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The following form is to be used:
where the conditions for the granting of an extension certificate to a short term detention are met.
Short Term Detention Extension Certificate
DET
The Mental Health (Care and Treatment) (Scotland) Act 2003 (the Act)
There is no statutory requirement that you use this form but you are strongly recommended to do so. This form draws attention to some procedural requirements under the Mental Health (Care and Treatment) (Scotland) Act 2003. Failure to observe procedural requirements may invalidate the certificate
Instructions v7.
Where not completing this form electronically, to ensure accuracy of information, please observe the following conventions:
Where a text box has a reference number to the left, you can extend your response on plain paper where there is insufficient space in the box. Extension sheet(s) should be clearly labelled with Patient's name and CHI number, and each extended response should be labelled with the appropriate text box reference number.
Write clearly within the boxes in BLOCK CAPITALS and in BLACK or BLUE ink
Shade circles like this -> Not like this ->
For example
Patient Details
Surname
First Name(s)
Other / Known as
Title
DoB dd / mm / yyyy
Postcode
CHI Number
Patient's home address
Gender Male Female
'Other / Known As' could include any name / alias that the patient would prefer to be known as.
Surname
First Name
Hospital
Ward / Clinic (if appropriate)
Title GMC Number
Health Board
Approved under section 22 of the Act by:
Approved Medical Practitioner Details
NHS
To be completed by the Approved Medical Practitioner
Detention Criteria
PART 1 - EXTENSION CERTIFICATE
As the AMP named on page 1, I declare that I have examined the patient. I am granting this extension certificate because I believe the patient meets the criteria set out in section 44(4) (a) to (d):
(a) I consider that it is likely, for the reasons stated below, that the patient has the following type(s) of mental disorder -
(b) I consider, for the reasons stated below, that because of the mental disorder, the patient's ability to make decisions about the provision of medical treatment for that mental disorder is significantly impaired.
(c) I am satisfied, for the reasons stated below, that it is necessary to detain the patient in hospital for the purpose of:
determining what medical treatment should be given to the patient; or giving medical treatment to the patient;
to the health, safety or welfare of the patient; or to the safety of any other person; and
(d) I consider that it is likely, for the reasons stated below, that if the patient were not detained in hospital there would be a significant risk-
Mental illness Yes No
Yes No
Yes No
Personality disorder
Learning disability
Primary ICD 10 Code F
F
F
Please enter primary ICD 10 diagnosis code for each disorder present.
PART 1 - EXTENSION CERTIFICATE (cont) (^) To be completed by the Approved Medical Practitioner
I authorise the detention of the patient in -
The detention in hospital is valid for the period beginning with the expiry of the short-term detention certificate and ending at midnight at the end of the 3rd subsequent working day.
eg: a short-term detention certificate ceases to authorise the patient's detention at midnight at the end of Friday. The extension certificate is therefore valid from midnight at the start of Saturday through to midnight at the end of Wednesday.
CERTIFICATION
I, the AMP, examined the patient on:
at
Date dd / mm / yyyy
time 24 hr clock
Hospital
Ward / Clinic
2. "Guardian" means a person appointed as a guardian under the Adults with Incapacity (Scotland) Act 2000 (asp 4) who has power by virtue of section 64(1)(a) or (b) of that Act in relation to the personal welfare of a person 3. "Welfare attorney" means an individual authorised, by a welfare power of attorney granted under section 16 of the Adults with Incapacity (Scotland) Act 2000 (asp 4) and registered under section 19 of that Act, to act as such 1. Notice to include: notice of the granting of the certificate; the AMP's reasons for why s/he believed the conditions in section 44(4) (a) to (d) (as detailed on page 2) are met in respect to the patient; as to whether the consent of the MHO was obtained to the granting of the certificate; and if the certificate was granted without consent to its granting having being obtained from the MHO, the reason why it was impracticable to consult the MHO.
Notes
The patient's named person (if any)
The patient
The Mental Welfare Commission
The Mental Health Tribunal for Scotland
The patient's MHO
Any welfare attorney of the patient (see note 3)
Any guardian of the patient (see note 2)
Notice (see note 1) will be given to the following parties within 24 hours beginning with the granting of the certificate.
A copy of the whole of form DET 4 will be sent to the following parties within 24 hours beginning with the granting of the certificate. -
PART 2 : RECORD OF NOTIFICATION (^) To be completed by the Approved Medical Practitioner
I certify that I have no conflict of interest as defined by the regulations
Signed by the AMP granting this certificate
at
Date dd / mm / yyyy
time 24 hr clock
The extension certificate MUST be granted within 24 hours of the completion of the medical examination. This certificate must be given to the hospital managers within 24 hours beginning with the granting of the certificate.
The extension certificate is valid from the beginning of: Date dd / mm / yyyy / /
