Deprivation of Liberty Safeguards Checklist
The Checklist is designed to help decide if a patient / resident is deprived of liberty, based on the
Mental Capacity Act 2005, the Deprivation of Liberty Safeguards (DoLS) and important case law.
It is intended to assist your assessment but it not exhaustive and the final decision must be yours
based upon the individual circumstances of the patient. If you are in any doubt please seek advice
from a senior clinician.
Step 1: Do you have any reason to believe that this person may lack mental capacity in
relation to their care/treatment? If so, proceed to step 2.
Step 2: Carry out a Mental Capacity assessment to ascertain whether the person has
capacity to agree to remain for the purposes of care/treatment. This must be in accordance
with the definition and test in the Mental Capacity Act, Sections 2 and 3.
Factor
1. Is the patient subject to one of the
following:
 Section of the Mental Health Act
 Existing DoLS authorisation
 Order of the Court of Protection
authorising Deprivation of Liberty
2. Does the patient lack capacity to agree to
remain in the hospital for care/treatment?
3. Are the ward doors locked/fixed with other
measures that prevent patients being able
to leave freely? and/or
Would your patient be prevented from
leaving should they wish to?
4. Is the patient subject to continuous
supervision and control by staff, e.g. over
their movements, diet, self-care, activities,
visitors?
5. If the patient is in hospital is there a plan to
discharge them to a nursing or care home
even though it is know that the patient or
relative or both objects?
Alternatively, does the patient lack capacity
to agree to go to a nursing/care home?



Yes
No
Comments
If you have ticked “yes” to this question, a
DoLS application is not required and you
do not need to continue with this checklist.
If you have answered “yes” proceed to
question 3.
If the answer to this is “no”, indicating that
the patient does have the mental capacity
to make this decision, you do not need to
proceed any further with this form and the
patient/resident should be free to leave
should they wish to.
Please tick yes/no to each question
If you have ticked “no” to both questions
in this section, a DoLS application is not
required.
If you have ticked “yes” to either/both
questions in this section, please proceed
to question 4.
If you have ticked “yes” in this section,
please proceed to a DoLS application.
If you have ticked “no”, a DoLS application
may not be required, but discuss with the
Safeguarding Adults Team or the DoLS
Team if you are in doubt
If you have ticked “yes” to either question,
you
should
inform
the
accepting
nursing/care home that a DoLS application
may need to be made by them in advance
of this person’s arrival.
If you have ticked “yes” to Q1, a DoLS application is not required
If you have ticked “yes” to Q2, 3 and 4, a DoLS application should be made unless after
assessment, Section under the MHA is more appropriate
If you have ticked “yes” to Q5, informing the Nursing/Care home accepting the patient that a DoLS
application may be necessary in advance of the person’s arrival.