The Private and Voluntary Health Care (England) Regulations 2001

Safety of patients and others

44.—(1) The statement of policies and procedures which is to be prepared and implemented by the registered person in accordance with regulation 9(1)(e) shall include policies and procedures in relation to—

(a) assessment of a patient’s propensity to violence and self harm;

(b) the provision of information to employees as to the outcome of such an assessment;

(c) assessment of the effect of the layout of the hospital premises, and its policies and procedures, on the risk of a patient harming himself or another person; and

(d) the provision of training to enable employees to minimise the risk of a patient harming himself or another person.

(2) The registered person shall in particular prepare and implement a suicide protocol in the hospital which requires—

(a) a comprehensive examination of the mental condition of each patient;

(b) an evaluation of the patient’s history of mental disorder, including identification of suicidal tendencies;

(c) an assessment of the patient’s propensity to suicide; and

(d) if necessary, appropriate action to reduce the risk of the patient committing suicide.