MB4

My Deepest Fear

MB4The history of disasters in policing and mental health arise from the fact that the police actually did exactly what the NHS explicitly sought or implicitly wanted them to do. Therefore, putting NHS staff alongside police officers, whilst it may bring very real benefits to some, will also bring an extra pressure dynamic to bear on operational officers at some critical times.

Imagine the scenario: there is a call from a desperate relative on 999. Their loved one has been living in crisis for several days and has been drinking throughout the afternoon. The triage car and other officers attends this call because there is a significant history about this patient that is known and it is in every sense a proper mental health emergency. Whilst the police officer is driving them there on “blues and twos” the police dispatcher is relaying a summary of attendances, warning markers and so on. We know that the person has previously been sectioned, that they’ve been AWOL whilst detained and have been detained at that location. We know that they have been resistant on arrest and that they’ve been drinking vodka today. Upon arrival, this man is in the street and his elderly relatives are asking for help. No amount of “tactical communication” is working – he is either too unwell, too drunk or both for either the nurse or the officer to persuade them out of the road. The triage car agree, he will have to be detained in his own interests.

Leave aside the debate which could immediately occur about whether to detain s136 or for a drunkenness-related offence, let’s just agree that the person will be detained. Where do we now go?

If you look at various section 136 policies around the UK, it will say, because of alcohol and aggression and the risk history involved, the man should be taken to the cells. We can only imagine the nurse would encourage this course of action being right there at the scene and knowing that this is what the joint protocol says. After all, we can’t assess the person under the Mental Health Act until the alcohol has worn off, can we? He needs to “sober up somewhere”, right?

What about physical healthcare needs? – what about the possibility that the person is suffering an underlying problem that is being masked or fogged by alcohol and aggression? How do we take that into account and – no offence to any mental health nurses anywhere in the UK – the triage car nurse would not be trained in the pre-hospital urgent care like our 999 colleagues in green. Remember, mental health nurses are (usually) not dual trained as general nurses. Would they carry with them, blood pressure cuffs, blood sugar testing equipment, thermometer, etc.? I realise that mental health nurses can / do physically examine patients, my question is “will they?” I’ll be frank: mental health nurse or not, I’d probably still be calling an ambulance – chapter 11 of the MHA Code of Practice stands.

How do we get the person to wherever they will be detained? – in most of the 11 ambulance services in the United Kingdom, they wouldn’t attend such a call anyway for various bureaucratic and on occasion discriminatory reasons. I’m pleased to say, the ambulance service where I work “get this” completely and would almost certainly attend, priority of unusual demands permitting. But yet again, knowing they may not feel obliged or able to attend, is no excuse for then doing the wrong thing – chapter 11 of the MHA Code of Practice stands.

You see the reason I have a deep, underlying fear of what is being suggested is not because I think it will fail to bring any benefits. I think there will be loads of benefits in terms of information sharing, s136 avoidance and I genuinely welcome that and more. Having said that, I can think of other, less resource intensive and probably cheaper ways of doing the same thing, but I do welcome it.

My deepest fear arises from the fact that the above case is not hypothetical: it is the real story of a UK death in police custody where the NHS actively wanted a police cell to be used for a patient who had received no pre-hospital triage and whose intoxicated, aggressive presentation led to a fast decision – a hasty one – that the only possible place we could remove the man to was police custody. The custody sergeant who did not resist that course of action by recognising the clinical threats involved was disciplined for gross misconduct.

I had some difficult writing this post, for two reasons -

  • Firstly, I couldn’t think which death in custody story to use for the “hypothetical” point – there were several candidate stories to make the same point;
  • Secondly, I am really conscious that it appears to be flying in the face of the thrust of the street triage initiative.

DECISION-MAKING AMIDST UNCERTAINTY

What I know from the work I’ve done over the last ten years on policing and mental health, is that we must equip our police officers to make the correct decision under pressure, which will sometimes, just occasionally, mean resisting the NHS and doing what they don’t want us to do. The reason we know this is because we could list the prosecutions where officers have faced criminal charges of neglect arising from “doing as they’re asked”.

