positive relationship for the child with the patient, who will usually be their parent or more rarely a family member such as a sibling. A visit by a child should only take place if it is in their best interest, which must remain paramount and take precedence over the interests of the adults involved when decisions are made about whether visits are appropriate. Any risks to the child should be identified and managed. These may be from the patient or from the environment in which visiting will take place.
When a child visits a psychiatric ward or hospital, they could suffer significant harm through physical, sexual and/or emotional harm (see Recognising Abuse and Neglect Procedure).
This section applies to children visiting all patients receiving in-patient treatment and care from specialist psychiatric services, whether or not they are detained under the Mental Health Act 1983. This includes children visiting detained adolescent patients and adolescents who are being cared for in adult facilities.
2. Visiting Patients in Psychiatric Wards
When children visit adult patients, all psychiatric in-patient settings should:
- Place the child's safety and wellbeing at the heart of professional practice for all staff involved in the assessment, treatment and care of patients;
- Take account of the needs and wishes of children as well as patients;
- Address the whole process, including preadmission assessment, admission, care planning, discharge and aftercare;
- Assess the desirability of contact between the child and patient, identify concerns and assess the potential risks of harm to the child in a timely way;
- Establish an efficient procedure for dealing with requests for child visits in those cases where concerns exist;
- Establish a process for child visits which:
- Ensures the child's safety and wellbeing is safeguarded;
- Is supportive of both the child and the adult;
- Does not cause delay in arranging contact;
- Maximises the therapeutic value of the visit.
- Set and maintain standards for the provision of facilities for child visiting;
- Ensure that staff are competent to manage the process of child visits.
In terms of best practice, child visiting should be supported to take place within child/family visiting areas which have been specifically developed to support an environment which functions independent on the wards (lounge, kitchen, outdoor and toilet facilities). As part of the Risk Assessment, consideration should be given to the need for staff to support visits in these areas in the same way as if they took place on the wards.
A local process is in place at West Park Hospital to support visits to the family area to ensure patient and family safety. This includes the provision of an alarm to family members which they can activate if they have any concerns. The family visiting areas is within the footprint of one of the wards but is entirely separate from the wards in terms of access. This allows patients and their families to feel safe and able to participate in activities such as watching TV, making simple snacks, helping with homework, etc. and includes an outdoor area with a garden and outdoor toys.
The revised Mental Health Act Code of Practice chapter 11 gives guidance on the visiting of psychiatric patients by children. It states that all hospitals should have written policies and procedures on the arrangements for the visiting of patients by children, which should be drawn up in consultation with Children's Services and local safeguarding children partnerships. A visit by a child should only take place following a decision that such a visit would be in the child's best interests. Decisions to allow such visits should be regularly reviewed.
Local policies should ensure that the best interests and safety of the children and young people concerned are always considered and that visits by children and young people are not allowed if they are not in their best interests. The child’s interests must remain paramount and take precedence over the interests of the adults involved when decisions are made about whether visits are appropriate.
Any risks to the child should be identified and managed. These may be from the patient or from the environment in which visiting will take place.
Information about visiting should be explained to children and young people in a way that they are able to understand. Environments that are friendly to children and young people should be provided.
Pre-visit Arrangements
Compulsory admission
When a compulsory admission is planned for an adult who is a parent, the approved mental health professional must assess the child/ren's needs and the suitability of arrangements for their care. If there are concerns (see Children of Parents with Mental Health Problems) about the safety or care arrangements of the child/ren, the approved mental health professional must request that Children's social care undertakes a Child & Family assessment (see Referrals Procedure and Assessment Procedure). Children's social care should make a recommendation to the hospital about the suitability of the children visiting their parent.
The approved mental health professional should, wherever possible, provide the hospital with the child/ren's assessment information. This may, as appropriate, include the recommendation made by Children's social care when the patient was admitted, together with the views of those with parental responsibility about the child/ren visiting the patient in hospital.
