Shadowing A Qualified Best Interest Assessor (BIA)

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This essay will provide an account of a shadowing opportunity with a qualified Best Interest Assessor (BIA) completing the Deprivation of Liberty Safeguards (DoLS) on a vulnerable individual, to help me with my learning in the process of being trained to become a qualified BIA. I will account for the reason for the best interest assessment by providing a background on the case and the required processes that were followed by the DoLS regulations and show how the assessor supported her conclusion. I will also refer to the principles of the Mental Capacity Act, 2005 as well as the DoLS code of practice to demonstrate my understanding of how the decision was reached considering the six various assessments and their requirements which sum up the DoLS assessment process. I will consider the appropriate legislation, case laws, and credible academic resources to support my findings. Finally, I will discuss any identified challenges, disagreements, and or any variance from the code of practice.

For the sake of confidentiality, the names of individuals and places within the essay and the ADASS form 3 would be anonymized.

Mrs. R is a 68-year-old widow and resides at a residential care home where she has been living since 02/02/2023. She has a diagnosis of dementia in 2020, hyperthyroidism, and curvature of the spine. Mrs. R’s diagnosis impacts her cognitive and functional ability such that, she is dependent on carers with her daily living activities. She has short-term memory and poor concentration. She eats independently but with lots of encouragement. Staff anticipates her food and fluid intake, offering her preferences and choices as she will not request anything from staff. She is on a high-calorie and fortified diet due to being underweight. Mrs. R has three adult children with her late husband who passed away in 2020. The children are Mr. T, DD, and M, who now lives abroad. Mrs. R worked for many years as a support worker in mental health services. She was an active lady who loved to walk, she also enjoyed socializing and had many friends. Mrs R’s dementia progressed after her husband’s death and a care package was put in place to support her, but carers reported she was often out when they visited. She would leave her home early in the morning and spend her day in the town centre. Mrs. R was found by the police on several occasions wandering through the town.

Shadowing A Qualified Best Interest Assessor (BIA)

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Mrs. R started to take items from the shops, and would forget to pay, the police made a referral to the Safeguarding Team after they noted she was extremely unkempt and confused. Mrs. R was visited at home by her social worker (SW) who advised that she was living in unsanitary conditions and had been neglecting herself for some time.

The SW spoke with Mrs. R’s son, Mr. T, who had been concerned for his mother’s welfare but was unsure of what to do to keep her safe. An urgent respite placement was agreed upon by the SW and Mr. T as it was the most appropriate option for Mrs. R to allow for a full assessment of her mental health and care needs. The outcome of the assessment was that the placement was the best option, therefore, Mrs. R is now a permanent resident. Mrs. R is largely continent with occasional accidents. She is assisted by one care staff with her care however she can be resistant to intervention and will attempt to push staff away or say she is going out. Staff offer plenty of reassurances, will sometimes leave, and revisit the situation when Mrs. R is more accepting of care. Mrs. R mobilizes independently without any aid and is reported to wander around the care unit looking busy and would say she is going to town. Staff use distraction techniques such as offering her tea and biscuits to get her to sit for a while. Mrs. R takes the following psychotropic medication for her dementia. Trained staff administer Mrs. R’s medication. She is not always compliant with taking her medication needing reassurance and patience from staff.

Due to the severity of Mrs. R’s cognitive impairment, she is unable to consent to her accommodation, care, and treatment she receives at the Residential Home. Mrs. R is under continuous supervision and not free to leave the care home. She is subject to a previous DoLS which expires on 16/05/2024. The conditions attached to the DoLS authorization were met by the care home when a further standard authorization request was sent to the Local Authority (LA) for a review.

MoJ (2008) describes the DoLS process as starting from when the (MA) which could be a hospital or care home becomes aware that an individual in their care may be deprived of their liberty. At this point, they must apply for DoLS to the Supervisory Body (SB) with is the Local Authority(LA),.

Before an individual is deprived of their liberty, the (MA) has a duty of care to inform the (SB), when they suspect an individual within their care is being deprived of their liberty (Ministry of Justice (MOJ) 2008, 18-19). In Mrs. R’s case, urgent authorization was not required because there was an already existing standard authorization that justified a legal DoL, therefore a review of her circumstances was required. According to the legislation and processes surrounding DoLS, standard authorization can last up to a year unless otherwise stated within the authorization (Allen, 2022).

