Visiting of Psychiatric Patients by Children

Safe and regular contact for children should be promoted with patients in psychiatric facilities, whenever it is appropriate to maintain relationships which are of importance to the child.

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.

Special hospitals contain detained patients who are considered very disturbed and should be seen as potentially dangerous. Patients are likely to remain in the setting for considerable periods of time. The setting is also potentially frightening for a child.

When children visit adult patients, all psychiatric in-patient settings should:

• Place child welfare 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 after care;
• 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 manner;
• Establish an efficient procedure for dealing with requests for child visits in those cases where concerns exist;
• Establish a process for child visits which is:
  • Not bureaucratic;
  • Supportive of both the child and the adult;
  • Does not cause delay in arranging contact;
  • Maximises the therapeutic value of the visit;
  • Ensures the child's welfare is safeguarded.
• Set and maintain standards for the provision of facilities for child visiting;
• Ensure that staff are competent to manage the process of child visiting.

The revised Mental Health Act Code of Practice January 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 an assessment that concludes 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.

When a compulsory admission is planned for an adult who is a parent, the approved social worker must assess the children's needs and the suitability of arrangements for their care. If there are any concerns, the Children's Social Care should undertake an assessment and make recommendations to the hospital about the children visiting and present the views of those with Parental Responsibility about the child visiting.

When a patient has been admitted informally, nursing staff should seek out information about children who may be visiting. If there is a Children's Social Care worker or an adult mental health care coordinator involved, the nursing staff must discuss the arrangements for any child visiting. This discussion must be clearly recorded. If there are any concerns and if there is no social worker involved, the ward manager must request that the Children's Social Care undertake an assessment and make recommendations to the hospital about the suitability of the child visiting.

Where Children's Social Care have been asked to undertake an assessment, their report should be sent back within one week of receipt of the written request/referral from the ward manager in order to avoid delay in arrangements for the child.

The ward manager is responsible for the decision to allow a visit by a child.

When a visit by a child is expected, the ward manager should consider the available information about the child alongside the assessment of the patient's needs for treatment and care and of the current state of the patient's mental health. The ward manager should make the decision in consultation with other members of the multi-disciplinary hospital team.

The ward manager must make their decision on the basis of the interests of the child being paramount.

Where a child visits unexpectedly, the visit may be refused if it is not feasible to make a proper assessment while they wait.

A decision to refuse or prohibit visiting by a child may be taken by the ward manager if they have reason to believe that it is not in the child's or patient's best interest for visits to take place.

If any offenders who pose a risk to children are inpatients on the ward children are not permitted to visit on the ward area.

Decisions to refuse visits should be given verbally and confirmed in writing and must be supported by clear evidence of concern and the difficulties of managing them.

The decision must be communicated to the patient, the child and those with Parental Responsibility.

Information about procedures to review any decision or make representations about it must be made available including access to assistance and independent advocacy.

The hospital or mental health trust providing the service must ensure that the facilities for contact are conducive to the child's safety and promotes good quality contact for both child and patient.

Children should have appropriate supervision when they are visiting mental health service users. They should normally be accompanied by someone who has Parental Responsibility or another responsible adult.

In some cases it may be better for visiting to take place 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 protection and child welfare issues in granting leave of absence under Section 17 of the Mental Health Act 1983.

Family Rooms are used for child visits to Mersey Care NHS Trust sites.

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).

Specialist hospitals have procedures specifically developed for the service about child visiting. The decision 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 authority has approved the visit in accordance with the directions pertaining to the patient's admission and in particular is satisfied that the visit is in the child's best interest.

The only exception is where there is a Child Arrangements Order made under the Children Act 1989 which specifies that the child may visit the patient in the special hospital. In such cases, visits should be allowed except where there are concerns about the patient's mental state at the time of the proposed visit, such that the nominated officer decides the visit would not be in the child's best interest.

The request for a child to visit must be in respect of a child within the permitted categories of relationship as set out in the Directions and associated guidance to Ashworth, Broadmoor and Rampton Hospital Authorities (HSC 1999/160 as amended by LAC 2000 (18)):

• If a patient has been convicted of murder or manslaughter, or an offence listed in Schedule 1 to the Sex Offenders Act (1997), or who have been found unfit to be tried, or not guilty by reason of insanity, in respect of a charge of murder or manslaughter or a Schedule 1 offence, the child must be within the permitted categories of relationship as set out below:
  
  
  1. The patient is a parent or relative of the child; or
  2. Has Parental Responsibility for the child; or
  3. Was co-habitating with the parent of the child immediately prior to their detention under the Mental Health Act (1983) and the child was treated as a member of the household.
     