Expected visit by a child
The ward manager/nurse in charge is responsible for the decision to allow a visit by a child. When a visit by a child is expected, the ward manager/nurse in charge should consider the available information about the child (as outlined in Pre-visit Arrangements), alongside the assessment of the patient's needs for treatment and care and an assessment of the current state of the patient's mental health. The ward manager/nurse in charge should then make the decision in consultation with other members of the multi-disciplinary hospital team.
The ward manager/nurse in charge must make their decision on the basis of the interests of the child being paramount, superseding those of the adult patient.
Unexpected visit by a child
If a child visits unexpectedly, the ward manager/nurse in charge is responsible for deciding whether it is feasible, whilst they wait, to consider the available information about the child (as outlined in Pre-visit Arrangements), alongside the assessment of the patient's needs for treatment and care and an assessment of the current state of the patient's mental health. The ward manager/nurse in charge should then make the decision in consultation with other members of the multi-disciplinary hospital team. If this is not feasible, the visit must be refused.
Patients admitted informally
Most patients are admitted informally. When a patient has been admitted on an informal basis, nursing staff should seek out information about children who may be visiting. When nursing staff are aware that a patient has a child, and there is a lead professional or adult mental health care co-ordinator working with the patient, nursing staff should check with the lead professional / care co-ordinator about the desirability of children visiting and the arrangements which have been made. Such discussions should be clearly documented.
If there are concerns about the safety or care arrangements of the child/ren (see Identifying concerns below, and Children of Parents with Mental Health Problems) and there is no lead professional involved, the ward manager/nurse in charge must request that Children's social care undertake a Child & Family assessment (see Referrals Procedure and Assessment Procedure). Children's social care should make a recommendation to the hospital about the suitability of the child/ren visiting the patient.
Where Children's social care has been asked to undertake such an assessment, their report should be sent back within 15 working days of receipt of the written request / referral from the ward manager/nurse in charge in order to avoid delay in arrangements for the child.
The ward manager/nurse in charge is responsible for the decision to allow a visit by a child, and must follow the same decision making process for informal admissions and for compulsory admission (see Expected visit by a child above).
In the vast majority of cases where no concerns have been identified, arrangements should be made to support the patient and child and to facilitate contact.
Identifying concerns
Concerns about the desirability of a child visiting may arise in a number of areas. These could relate to:
- Consideration of the child's best interests;
- The patient's history and family situation;
- The patient's current mental state (which may differ from an assessment made immediately prior to or on admission);
- The response by the child to the patient's illness;
- The wishes and feelings of the child;
- The developmental age and emotional needs of the child;
- The views of those with parental responsibility;
- The nature of the service and the patient population as a whole;
- Availability of a suitable environment for contact.
See also Children of Parents with Mental Health Problems.
The hospital multi-disciplinary team should use the Threshold Guidance and Single Assessment procedures to consider the best interests of the child in these situations.
A range of options may present themselves when concerns are identified in any of the areas above, and the concerns need not automatically result in a refusal of visiting. The hospital multi-disciplinary team must consider first and foremost whether the visit is in the best interests of the child.
Decisions to refuse a child's visits
The ward manager/nurse in charge may refuse to allow a child to visit if they have reason to believe it is not in the best interest of the child or patient. The safety and wellbeing of the child is the paramount consideration.
Decisions to refuse visits should be given verbally and confirmed in writing. They must be supported by clear evidence of concerns and the difficulties of managing them.
Policies should clearly set out the steps to be taken in making the decision to refuse visiting, including the process for:
- Consulting with the patient, the child (depending on age and understanding), those with parental responsibility and, if different, person/s with day to day care for the child, advocates and, where relevant, the Children's social care;
- Communicating the decision to the patient, the child, those with parental responsibility, carers, and members of the relevant network;
- Reviewing any decision and the means of communicating this to the patient, advocate or other person or agency involved in the decision;
- Enabling a patient and others with parental responsibility to make representation against any decision not to visit, including access to assistance and independent advocacy. Such a system should be consistent with the Trust's overall complaints procedure and should contain an independent element.