Shadowing A Qualified Best Interest Assessor (BIA)

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The (MA) gives themselves 7 days of urgent authorization and completes a standard form to the (SB). The urgent authorization can be extended by another 7 days but that would need to be authorized by the (SB) (SCIE, 2022). SCIE (2022) Further explains that, the MA must inform the individual’s Relevant Person’s Representative (RPR) which could be family, friends, or if they are involved with any independent mental capacity advocate (IMCA) before granting the urgent authorization. This gives the SB the right to decide within 21 days of receipt of the standard request. MoJ (2008, pp 3.14), highlights that the MA is required to retain a record of every standard authorization, and these must be documented on the ADASS Form 3.

In Mrs R’s review of the existing DoLS, the SB must commission the appropriate professionals to complete the 6assessments which are; Age assessment, Mental health assessment, Eligibility assessment, No refusals assessment, Mental Capacity Assessment (MCA) and Best interest assessment (BIA); The outlined assessment must be completed by at least 2 professionals who are the best interest assessor and the mental health assessor, and none of them must be involved in the individual’s care (Alzheimer’s Society 2021).

In England, the SB is the LA while in Wales it is either the LA for DoLS in care homes or the health board for DoLS in the hospitals (Alzheimer’s Society 2021).

The best interest assessor must be a qualified social worker, a nurse, a chartered psychologist, or an occupational therapist (Alzheimer’s Society 2021). According to MoJ (2008), The best interest assessor completes the Age, No refusals, MCA, and Best interest assessment, however, some LA employ doctors to complete the MCA. A doctor approved under section 12 (S12) of the Mental Health (MH) Act 1983 or a registered medical practitioner with at least 3 years post-registration experience such as a General Practitioner (GP) with special interest is the only practitioner that can complete the Mental health assessment (MoJ 2008 4.35). The eligibility assessment can be completed by a S12 doctor, or an Approved Mental Health Practitioner (AMHP) who must be a qualified BIA (MoJ 4.52-4.54).

In the case of Mrs R, the SB commissioned a social worker who is also a qualified BIA to complete the best interest assessment. There was also a S12 doctor who completed the eligibility and mental health assessment. Mrs R’s son has Lasting Power of Attorney (LPA) for finance and welfare, and he was happy to act as the Relevant Person’s Representative (RPR), he understood the processes and did not require any additional support therefore, there was no need for an Independent Mental Capacity Advocate (IMCA) (Department for Constitutional Affairs 2007 178).

Shadowing A Qualified Best Interest Assessor (BIA)

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The BIA completed the Age assessment. MoJ (2008) states the importance of practitioner checking to ensure the individual is over 18 years of age. It further highlights it is a good practice to check birth certificates or relevant care documents. In Mrs. R’s case, the BIA checked her care plan, and the previous standard DoLS authorization and she did confirm her age with the RPR who Mrs. R’s son. Mrs. R is 68year therefore she is eligible according to the legal guidance on DoLS, all the same, if there were complexities around her age, the BIA could use her judgment or belief based on the gathered information (MoJ, 2008, pp. 4.23).

The BIA completed the No refusal assessment to identify if there were advanced decisions in place which is contrary to the deprivation of Mrs. R’s liberty, or if the LPA or deputy by the court of protection has any objection to the DoL. If there are any conflicts or over-riding decisions including objection to treatment, they should be reported immediately to the SB for an investigation to be completed to explore if DoLS is still required by the court of protection (Dimond 2016). Following Mrs. R’s review, the BIA spoke to Mr. T, the RPR for Mrs. R to clarify if there are any objections or if he was aware of any advanced decisions, Mr. T, reported there is nothing in place that could object to the deprivation of Mrs. R’s liberty. The BIA could check this with the Office of Public Guidance (OPG) if required ((Rogers et al, 2015).

In Mrs, R’s case, the Eligibility assessment was completed by an S12 doctor, and he concluded Mrs R is eligible for DoLS. The purpose of this assessment is to establish if the individual is actively under the Mental Health Act 1983, or if there is any legislation under the stated Act that would best suit, support, and protect the individual and would not conflict with the guidance within the legislation (MoJ 2008 4.40-4.41).

