Visits to Psychiatric Wards and Facilities

1. Introduction

Visits by children to psychiatric wards or hospitals should be undertaken to maintain a positive relationship for the child with the patient, who will usually be their parent or more rarely a family member such as a sibling. A visit by a child should only take place if it is in the child's best interest and this 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.

Visits by children to psychiatric wards need to be assessed, planned and managed to ensure that they are not exposed to physical, sexual or emotional harm.

This section applies to children visiting all patients receiving in-patient treatment and care from specialist psychiatric services, whether or not they are detained under the Mental Health Act 1983. This includes children visiting detained adolescent patients and adolescents who are being cared for in adult facilities.

2. Visiting Patients in Psychiatric Wards

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;
• Prioritise the needs and wishes of children;
• Address the whole process, including preadmission assessment, admission, care planning, discharge and aftercare;
• 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 way;
• Establish an efficient procedure for dealing with requests for child visits in all cases, this is especially important 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 for the child;
  • 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 visits.

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.

Pre-visit Arrangements

Compulsory Admission

When a compulsory admission is planned for an adult who is a parent, the approved mental health professional must assess the child/ren's needs and the suitability of arrangements for their care. If there are concerns (see Children of Parents with Mental Ill Health Procedure) about the safety or care arrangements of the child/ren, the approved mental health professional must request that local authority Children's Services undertakes an assessment (see Early Help Assessment (EHA) Procedure). Local authority Children's Services should make a recommendation to the hospital about the suitability of the children visiting their parent.

The approved mental health professional should, wherever possible, provide the hospital with the child/ren's assessment information. This may, as appropriate, include the recommendation made by local authority Children's Services when the patient was admitted, together with the views of those with parental responsibility about the child/ren visiting the patient in hospital.

Expected Visit by a Child

The Hospital should identify a Manager who is responsible for the decision to allow a visit by a child. This may be the Ward Manager. When a visit by a child is expected, the ward manager/nurse in charge should consider the available information about the child (as outlined in Pre-visit Arrangements), alongside the assessment of the patient's risk and needs for treatment and care and an assessment of the current state of the patient's mental health. The ward manager/nurse in charge should then make the decision in consultation with other members of the multi-disciplinary hospital team as to whether the visit can proceed.

The ward manager/nurse in charge must make their decision on the basis of the interests of the child being paramount, superseding those of the adult patient.

Unexpected Visit by a Child

If a child visits unexpectedly, the ward manager/nurse in charge is responsible for deciding whether it is feasible, whilst they wait, to consider the available information about the child (as outlined in Pre-visit Arrangements), alongside the assessment of the patient's needs for treatment and care and an assessment of the current state of the patient's mental health. The ward manager/nurse in charge should then make the decision in consultation with other members of the multi-disciplinary hospital team. If this is not feasible, the visit must be refused.

Patients Admitted Informally

Most patients are admitted informally. When a patient has been admitted on an informal basis, nursing staff should seek out information about children who may be visiting. When nursing staff are aware that a patient has a child, and there is a local authority children's social worker or adult mental health care co-ordinator working with the patient, nursing staff should check with the social worker / care co-ordinator about the desirability of children visiting and the arrangements which have been made. Such discussions should be clearly documented.

If there are concerns about the safety or care arrangements of the child/ren (see Identifying concerns below, and Children of Parents with Mental Ill Health Procedure) and there is no local authority children's social worker involved, the ward manager/nurse in charge must make a referral to the local authority, including a request that local authority Children's Services undertake an (see Early Help Assessment (EHA) Procedure). Local authority Children's Services should make a recommendation to the hospital about the suitability of the child/ren visiting the patient.

Where the local authority Children's Services has been asked to undertake such an assessment, their report should be sent back within one week of receipt of the written request / referral from the ward manager/nurse in charge in order to avoid delay in arrangements for the child.

The ward manager/nurse in charge is responsible for the decision to allow a visit by a child, and must follow the same decision making process for informal admissions and for compulsory admission (see Expected visit by a child above).

In the vast majority of cases where no concerns have been identified, arrangements should be made to support the patient and child and to facilitate contact.

Identifying Concerns

Concerns about the desirability of a child visiting may arise in a number of areas. These could relate to:

• Consideration of the child's best interests;
• The pre-existing relationship between the patient and the child;
• The patient's history and family situation;
• The patient's current mental state (which may differ from an assessment made immediately prior to or on admission);
• The response by the child to the patient's illness;
• The wishes and feelings of the child;
• The developmental age and emotional needs of the child;
• The views of those with parental responsibility;
• The nature of the service and the patient population as a whole;
• Availability of a suitable environment for contact.

See also: Children of Parents with Mental Ill Health Procedure.

The hospital multi-disciplinary team may use the Triangle chart for the Assessment of Children in Need and their Families, Working Together to Safeguard Children) to consider the best interests of the child in these situations.

A range of options may present themselves when concerns are identified in any of the areas above, and the concerns need not automatically result in a refusal of visiting. The hospital multi-disciplinary team must obtain a balance between the management of risk of harm and the interests of the child/ren and patients.

It may be helpful for the Hospital Trust and / or Safeguarding Children Partnership to consider whether or not to provide a service to facilitate contact. Research has highlighted the dangers of loss of contact with children for people who are psychiatric in-patients in hospital.

