Deprivation of Liberty Safeguards:
Practice and Procedures Policy
Version
2
Name of responsible (ratifying) committee
Safeguarding Committee
Date ratified
29 September 2015
Document Manager (job title)
Adult Safeguarding Lead Nurse
Date issued
01 October 2015
Review date
30 September 2017
Electronic location
Clinical Policies
Related Procedural Documents
Mental Capacity Act Policy, Consent Policy,
Safeguarding Adults Policy, DH Restraint Guidance
2014, Restraint Policy
Key Words (to aid with searching)
Mental capacity act; capacity assessment; best
interests; deprivation of liberty safeguards
Version Tracking
Version
Date Ratified
Brief Summary of Changes
Author
2
29.09.2015
Policy reviewed and updated in line with Supreme Court
Ruling (March 2014) and Department of Health guidance
issued January 2015.
Adult
Safeguarding
Lead Nurse
Deprivation of Liberty Safeguards Policy
Version: 2
Issue Date: 01 October 2015
Review Date: 30 September 2017 (unless requirements change)
Page 1 of 32
CONTENTS
QUICK REFERENCE GUIDE…………………………………………………………………………………..3
1. INTRODUCTION…………………………………………………………………………………………5
2. PURPOSE…………………………………………………………………………………………………..5
3. SCOPE………………………………………………………………………………………………………6
4. DEFINITIONS………………………………………………………………………………………………6
5. DUTIES AND RESPONSIBILITIES………………………………………………………………………7
6. PROCESS
6.1. DETERMINE IF A DOLS IS REQUIRED……………………………………………………………7
6.2. APPLYING FOR A DOLS AUTHORISATION……………………………………………………….8
6.3. COMPLETING THE DOLS APPLICATION FORMS………………………………………………10
6.31. WHO COMPLETS THE FORMS……………………………………………………….…..10
6.32. WHERE TO SEND THE FORMS…………………………………………………….…….10
6.4. WHO TO NOTIFY……………………………………………………………………………………..12
6.5. WHAT HAPPENS NEXT…………………………………………………………………………….12
6.51. DOLS IS GRANTED…………………………………………………………………………....13
6.52. DOLS IS REFUSED……………………………………………………………………………13
6.6. A PATIENT DIES WHILST SUBJECT TO A DOLS AUTHORISATION………………….……14
6.7. UNAUTHORISED DEPRIVATIONS OF LIBERTY………………………………………………...14
7. TRAINING REQUIREMENTS…………………………………………………………..……………….15
8. REFERENCES AND ASSOCIATED DOCUMENTATION…………………………………….……15
9. EQUALITY IMPACT STATEMENT……………………………………………………………….……15
10. MONITORING COMPLIANCE WITH, AND EFFECTIVENESS OF, PROCEDURAL
DOCUMENTS……………………………………………………………………………………………17
APPENDIX 1: DOLS FORM 1 – STANDARD AND URGENT DOLS REQUEST………………….18
APPENDIX 2: DOLS FORM 2 - FURTHER REQUEST FOR A FURTHER STANDARD
AUTHORISATION…………………………………………………………………………………………25
APPENDIX 3: GUIDANCE FOR COMPLETING DOLS APPLICATION FORMS …………………27
Deprivation of Liberty Safeguards Policy
Version: 2
Issue Date: 01 October 2015
Review Date: 30 September 2017 (unless requirements change)
Page 2 of 32
Patient lacks mental capacity to consent to hospital accommodation and meets the Acid Test
and admission is likely to last more than a matter of days or there are high risk DOLS triggers
QUICK REFERENCE GUIDE
(1)
Application Process for DOLS Authorisation (from 05/10/2015)
The Standard DOLS
Authorisation Expires and a
DOLS is still required
Complete DOLS Form 2
Trust DOLS signatories
(team with clinical responsibility
for the patient):
 ST3 and above
Out of hours:
 Duty Matron
 Hospital@Night
An Urgent DOLS Authorisation
comes into force as soon as
the DOLS application is
completed and signed.
Email copy of form to:
Complete DOLS Form 1
pages 1-6
Explanation to patient
and relatives


PHT DOLS Group mailbox
Retain original form in
medical notes
Ensure patient is given a
copy of all DOLS
documentation prior to
them leaving hospital
Email updates to PHT DOLS Group mailbox if:
Patient is discharged / dies
DOLS no longer required (Include reason)
A ‘death in DOLS’ (Valid Urgent or Standard
Authorisation) = a death in State Custody.
The Coroner must be informed. Ensure your email
includes confirmation that Coroner has been notified.
Deprivation of Liberty Safeguards Policy
Version: 2
Issue Date: 01 October 2015
Review Date: 30 September 2017 (unless requirements change)
DOLS
GRANTED
Await outcome of DOLS
Office Assessments.
‘Lapsed’ Urgent
DOLS
You can lawfully detain the patient in
hospital until:
 Their mental capacity to consent /
refuse to being accommodated in
hospital returns
 They are transferred to another
care provider / discharged to a
safe destination
 You would no longer prevent
them from leaving hospital
 The Standard DOLS authorisation
expires
DOLS NOT
GRANTED
Work in the patients Best Interests:
 Continue to accommodate
and treat in the patients Best
Interests
 Complete ‘lapsed DOLS’ datix
 Request priority assessment
from DOLS Office if any high
risk DOLS triggers
Page 3 of 32
 Consider alternatives to treatment
and accommodation
 Seek senior clinical / legal advice if
unsafe to be discharged
 Allow to leave hospital taking all
reasonable care to ensure safety
e.g. TTO’s, inform GP
 Ask for 2nd opinion (DOLS and/or
Mental Health)
QUICK REFERRENCE GUIDE (2)
The Acid Test
A person may be considered to be deprived of their liberty if they lack the
mental capacity to consent to accommodation in hospital (or care home) if:
The person is subject to
continuous supervision
and control
•Is the oversight continuous? (The person does not
need to be in direct line of sight)
•Does the care regime amount to supervision?
•Is there a clear element of control?
AND
The person is NOT free
to leave
•The patient (or their relatives) does NOT need to
request discharge
 The patient does NOT have to make meaningful
attempts to leave
 Would you stop them if they tried to leave
hospital? (Allowing the person to leave the ward
(e.g. to the shop) but not to leave the hospital
grounds would still be a deprivation of their
liberty).
•Does the care regime amount
supervision?
•Is there a clear element of control?
to
High Risk triggers for applying for DOLS / Taking a Lapsed DOLS to the Court of Protection
• Patient (or family) stating they wish to leave hospital
• Repeated use of physical or chemical restraint to prevent the person leaving / control
behaviour
• Family attempting to remove the person from hospital against medical advice
 Restrictions on family / friend contact
• LPA believed to be acting in their own interests rather than the patients Best interests
• Serious conflict between professionals and / or family regarding Best Interests
• Nursing 'special' required for non-clinical reasons
• Adult Safeguarding concerns
Re-assess mental capacity of the person to make their own decision
Please seek senior clinical advice
Deprivation of Liberty Safeguards Policy
Version: 2
Legal advice can be obtained 24/7 of a serious issue arises out of hours
Issue Date: 01 October 2015
Review Date: 30 September 2017 (unless requirements change)
Page 4 of 32
1. INTRODUCTION
The Deprivation of Liberty Safeguards (DOLS) were introduced in April 2009 and are part of the
Mental Capacity Act 2005 (MCA). These safeguards are an important way of protecting the rights
of vulnerable people.
