I have just finished a discussion about the conveyance of patients who are detained under the Mental Health Act. This is a subject which has now reached the political level because the UK Home Secretary indicated in her speech to the Police Federation conference in May 2012 that she wanted to try to ensure that police officers spend less time “escorting mental health patients”. I know that she is looking at how this can be achieved in conjunction with the Department of Health.
There are various situations in which the police convey patients – some of them are inevitable, some of them potentially avoidable:
- Following a police led detention under the Act - s136 detention for example; or following the re-detention by the police of someone who is AWOL from hospital.
- Following an application for someone’s admission under the MHA - typically, the sort of situation in which an Approved Mental Health Professional and one or two doctors have ‘sectioned’ someone and seek police support for conveyance of that detained person.
- Following a request that a psychiatric inpatient be transferred - typically, this may the need to transferred someone to another psychiatric unit or to A&E if an inpatient has urgent physical health problems.
Situation 1 is unavoidable - if the police detain someone and no other method of conveyance is available, then “you are where you are”. The Mental Health Act Code of Practice states that conveyance of anyone detained under the Act should be done by non-police transport, wherever possible – so there is legal basis for asking the ambulance service to support you. This is not only because what you think may be a mental health problem could be something else besides; but also it is concerned with ensuring the dignity of people who have not been arrested for an offence. Their transportation should reflect this status as ‘patient’ rather than ‘suspect’.
In fairness to police services, some Ambulance Trusts have strong views about conveyance of mental health patients, especially following police detention. One senior paramedic (not in my own force area’s ambulance service) once curtly asked me, “Do you really think that’s a good use of an intensive care unit on wheels?!” I couldn’t give two hoots whether it is or not, if I’m honest: it is a legal requirement from the Code and I’d happily achieve non-police conveyance another way if there was an established mechanism by which to do so. As there usually isn’t, you’ll be asked anyway. If the NHS then want to say no, that’s up to them but I’ll be mentioning it to the Coroner should the need arise and they can explore the NHS commissioning and conveyance arrangements if they need to. You can then explain Chapter 11 of the Code of Practice in the context of your decision.
Such legal situations would include: sections 135(1) (warrant to a place of safety), 136 (emergency removal to a place of safety), 18 (AWOL patients) and 138 (absconders from PoS detention). If you don’t request an ambulance, you’ll never get one so why not try? If you do try and fail – for whatever right or wrong reason – then it’s on the audit trail that you tried and this is key: Dorset Police and either Kent or Sussex Police (link to follow when found!) have each had situations in the last couple of years where they removed someone by police vehicle after detention in the above legal situations and the person died in transit. I also have an example from my own force of a man who was detained by officers under s136 where it was perfectly reasonable of them to do so. Because they called an ambulance to the scene, paramedics were able to do standard physical observations checks which included a blood sugar test and as they did this the man collapsed and was rushed to A&E. Had he been taken to the police cells in a car, he probably would have collapsed in the holding area of the cell block and the A&E consultant who treated him suggested it was possible he may have died. It turned out that he was an undiagnosed diabetic and has no mental disorder at all.
Situation 2 could be better planned - this includes the “Mental Health Act Assessment on Private Premises” situation. I have a great deal of sympathy with AMHPs here. They are required to co-ordinate assessments and then the admission if it is required, but they often don’t have access to the resources to make this happen. In some situations where ambulance and police are required to convey, they find a “catch-22″ ongoing where the police won’t even despatch an officer until the ambulance is there or vice versa. Presumably this occurs because neither agency wants to then be told that the other emergency service has been diverted to [insert your preferred emergency here] and be asked to crack on unsupported. Paramedics don’t want resistant, escape risks in the back of their ambulance; the police don’t want people with medical problems in their police cars. Happy times for AMHPs.
What happens where the conveyance is required not just because of a need to move someone, but a need to move someone who is presenting risks to safety – either their own or that of others? Although unclear about why the police would be called to convey someone who is compliant, I can understand why an AMHP may want the police because of what I’ve previously called RAVE risks. But what precisely is the role? Where does the potential for harm turn a situation where the police are in the background, in support of an AMHP, to one where they take the lead in the physical coercion of someone who is presenting actual violence and danger? I’ve posted elsewhere about debates that go on about the coercion of patients – should it always be a role for the police or should mental health services have trained staff available? Obviously this question links directly into the subsequently necessary question of conveyance and who will do it.
However, this again often comes back to commissioning. In many areas, as well as designing services in a way which means control or restraint trained staff are not available there are often no planned arrangements for achieving conveyance of patients after MHA detention – it is a question of asking and hoping for a 999 ambulance to be available. You can easily see why AMHPs with actual patients in the real world turn to the police for help. In some areas they have arranged the non-999 vehicles to undertake this task, with a ‘bookable’ system. In other areas, few in number, there are contractual arrangements with a private organisation who can be requested by the AMHP for conveyance, including staff with some capacity to manage resistant patients.
Situation 3 is arguably not a police responsibility – except where urgent risks need to be mitigated. The Code of Practice clearly states that it is the responsibility of Primary Care Trusts to ensure they have properly commissioned arrangements for conveyance of patients. This is an area of business where some police forces have just issued a fairly blunt directive: we do not convey patients between psychiatric units, ever. Such direction is not just about demand on resources which could be prioritized elsewhere. It is also about questioning whether the police are the correct people to make urgent transfers of detained patients. What kind of medical or paramedical supervision is needed? In whose legal custody is the person if they are being moved by the police and / or ambulance service and / or doctors and / or nurses? Who is in charge of this where medical risks have blended into safety risks?! What do we do with disagreements about transfer?!! It goes on …
One point to make very clear, is that there have been incidents where police officers and paramedics are asked to transfer detained MHA patients who have been sedated – para 11.5 of the MHA CoP states, “Patients who have been sedated before being conveyed should always be accompanied by a health professional who is knowledgeable in the care of such patients, is able to identify and respond to any physical distress which may occur and has access to the necessary emergency equipment to do so.” Paramedics I have spoken to do not usually regard themselves as ‘suitable’ professionals. There are issues around what drugs they are licensed to administer and the issue of not wanting to supervise patients where the dosage of medication was administered by someone else where it involves estimates about patients and travelling time.
Ambulance services often refuse to convey sedated patients where the trust who seek support for conveyance are not supplying a doctor or suitable nurse. It is perfectly proper to suggest that the police should do likewise for even more reasons.
Some requests for transfer arise from the fact that a patient’s condition warrants a different type of mental health unit. For example, a patient initially admitted to a Psychiatric Intensive Care Unit may need to be moved to medium secure care. A patient on an acute admissions ward, may need to be secluded but the hospital or clinic in which they are detained may not have a seclusion facility or it may not be available. There is a legitimate difficulty in gauging where police responsibilities lie and I’m going to make a specific post out of the considerations that may apply to the ‘rapid transfer’ of a patient to another psychiatric unit where mental health professionals are seeking police support in a hurry because of unmanageable risks. For now, I just keep coming back to a question I’ve asked inpatient nursing or medical staff when faced with these requests: “before we get police officers and paramedics to improvise their way through this, what contingency arrangements do you have access to through your managers?” Too often the answer is: “None.” Actually and quite frankly: I’ve never known the answer be anything other than “None.”
And can I end by just saying this – conveyancing is what you do when you buy and sell a house; conveyance is about the movement of people or stuff!