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A Dozen Little Details

CoPThe Code of Practice to the Mental Health Act 1983 is almost four hundred pages long, divided into thirty-odd chapters and it is an awful lot to take in. I did read it right through many years ago and vowed I would never do so again! I will probably have to do so at the end of the year, because they’re currently updating the 2008 version and we will apparently see a 2014 update. I’ve been mentioning the importance of the document on this blog since the very beginning and, if anything, I have become more convinced of its importance over time.

I have contrasted the weight placed upon it in some situations by with that placed upon the Police and Criminal Evidence Act Codes of Practice; I have highlighted one particular paragraph of the Code – paragraph 10.22 – because of its importance the extent to which it is often ignored; and I have written about the stated case of Munjaz in which the highest Court in the United Kingdom reminds us that this is not a document dispensing advice that we can take or leave depending upon whether it suits us – this is statutory guidance with which we must comply unless there are “cogent reasons for departure.

So this stuff is the law to be followed in the vast majority of situations.

IMPROVING WORKING KNOWLEDGE

This morning, I sent out one tweet with a link to the Codes of Practice which listed the main paragraphs that I think a police officer needs to know about, in order to police effectively. Knowledge of these paragraphs is key to knowing whether to say “Yes” or “No” to certain questions that operational officers will encounter and they cover the main issues: places of safety, MHA assessments on premises along with the recovery of AWOL patients and the conveyance of patients in all circumstances.  I have often seen the wrong answer given because of a lack of this knowledge.

So, if you’re not quite at the stage where you are prepared to give over a few days of your life that you’ll never get back, here are a dozen little details to focus on. Whether you commit them to memory, or just focus on remembering the summary of what they’re about, it should improve your ability to police effectively in this area —–

4.12 – Don’t threaten patients with being “sectioned” to induce them to agree to voluntary admission – The threat of being “sectioned” should never be used to persuade a patient to enter hospital. How voluntary is it anyway, if it only occurred after being threatened with legal detention?

4.47 – Explain why police are still needed at a MHA assessment without a warrant – Where a Mental Health Act assessment is going to take place in a dwelling but where no s135(1) warrant is in force, the AMHP co-ordinating the assessment should explain why police involvement remains necessary if it is sought.

4.55 – MHA assessment does not always have to be delayed until the effects of drugs or alcohol have worn off – It is often said that “You can’t assess someone under the MHA whilst they’re under the influence of substances. This is the paragraph that shows this is not correct. The paragraph certainly advises delay where possible, but it may not always be possible.

4.90 – Applications for admission under the MHA must be made to a specific hospital – it is not sufficient to specify the mental health trust to which the patient will be admitted.

10.10 – You can make applications for s135(1) warrants without previous attempts to gain entry – It is often said that you can’t obtain a warrant without previous attempts to gain entry having been made. This is the paragraph that shows this to be incorrect. It stipulates that if applications are made without previous efforts, AMHPs need to set out the reasons for the Magistrate. This is in order to draw their attention to the fact that they can and to the reasons as to why in this particular case.

10.22 – The police station should not be the automatic first or second choice as a place of safety – this is the paragraph that custody officers and detaining officers should bear in mind when considering the use of the police station as a place of safety. What else did you consider or try, before resorting to it? If you can’t answer that question, you’ve got more thinking to do before seeing the custody sergeant. If you’re the custody sergeant, I’d ask the question!

11.5 – Sedated patients should be accompanied during conveyance by a suitable professional who is trained in the care of such patients – this will normally not be a paramedic because they are not licensed to adminster drugs to sedated patients. It will normally be a nurse of a doctor and officers asked to assist in the transfer of patients from one place to another, should bear in mind this requirement and ensure such a professional is involved.

11.17 – Police involvement in the conveyance of patients under the MHA should be based upon them being violent and / or dangerous – this is obviously a far higher threshold than patients being resistant to admission or transfer and officers should be certain to ensure that they are acting according to this part of the Code. It may be that local protocols assume all coercion under the MHA should be done by the police: this appears to be outside the intentions of Parliament who gave others the power to do so and this paragraph sets the bar somewhat higher than a patient being merely resistant to admission / transfer.

21.36 – Voluntary patients cannot be required to seek permission to leave hospital – but they can be asked to inform staff that they are leaving. This is important in situations where officers are called to mental health wards to reports of offending, involving voluntary patients. The Care Quality Commission repeatedly warn of the dangers of de facto detention whereby patients under no obligation to remain in hospital are ‘denied’ leave for various reasons. Where a voluntary patient chooses to leave hospital, either briefly or completely, they should be allowed to do so unless the nurse of doctor involved applies a holding power under section 5 of the Act.

22.13 – The recovery of AWOL patients whose location is known is a matter for MH services – but the police can be asked to assist in the risks involved suggest it is appropriate. So where, for example, a s3 patient who has been granted s17 leave fails to return on time and telephone enquiries by the ward reveal they are at home, it is up to ward staff to co-ordinate re-detention. It is for NHS managers to ensure they have access to resources by which to do so.

22.20 – All unauthorised absences by patients should be reviewed to identify risks and prevent recurrences – it is a requirement that all absences be reviewed. Given the frequent involvement of police resources in searching for patients who are absent, it seems reasonable to for the police to have an input into this process, especially because the police will have a record of that persons absence history which may cut across different hospitals or even different mental health trusts. That could very well assist the management of risks.