Depriving a person of their freedom may breach a person’s human right to liberty Article 5 (1)
European Convention of Human Rights and Article 5(4), the right to have the lawfulness of
detention reviewed by a court. The safeguards protect people who lack the ability to make certain
decisions for themselves and ensure their freedom is not inappropriately restricted.
Whilst every effort should be made to avoid depriving a person of their liberty, in certain
circumstances it can be a necessary requirement to enable provision of effective care or treatment.
The DOLS authorisation provides the legal framework and protection, when a deprivation of liberty
is considered to be unavoidable, by allowing hospitals (and care homes) to accommodate a person
in their best interests as defined by the MCA. Care must always be taken to ensure that if
deprivation of liberty cannot be avoided, it should be for no longer than is necessary.
DOLS are underpinned by the five key principles of the Mental Capacity Act:
 A presumption of capacity - every adult has the right to make his or her own decisions
and must be assumed to have capacity to do so unless it is proved otherwise;
 The right for individuals to be supported to make their own decisions - people must be
given all appropriate help before anyone concludes that they cannot make their own
decisions;
 That individuals must retain the right to make what might be seen as eccentric or unwise
decisions;
 Best interests – anything done for or on behalf of people without capacity must be in their
best interests; and
 Least restrictive intervention – anything done for or on behalf of people without capacity
should be the least restrictive of their basic rights and freedoms.
In 2014 the Supreme Court reviewed the circumstances of three people (“P v Cheshire West and
Chester Council and another” and “P and Q v Surrey County Council”). Previously the Courts had
ruled all three people were not deprived of their liberty, however the Supreme Court ruling
overturned this, determining that all 3 were in fact deprived of their liberty.
The Supreme Court ruling introduced the ‘Acid Test’ to determine whether or not someone is
being deprived of their liberty and applies when an individual lacks capacity to make a decision
about being accommodated in hospital:
 Is the person subject to continuous supervision and control?
The oversight must be continuous (though does not have to be ‘in line of sight’), must
amount to supervision, and have a clear element of control.
AND
 Is the person free to leave?
The person may not be asking to go or showing by their actions that they want to leave but
the issue is about how staff would react if the person did try to leave or if relatives/friends
asked to remove them.
2. PURPOSE
The guidance within this policy is intended to ensure the Trust discharges its duty under the MCA
and DOLS legislation and meets the requirements of its registration with the Care Quality
Commission.
This policy outlines the legal framework around DOLS and gives guidance on the local policies,
practice and procedures that should be followed by Portsmouth Hospitals NHS Trust staff when
working with individuals who may lack mental capacity or are(or may become) deprived of their
liberty.
Deprivation of Liberty Safeguards Policy
Version: 2
Issue Date: 01 October 2015
Review Date: 30 September 2017 (unless requirements change)
Page 5 of 32
All persons working in a professional or paid role with people who may lack mental capacity have a
legal duty to have regard to the Mental Capacity Act Code of Practice. Staff should view this
guidance as supplementary to the statutory Mental Capacity Act Code of Practice and the DOLS
Code of Practice. http://pht/Departments/safeguarding-adults/default.aspx
3. SCOPE
All staff working within the Trust are likely to come into contact with vulnerable people who may
lack the mental capacity to consent to care or treatment where it may be necessary to deprive that
person of their liberty, in their best interests, in order to protect them from harm.
This policy applies to persons aged 18 years and over only. In circumstances where a person aged
17 years or under may be deprived of their liberty please contact either the Child Safeguarding
department on ext. 4314 or the Legal Department on ext. 6527 for advice (or via Hospital Duty
Manager out of Hours).
Assessing mental capacity and making decisions for those unable to do so for themselves is an
interdisciplinary and/or multidisciplinary issue. Therefore, this policy applies to all permanent,
locum, agency and bank staff of Portsmouth Hospitals NHS Trust and the MDHU (Portsmouth),
including doctors, nurses, allied health professionals, support staff, social care professionals and
managers.
Whilst the policy outlines how the Trust will manage DOLS it does not replace the personal
responsibilities of staff with regard to issues of professional accountability for governance.
In the event of an infection outbreak, flu pandemic or major incident, the Trust recognises that it
may not be possible to adhere to all aspects of this document. In such circumstances, staff should
take advice from their manager and all possible action must be taken to maintain ongoing patient
and staff safety.
4. DEFINITIONS
DOLS - Deprivation of Liberty Safeguard: a legal authorisation that allows a managing authority
(hospital or care home) to deprive someone who lacks mental capacity of their liberty.
Mental capacity: Mental capacity is the ability of an individual to make decisions about specific
aspects of their life.
Mental Incapacity: an inability to make a specific decision at a particular time due to “an
impairment or disturbance in the functioning of their mind or brain”.
A person may be assessed as lacking capacity if they have any impairment of the brain or mind,
and are unable to do one or more of the following :




Understand information given to them
Retain that information long enough to be able to make a decision
Weigh up the information available to make a decision
Communicate their decision
Managing Authority: the organisation responsible for the care home or hospital applying for the
DoLS authorisation i.e. Portsmouth Hospitals NHS Trust.
Supervisory Body / Authority: the Local Authority which covers the person’s normal place of
residence. Local Authorities are responsible for considering a DoLS request, arranging the
required independent assessments and agreeing or denying a DoLS authorisation.
Deprivation of Liberty Safeguards Policy
Version: 2
Issue Date: 01 October 2015
Review Date: 30 September 2017 (unless requirements change)
Page 6 of 32
5. DUTIES AND RESPONSIBILITIES
Chief Executive will ensure that the Trust complies with relevant legal and statutory requirements
related to the Deprivation of Liberty Safeguards.
All Consultants should have a working knowledge of the MCA Code of Practice and DOLS
legislation, will act as decision makers and are responsible for ensuring their teams complete the
relevant assessments and documentation. They will also provide guidance within their teams.
All Managers must be aware of Trust Policy and Guidelines and ensure their staff comply with the
requirements of these documents.
The Learning and Development Department will facilitate the collection of training data and
support training and induction programme delivery.
Clinical Service Centre Management Teams will identify key clinicians to undertake additional
training and ensure effective cascade of key information to staff groups.
Medical staff (ST3 and above) are designated signatories for the DOLS application.
Duty Matrons and Hospital@Night can act as designated DOLS signatories out of hours if
required.
Individual members of staff must ensure they follow this policy.
Safeguarding Adult Lead Nurse is responsible for collation of DOLS data, reporting of any known
instances of an unauthorised DOLS and completion of the required CQC DOLS notifications. They
will also provide advice and training to Trust staff to ensure compliance with MCA.
CSC Safeguarding Operational Leads will act as a first line of contact and information resource
within their area and across the Trust, providing advice, support and education as required.
6. PROCESS
6.1 Determine if a DOLS Authorisation is required (See table 1)
A DOLS authorisation can only be granted to a person who lacks mental capacity to make a
decision about hospital accommodation due to a mental disorder (disturbance / disorder of the
mind). The mental disorder must directly relate to the person inability to make the relevant
decision. (Department of Health (DH) guidance states that unconsciousness in itself is not
considered to be a mental disorder).
It is important to bear in mind that, while the deprivation of liberty might be for the purpose of giving
a person treatment, a DOLS authorisation does not itself authorise treatment. Treatment that is
proposed following authorisation of deprivation of liberty may only be given with the person’s
consent (if they have capacity to make that decision) or in accordance with the wider provisions of
the MCA.