Various cases over just the last ten years, many of them highlighted on this blog, show that the NHS has not commissioned and integrated itself to react to the number or nature of mental health emergencies that this country generates – this is precisely why the CQC have just yesterday announced a thematic inspection of emergency mental health care. When I get back from holiday, I am going to write a blog for their attention, specific to my view on that whole business.

But for here and now, for the debate following the announcement of street triage: we have to define the problem we’re trying to solve before identifying the solution. You could solve the “inappropriate s136″ problem any number of ways without having to pay a nurse to stop the cop from doing the wrong thing. << This is the very raison d’être of at least one triage scheme already running – the NHS don’t trust their police to get it right, so they resourcing an opportunity to stop them from getting it wrong. Why not just train them to get it right?! Is it because we still haven’t defined what “right” actually means for s136? … probably. We know from reading the joint HMIC / CQC report on police cells as a place of safety and from the CQC annual reviews of the Mental Health Act that those who need to know about the police mental health interface don’t actually understand it.

We all know that the volume of calls to the police could be far better managed with mental health support through information sharing and joint working. What I’m less convinced of, is that these joint working arrangements will take proper account of things that the NHS have historically been unable to brigade: the urgent, emergency reaction to unknown clinical risks, involving intoxication and aggression.

And again, we see the trap being fallen into – this stuff will not go wrong very often, but when it does go wrong it will go really, really, wrong. Bearing in mind that nurses also have very different training around the use of force and restraint, I’m also concerned that we will see again, nurses flagging concerns about the use of force even where officers are acting in a text-book fashion, according to their training. We’ve seen this in the Olaseni LEWIS case and others: we’ll see it again until somebody defines the problem we’re trying to fix and designs the solution to fix that problem.

I’m not hoping to fix the problem to which “street triage” is the answer – for that, you need to fix CrisisTeam services as a whole and it will take more than free security and a lift from the police. Street triage is “pulling people out of the river”. Eventually, as Desmond TUTU rightly said, “we have to get upstream and work out why they’re falling in.”

I worry that untoward events will still occur; and that in hindsight, they will appear quite predictable.

___________________________________________________________________________________________________________

BadgeThe Mental Health Cop blog won

- the Mind 2012 Digital Media Award, in memory and in honour of Mark Hanson.
The Awards celebrate the “best portrayals of and reporting on mental health in the media.”
- a World of Mentalists 2012 #TWIMAward for the best in mental health blogs.
It was described as “a unique mix of professional resource, help for people using services and polemic.”

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24 thoughts on “My Deepest Fear

  1. Agreed long term we need to do more preventive work and short term we need a fully resourced MH Team with doctors, AMHPs CPNs, quick access to appropriate transport which can operate on a 24/7 basis until then we’re just plastering over the same cracks again and again. The triage scheme maybe helpful but in one of the pilot areas it was a response to a particular issue with that police force classing nearly every awkward drunk as a Section 136. To the extent that anyone working in mental health thought of it as a running joke. I know this isn’t the case in other areas just hope the information from pilots is fully evaluated rather than declared a success because somebody high up already thinks this is the answer which is what normally happens in the NHS

  2. I know we see opposite signs of the coin, but I find your blog very negative without any first hand experience, please try and brace street triage for our patients sake. Please try not to focus on sceptical assumptions go out with RMN in street triage car and blog about it afterwards

    1. Without any first hand experience?! I’ve been a police officer for over fifteen years, twelve on the frontline of policing where mental health issues were daily, if not hourly, business and the other three doing nothing other than work on mental health issues from a policy and partnerships perspective. I may not have had direct experience of a triage car (oddly, because they don’t operate in my area) but I have had literally hundreds and hundreds of conversations over the years about operational incidents where I have implored, if not begged, mental health services to come with me and my officers on joint visits that CrisisTeams and community teams have asked us to do. Usually, they won’t.