Making arrangements for visits
The hospital or mental health trust providing the service must ensure that the hospital contains facilities for all patients to have contact with their children in a venue which is conducive to the child's safety and good quality contact for both child and patient.
Children should have appropriate supervision according to their age and need when they are visiting mental health service users. They should normally be accompanied by someone who has parental responsibility.
In some cases, it may be better for arrangements to be made for visiting away from the hospital. In the case of detained patients, this will require due consideration of the need for leave. Staff must be aware of the child protection and child wellbeing issues in granting leave of absence under s.17 of the Mental Health Act 1983.
3. Visiting Patients in the Special Hospitals: Ashworth, Broadmoor and Rampton
Visits to high-security psychiatric hospitals must be in accordance with:
- The High Security Psychiatric Services (Arrangements for Visits by Children) Directions (2013) (as amended by the High Security Psychiatric Services (Arrangements for Safety and Security) Directions 2019); and
- Guidance on the High Security Psychiatric Services (Arrangements for Visits by Children) Directions 2013 (as amended by the Guidance on the High Security Psychiatric Services (Arrangements for Safety and Security) Directions 2019).
This guidance also covers local Forensic Units.
Specialist hospitals must have procedures for child visiting that have been developed specifically for that service. Decisions about whether to permit a child to visit a unit must always be based on:
- The interests of the child;
- The service user's offending history;
- The clinical history of the service user;
- The conditions under which the visit will take place.
A hospital may not allow a child to visit any patient unless the hospital's authority has approved the visit and in particular is satisfied that the visit is in the child's best interests.
Request for a Child to Visit
There may be cases where the patient has been:
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Convicted of murder or manslaughter, or an offence which leads to them being identified (by probation / youth justice services, police or health services, individually or via the Multi-Agency Public Protection Arrangements) as posing an ongoing risk to a child; or
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Found unfit to be tried or not guilty by reason of insanity, in respect of a charge of murder or manslaughter or an offence which leads to them being identified (by probation / youth justice services, police or health services, individually or via the Multi-Agency Public Protection Arrangements) as posing an ongoing risk to a child.
In these circumstances, the child must be within the permitted categories of relationship set out in Guidance on the High Security Psychiatric Services (Arrangements for Visits by Children) Directions 2013.
If the patient's circumstances are not those in section above or the child is within the permitted categories of relationship, the nominated officer should:
- Obtain written permission from the patient to contact those with parental responsibility for the child;
- Write to the person/s with parental responsibility for the child:
- Explaining that a request for a visit has been made;
- Asking for confirmation of the relationship between the patient and the child;
- Requesting consent for the child to visit the patient;
- Explaining that before a visit can proceed, Children's social care will be asked to assess whether the visit is in the child's best interests.
- Write to any person/s without parental responsibility but with day-to-day care for the child (e.g. a grandparent), explaining that a request for a visit has been made and that the person with parental responsibility will be contacted.
If the hospital's assessment of the risk of harm posed by the patient to the child does not rule out a visit, the nominated officer must:
- Refer the request to First Contact for advice on whether the visit is in the best interests of the child;
- Include in the request a copy of the hospital's assessment and any other any relevant information about the patient, to assist Children's social care to assess whether the proposed visit is in the child's best interests;
- Include in the request any information about other Children's social care services which have relevant information about the child or the child's family;
- Inform the parents of the child that Children's social care have been asked to make contact with the family.
Children's social care response
On receipt of the request from the hospital (see section above), Children's social care should contact those with parental responsibility (and those caring for the child if they are different) to arrange to undertake an assessment to establish:
- The child's wishes and feelings about the visit, taking account of their age and understanding;
- The child's legal relationship with the named patient;
- The quality of the child's relationship with the named patient, prior to hospitalisation and currently;
- Whether there has been past abuse of the child, alleged or confirmed, by the patient;
- The likelihood of future risks of significant harm to the child if the visits took place;
- The views of those with parental responsibility and, if different, person/s with day-to-day care for the child;
- If it is known the child has lived in other Children's social care areas, what other relevant information is known about the child and family;
- The frequency of contact that would be appropriate.