The Supreme Court ruled that the following factors are no longer relevant to whether or not
someone is deprived of their liberty:
 the person’s compliance or lack of objection;
 the suitability or relative normality of the placement (after comparing the person’s
circumstances with another person of similar age and condition);
 the reason or purpose leading to a particular placement.
It is always necessary in each case to consider further:
1. Whether the Deprivation of Liberty lasts more than a negligible period of time. The DOLS
Code of Practice suggests that unless a Standard DOLS Authorisation will be required then
an application may not be necessary. ‘Negligible’ is not defined in law and in the short term,
Deprivation of Liberty Safeguards Policy
Version: 2
Issue Date: 01 October 2015
Review Date: 30 September 2017 (unless requirements change)
Page 7 of 32
Table 1
Is a DOLS indicated?
(Adult patients over 18 years of age only)
Has the person got a mental disorder?
YES: assess mental capacity to make the
decision about hospital accommodation.
NO: A DOLS authorisation cannot be used.
Did the person give consent to the care and
treatment regime e.g. the patient gives advance
consent whilst they still have capacity (surgery,
elective procedures etc).
YES: A capacitous person has consented to the
care and treatment regime. No further action
required.
NO: continue to the next question
Is there reason to doubt the patient’s mental
capacity to make decisions about being
accommodated in hospital?
YES: continue to next question
Does the Mental Health Act apply?
YES: A DOLS authorisation should not be used.
Apply the relevant MH Section now.
NO: apply the Acid Test.
Is the Acid Test met?
 Is the person subject to continuous supervision
and control? The oversight must be continuous
(though does not have to be ‘in line of sight’), it
must amount to supervision, and have a clear
element of control.
AND
 Is the person free to leave? The person may
not be asking to go or showing by their actions
that they want to but the issue is about how
staff would react if the person did try to leave or
if relatives/friends asked to remove them.
YES: The patient is being deprived of their
liberty.
Can the necessary care / treatment be provided in
another setting or manner that would avoid
depriving the person of their liberty?
If care could be provided elsewhere but this option
is not currently available (e.g. awaiting placement in
care home) the answer is NO
NO: Determine if a DOLS is required now or
whether the powers of the MCA alone can be
utilised.
DOLS high Risk Triggers present?
YES: Seek senior advice and consider DOLS
application immediately.
NO: A DOLS authorisation cannot be used.
NO: A DOLS authorisation cannot be used.
YES: A DOLS authorisation cannot be used
NO: The patient is being deprived of their
liberty
YES: make alternative arrangements. DOLS will
not be required as the person will not be deprived
of their liberty.
NO: Consider using the powers of the MCA alone.
*Anticipated to regain mental capacity within 7
days OR
Predicted Discharge Date of less than 7 days
YES: Use the MCA. Complete Trust MCA
Admission form.
No: Apply for DOLS.
*The DOLS Code of Conduct suggests that an urgent authorisation should not be used where there is no
expectation that a standard deprivation of liberty authorisation will be needed.
Deprivation of Liberty Safeguards Policy
Version: 2
Issue Date: 01 October 2015
Review Date: 30 September 2017 (unless requirements change)
Page 8 of 32
For example:
•
When treatment of the underlying physical illness is expected to lead to rapid resolution of
the mental disorder such that a standard deprivation of liberty authorisation would not be
required. It would not be appropriate to give an urgent authorisation simply to legitimise the
short-term deprivation of liberty.
•
When a person is in an accident and emergency unit or a care home, and it is anticipated
that within a matter of a few hours or a few days the person will no longer be in that
environment
2. the powers of the MCA alone can be utilised. In the absence of high risk DOLS triggers (see
below)Trust guidance is up to 7 days.
3. Whether the person is able to give consent to the deprivation e.g. the patient gives advance
consent whilst they still have capacity.
DOLS High Risk trigger factors








Patient (or family) stating they wish to leave hospital
Repeated use of physical or chemical restraint to prevent the person leaving / control
behaviour
Family attempting to remove the person from hospital against medical advice
Restrictions on family / friend contact
LPA believed to be acting in their own interests rather than the patients Best interests
Serious conflict between professionals and / or family regarding Best Interests
Nursing 'special' required for non-clinical reasons
Adult Safeguarding concerns
Does the Mental Health Act 1983 apply?
When a person lacking mental capacity is in a hospital or care home receiving treatment for a
mental disorder and is/is likely to have their liberty deprived, consideration should be given to use
the provisions of the Mental Health Act rather than DOLS. If the person fits the criteria for a mental
health section to be applied then that should be the chosen route.
A mental health section does not normally allow treatment of a physical problem or illness that is
unrelated to their mental health condition. In these circumstances a DOLS may be required, but
the law is complex so senior clinical and legal advice should be sought.
Factors that may indicate use of the Mental Health Act rather than DOLS include:
• The patient’s lack of capacity to consent to treatment and care is fluctuating or temporary and the
patient is not expected to consent when they regain capacity. This may be particularly relevant to
patients having acute psychotic, manic or depressive episodes;
• A degree of restraint needs to be used which is justified by the risk to other people but which is
not permissible under the MCA as it cannot be said to be proportionate to the risk to the patient;
and There is some other specific identifiable risk that the person or others might potentially suffer
harm as a result. For example, if there is a risk that the person may need to be returned to the
hospital or care home at some point in a manner that would not be authorised under DOLS.
DOLS and Critical Care (E5 ward only)
Due to level of chemical restraint (sedation), observation and monitoring that occurs when
someone requires admission to a Critical Care unit (Intensive Care) it could be considered that the
majority of patients cared for within this environment will meet the Acid Test. There is varied
practice across the country with regard to DOLS applications in this situation, and Case Law does
not yet give clear guidance.
Deprivation of Liberty Safeguards Policy
Version: 2
Issue Date: 01 October 2015
Review Date: 30 September 2017 (unless requirements change)
Page 9 of 32
Taking into consideration the DH stance on unconsciousness, until further guidance is issued Trust
guidance in relation to DOLS in critical care (E5 ward) can be seen in Table 2:
Table 2:
DOLS in Critical Care (E5 ward)
DOLS Application will not normally be made
when:
DOLS Application should be considered
when:
A capacitous patient has consented to an
elective procedure in the knowledge that
admission to the critical care unit is likely / a
possibility.
Continuous sedation is discontinued. Lack of
capacity to consent to ongoing hospital
accommodation persists and exceeds Trust
guidance on using the powers of the MCA alone
i.e. 7 days. Day 1 = the day sedation is
discontinued.
OR
A patient is admitted to critical care in an
emergency situation and mental capacity for
admission cannot be immediately assessed e.g.
due to unconsciousness / severity of sudden
illness and capacity cannot be assessed due to
on-going continuous sedation.
AND
Next of Kin are in agreement with treatment and
care plan.
OR
There is conflict between professionals and next
of kin / family regarding care and treatment of
the patient.
OR
High risk DOLS triggers during the MCA period,
as per Table 1.
AND
Any patient who has not triggered a DOLS
application should be reviewed at least every 28
days.
When can’t a DOLS be used?
 The person is under 18 years of age;
 The person has made a valid and applicable Advance Decision refusing a necessary
element of treatment for which they were admitted to hospital (see MCA Policy)
 The use of the safeguards would conflict with a decision of the persons attorney or Deputy
of the Court of Protection;
 The patient lacks capacity to make decisions on some elements of the care and treatment
they need, but has capacity to decide about a vital element and has already refused it or is
likely to do so.