      I have been in literally hundreds and hundreds of operational situations with RMNs or CPNs and psychiatrists and I have not once seen any of them do a physical examination of a patient. I have seen them miss the diabetics and the head injuries through what paramedics have subsequently said were fairly obvious indicators that “something’s not quite right”; I’ve seen them, quite literally, walk away and refuse to deal with people who were intoxicated or aggressive, despite a well establish MH history. So my experience in this field is considerable and it’s not all sweetness and light.

      You may not agree with my view – and I’m not asking you to – but you are going to have to acknowledge they are based about years of dedicated interest and study and you should actually come up with an argument, instead of attempting to patronise me. It would be just as easy to patronise you about your view by saying that you’ve never been the arresting or custody officer who has been led with a complex clinical nightmare to manage using your first-aid skills but that would be missing the point, too. The unspoken undertone of this blog is what we know will happen if things go wrong – it’s (another) MH system stacked to build hidden risks that we’ll all be surprised about when they emerge. << And that is not the same thing as saying the scheme isn't welcome. I repeatedly say, above, that I welcome it for what it's worth. I just have reservations about gaps that need plugging and other feedback flying in from this post suggests support for what I’m arguing; and not just from the police.

      1. Good response mentalhealthcop! I have been an RMN for nigh on 30 years and have experience of acute psychiatric wards, community mental health and A&E liaison ( literally being in A&E doing MH assessments). I, too, share your concerns for similar reasons namely the competences required by the RMNs in attendance ( not only health but legal) at the point of triage. RMNs do not have any legal authority to act and would be reliant in their police colleagues to respond to any threats or actual violence/aggression. The RMNs involved will need to demonstrate competences in mental state examination and risk as well assessing capacity prior to an assessment being completed. Furthermore, the RMN will need to ensure that the individuals ability to give informed consent is documented. I also believe that employing trusts will have to undertake a significant risk review in order to agree to accept vicarious liability on behalf of their staff. Additionally,it may be that the RMNs will need to ensure that their professional body (NMC) would agree to nurses acting in such a capacity as well as the RMNs themselves requiring personal indemnity insurance. As a final point, and having worked in Crisis Teams too, the question ‘who has admitting responsibility’ needs to be answered. To my knowledge, most acute beds can only be admitted to by/with the agreement of a ‘Responsible Clinician’ ie a Consultant psychiatrist or SpR! I really do understand the need for joint working but as some of the post-ers above have noted, the skills set required in such complicated scenarios should include all staff working together-Police, MH, Paramedical, General Health (in case ED is required) and AMHPs rather than ‘ it’s between Police and MH’.
        Keep blogging and posting! Always generates synaptic activity when I read your stuff!

    2. I don’t think he’s being negative. I think he’s just pointed out valid reservations about an initiative that doesn’t have much of an evidence base behind it.

      I’m not sure if this is a concern of yours, but I don’t think this post is attempting to denigrate the expertise of mental health nurses. I’m a mental health nurse who’s had many discussions with Inspector Brown and I’ve never had any impression that he lacks respect for mental health nurses.

  3. Thank goodness this live & wicked problem is being highlighted…I am wrestling with it at the moment….it is a circular problem with so many people without emotional resilience needing interventions and help but not necessarily being brought into hospital ( you see how i carefully avoid using the phrase PD) the system is set up for police to respond to risky behaviours, for 136 to be applied, for hours to pass, for the person to be bounced out of the system…for it to happen all over again..we need a way of diverting people to the right resources without recourse to admission or at times even the crisis teams…leaving these resources free for the most in need and unwell.
    Secondly as an RMN i know first hand that many of us are woefully unfamiliar with physical health interventions let’s point out ” the elephant in the room here is relaxing on a sun lounger “… this area is now being embraced because it has affected our patients wellbeing for so long…but for many staff I train, or sadly investigate in SUI inquiries, their knowledge of physical health care, and physical symptoms that exacerbate or mimic mental health behaviours of arousal /agitation/ aggression and is often limited.
    Lastly I welcome triage nurses and embrace the concept, but they are few and far between, we need to tackle the problem with the largest possible impact and that is train the police in recognising and identifying what is MH and what is a.n.other behaviours – that need direction down a non health route – lets use social care options more.
    I am working to try and crack this thorny issue and would welcome more input from mh teams but do not think it will go away, unless we really face that we ALL need to change to try and shift the elephant out of the room before he squashes the lot of us!

