For all parents and carers affected by barring/heavy ongoing restrictions, this blog is for you. It is regarded as totally unacceptable by the Care Minister (Stephen Kinnock however this is the reality for many in the UK. The ITN programme explored effects on some vulnerable person, parents and carers affected but the sad reality is that this situation is widespread, nationwide with many affected – thousands of vulnerable people are currently incarcerated on MH units for many years, not being properly assessed for physical health/neurological conditions such as FND, epilepsy, denied pathophysiological referrals/tests under neurology, endocrinology and immunology. Others in the community are likewise affected. Following a seizure for instance referral should be made according to Nice Guidelines NG217 within two weeks to see a specialist and there are specific guidelines for delirium. There are families whose vulnerable relative has been sent a long distance away, making visits difficult. It is wrong parents and carers are treated in such a dismissive manner, excluded from care meetings and any involvement by the NHS and certain care homes backed by Local Authorities. For those who complain the ultimate bullying is to deny contact or restrict contact without proper review, often for years on end. This has a widespread, devastating effect on families. On Mother’s Day my thoughts went out to all mothers who have no contact. It is a violation of human rights under Article 8 HRA to the vulnerable person and their families. I hope that something is done about this situation by the Government, especially with regard to neglect towards physical health and denial of pathophysiological tests to that person.
[Mother/Father’s Name]
[Address]
[Postcode]
[Email / Telephone]
[Date]
Clinical Management Team
[Hospital / Trust Name]
[Ward / Unit Name]
[Hospital Address]
Formal Request for Review of 2:1 Supervision and Written Reasons
Dear Clinical Management Team,
Re: 2:1 Supervision During Visits With My Relative (Son/Daughter)
I am writing as the mother of [Patient’s Name] regarding the requirement that two members of staff supervise my visits with my daughter.
While I understand that hospitals must manage risk appropriately, I am concerned that the requirement for two-to-one (2:1) supervision during my visits appears to have been imposed for some time without any clear explanation being provided to me, and without any indication that the restriction has been regularly reviewed.
As you will be aware, decisions affecting detained patients must comply with the Mental Health Act 1983and the guiding principles contained within the Mental Health Act Code of Practice.
The Code of Practice provides that:
· Paragraphs 1.2 and 1.8 require that patients should only be subject to restrictions that are necessary and proportionate, and that the least restrictive option must be considered.
· Paragraph 1.5 requires that any restrictive intervention must have a clear purpose and must not be imposed simply as a matter of routine.
· Paragraph 1.7 emphasises the importance of respect, dignity and maintaining relationships with family members.
In addition, the continued imposition of 2:1 supervision during family visits interferes with the patient’s right to family life under Article 8 of the European Convention on Human Rights, which forms part of UK law through the Human Rights Act 1998. Any such interference must therefore be necessary, proportionate and capable of clear justification.
The presence of two staff members during visits makes it extremely difficult for my son/daughter and I to have normal private conversations and significantly affects our ability to maintain a meaningful family relationship.
If this restriction has not been regularly reviewed against current risk, it raises a concern that the requirement may be operating as a routine or blanket restriction, rather than a proportionate response to an identified risk.
Accordingly, I would be grateful if you could please provide the following information:
1. The clinical rationale for imposing 2:1 supervision specifically during my visits.
2. The dates and outcomes of all reviews of this restriction since it was first introduced.
3. The risk assessment(s) currently relied upon to justify maintaining this level of supervision.
4. Whether less restrictive arrangements for family visits have been considered.
5. The date when this restriction will next be formally reviewed.
If this requirement has not been subject to regular and documented review, I am concerned that the continued imposition of 2:1 supervision during my visits may be disproportionate and therefore potentially unlawful.
For the avoidance of doubt, this letter should be treated as a formal request for written reasons for the restriction currently being imposed, and I would be grateful for a written response within 14 days.
If it would assist, I would also be happy to discuss the matter with the clinical team so that an arrangement can be agreed which appropriately balances safety with my daughter’s right to maintain a normal family relationship.
Yours sincerely,
[Mother’s Name]
HERE ARE THE GUIDELINES AND THOSE REGARDING SEIZURES AND DELIRIUM FOR ANYONE AFFECTED
NICE Guideline NG10 – Violence and Aggression: Short-Term Management in Mental Health Settings, and NHS Trust Enhanced Observation Policies.
Risk assessments must be regularly reviewed
The guideline requires continuous review of risk management plans:
Risk assessments and risk management plans should be regularly reviewed, and care plans must be based on accurate and thorough risk assessments.