     Prior to any visit being agreed there must always be an assessment by the relevant Children's Social Care where the child lives, in order to determine whether it is in the best interests of the child for a visit to take place. The assessment must state whether it is in the child's best interest to visit a patient and should be conveyed in writing to the hospital within one month of receiving the referral letter from the hospital.

The Directions impose a duty on the Hospital to appoint a nominated officer to consider a request by a patient for a child to visit.

If 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 Services in their area will be asked to assess whether the visit is in the child's best interest.
• Write to any person without Parental Responsibility but with day-to-day care for the child (e.g. grand parent) explaining that a request for a visit has been made and that the person with Parental Responsibility will be contacted.

If a child is Looked After and is subject to a Care Order, Children's Social Care has responsibility for providing consent but the decision should be taken following consultation with those others who also have Parental Responsibility.

Where a child is Looked After but not subject to a Care Order, the person with Parental Responsibility is required to give their consent to the visit.

If a child was not known previously to Children's Social Care, and the person(s) with Parental Responsibility has indicated they will cooperate with the assessment, Children's Social Care should consider this as a request under Section 17 of the Children Act 1989.

However if the parent requesting a visit is a sex offender or, poses a risk of Significant Harm, Children's Social Care should conduct a risk assessment under Section 47 of the Children Act 1989.

If those with Parental Responsibility state that they are prepared to allow their child to visit the patient, the nominated officer should arrange for the patient's clinical team to undertake an assessment.

This assessment is to judge the level of risk, if any, presented by the patient to children and to the particular child for whom the visit request has been made.

If the previous steps have been taken and the hospital's assessment of risk of harm posed by the patient to the child does not rule out a visit, the nominated officer must:

• Contact the Head of Children's Social Care where the child resides to request advice on whether the visit is in the child's best interest;
• Include in the request a copy of the hospital's assessment and any other relevant information about the patient, to assist Children's Social Care to carry out the assessment;
• Include in the request any information about other local authorities which have relevant information about the child and the family;
• Inform the parents that Children's Social Care have been asked to make contact with them.

All requests from the hospitals should be sent to the Quality Assurance Service Manager, Safeguarding Unit. If the request has not proceeded through this route the Service Manager should be notified immediately.

On receipt of the request from the hospital the Safeguarding Manager will:

• Evaluate the information;
• Check any information across electronic and manual records held by the Children's Social Care to see if the child is known; and
• Contact the relevant Children's Social Care team who will undertake the assessment and prepare a report for the nominated officer at the hospital.

Children's Social Care should contact those with Parental Responsibility and those caring for the child (if they are different) as part of the assessment and should seek to establish:

• 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 visit takes place;
• The child's wishes and feelings about the visit taking account of their age and understanding;
• The views of those with Parental Responsibility and, if different, those with day to day care for the child;
• If it is known the child has lived in other local authority areas, relevant information about the child and family from the relevant local authority and any knowledge the Probation Provider in that area may also have of the patient, the child's family or the accompanying adults;
• The frequency of contact that would be appropriate;
• In the case of a child Looked After, the assessment should determine who will accompany the child.

The assessment must make clear recommendations based on the information gathered and must set out clearly the grounds for contact to take place or not, bearing in mind at all times the child's best interests.

Refusal to cooperate - where the person with Parental Responsibility refuses to cooperate with the assessment by Children's Social Care, legal advice should be sought.

If the child is known to Children's Social Care it could make its report on the basis of the information it has already but make clear that the information is not up to date and does not take account of the wishes and feelings of the child. Alternatively, if there is no information about the child, it should inform the hospital that it is unable to make any report.

The completed assessment report must be sent within a month to the nominated officer at the hospital, who will discuss the recommendations with Children's Social Care and make a decision about the visit taking into account any potential risk posed by the patient and the potential likelihood of Significant Harm being suffered by the child.

The decision should take account of:

• The nature (for example, quality and duration) of the child's attachment to the patient;
• Past abuse and/or likelihood of suffering Significant Harm to the child from the named patient;
• The views of the child, taking account of their age and understanding, and of those with Parental Responsibility and, if different, those with day to day care for the child;
• The opinions of professionals who have knowledge of the child;
• The hospital assessment.