 If the main reason is to restrict contact with individuals who may cause the person harm. If
it is believed to be in a person’s best interests to limit contact an application should be
made to the Court of Protection.
6.2 Applying for a DOLS Authorisation
There are two types of DOLS authorisation:
• Urgent Authorisation – An Urgent DOLS must be applied if the person is being deprived of
their liberty at this point in time. This is applied by a Managing Authority (i.e. the Trust) and is
effective immediately once the form is completed and signed. It lasts a maximum of 7
calendar days (day 1 being the day of application). An application for a standard DOLS must
be made at the same time in order to trigger independent DOLS assessment (Appendix 1
pages 1-6) . Without this, the urgent DOLS may be considered unlawful.
In exceptional circumstances at the request of the DOLS office only, an Extension to an
Urgent DOLS can be granted for a further period of 7 days. (see Appendix 1 page 7)
Deprivation of Liberty Safeguards Policy
Version: 2
Issue Date: 01 October 2015
Review Date: 30 September 2017 (unless requirements change)
Page 10 of 32
• Standard Authorisation – this is granted by a supervisory body (Local Authority DOLS
Office) following independent assessment. This is always used in conjunction with an urgent
authorisation but could be applied for on its own in anticipation of a future need for DOLS
e.g. elective surgery for someone who is under a DOLS in a care home. If granted, a
standard DOLS will have an expiry date, with a maximum of 1 year being granted. The time
granted is dependent on the individual circumstances.
Before granting an urgent authorisation, the managing authority should try to speak to the family,
friends and carers of the person. Their knowledge of the person could mean that deprivation of
liberty can be avoided. The managing authority should make a record of their efforts to consult
others.
In the situation where the person to be admitted is already subject to a DOLS authorisation in a
care home, then it is very likely that the Trust will need to apply for DOLS authorisation in order to
effect admission. For elective cases this can be applied for in advance of the planned admission
date and it is the admitting clinicians’ responsibility to ensure this is completed.
6.3 Completing the DOLS application forms.
Within the acute hospital, it is most common that a deprivation of liberty occurs suddenly and
unexpectedly e.g. an emergency admission situation or as a result of a clinical deterioration. In
these circumstances, when the deprivation is already occurring and cannot be avoided, the Trust
as the managing authority must apply an Urgent DOLS Authorisation and request a Standard
DOLS. Once DOLS forms are completed and signed it is legal to prevent the person leaving
hospital.
Form
1
Form Name
Standard Request, Urgent
When
 To put in place Urgent DOLS and
Authorisation and Extension to Urgent
request a Standard DOLS

To request a Standard DOLS in advance

Extension of the Urgent DOLS (only
completed request of DOLS Office)
2
Further Request for a Further Standard
Authorisation

Current Standard DOLS Authorisation is
coming to an end and the person needs
to remain in hospital, deprived of their
liberty past the current DOLS expiry
date)
The application forms can be completed electronically or by hand. Unless the signatory has an
‘electronic signature’ then forms will need to be printed and signed by hand.
Guidance on completing the forms can be found in Appendix 3.
6.31
Who completes the DOLS forms?
It is the responsibility of the clinical team caring for the patient to apply for a DOLS
Authorisation. The care team should not be referring to other services for this. Trust
signatories for DOLS forms are:
 Medical staff (ST3 grade and above)
 Duty Matron and Hospital@Night can also act as designated signatories if required out of
hours
Deprivation of Liberty Safeguards Policy
Version: 2
Issue Date: 01 October 2015
Review Date: 30 September 2017 (unless requirements change)
Page 11 of 32
6.32
Where to send the forms
DOLS application forms are sent to the relevant DOLS Office who arrange for independent
assessments to be undertaken. In order to improve data security and monitoring, as of the
5th October 2015 this process will be managed centrally:
The clinical team must email completed DOLS applications to:
PHT.DOLS@porthosp.nhs.uk
Do not put the forms in the internal mail system.
Applications will be forwarded via secure email to the relevant DOLS office.
The original forms should then be filed in the patient’s medical record.
6.4 Who to notify
 The patient - must be given a copy of the DOLS forms and have it explained to them,
including the right to appeal. It may not be appropriate to do this at the time of the
application, however, they must be given a copy prior to discharge and this should be
documented in the patient’s medical records.
 The patients family / Next of Kin – Must be informed of the application being made, that
it is a legal requirement for the Trust to do so, and that they will be contacted by an
independent DOLS assessor.
 CSC management team
 (Care Quality Commission (CQC) - It is a requirement of the Trust’s registration with that
the CQC are informed of all DOLS applications and outcomes. This is managed centrally
by the Trust Adult Safeguarding Office).
6.5 What happens next?
The Supervisory Body (DOLS Office) makes arrangements for the required assessments to
be undertaken. Clinical staff should support this assessment process but are not required to
undertake the assessments themselves. Access to the medical records should be made
available to the assessors.
Normal care and treatment of the patient, including discharge planning should continue
during the assessment period. Where the patient also lacks mental capacity to make
decisions about treatment options then, in line with the MCA, decisions must be made in their
best interest.
If for any reason the DOLS office does not complete the required assessments within the 7day Urgent Authorisation period and an Urgent Extension is not granted then the DOLS can
be considered ‘lapsed’. In these circumstances it is essential to continue to accommodate
and treat the person in their Best Interests as defined by the MCA:
 Contact DOLS office and request a priority assessment if any DOLS high risk triggers
are present. If a priority assessment is not undertaken, senior clinical and legal
advice should be taken to consider if the case needs to be referred to the Court
of Protection.
 Ward staff should complete an internal incident form (Datix). This should be flagged
as Adult Safeguarding highlighting a lapsed DOLS due to non-assessment by the
DOLS Office.
 Conduct regular reassessment of patient’s mental capacity to make a decision about
remaining in hospital.
 Conduct regular reassessments to see if the person still meets both elements of the
Acid Test.
DOLS Office contact Numbers
Portsmouth DOLS Office: 023 9268 8666 – for residents in postcodes PO1-PO6
Southampton DOLS Office: 023 8083 4776 – for residents of Southampton City
Hampshire DOLS Office: 01962 845213 – all other Hampshire postcodes
Visitors to the area: seek assistance from Portsmouth DOLS Office
Deprivation of Liberty Safeguards Policy
Version: 2
Issue Date: 01 October 2015
Review Date: 30 September 2017 (unless requirements change)
Page 12 of 32
On completion of the assessment process, the Supervisory Body will either grant or deny the
DOLS Authorisation. The DOLS Office will send the outcome forms to the ward and these
forms must be filed in the medical record. A copy of these forms will also be sent to the Trust
Safeguarding Office.
6.51
A Standard DOLS Authorisation is granted
The care plan should include ongoing review of the treatment plan and the need for a
continuing DOLS Authorisation.
A patient held under DOLS may be kept in Portsmouth Hospitals for the proposed
treatment and care until:
 The course of treatment is completed and the patient now longer needs to remain
in hospital and can return to their normal place of residence
 Arrangements have been made for on-going care to continue in another location
e.g. care home or specialist hospital
 The DOLS is judged to no longer be required. The clinical team must inform the
DOLS Office and Trust Adult Safeguarding office.
 The DOLS expires. If continuing treatment and care is required in circumstances
that amount to a deprivation of liberty then a further Standard Authorisation will be
required. DOLS form 2 should be completed and sent to the DOLS Office as
detailed above.