  4. When reading about this new initiative I too struggle to see what will be gained by it. I wonder whether investing more in the mental health service ie further up the river as you put it, would be a better use. I have ended up in a police cell on Section 136 and stepping through what happened got to thinking would it have been different if there was a triage nurse? Quite probably but maybe not for the best. The nurse might access my records and say there’s not a lot we can do for this person we don’t usually admit her to hospital so just let her go. At least police time and a cell would not have been used. From my perspective I would not have got help and remain in the same desperate place possible likely to go on and attempt suicide. At least the police seem to care and have a duty to preserve life which is more than the average m h service professional. But it is not their place and should never be their place to have to be more helpful than the mental health services. There needs to be better crisis and acute care to prevent those of us with mental health issues coming into contact with the police in the first place.

    Mental health cop keep on coming with your opinions you make a lot of sense and unless people speak out things will never change.

  5. As a member of Jo Public, my humble experience has given me personal experience of this situation, particularly relevant this Glastonbury weekend! Attending a small music festival some years ago, I was witness to several officers attempting to arrest/restrain a very resistant woman. I was aware that she had been taking drugs, that she had a history of mental health issues, and had probably not slept for a day or two, so I went over to offer support, as I would be a recognisable face to a distressed person, and also have Mental health First Aid training. The officers were treating her simply as an aggressive person, and seemed to have no idea of the history of the situation. I managed to persuade the woman to calm down enough so that she could be taken by the officers into their vehicle. I then started to try and tell the officers my concerns about both her physical and mental well-being. Their response was to inform me that paramedics had already been to the site, assessed the woman as too aggressive to treat, called in the police and then left the site. I followed this up with a call to the custody sergeant, informing him of my concerns, but was told that she couldn’t be assessed until she had “sobered up”. As it turned out, it was several days before she received a mental health assessment, by which time she was much calmer, but also very uncooperative after time in police cells. I understand that it wasn’t until imprisonment for assault of a PC during this arrest that she received any mental health treatment. I am aware that as a member of the public I do not have the full story, but I can’t help but think this situation could very easily have ended in a medical emergency, either physical or mental, and that if paramedics had remained to supervise/inform the arrest/detaining procedure that it would have been a more positive experience for both the woman and the officers involved.

  6. As an ED nurse with many years of caring for the acutely ill (both physically and mentally) I have concerns about the “street triage” scheme. I can see that there could be some benefit as long as the CPNs are able to access appropriate mental health pathways/services for patients. However, if someone is acutely mentally ill all potential physical causes must be ruled out – are the nurses performing street triage equipped with the skills and kit to do this, or will the skills of a paramedic also be required? Like mental health cop I worry that the risks could be increased, not decreased by this scheme. It’s all well and good performing a mental health assessment in someone’s home – what if the person is on the side of a canal? I believe the resources would be better spent developing paramedics mental health assessment skills, enabling them to access mental health services for patients directly and ensuring that emergency mental health care is readily available in the appropriate place.
    I have seen too many patients who appear to be mentally unwell have significant life threatening medical problems and unless the street triage nurses have significant clinical emergency care / Pre-hospital experience and are able to autonomously perform complete health assessments and diagnosis I don’t see how this scheme can be the “fix” it is portrayed to be.

  7. Enjoying reading this blog and replies on a train up to Newcastle.I work in Mental Health and I think that the most important thing is to try wherever possible to work together and share our knowledge and skills with each other in the interests of preventing more deaths in custody.We all need to be more amenable and responsive to other agencies when they ask for our advice or support on the front line.

  8. I could have written exactly the same thing myself! Many a time the police have been the only people available to help me. As I was reading this post I too was thinking what a fantastic blog this is. Mental health cop please keep writing, as a MOP who has regular contact with both police and mental health services I would hope your work and commitment will make a difference.

