This learning came from a SAR referral where the remit of a CTO was not fully understood by non-mental health trust partners supporting an individual with complex needs. This fits in with the theme 'Collaborative working and decision-making".

The Safeguarding Adult Review Group felt that the wider partnership would benefit from the overview below.

What is a Community Treatment Order?

• If a person is receiving treatment for their mental disorder in hospital under some types of treatment order (section), the person in charge of the treatment (responsible clinician) can arrange for the person to be discharge from hospital on to a Community Treatment Order.
• If the responsible clinician puts a person on a CTO, it means that they feel that treatment can be delivered in the community instead of in a hospital. 
• An approved mental health professional needs to agree that a CTO is appropriate and necessary.
• The underlying section is ‘suspended’ whilst a person is on a CTO.

CTO conditions

• The CTO will have some conditions attached.  These conditions are put in place to ensure that a person remains well in the community.  The conditions will be discussed with the person and the team before discharge.
• CTOs always include two mandatory conditions: 

1. To meet with the responsible clinician for an assessment to extend the CTO before it expires, and

2. To meet with a second opinion appointed doctor, if asked to.

• Other non-mandatory conditions might include medication or attending appointments with the community team.

Treatment in the community

• The responsible clinician will discuss the medical treatment with the patient and complete a consent certificate if the person has capacity to accept treatment, and consents to it.
• If a person lacks capacity to consent or refuses to give consent, a second opinion appointed doctor will be asked to review the treatment plan to ensure the proposed treatment is appropriate.
• Even if a second opinion appointed doctor authorises the treatment, a CTO patient may still refuse the treatment.  Treatment may not be provided in the community if a CTO patient refuses it.

Extending the CTO

• The initial CTO lasts for six months.  Before the CTO expires, the responsible clinician will meet with the patient to consider whether the CTO needs to be extended.
• If the responsible clinician feels the CTO needs to continue, they can extend it for up to six months.
• After that, the responsible clinician can extend the CTO for up to a year at a time.

Automatic recall to hospital

• If a person fails to meet one of the two mandatory conditions, they may be automatically recalled back to hospital in order to meet with the responsible clinician or second opinion appointed doctor.
• If a person fails to meet any of the non-mandatory conditions, such as accepting medication, recall is not automatic. 

When is recall necessary?

• Recall to hospital may be necessary if the responsible clinician feels they are too unwell to be treated safety in the community.
• A person is able to consent to a period of informal admission.  Otherwise, the CTO allows the responsible clinician to recall them to hospital for treatment very quickly without a full mental health act assessment.
• Unless a person has failed to meet one of the two mandatory conditions, the person may only be recalled to hospital if they meet the recall criteria.  The criteria for recall are similar to the criteria for the original detention, namely that the person is suffering from a mental disorder of a nature or degree that warrants hospital treatment.
• A written notice of recall must be provided to the patient to inform them they are being recalled to hospital and the reason why.
• The person can make their own way to hospital or an ambulance or the police might be required to return the person to hospital.
• If it is necessary a warrant of entry can be sought from the courts to compel recall to hospital.
• A recalled CTO patient who fails to return to hospital is considered to be absent without leave.

Revoking (ending) the CTO

• The CTO recall lasts up to 72 hours during which time the person will be assessed by the inpatient team, and a decision will be made whether they can again be discharged home, or whether they require a further period of treatment in hospital. 
• The person can accept informal admission at this stage. If the person accepts informal admission, the CTO continues whilst they remain in hospital.
• If the person lacks capacity to consent to informal admission, or if they refuse, the CTO may be ended (revoked). 
• An approved mental health practitioner needs to agree that the CTO needs to be revoked.
• The effect of revoking the CTO is that the CTO ends, and the underlying ‘suspended’ section comes back into force

Rights of a person on a CTO

• Anyone on a CTO has the legal right to receive support from an independent mental health advocate
• A person subject to a CTO may appeal against their CTO to the Mental Health Tribunal.
• If a CTO is revoked, the hospital will automatically refer the matter to the Mental Health Tribunal.