This principle directly affects enhanced observation levels such as:
· 1:1 observation
· 2:1 observation
· constant observation
If the observation level is not being reviewed regularly, it may breach national clinical guidance.
How NG10 Connects to 2:1 Supervision
Although NG10 does not specify the exact term “2:1 supervision”, it governs the restrictive interventions and observation frameworks that hospitals rely on when implementing such measures.
Typical NHS observation levels include:
Observation level Description
General
observation periodic checks
Intermittent
observation checks at set intervals
Within eyesight continuous observation
Within arm’s
length very high-risk monitoring
2:1 observation two staff members observing the patient
Under NICE and NHS policy:
· the clinical justification must be documented
· the observation must be reviewed frequently
· it must remain proportionate and justified by evidence
PRE-ACTION PROTOCOL LETTER TO FOLLOW UP IF NO RESPONSE
[Your Name] [Your Address] [Postcode] [Email / Telephone]
Date: [Insert Date]
BY EMAIL AND RECORDED DELIVERY
The Responsible Clinician The Ward Manager The Mental Health Act Office [Name of NHS Trust] [Hospital Address]
LETTER BEFORE ACTION – INTENDED COURT OF PROTECTION PROCEEDINGS
Re: [Patient’s Full Name / DOB] – Unlawful Contact Restrictions and 2:1 Supervision
Dear Sir/Madam,
I write formally concerning the ongoing restrictions placed upon my contact with [Patient’s Name], who is currently receiving care at [Ward/Hospital] under the responsibility of [NHS Trust].
This letter constitutes a formal Letter Before Action and should be treated as notice that, unless the matters set out below are addressed urgently, I intend to issue proceedings in the Court of Protection without further notice.
Unlawful Interference With Family Life
The Trust is currently restricting or controlling my contact with [Patient’s Name], apparently on the basis of the patient’s 2:1 supervision / enhanced observation level.
These restrictions amount to a serious interference with family life, protected under the Human Rights Act 1998 – Article 8 (Right to respect for family life)
Any interference with Article 8 rights must be lawful, necessary, proportionate and supported by evidence of risk
At present, the Trust has failed to demonstrate that these requirements are satisfied.
Statutory Duties Under the Mental Capacity Act
If the patient lacks capacity to determine contact arrangements, the Trust is under a statutory duty to act in accordance with the Mental Capacity Act 2005.
In particular:
· Section 4 requires all decisions to be taken in the person’s best interests, including proper consideration of family relationships.
· Sections 15 and 16 confer jurisdiction on the Court of Protection to determine issues relating to welfare, contact, and care arrangements.
Where contact between a patient and family member is restricted without lawful justification, the Court may make binding welfare orders regulating contact and directing the NHS Trust to amend its care arrangements.
Observation Policies and 2:1 Supervision
The Trust appears to be relying on the patient’s 2:1 supervision level as justification for the present restrictions.
Enhanced observation measures of this type are governed by NICE Guideline NG10 – Violence and Aggression: Short-Term Management in Mental Health Settings, and NHS Trust Enhanced Observation Policies.
These policies require that:
· Enhanced observations must be risk-based and individually justified
· Observation levels must be subject to regular clinical review
· The least restrictive principle must be applied
· Restrictions on family contact must be supported by a specific risk assessment relating to that contact
Enhanced observation does not provide lawful authority for blanket restrictions on family contact.
Serious Procedural Concerns
Despite repeated requests, the Trust has failed to provide:
· the risk assessment said to justify restricting family contact
· the care plan provisions governing such restrictions
· observation review records relating to the patient’s 2:1 supervision
· any evidence demonstrating that less restrictive alternatives have been considered
If these documents do not exist, the current restrictions may be unlawful and incompatible with both the Mental Capacity Act and Article 8 rights.
Required Disclosure
In order to avoid litigation, the Trust is requested to provide the following within 14 days:
1. The patient’s current care plan.
2. All risk assessments relating to family contact.
3. All observation level review records relating to the patient’s 2:1 supervision.
4. The policy or clinical basis relied upon to restrict family contact.
5. Confirmation of the schedule and procedure for reviewing observation levels and associated restrictions.
Intended Court of Protection Application
If the above information is not provided, or if the current restrictions remain in place without lawful justification, I will issue proceedings in the Court of Protection seeking:
· A declaration regarding the patient’s capacity to decide contact
· A declaration that the current restrictions are unlawful and disproportionate
· A welfare order regulating contact between the patient and family members
· Directions requiring the Trust to amend the care plan and observation arrangements
· Any further relief the Court considers appropriate
The Court of Protection has the power to make binding orders requiring NHS Trusts to alter care arrangements where they unlawfully interfere with family life.