 The person’s mental capacity returns and they are able to make their own
decision about continuing with treatment and care. In this circumstance the
DOLS is no longer valid, even if the person decides to leave hospital or refuses to
comply with treatment and care against medical advice.
A DOLS Authorisation is specific to the Managing Authority and the address where
the person will be held. Therefore it is permissible to transfer a patient who is held
under a DOLS to another ward within the same location and belonging to the same
provider. If the patient is transferred between different Trust hospitals e.g. Petersfield,
Gosport and Queen Alexandra then a new Urgent/Standard application must be
made.
It is recommended that any ward moves are undertaken for clinical reasons only or as
part of the anticipated patient journey (e.g. to move from intensive care to a ward
when this level of care is no longer necessary; from MAU to the relevant specialty
ward; to facilitate the provision of a side room if this was deemed essential). Any ward
move should be undertaken in the person’s best interest and it is recommended that
patients under a DOLS Authorisation are not outlied.
6.52.
A Standard DOLS Authorisation is refused
If the authorisation is refused or cannot be granted because the qualifying criteria
have not been met, then the treatment and care plan should be reviewed again to see
if less restrictive alternatives can be put in place. In this way the patient may consent
to remain in hospital and undergo treatment.
Alternatively consideration could be given to whether a different treatment option or
care location can be arranged which would be acceptable to the patient e.g. change
of antibiotics to allow administration to take place in the community, a less invasive or
aggressive therapy, transfer to a facility closer to family.
If the patient refuses all options presented then clinical staff should take steps to
reduce the risks of discharge e.g. discharge medications, liaison with GP, social care
and other community services, informing next of kin etc.
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Issue Date: 01 October 2015
Review Date: 30 September 2017 (unless requirements change)
Page 13 of 32
However if there are major concerns about the patients safety should they leave
hospital and fail to comply with what is deemed essential treatment and care, senior
clinical and legal advice should be sought. In some cases application to the Court of
Protection may be required. Requests for legal advice should be made through the
Trust Legal Services office ext. 6527 or via Hospital Duty Managers out of hours.
6.6
A patient dies whilst subject to a DOLS Authorisation
A DOLS Authorisation is considered to be a form of lawful state detention. Therefore
in the event of the person dying the Coroner must be informed, as this will be
considered a death in custody.
The following should be reported:


Anyone who dies under the 7-days Urgent DOLS Authorisation
Anyone who dies under a Standard DOLS Authorisation
You do not need to report when:
x
x
A DOLS Authorisation has been refused following DOLS office
assessments (unless there are other reasons for doing so)
Lapsed DOLS: A DOLS has been applied for and the Urgent Authorisation
has lapsed due to lack of assessments by the DOLS Office even though in
their Best Interests we continue to ‘detain’ the person in hospital (unless
there are other reasons for doing so).
The Clinical team caring for the patient is responsible for reporting the death to the
Coroner.
Staff will need to be sensitive to the impact this may have on next of kin, family and
friends. The next of kin must be informed of the requirement to report to the Coroner
and that an inquest will be held. This is a legal requirement and does not in itself
imply that there is anything ‘untoward’ with the circumstances of their loved ones
death or the care and treatment provided. An inquest does not always necessitate a
post mortem to be performed, however this decision will be made by the Coroner.
A Registered Nurse may not verify the death of someone who is under a DOLS
Authorisation even if the death is ‘expected’ and would otherwise by permissible
under the ‘Policy for when an Adult Dies’.
6.7. Unauthorised Deprivations of Liberty
If a public body does not have the authority to deprive an individual of their liberty they will be
acting unlawful contrary to the Human Rights Act 1998. Consequences of failing to obtain an
authorisation may expose the Trust not only to a claim before the courts but also to sanction
from regulators and / or the Ombudsman.
If staff are concerned that an unauthorised deprivation of liberty has occurred or is likely to
occur within the Trust then a senior clinician should review the situation as a matter of
urgency. Steps should be taken to avoid/prevent any further/potential deprivation of liberty.
In order to achieve this it may be necessary to apply an Urgent Authorisation or review the
steps outlined in Table 1.
Any unauthorised deprivation of liberty must be reported as an adverse incident on Datix and
graded as Amber. A Safeguarding Alert must also be raised and the relevant CSC
Management team must be informed as a matter of urgency .
Deprivation of Liberty Safeguards Policy
Version: 2
Issue Date: 01 October 2015
Review Date: 30 September 2017 (unless requirements change)
Page 14 of 32
All unlawful DOLS will be reported to the CQC and external Safeguarding partners. The Trust
Adult Safeguarding office will coordinate these notifications with the Governance Department
and the relevant CSC Management Team.
If there is a concern that a deprivation of liberty may be occurring in non-Trust
accommodation then staff should discuss the concerns with their line manager as soon as
possible and the Managing Authority of the care home of hospital. The Supervisory Authority
should also be notified.
7 TRAINING REQUIREMENTS
Introductory Level: All trust staff will have a basic DOLS awareness. This will be achieved via the
essential update programme.
Enhanced Level:
 All inpatient based clinical staff who deliver direct patient care
 Designated Trust DOLS signatories
 Security staff
Enhanced level training is available internally via classroom-based sessions and is delivered by
Trust and CSC Adult Safeguarding Leads. Training is also available in partnership with our
external health and social care partners. Details are available from Safeguarding Leads.
Each line manager has the responsibility to ensure their staff are afforded the opportunity to
undertake all essential skill training.
8 REFERENCES AND ASSOCIATED DOCUMENTATION
Mental Capacity Act 2005.
Deprivation of Liberty Safeguards: A guide for hospitals and care homes. DH. 2009
What are the Mental Capacity Act 2005 Deprivation of Liberty Safeguards. DH. 2008
Mental Health Act 2007.
The Mental Capacity Act 2005 Deprivation of Liberty Safeguards and you. Easy Read. DH. 2009
Deprivation of Liberty Safeguards Code of Practice to supplement the main Mental Capacity Act
2005 Code of Practice. Ministry of Justice. 2008
Identifying a deprivation of liberty: a practical guide. The Law Society. 2015
Update on the Mental Capacity Act and DOLS following the 10 March 2014 Supreme Court
Judgement. (Letter) Niall Fry, MCA-DOLS policy Lead. Department of Health. January 2015
9 EQUALITY IMPACT STATEMENT
Portsmouth Hospitals NHS Trust is committed to ensuring that, as far as is reasonably practicable,
the way we provide services to the public and the way we treat our staff reflects their individual
needs and does not discriminate against individuals or groups on any grounds.
This policy has been assessed accordingly.
Our values are the core of what Portsmouth Hospitals NHS Trust is and what we cherish. They
are beliefs that manifest in the behaviours our employees display in the workplace.
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Review Date: 30 September 2017 (unless requirements change)
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Our Values were developed after listening to our staff. They bring the Trust closer to its vision to
be the best hospital, providing the best care by the best people and ensure that our patients are at
the centre of all we do.
We are committed to promoting a culture founded on these values which form the ‘heart’ of our
Trust:
Respect and dignity
Quality of care
Working together
No waste
This policy should be read and implemented with the Trust Values in mind at all times.
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Review Date: 30 September 2017 (unless requirements change)
Page 16 of 32
10 MONITORING COMPLIANCE WITH, AND THE EFFECTIVENESS OF, PROCEDURAL
DOCUMENTS
Monitoring of compliance with this guidance will be undertaken at two levels: one at a corporate
level related to corporate function and response and at a divisional level related to compliance at
practice level. Results will be reported to the Safeguarding Committee.