In the case of Mrs. R, a certified S12 doctor completed the mental health assessment in line with the legislative requirement of 2 different assessors who must be trained in their roles in completing the 6 assessments (SCIE 2022)

SCIE (nd) highlights that the purpose of the Mental Health (MH) Assessment as establishing whether the individual has a diagnosis of a mental disorder according to the meaning provided by the Mental Health Act which is the disorder or disability of the mind other than dependency on alcohol or drug. SCIE (nd) further highlights that, this assessment is not to determine whether the individual requires mental health treatment but it does consider if at all the individual’s MH is likely to be impacted or affected by being deprived of their liberty. The S12 doctor established that Mrs. R has a diagnosis of Dementia, affecting the cognitive domains of memory, language, perceptual-motor, social cognition, and executive functioning. As a result of the cognitive impairment, she is dependent on staff for most activities of daily living. He further stated although Mrs R’s liberty is deprived, it does not affect her mental health and her wellbeing.

Shadowing A Qualified Best Interest Assessor (BIA)

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Reflecting on my shadowing experience with Mrs. R’s case, Mrs. H, the BIA, completed the Mental capacity assessment (MCA) on Mrs. R to establish if Mrs, R can consent to her placement and the consequent deprivation of her liberty as she was a permanent resident in a residential care home. The 2stage test was considered as noted within the Mental Capacity Act (2005) as the diagnostic test where the individual must be diagnosed to understand if there is a long or short-term impairment of the mind that affects their cognition, and the functional test where it is explored if the individual can understand, retain, weigh, and communicate the relevant decision (MoJ 2008). The BIA must take care to document appropriately to justify the outcome as well as the action taken as highlighted in PC and NC v. City of York Council (2013) (Roger and Bright 2019 80-81). The BIA must consider the Causative Nexus which is the conclusion arrived to glue the findings together, justifying a conclusion of capacity or incapacity to make a specific decision. If the relevant individual is deemed to have capacity, the SB must be notified immediately, and the process must be stopped (Mental Capacity Ltd 2023). Conversely, if the person lacks capacity, the BIA proceeds to the best interest assessment and considers if the relevant individual can express who they would like to be their RPR and whether the RPR meets the criteria (Mental Capacity Ltd 2023).

In Mrs R’s case, she had an impairment of the brain which impacted her cognition as identified within the mental health assessment. Mrs. R was unable to choose her RPR, she stated her son is her brother. I observed from the shadowing opportunity that even though it was a review of the standard authorisation the BIA assumed Mrs. R had capacity, she used simple sentences, supported her to participate in the assessment. As the causative nexus was that Mrs. R lacked capacity around her placement and her DoL, a best-interest assessment had to be completed.

From the 5 completed assessments, the BIA concluded that, the best interest assessment will be applicable in Mrs. R’s case. Mind (2023) explains that, the Best interest assessment is to explore whether the relevant person is going to be, or is being deprived of their liberty, and if it is in their best interest. Mental Capacity Ltd (2023) highlights that, the BIA must consider their care plans, risk assessments, daily notes, and any additional relevant documentation. They should also consider all relevant persons who may include staff at the care home or hospital, health professionals, friends, and families. All the same, confidentiality and respect for data privacy under the GDPR must be adhered to. The BIA must also establish if the Acid Test is met, as highlighted in the case of HL V United Kingdom (2004); where the European Court of Human Rights judgment states that those who are under continuous supervision and control and are not free to leave constitutes a DOL(MoJ2008). The Best interest assessment determines whether the care and treatment are in proportion to the relevant individual’s needs by considering the duration, type, effect, manner, and intensity the individual is deprived of.

BIAs weigh up all the available options for the provision of care and treatment, ensure they are succinct, and document all the facts within the ADASS form 3. The BIA then makes a recommendation to the SB, with the balance of probabilities, if they believe the DoLS authorization is appropriate, and if so, would there be any DoLS-specific recommendations for the MA?

In Mrs R’s case, all the relevant documentation including the previous standard authorization, care plans, and risk assessment plans were checked by the BIA.