Opportunity to Resolve Without Litigation
Litigation can still be avoided if the Trust:
· reviews the current restrictions urgently,
· provides the documentation requested above, and
· confirms that the patient’s contact with family will be managed in accordance with statutory duties and the least restrictive principle.
If no satisfactory response is received within 14 days, proceedings will be commenced without further notice.
Yours faithfully,
[Your Name]
NICE NG217 Guideline on Seizures
1. Urgent referral after first seizure or recurrence
NG217 1.1.1 – First suspected seizure
“Refer children, young people and adults urgently (for an appointment within 2 weeks) for an assessment after a first suspected seizure”
— NICE NG217¹, Recommendation 1.1.1.
This uses urgent referral, defined by NICE as an appointment within 2 weeks, for anyone after a suspected seizure.
NG217 1.1.2 – Seizure recurrence
“Refer children, young people and adults urgently (for an appointment within 2 weeks) for an assessment if they have a seizure recurrence after a period of remission.”
— NICE NG217¹, Recommendation 1.1.2.
A recurrence after remission is repeated and unexplained, and under NICE this is explicitly urgent — same timeframe as first seizure.
2. Implication for repeated unexplained seizures
Even though NG217 does not use those exact words (“repeated unexplained seizures”) in a standalone recommendation, the guidance is clear from these linked recommendations:
- Any recurrence (repeated seizure) after a seizure-free period triggers the same urgent referral timing as a first seizure.
→ This means 2 weeks maximum to specialist assessment. - The guideline does not recommend routine or non-urgent pathways for recurrent or potentially multiple unexplained seizures in adults or children.
3. Investigations are recommended promptly too
While NG217 separates referral timing (urgent within 2 weeks) from investigations, it also states:
EEG timing
“…if an EEG is requested after a first seizure, perform it as soon as possible (ideally within 72 hours after the seizure).”
— NICE NG217, EEG section.
This supports early investigation following urgent specialist review.
Neuroimaging
“Offer brain neuroimaging tests if an underlying structural cause is suspected…”
— NICE NG217.
This reinforces that after urgent specialist assessment, relevant investigations should not be unreasonably delayed when clinically indicated.
| Situation | NICE Recommendation | Timeframe |
| First suspected seizure | Urgent specialist referral (1.1.1) | Within 2 weeks |
| Repeat seizure after remission (i.e., repeated unexplained) | Urgent specialist referral (1.1.2) | Within 2 weeks |
| EEG after suspected seizure | Early investigation | Ideally within 72 hrs |
| Neuroimaging if needed | Prompt test as indicated | No specified fixed max—but not deferred |
Key takeaway from NICE wording
NICE NG217 does not permit prolonged routine delays for repeated unexplained seizures. According to its urgent referral recommendations (1.1.1 & 1.1.2):
A recurrence or repeated unexplained seizure merits the same urgent (2-week) referral as a first seizure.
Follow-up investigations (EEG, imaging) should then be arranged as soon as clinically appropriate, not deferred indefinitely.
NICE GUIDELINES CG103 DELIRIUM
Before the referral meeting and most certainly before the scan Lynsey needs to be properly rested to avoid physiological confounders.
Good clinical practice in cognitive and neurological assessment requires that potentially reversible causes of impaired cognition are identified and corrected before diagnostic conclusions are drawn.
Under NICE guideline CG103 (Delirium: prevention, diagnosis and management), clinicians must assess for acute physiological contributors to confusion, including dehydration, infection, hypoxia, hypoglycaemia, metabolic disturbance, and medication effects. The guideline emphasises that delirium is common, serious, and frequently reversible, and that failure to detect underlying medical causes risks misdiagnosis.
Accordingly, cognitive assessment should occur only when the patient is medically stable. Good practice therefore includes:
- Excluding delirium and acute illness
- Correcting dehydration and metabolic abnormalities. (nourishment, breakfast to avoid hypoglycaemia)
- Reviewing medications and substances
- Managing pain and sleep disturbance (a proper nights sleep before to avoid confusion due to tiredness)
- Ensuring appropriate sensory aids and a suitable testing environment
While CG103 does not explicitly state that a patient must be “relaxed and properly nourished,” its requirements to identify and treat reversible contributors to confusion implicitly support optimisation of physiological and environmental conditions prior to assessment.
In summary, consistent with CG103, cognitive evaluation should be undertaken under conditions that minimise reversible confounders to ensure diagnostic validity and patient safety.
Psychiatric Abuse UK 