Children's social care should send the completed assessment report to the nominated officer in the facility, advising whether the visit would be in the best interests of the child.
If Children's social care advises that a visit would be in the child's best interests, the nominated officer in the facility should discuss this with Children's social care and make a decision about the visit, taking account of any potential risk posed by the patient and the potential of significant harm being suffered by the child.
In these cases the assessment must be approved by a Strategic Manager in Children's social care.
Refusing a visit
There are five circumstances in which the nominated officer must refuse to allow a child to visit. These are if:
- The relationship between the patient and the child is not within the permitted categories of relationship. The nominated officer must notify the patient of the decision and reasons for it in writing. However, the patient has no right to make representations against this decision;
- The person/s with parental responsibility responds to the nominated officer stating that they do not agree to the child visiting the patient. The decision and the reasons for the decision must be put in writing to the patient;
- The hospital's assessment indicates that the patient's mental health state and/or risk to children is such (in the immediate or longer-term) that it would not be appropriate for the child to visit the patient. The decision to refuse the visit must be put in writing to the patient and the person with parental responsibility and include details of the complaints procedure;
- The relevant Children's social care service concludes that a visit is not or may not be in the child's best interests. The decision to refuse the visit must be put in writing to the patient, the child (if appropriate), those with parental responsibility, person/s with day to day care for the child, if different, and Children's social care. Details of the review procedure should be given;
- There are concerns about the patient's mental state at the time of the visit. The reasons for the refusal should be explained to the patient, those with parental responsibility, person/s with day to day care for the child, if different, and, if appropriate, the child.
The visit
Any visits by children must:
- Take place in an appropriate atmosphere and setting (i.e. child-centred and child-friendly), taking account of the age of the children (as advised by the Children's social care service local to the hospital) whilst maintaining the required level of security;
- Be properly supervised throughout the visit, with sufficient staff present (of an appropriate grade and with requisite knowledge and understanding and enhanced Disclosure and Barring Service checks - for children, not just vulnerable adults) to supervise the children's visits at all times and to prevent unauthorised contacts;
- Allow the child contact with only the named patient for whom a visit has been approved. No children are to access the ward areas.
The nominated officer in the facility must ensure that a child's contact with a patient within the hospital takes place at a frequency which is in the child's best interests, taking account of advice from Children's social care. All visits by children shall be specifically authorised by the nominated officer and Strategic Manager for Children's social care.
The High Security Psychiatric Services (Arrangements for Safety and Security) Directions 2019 provide that visiting children must not bring food into the secure area (i.e. within the security perimeter) without the specific permission of the responsible clinician.
Where there is NOT a Child Arrangements Order in place under Section 10 Children Act 1989 providing for contact between the child and a person who is a patient in the hospital, visitors, including visiting children, must be subject to a rub-down search and have their possessions inspected before they are permitted to enter the secure area. A rub-down search means a search of the person and the contents of their pockets but does not include a search that involves the removal of any item of clothing other than an outer layer of clothing. Any visiting child must not be permitted to enter the secure area unless the visitor responsible for the child (or the child if of sufficient understanding to make an informed decision about any search or inspection) consents to a rub-down search of the child and to an inspection of their possessions. A rub-down search must be carried out with due regard for the dignity of the person being searched, and by a person of the same sex as the person being searched unless there are exceptional circumstances and the child/responsible adult consents to the search on that basis. Where a visitor (including a visiting child) is not permitted access, the Chief Executive of the hospital shall, if so requested, review that decision and may permit entry subject to such conditions as the Chief Executive requires.
Where there IS a Child Arrangements Order in place under Section 10 Children Act 1989 providing for contact between the child and a person who is a patient in the hospital, and the child and any accompanying visitor is permitted to enter the secure area without being searched or their possessions inspected, entry to the secure area may be subject to such conditions as the Director of Security may require.
All visitors must pass through a metal detection portal on entry except where medical or other extenuating reasons make this impracticable.