A clear judgement should be made whether the visit is, overall, in the child's best interests and if so, the frequency of contact that would be appropriate.

The suitability of the adult or adults who are to accompany the child on a hospital visit should also be considered.

Where visits are agreed, the hospital remains responsible for maintaining an overview of the risks, which may vary according to the health of the patient, other environmental factors and the impact on the child if visiting is allowed. This may involve further liaison with Children's Social Care.

All visits must be properly supervised and all unauthorised contacts are to be prevented.

No children are to visit on ward areas.

The nominated officer 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 interest.

All visits by children shall be specifically authorised by the nominated officer and clear records must be kept.

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.

There are five circumstances in which the nominated officer must refuse to allow a child to visit.

These are if:

• The relationship between the child and the patient is not within the permitted categories of relationship as set out in the Directions. 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 respond 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 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 of 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 of the child, if different, and, if appropriate, the child.

Medium secure hospitals have patients who are detained under the Mental Health Act who are significantly disturbed and may be in hospital for lengthier periods of time, often in excess of a year. The process for agreeing visits operates with a similar degree of formality as those for special hospitals.

Medium secure units also have a nominated officer who administers all requests for children to visit. Where the hospital clinical team concludes, from its own assessments, that a visit is not in the interests of the child, the visit is refused.

Where the hospital clinical team supports the application for a child to visit, a specific member of the clinical team, usually the forensic social worker, will liaise with Children's Social Care which has responsibility for the child if the child is Looked After or Children's Social Care for the area in which the child resides.

The written request from the hospital will ask whether the local authority has information which would suggest that a visit to the named patient would be against the best interests of the child.

Any subsequent assessment carried out by Children's Social Care should cover the same considerations as outlined above in the section on special hospitals.

Where the conclusion of the assessment by Children's Social Care is that the visit is not in the best interests of the child, then the visit will not be allowed. It is the social worker's responsibility to advise the child and family. The hospital will advise the patient.

If visiting is agreed, it remains the responsibility of the clinical team to oversee that the visit remains safe and appropriate for the child, and to take action if the assessment of risk changes. Previous risk assessments from other institutions may not take account of changes in the patient's current risk assessment and/or a child's current circumstances.

It is the nominated officer who authorises visits when the assessments have been completed and who will ensure that the child's best interests will remain paramount.

All medium secure units will have systems in place to oversee that visits by a child are conducted in a safe and appropriate environment and that there are records maintained of all visits. This will include a record of the patient's behaviour, any problems which occurred, any concerns regarding the behaviour of the parent and the response of the child.

The decision to refuse visits to children in these facilities should be a rare exception and one which identifies clear risk to the child, either physically or emotionally, which would negate the value of the visit for the child.

For all patients the hospital clinical team will assess, at the point of admission, the specific needs of the patient and the child with regards to child visiting arrangements. In most instances this will lead to a decision that visiting can proceed.

The facility will ensure that visits by a child are conducted in safe and appropriate conditions. For example, each ward will provide an appropriate area for use as a visiting venue. Records should also be maintained of all visits, which include notes of the patient's behaviour, any problems which occurred, any concerns regarding the behaviour of the parent and the response of the child.

If there are specific concerns that the patient may pose a risk to a child who visits, Children's Social Care should be contacted and asked to assess these risks. The assessment will then cover the same issues as outlined in the previous section.

The outcome of the assessment needs to be communicated directly to the nominated officer at the Hospital. This should include a statement about whether in the view of Children's Social Care it is in the interests of the child for visits or other types of contact to be permitted and the reasons for the decision are to be set out.

In order to maintain up-to-date records, the Safeguarding Unit needs to be informed of the outcome of the assessment once it is completed. A copy of the recommendations must be sent to the Safeguarding Manager.

Each Director of Children's Services is required to set up a system for monitoring the implementation of this guidance and report to LSCP on a quarterly basis. The Quality Assurance Service Manager will provide quarterly reports to LSCP.

In order to monitor the implementation the report must be sent to the Service Manager, who will be responsible for assessing and monitoring this procedure and to consider whether recommendations are consistent with overall protection of the child. The report must be received within 25 days of the request being received from the hospital which will allow for an agreed response within 28 days of receipt of the initial request.