Minimum
requirement to be
monitored
Lead
Tool
Frequency of
Report of
Compliance
Reporting
arrangeme
nts
Lead(s) for acting
on
Recommendation
s
85% of all Trust
staff will have
completed
Introductory Level
training.
CSC
Management
Teams
Report from
Learning and
Development
Department
Quarterly
Safeguarding
Committee
Adult Safeguarding
Lead Nurse
85% of identified
staff groups have
completed
Enhanced Level
training
CSC
Management
Teams
Report from
Learning and
Development
Department
Quarterly
Safeguarding
Committee
Adult Safeguarding
Lead Nurse
85% of staff
sampled will be
aware of where to
seek advice within
the Trust with
regard to DOLS
issues
Safeguarding
Operational
Leads
Audit ( sample of
10 staff per
specialty)
Annually
Safeguarding
Committee
CSCs
Deprivation of Liberty Safeguards Policy
Version: 2
Issue Date: 01 October 2015
Review Date: 30 September 2017 (unless requirements change)
Page 17 of 32
APPENDIX 1: DOLS Form 1 - Standard and Urgent DOLS Request
Case ID Number:
DEPRIVATION OF LIBERTY SAFEGUARDS FORM 1
REQUEST FOR STANDARD AUTHORISATION AND URGENT AUTHORISATION
Request a Standard Authorisation only (you DO NOT need to complete pages 6 or 7)
Grant an Urgent Authorisation (please ALSO complete pages 6 and 7 if
appropriate/required)
Full name of person
being deprived of liberty
Sex
Date of Birth (or
Est. Age
estimated age if unknown)
Relevant Medical History (including diagnosis of mental disorder if known)
Sensory Loss
Communication
Requirements
Name and address of the care home or
hospital requesting this authorisation
Telephone Number
Person to contact at the
care home or hospital,
(including ward details if
appropriate)
Name
Telephone
Email
Ward (if
appropriate)
Usual address of the
person, (if different to
above)
Telephone Number
Name of the Supervisory Body
where this form is being sent
How the care is funded
Local Authority please
specify
NHS
Self-funded by person
Deprivation of Liberty Safeguards Policy
Version: 2
Issue Date: 01 October 2015
Review Date: 30 September 2017 (unless requirements change)
Local Authority and
NHS (jointly funded)
Funded through
insurance or other
Page 18 of 32
REQUEST FOR STANDARD AUTHORISATION
THE DATE FROM WHICH THE STANDARD AUTHORISATION IS REQUIRED:
If standard only – within 28 days
If an urgent authorisation is also attached – within 7 days
PURPOSE OF THE STANDARD AUTHORISATION





Please describe the care and / or treatment this person is receiving or will receive day-to-day and attach a relevant
care plan.
Please give as much detail as possible about the type of care the person needs, including personal care, mobility,
medication, support with behavioural issues, types of choice the person has and any medical treatment they receive.
Explain why the person is or will not be free to leave and why they are under continuous or complete supervision
and control.
Describe the proposed restrictions or the restrictions you have put in place which are necessary to ensure the
person receives care and treatment. (It will be helpful if you can describe why less restrictive options are not
possible including risks of harm to the person.)
Indicate the frequency of the restrictions you have put in place.
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Review Date: 30 September 2017 (unless requirements change)
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INFORMATION ABOUT INTERESTED PERSONS AND OTHERS TO CONSULT
Family member or friend
Name
Address
Telephone
Anyone named by the person as Name
someone to be consulted about
their welfare
Address
Telephone
Anyone engaged in caring for the Name
person or interested in their
welfare
Address
Telephone
Any donee of a Lasting Power of Name
Attorney granted by the person
Address
Telephone
Any Personal Welfare Deputy Name
appointed for the person by the
Court of Protection
Address
Telephone
Any
IMCA
instructed
in Name
accordance with sections 37 to
39D of the Mental Capacity Act Address
2005
Telephone
Deprivation of Liberty Safeguards Policy
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Review Date: 30 September 2017 (unless requirements change)
Page 20 of 32
WHETHER IT IS NECESSARY FOR AN INDEPENDENT MENTAL CAPACITY ADVOCATE
(IMCA) TO BE INSTRUCTED
Place a cross in EITHER box below
Apart from professionals and other people who are paid to provide care or treatment, this
person has no-one whom it is appropriate to consult about what is in their best interests
There is someone whom it is appropriate to consult about what is in the person’s best interests
who is neither a professional nor is being paid to provide care or treatment
WHETHER THERE IS A VALID AND APPLICABLE ADVANCE DECISION
Place a cross in one box below
The person has made an Advance Decision that is valid and applicable to some or all of the
treatment
The Managing Authority is not aware that the person has made an Advance Decision that may
be valid and applicable to some or all of the treatment
The proposed deprivation of liberty is not for the purpose of giving treatment
THE PERSON IS SUBJECT TO SOME ELEMENT OF THE MENTAL HEALTH ACT (1983)
Yes
No
If Yes please describe further e.g. application/order/direction,
community treatment order, guardianship
OTHER RELEVANT INFORMATION
Names and contact numbers of regular visitors not detailed elsewhere on this form:
Any other relevant information including safeguarding issues:
PLEASE NOW SIGN AND DATE THIS FORM
Signature
Print Name
Date
Time
I HAVE INFORMED ANY INTERESTED
PERSONS OF THE REQUEST FOR A DoLS
AUTHORISATION (Please sign to confirm)
Deprivation of Liberty Safeguards Policy
Version: 2
Issue Date: 01 October 2015
Review Date: 30 September 2017 (unless requirements change)
Page 21 of 32
RACIAL, ETHNIC OR NATIONAL ORIGIN
Place a cross in one box only
White
Mixed / Multiple Ethnic groups
Asian / Asian British
Black / Black British
Not Stated
Undeclared / Not Known
Other
Ethnic
Origin
(please
state)
THE PERSON’S SEXUAL ORIENTATION
Place a cross in one box only
Heterosexual
Homosexual
Bisexual
Undeclared
Not Known
OTHER DISABILITY
While the person must have a mental disorder as defined under the Mental Health Act 1983, there may be
another disability that is primarily associated with the person. This is based on the primary client types used in
the Adult Social Care returns.
To monitor the use of DoLS, the HSCIC requests information on other disabilities associated with the individual
concerned. The presence of “other disability” may be unrelated to an assessment of mental disorder or lack of
capacity.
Place a cross in one box only
Physical Disability: Hearing Impairment
Physical Disability: Visual Impairment
Physical Disability: Dual Sensory Loss
Physical Disability: Other
Mental Health needs: Dementia
Mental Health needs: Other
Learning Disability
Other Disability (none of the above)
No Disability
RELIGION OR BELIEF
Place a cross in one box only
None
Not stated
Buddhist
Hindu
Jewish
Sikh
Muslim
Any other religion
Christian
(includes Church of Wales, Catholic, Protestant and all other Christian denominations)
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Review Date: 30 September 2017 (unless requirements change)
Page 22 of 32
ONLY COMPLETE THIS SECTION IF YOU NEED TO GRANT AN URGENT AUTHORISATION
BECAUSE IT APPEARS TO YOU THAT THE DEPRIVATION OF LIBERTY IS ALREADY
OCCURING, OR ABOUT TO OCCUR, AND YOU REASONABLY THINK ALL OF THE
FOLLOWING CONDITIONS ARE MET
URGENT AUTHORISATION
Place a cross in EACH box to confirm that the person appears to meet the particular condition
The person is aged 18 or over
The person is suffering from a mental disorder
The person is being accommodated here for the purpose of being given care or treatment.