Decisions to Refuse a Child's Visits

The ward manager/nurse in charge may refuse to allow a child to visit if they have reason to believe it is not in the best interest of the child or patient.

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

Policies should clearly set out the steps to be taken in making the decision to refuse visiting, including the process for:

• Consulting with the patient, the child (depending on age and understanding), those with parental responsibility and, if different, person/s with day to day care for the child, advocates and, where relevant, local authority Children's Services;
• Communicating the decision to the patient, other family members, the child and those with parental responsibility;
• Reviewing any decision and the means of communicating this to the patient, advocate or other person or agency involved in the decision;
• Enabling a patient and others with parental responsibility to make representation against any decision not to visit, including access to assistance and independent advocacy. Such a system should be consistent with the Trust's overall complaints procedure and should contain an independent element.

Making Arrangements for Visits

The hospital or mental health trust providing the service must ensure that the hospital contains facilities for all patients to have contact with their children in a venue which is conducive to the child's safety and good quality contact for both child and patient.

Children should have appropriate supervision according to their age and need when they are visiting mental health service users. They should normally be accompanied by someone who has parental responsibility for their care and well being.

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

3. Visiting Patients in the High Security Psychiatric Services: Ashworth, Broadmoor and Rampton

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).

High Secure hospitals must have procedures for child visiting that have been developed specifically for that service. Decisions about whether 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's authority has approved the visit in accordance with the Directions and is satisfied that the visit is in the child's best interests.

The only exception to this is where there is a Child Arrangement order or for a Looked After Child a contact 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 interests (see Refusing a visit).

Request for a Child to Visit

There may be cases where the patient has been:

• Convicted of murder or manslaughter, or an offence which leads to them being identified (by probation / youth offending services, police or health services, individually or via the Multi-Agency Public Protection Arrangements) as posing an ongoing risk to a child; or
• Found unfit to be tried or not guilty by reason of insanity, in respect of a charge of murder or manslaughter or an offence which leads to them being identified (by probation / youth offending services, police or health services, individually or via the Multi-Agency Public Protection Arrangements) as posing an ongoing risk to a child.

In these circumstances, the child must be within the permitted categories of relationship set out in Guidance on the High Security Psychiatric Services (Arrangements for Visits by Children) Directions 2013.

Each High Secure Hospital will identify a Senior Manager to assume the role of Nominated Officer.

If the patient's circumstances are not those in section above or 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, local authority Children's Services will be asked to assess whether the visit is in the child's best interests.
• Write to any person/s without parental responsibility but with day-to-day care for the child (e.g. a grandparent), explaining that a request for a visit has been made and that the person with parental responsibility will be contacted.

In the case of a child who is looked after by the local authority and subject to a care order (with parental responsibility shared by the local authority and the parent/s), local authority Children's Services has responsibility for providing consent (following consultation with those with parental responsibility). Where a child is looked after by the local authority but not subject to a care order, the person with parental responsibility is required to give their consent.

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. Procedures for undertaking this type of assessment should be agreed with both the relevant local authority Children's Services and Safeguarding Children Partnership for the hospital.

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

• Contact the Director of Children's Services for the local authority where the child resides to request advice on whether the visit is in the best interests of the child;
• Include in the request a copy of the hospital's assessment and any other any relevant information about the patient, to assist the local authority Children's Services to assess whether the proposed visit is in the child's best interests;
• Include in the request any information about other local authority Children's Services which have relevant information about the child or the child's family;
• Inform the parents of the child that local authority Children's Services have been asked to make contact with the family.

Local Authority Children's Services Response

On receipt of the request from the hospital (see section above), local authority Children's Services should contact those with parental responsibility (and those caring for the child if they are different) to arrange to undertake an assessment 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 visits took 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, person/s with day-to-day care for the child;
• If it is known the child has lived in other local authority Children's Services areas, what other relevant information is known about the child and family;
• The frequency of contact that would be appropriate.

Local authority Children's Services should send the completed assessment report to the nominated officer, advising whether the visit would be in the best interests of the child.

If local authority Children's Services advise that a visit would be in the child's best interests, the nominated officer should discuss this with local authority Children's Services and make a decision about the visit, taking account of any potential risk posed by the patient and the potential of significant harm being suffered by the child.

If the person/s with parental responsibility refuses to co-operate with the Children's Services assessment, Children's Services should consider its legal position:

• If the child is known to local authority Children's Services, 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;
• If local authority Children's Services hold no information about the child, it should inform the hospital that it is unable to make any report.

The Visit

Any visits by children must:

• Take place in an appropriate atmosphere and setting (i.e. child-centred and child-friendly), taking account of the age of the children (as advised by local authority Children's Services local to the hospital) whilst maintaining the required level of security;
• Be properly supervised throughout the visit, with sufficient staff present (of an appropriate grade and with requisite knowledge and understanding and enhanced Disclosure and Barring Service checks - for children, not just vulnerable adults) to supervise the children's visits at all times and to prevent unauthorised contacts;
• Allow the child contact with only the named patient for whom a visit has been approved. No children are to visit on the 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 interests, taking account of advice from Children's Services. All visits by children shall be specifically authorised by the nominated officer.

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.

Refusing a Visit

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

• The relationship between the patient and the child is not within the permitted categories of relationship. 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 responds 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 local authority Children's Services 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 for the child, if different, and local authority Children's Services. 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 for the child, if different, and, if appropriate, the child.