    1. Comment meant to be in response to JL ( I wasn’t trying to say I could have written ur blog, but that specific reply comment!)

  9. If MH nurses are going to do street triage, I’d suggest they should have some additional training, maybe by the Ambulance Trust, on pre-hospital patient assessment. I don’t know how long it would take to do, maybe a focussed two week intensive course to refresh the skills they probably learnt in the first year of their nursing degree.

    Back up the learning with some shifts with the Ambulance Trust, and in the ED, and provide a medical assessment form that needs to be completed for every patient they see. Include medical red flags on the form.

    This might make it less likely that physically ill patients end up in police cells, or in a mental health PoS when they should be in the ED.

    1. I don’t think that this will equip the CPNs enough. It takes over 2 years and a minimum of 1500 hours of supervised clinical experience for a paramedic to be able to make autonomous clinical decisions about patients. Skills learned in year one nursing are quickly lost if not practiced constantly and are nowhere near at the high level required to perform complete assessments of patients. I have found that most people vastly underestimate the clinical level that paramedics are now educated to – their skills are highly complex and cannot be replicated with a short course of classes and education.

    2. Additional training to enable MH nurses to safely assess patients in order to rule out medical causes would need to be extensive. Paramedic education takes at least 2 years and they are required to do at least 1500 hours of supervised clinical practice. Merely topping up skills that are learned in the first year of nursing program will not be nearly sufficient to allow nurses to safely make autonomous decisions and diagnoses.

      1. I know this – I’m not a paramedic, but I have friends who are, and others who are training to be paramedics. My comment was more that if the street triage using CPN’s is going to happen, some training on medical patient assessment is needed on top of CPN training to help with decision making.
        This would be focussed towards deciding where a patient needs to go, and how fast, and the obs such as blood pressure, blood sugar measurement, pulse, oxygen sats etc.
        Not ruling things out, necessarily, but more looking for suggestions that something needs medical management rather than a mental health placement, guided by a protocol or prompt sheet.

  10. Can i just ask if being kept in a police cell with two officers, legs in leg restraints and hands handcuffed behind the back, with one officer sitting/putting weight on your legs and the other keeping you on the floor on your front and pushing you down on your back and pushing down on your back everytime you try to move from that position. Anyway will staying in that position for at least 8 – 10 hrs straight make your blood pressure go up to lets say 160?

  11. I have many concerns about this being seen as a positive move and this may be very biased but here goes. In may experience:
    Police have experience in making difficult decisions, mental health nurses don’t
    Police have experience restraining people who don’t want to be restrained , mental health nurses don’t
    Police seem better at avoiding unhelpful comments (I said this was a biased comment!)
    Custody sergeants prime focus is the safety of detainees (said it was biased) not sure that mental health units have the same clear curt chain of command
    If someone is a risk to themselves or others I hope we all agree they need to be detained for their own good, so what is a mental health nurse going to add?
    Mental health services seem to find it difficult to provide timely assessments, unless the law is changed how will this be changed by having a mental health nurse on the scene?
    What happens if a mental health nurse says no they aren’t mentally ill – will that mean that they are left on the street?

    Where will the resoutrces come from? It is hard enough getting any sort of crisis care from the NHS…….