Please describe further on page 2
The person lacks capacity to make their own decision about whether to be accommodated
here for care or treatment
The person has not, as far as the Managing Authority is aware, made a valid Advance
Decision that prevents them from being given any proposed treatment
Accommodating the person here, and giving them the proposed care or treatment, does not,
as far as the Managing Authority is aware, conflict with a valid decision made by a donee of a
Lasting Power of Attorney or Personal Welfare Deputy appointed by the Court of Protection
under the Mental Capacity Act 2005
It is in the person’s best interests to be accommodated here to receive care or treatment,
even though they will be deprived of liberty
Depriving the person of liberty is necessary to prevent harm to them, and a proportionate
response to the harm they are likely to suffer otherwise
The person concerned is not, as far as the Managing Authority is aware, subject to an
application or order under the Mental Health Act 1983 or, if they are, that order or application
does not prevent an Urgent Authorisation being given
The need for the person to be deprived of liberty here is so urgent that it is appropriate for
that deprivation to begin immediately before the request for the Standard Authorisation is
made or has been determined
AN URGENT AUTHORISATION IS NOW GRANTED
This Urgent Authorisation comes into force immediately.
It is to be in force for a period of:
days
The maximum period allowed is seven days.
This Urgent Authorisation will expire at the end of the day on:
Signed
Print name
Date
Time
Deprivation of Liberty Safeguards Policy
Version: 2
Issue Date: 01 October 2015
Review Date: 30 September 2017 (unless requirements change)
Page 23 of 32
REQUEST FOR AN EXTENSION TO THE URGENT AUTHORISATION
If Supervisory Body is unable to complete the process to give a Standard Authorisation (which has
been requested) before the expiry of the existing Urgent Authorisation
An Urgent Authorisation is in force and a Standard Authorisation has been requested for this
person.
The Managing Authority now requests that the duration of this Urgent Authorisation is extended for
a further period of
DAYS (up to a maximum of 7 days)
It is essential for the existing deprivation of liberty to continue until the request for a Standard
Authorisation is completed because the person needs to continue to be deprived and exceptional
reasons are as follows (please record your reasons):
Please now sign, date and send to the SUPERVISORY BODY for authorisation
Signature
D
a
t
e
RECORD THAT THE DURATION OF THIS URGENT AUTHORISATION HAS BEEN EXTENDED
This part of the form must be completed by the SUPERVISORY BODY if the duration of the Urgent
Authorisation is extended. The Managing Authority does not complete this part of the form.
The duration of this Urgent Authorisation has been extended by the Supervisory Body.
It is now in force for a further
days
Important note: The period specified must not exceed seven days.
This Urgent Authorisation will now expire at the end of the day on:
SIGNED
(on behalf of the Supervisory Body)
Signature
Print Name
Date
Deprivation of Liberty Safeguards Policy
Version: 2
Issue Date: 01 October 2015
Review Date: 30 September 2017 (unless requirements change)
Time
Page 24 of 32
APPENDIX 2: DOLS FORM 2 - FURTHER REQUEST FOR A FURTHER STANDARD
AUTHORISATION
Case ID Number:
DEPRIVATION OF LIBERTY SAFEGUARDS FORM 2
REQUEST FOR A FURTHER STANDARD AUTHORISATION
Full name of person
deprived of their liberty
being
Sex
Date of Birth
(or estimated age if unknown)
Est. Age
Name and Address of Managing
Authority (care home or hospital)
requesting this authorisation
Person to contact at the care Name
home or hospital, (include ward
Telephone
details if appropriate)
Email
Ward (if appropriate)
THE PURPOSE OF THE AUTHORISATION is to enable the following care and / or
treatment to be given:


Please describe the care and / or treatment this person is receiving or will receive day-to-day and attach a
relevant care plan.
Please give as much detail as possible about the type of care the person needs, including personal care,
mobility, medication, support with behavioural issues, types of choice the person has and any medical treatment
they receive.
THE DATE FROM WHICH THE STANDARD AUTHORISATION IS SOUGHT:
A further Standard Authorisation is required to start on this date
so it is force immediately after the expiry of the existing Standard
Authorisation.
Deprivation of Liberty Safeguards Policy
Version: 2
Issue Date: 01 October 2015
Review Date: 30 September 2017 (unless requirements change)
Page 25 of 32
OTHER RELEVANT INFORMATION
Please include details of any changes previously given in Form 1 e.g. in the care plan, medical information, person’s
behaviour or visitors.
Signature
Print name
Date
Time
I HAVE INFORMED ANY INTERESTED PERSONS
OF THE REQUEST FOR A FURTHER STANDARD
AUTHORISATION (Please sign to confirm)
Deprivation of Liberty Safeguards Policy
Version: 2
Issue Date: 01 October 2015
Review Date: 30 September 2017 (unless requirements change)
Page 26 of 32
APPENDIX 3: GUIDANCE ON COMPLETING DOLS APPLCATION FORMS
FORM 1:
STANDARD REQUEST, URGENT AUTHORISATION
AND EXTENSION TO URGENT
In the acute hospital setting it is likely that a deprivation of liberty occurs as an ‘emergency’ and
cannot be predicted and a DOLS Authorisation applied for in advance. In these circumstances it is
necessary to apply for both an Urgent and Standard DOLS Authorization.
Page 1: This page will take you through the person’s basic details.
It is helpful to assessors if you can summarise relevant medical history, give details of any sensory
loss and in particular describe the person’s communication needs as this will help the assessor
prepare and enable them to consider whether any aids are needed or in fact whether an interpreter
may be needed.
However, the presence of sensory loss or communication needs is not necessarily indicative of a
lack of capacity.
Page 2: Purpose of the Authorisation - this provides two essential pieces of information.
A description of the care and treatment - in other words: Why do you need to accommodate the
person in the care home or hospital?
It asks you to describe in detail the care and/or treatment the person is receiving. It is helpful to
assessors if this is as detailed as possible rather than a vague statement such as “24 hour care”.
Secondly you are asked to explain why the person meets the acid test for a deprivation of liberty.
The following information may be helpful:
http://www.39essex.com/docs/newsletters/deprivation_of_liberty_after_cheshire_west__a_guide_for_front-line_staff.pdf
http://www.cqc.org.uk/sites/default/files/20140416_supreme_court_judgment_on_deprivation_of_li
berty_briefing_v2.pdf
http://www.39essex.com/content/wpcontent/uploads/2014/02/deprivation_of_liberty_in_the_hospital_settingv3.pdf
In this section you need to describe all the measures you are taking which have led you to make a
request for an Authorisation:
• describe the environment the person is in
• who has determined where they live
• whether it is a temporary or permanent arrangement
• how are they monitored by staff leading you to conclude they are under continuous or complete
supervision and control and are not free to leave.
When describing all the restrictions it is helpful to say how frequently they are taking place.
For example it is better to say: “Mrs X has to be reassured and redirected by staff at least 4-5
times a day as she is distressed and wants to leave.”
rather than:
“Mrs X says she wants to leave.”
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Issue Date: 01 October 2015
Review Date: 30 September 2017 (unless requirements change)
Page 27 of 32
It is better to say:
rather than:
“1:1 support is in place at all times of day, when John is in his
room or moving around the building, when he has meals or takes
part in social events. However at night there is less support as
there is a sleeping night and no checks are made beyond the
routine checks.”
“John has 1:1 support.”