All the relevant people about Mrs R’s case were contacted, namely Mr T, and the senior carer KR. They all concurred to the fact that it is in Mrs R’s best interest for her to be deprived of her liberty. All their views were documented on the Form 3. Some of the restrictions in place for Mrs are; Mrs R receives 24-hour care and monitoring, Mrs R lacks the mental capacity to decide on her accommodation, Mrs R needs assistance from one staff member to complete her daily personal care and hygiene and Mrs. R has no control over how her medication is managed.

Mr T agrees to continue in his role as RPR and has been reminded of his duties and responsibilities and the support of an s39D IMCA if required.

Mrs. R’s DoL was granted for 12 months without any recommendation as the placement was meeting her needs appropriately and promoting her best interest without any impact on her mental health and wellbeing.

Reflecting on my shadowing experience and my lectures as a BIA student, I have learnt the importance of a holistic and robust assessment and its impact on the relevant individual as demonstrated in the London Borough of Hillingdon v Neary case (Essex Chambers 2011). I am not oblivious to the fact that there are numerous forms and processes to be completed to deprive an individual’s liberty legally, however, all the necessary processes and parties must be supported accordingly in a least restrictive and non-judgmental manner for a positive outcome.

Shadowing A Qualified Best Interest Assessor (BIA)

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Reference List

Alzheimer’s Society (2021). The Deprivation of Liberty Safeguards assessment. Alzheimer’s Society. Available from The Deprivation of Liberty Safeguards assessment | Alzheimer’s Society (alzheimers.org.uk) [Accessed 4 June 2024]
Allen, O. (2022) What is Standard Authorisation DoLS?. GN Law, (23 May). Available from What is Standard Authorisation DoLS? | GN Law [Accessed 2^nd June 2024].
Department for Constitutional Affairs (2007). Mental Capacity Act 2005 Code of Practice. London: The stationary office on behalf of Ministry of Justice.
Dimond, B. (2016). Legal aspects of mental capacity: a practical guide for health and social care professionals. Chichester, West Sussex: Wiley Blackwell.
Essex Chambers (2011). MENTAL CAPACITY CASE London Borough of Hillingdon v Neary. [online] Essex Chambers. Available from : https://www.39essex.com/information-hub/case/london-borough-hillingdon-v-neary-0 [Assessed 5 June 2024]
Mental Capacity Ltd (2023), The six key assessments for DoLS. Mental Capacity in Practice [online] Mental Capacity in Practice. Available from :The six key assessments for DoLS – Mental Capacity Ltd (mental-capacity.co.uk)[Accessed 5 June 2024].
Mind (2023), Mental Capacity Act 2005 Explains how the Mental Capacity Act affects you and how you can plan ahead for when you no longer have the mental capacity to make decisions for yourself. Applies to England and Wales. [online] Mind. Available from : https://www.mind.org.uk/information-support/legal-[rights/mental-capacity-act-2005/deprivation-of-liberty/ [Accessed 2 June 2024]
Ministry of Justice (2008) Mental Capacity Act 2005 Deprivation of liberty safeguards. Code of Practice to supplement the main Mental Capacity Act 2005 Code of Practice. London: The Stationary Office.
Rogers, J., Bright, L. and Davies, H. (2015) Social Work with Adults, London: Sage.
Rogers, J Lucy Bright, L Assessments of mental capacity: upholding the rights of the vulnerable or the misleading comfort of pseudo objectivity. THE JOURNAL OFADULT PROTECTION, 21(2) 74-84 80-82. Available from pdf (lincoln.ac.uk) [5 June 2024].
Social Care Institute For Excellence (2022). Deprivation of Liberty Safeguards at a glance. [online] Social Care Institute for Excellence (SCIE). Available from: https://www.scie.org.uk/mca/dols/at-a-glance[Accessed 2 June 2024]
Social Care Institute for Excellence (2022). Deprivation of Liberty Safeguards (DoLS) at a glance. [online] SCIE At a glance 43. Social Care Institute for Excellence (SCIE). Available from: Deprivation of Liberty Safeguards (DoLS) at a glance – SCIE [Accessed 5 June 2024].
Social Care Institute For Excelle(nd). DoLS: Mental health assessment

What makes a good mental health assessor. [online] Social Care Institute for Excellence. Available from: DoLS: Mental health assessment – SCIE [Assessed 5 June 2023]

By admin in Essays on January 16, 2025