  12. MH COP, Please continue to ask the questions and pose the scenarios that you do! Only by consistently but professionally challenging the status quo will we improve the field! The “triage car” should be out there now, being piloted and rolled out as we modify the knowledge, skills and attitudes of the professionals involved in the back room and front line implementation. It is a radical case of joined up working, but when it works, it will no doubt be of immense benefit to the person at the centre of the storm, and prevent the need for SUI and prosecuting of colleagues.
    I think that asking Paramedics to step up with MH assessment is inappropriate …although my colleagues therein are wonderfully adaptive, they are already the Jack and Jill’s of everything to everybody. I would propose that the physical assessment of the person at the centre of this care IS the remit of the MH nurse. Physical assessment ( AVPU, pupil reaction, pulse, BP and resp rate) can be done almost instantly and then rapidly followed by a blood sugar measurement in less than 5 minutes. If this is plotted against acceptable parameters and appropriate red flags considered ( either formally on one of the NHS self carbon pads…love a form!) or mentally but subsequently documented on the proposed shared information via a tablet(?), it would start the consideration of a physical/mental health cause of the crisis. It needs to be contemporaneous, and perhaps by a person in the triage team in tune with their colleagues…maybe even a shared role ( I am getting far too excited here!) After all, HCP are trained to consider an individual in a “wholistic” way…..fully accounting for psychosocial factors, sexuality, care of cats and dogs and so forth ……so physical assessment is also the remit of MH staff( do they not measure blood sugar on MH inpatients?). Likewise, Police staff undertake a myriad of non Police assessments surely- also including care of cats and dogs!
    Assessment of physical parameters is undertaken by nursing staff not educated to Degree level ( Healthcare Assistants) so formulating a bolt on course along the lines proposed previously for Degree or Diploma MH nurses with their post registration experiences is totally appropriate.

    Am I too starry eyed?

    Have a good holiday!

  13. I’m not hoping to fix the problem to which “street triage” is the answer – for that, you need to fix CrisisTeam services as a whole and it will take more than free security and a lift from the police. Street triage is “pulling people out of the river”. Eventually, as Desmond TUTU rightly said, “we have to get upstream and work out why they’re falling in.”

    I think this is a very important point. Personally I wonder whether the reason for this new initiative is partly because more people are falling into the river as a result of cutbacks in mental health services. I worry that austerity may be turning the police into the de facto mental heatlh crisis service.

    Certainly recent months have seen plenty of cracks opening for people to fall through. My biggest concern at the moment is the way social workers have been pulled out of mental health services. The NHS and social care are coming apart, so nurses and police officers have to come together? As you say, this may be an exercise in “doing the wrong thing righter” rather than doing the right thing by putting the social workers back into the mental health teams.

  14. Hello, asking you in desperation…
    Do you know what the legalities are around the mental health/crisis team doing assessments? Specifically whether they are obliged to assess someone? Especially someone taken to A&E by police? (not under section136, though they threatened to… however when crisis team refused to show cops didn’t pursue it.)
    Newcastle Crisis Team have refused to assess a friend with VERY severe MH symptoms, but claim as they assessed him 6 months ago they know he’s fine.
    Trying to work out where to go from here.

  15. Apologies – have just found this blog and it has been of fantastic use to my colleagues and myself, Is there any guidance on how to deal with 136 suites who refuse to treat patients for the following reasons 1) We have dealt with him before, he isnt mental 2) We are full (despite saying the opposite prior to arrival 3) bare faced lying by saying they are full and when Ambulance crew questions them we find they arent full… They apparently just dont have the staff

    1. as usual MHcop a really informative read with a lot of great debate sparked by it. as a mental health nurse who is now looking into our own trusts section 136 care pathway and possible future developments in this area, i too have reservations about the use of ‘triage cars’. the obvious one? no matter how skilled we are as nurses, we cannot diagnose. we can assess and we can then refer if we feel it necessary, but the lack of the indepth skill of assessment may well lead to appearances in coroners court and the distress of loved ones – lets face it and be honest, most MH nurses i know (myself included) are pretty useless at addressing physical ill health.I wouldnt want to be responsible for missing something like a head injury and having a death occur to that individual. i cant help feeling uneasey – like a triage car is a cheap end solution to an issue long standing that requires serious rethinking and resources given to it. i wonder if the debate should be shifted…i would feel far happier exploring the option of developing phone advice, or MH nurses working more closely in the custody setting. the second of my concerns is about the ‘what happens next’ scenario if the member of the public is unwell mentally, and is refusing to say, leave their home..i dont beleive that having a mental health nurse ‘at the scene’ will ensure that the police are able to access an AMHP or a Dr any quicker.call me cynical…but a triage car? i have yet to be impressed or won over. Keep blogging MH cop…love reading your stuff!

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