Page 3: What is an Interested Person?
An interested person is any of the following:







The relevant person’s spouse or civil partner;
Where the relevant person and another person of the opposite sex are not married to
each other but are living together as husband and wife - the other person;
Where the relevant person and another person of the same sex are not civil partners of
each other but are living together as if they were civil partners - the other person;
The relevant person’s children and step children;
The relevant person’s parents and step parents;
The relevant person’s brothers, sisters, half-brothers, half-sisters, step brothers and step
sisters;
The relevant person’s grandparents or grandchildren.
The form also asks for other people such as anyone caring for the person or interested in their
welfare. This could include social workers or care staff.
Page 4: IMCA – Advance Decision – Mental Health Act
IMCA:
It is necessary for the Managing Authority to inform the DoLS team if the person will need an IMCA
to support them.
The DoLS team at the Supervisory Body will make the referral but you need to state whether the
person has anyone appropriate to consult with.
Advance Decisions:
There is also a question about any Advance Decisions to refuse treatment the person may have
made that you are aware of.
Mental Health Act 1983:
If you are aware of any aspect of the Mental Health Act that applies to the person, for example
they may be subject to a Guardianship Order, then this is where you need to include that
information, with as much detail as you are able to provide.
Once you sign and date the form you will also be asked to confirm that you have advised any
interested persons of the request for a DoLS Authorisation. Communication with close family
members is very important from the beginning.
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Issue Date: 01 October 2015
Review Date: 30 September 2017 (unless requirements change)
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Page 5: Important Data Collection
This information is required for the quarterly DoLS returns to the Health and Social Care
Information Centre. Please note this information is based on the Adult Social Care collection and
the disability here does not refer to mental incapacity but to any other disability that may apply to
the person.
Page 6: Urgent Authorisation – complete only where the need for the deprivation of liberty is so
urgent that it is in the best interests of the person for it to begin while the application is being
considered.
Although the original intention was that an Urgent Authorisation would be for “sudden unforeseen
needs” in practice this has not been the case and Managing Authorities often use Urgent
Authorisations. There is an expectation that in the vast majority of cases it should be possible to
plan ahead and make sure that a Standard Authorisation is requested ahead of the need for the
deprivation of liberty to begin.
An Urgent Authorisation should only be given where the need for the deprivation of liberty is so
urgent that it is in the best interests of the person for it to begin while the application for a Standard
Authorisation, which is expected to be necessary, is being considered. There are some situations
where an Urgent Authorisation is generally not needed, such as:
• Someone has developed a mental disorder as a result of a physical illness which can be treated
and treating it will rapidly resolve the mental disorder. An example of this would be someone
currently confused due to a urinary tract infection, but when treated with antibiotics the confusion
usually resolves within a negligible period of time.
• Where a person is in accident and emergency or a care home and it is anticipated that in a
matter of hours the person will no longer be there.
The tick boxes are straightforward as all of the details will have been provided earlier in the form.
The Urgent Authorisation can be given for a period of up to seven calendar days and comes into
force at the time it is signed.
Page 7: Request for an Extension of the Urgent Authorisation
Complete page 7 only of requested to do so by the DOLS Office.
The intention of adding the request for an extension of an Urgent Authorisation to the initial form is
to identify this at the beginning due to the unprecedented numbers of applications following the
Supreme Court Judgement:
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/300106/DH_Note_re
_Supreme_Court_DoLS_Judgment.pdf
The DoLS Code of Practice describes that an Urgent Authorisation can be extended if there are
“exceptional reasons” why the Standard Authorisation cannot be dealt with within the seven days.
The Code of Practice gives an example of when an extension may be justified as an assessor not
being able make contact with someone who it is essential to speak to. The Supervisory Body must
decide what it considers to be “exceptional reasons”. The Code is very clear about the following:
• A decision about exceptional reasons must be soundly based and defensible;
• It would not usually be justified due to staff shortages;
• An Urgent Authorisation can only be extended once.
Deprivation of Liberty Safeguards Policy
Version: 2
Issue Date: 01 October 2015
Review Date: 30 September 2017 (unless requirements change)
Page 29 of 32
FORM 2:
REQUEST FOR A FURTHER STANDARD AUTHORISATION
A Further Standard Authorisation is a new request for the same person.
When an existing DoLS Authorisation is coming to an end the Managing Authority must review
whether it is still necessary. It is possible, at any stage, that things have changed and the person
no longer needs such a restrictive environment. In this case the Managing Authority needs to
request a Review to cease the DoLS Authorisation (Form 9 – Standard Authorisation Ceased).
If however, having reviewed the person’s current situation, the Managing Authority concludes that
the Authorisation needs to continue then a Further Authorisation should be requested. This can be
done up to 28 days in advance and should not be left to the last moment.
The amount of information needed when a Further Request for Authorisation is being made, is
much less than the initial requirement as the Supervisory Body will have already received a great
deal of personal details and comprehensive information and will have carried out the necessary
assessments to grant an initial Authorisation.
This form is short and should assist Managing Authorities to request further authorisations in a
timely way.
The main focus of this form is on two essential pieces of information:
1)
The purpose of the deprivation of liberty, in other words why the person is still a resident
or a patient and a description of the current care or treatment arrangements
2)
An opportunity to update any changes to the care or treatment plan and the restrictions in
place, update information and record changes since the previous Authorisation was given.
Deprivation of Liberty Safeguards Policy
Version: 2
Issue Date: 01 October 2015
Review Date: 30 September 2017 (unless requirements change)
Page 30 of 32
Equality Impact Screening Tool
To be completed and attached to any procedural document when submitted to the appropriate
committee for consideration and approval for service and policy changes/amendments.
Stage 1 - Screening
Title of Procedural Document: Deprivation of Liberty Safeguards: Practice and Procedures Policy
Date of Assessment
24 September 2015
Responsible
Department
Risk Management Dept
Name of person
completing
assessment
Anne Taylor
Job Title
Adult Safeguarding Lead
Does the policy/function affect one group less or more favourably than another on the basis
of :
Yes/No
 Age
No
 Disability
No
Comments
Learning disability; physical disability; sensory
impairment and/or mental health problems e.g.
dementia
 Ethnic Origin (including gypsies and travellers)
No
 Gender reassignment
No
 Pregnancy or Maternity
No
 Race
No
 Sex
No
 Religion and Belief
No
 Sexual Orientation
No
If the answer to all of the above questions is NO,
the EIA is complete. If YES, a full impact
assessment is required: go on to stage 2, page 2
More Information can be found be following the link
below
www.legislation.gov.uk/ukpga/2010/15/contents
Deprivation of Liberty Safeguards Policy
Version: 2
Issue Date: 01 October 2015
Review Date: 30 September 2017 (unless requirements change)
Page 31 of 32
Stage 2 – Full Impact Assessment
What is the impact
Level of
Impact
Mitigating Actions
(what needs to be done to minimise /
remove the impact)
Responsible
Officer
Monitoring of Actions
The monitoring of actions to mitigate any impact will be undertaken at the appropriate level
Specialty Procedural Document:
Specialty Governance Committee
Clinical Service Centre Procedural Document:
Clinical Service Centre Governance Committee
Corporate Procedural Document:
Relevant Corporate Committee
All actions will be further monitored as part of reporting schedule to the Equality and Diversity
Committee
Deprivation of Liberty Safeguards Policy
Version: 2
Issue Date: 01 October 2015
Review Date: 30 September 2017 (unless requirements change)
Page 32 of 32