This list is NOT exhaustive: there are other paragraphs in the Code of Practice where it may be worth committing the thrust of it to memory but in order to keep this list manageable, I have capped it at a dozen things. I would encourage frontline police officers (in which I include custody and communications staff) to read the full text of these paragraphs and consider them in operational situations. They can make the difference as to whether you say “Yes” or “No” to requests that are made of the police.
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24/7 police inspector but blogging in a personal capacity. Interested in mental health issues and criminalisation but views do not represent those of any police force or police organisation.

Discussion

15 thoughts on “A Dozen Little Details

  1. Hi, really useful reminder of some important Guidance and I didn’t know that the Code was being revised this year. . But the picture is of the Reference Guide,which I assume is a mistake. Cheers Alex Davis.

    Posted by Alex Davis | March 3, 2014, 9:45 pm
  2. I find 10.24 interesting they understand police custody ‘may cause distress and anxiety to the person concerned and may affect their co-operation with, and therefore the effectiveness of, the assessment process’ yet how long are some individuals held in a cell ?

    Posted by mudannyfc (@mudannyfc) | March 3, 2014, 10:43 pm
  3. I like the COP ……….. but see it ignored everyday……..

    I might add to the dity dozen (that gives away my age I think)

    COP 4.44 -the Assessing Team is supposed to go together – “Unless there is a good reason for undertaking seperate assessments ….”. What we have now in reality is medics completing Med Recs & then making the referral for the MHA Assessment. In terms of a Sec 3 – often either listing a number/all of the local wards on the form, or indeed leaving it blank or flouting 4.90 & writing the MH Trust in the form. In this respect I have become very interested in Sec 126 i.e. (4) (a) & (b). ……..& then the bed is found out of area ………!

    COP 4.75 the medic is supposed “to take the necessary steps to secure a suitable hospital bed.” More & more this responsibility is devolved to a Bed Manager/Team. I think the ignoring of this little gem has over all had a negative impact on the whole process of assessment for a number of reasons………… “ownership”.

    COP 10.2 & 10.3 & indeed the MHA & the actual 135(1) Warrant itself is clear that the authority/power invested in the Warrant is given to a police officer/constable. So why is the AMHP always the one stuck between a rock & a hard place when attempting to co-ordinate the execution of a 135(1) Warrant. 10.9 partly explains this but then again mentions the hospital managers & LSSA also.

    Don’t get me started on COP 11 = Conveying !

    Which then takes me back to Sec 129 & the offence of obstruction. I often wonder who or which organisation is actaually obstructing the AMHP…… & which MHC I should call :-)

    Posted by asifamhp | March 4, 2014, 10:32 am
  4. Section 21.36 – Voluntary patients cannot be required to seek permission to leave hospital.

    As a previous “voluntary” patient who spent the best part of a year being denied leave for every reason under the sun (including “the doctor is on holiday this week”, “I’m not authorised to let you out” and the all too frequent “the doctor will just section you”) what action could you suggest people in this situation should/could take? My experience has been that even with knowledge of this section, hospital staff are more concerned about pressure from their bosses than following the MHA, and the Police can’t be expected to know everything (though you are helping enormously!). What would be your advice?

    Also, for clarification, does this refer just to completely discharging yourself or would it also apply to going for a walk?

    Posted by Aidan | March 4, 2014, 3:11 pm
    • Complain to the CQC. The CQC doesn’t deal with individual complaints UNLESS they are about the use/misuse of the MHA. I would send a copy of the complaint to the Chief Executive of the Trust and the Medical Director and also to the CCG that commissions that Trust.Best wishes Alex Davis

      Posted by Alex Davis | March 7, 2014, 9:16 am
  5. The issue with 22.13, returning awol patients, is that people who absent thenselves rarely want to voluntary return to hospital, so the nhs staff may well know their location, but what can they do in reality? This is why the police get asked to help as you have the resources to enforce the law. NHS staff do generally try hard not to involve the police in AWOL’s as a matter of course, but often don’t have any choice.

    Posted by jim | March 4, 2014, 7:21 pm
    • The police are the only ones with the resources because MH trusts who know what the law is as well as I do, have *chosen* not to prepare to give reality to Parliament’s intentions when they enacted the MHA. Parliament gave legal authorities (as well as responsibilities) to MH professionals for a reason. I’d like a conversation about when those responsibilities will be discharged. MH trusts are in the business of coercing human beings – it seems an unusual business to be in, if you don’t want to coerce people yourself and you’re not prepared to do so. << A personal view.

      Posted by mentalhealthcop | March 6, 2014, 9:17 pm
    • As a police officer I’ve no problem assisting in returning AWOL patients. But the staff won’t even turn out and just expect me to do it on my own. Most don’t even know it’s their legal responsibility.

      Posted by sectioneddetection | March 7, 2014, 11:39 pm
    • If you sit down to make a list of core responsibilities of the police, you’d think about having to attend and deal with certain things. This might include policing football matches and disorder, dealing with vulnerable victims of crime for serious and sensitive investigations where they have been traumatised, as well as volume work like shoplifters and drunks. This then means you start to envisage what the officers will be doing. Some will need riot gear and training to work properly in situations of crowds and serious disorder, interviewing vulnerable people who have experienced trauma and investigating criminals who lie and deceive whilst being highly manipulative; you also start to see the need for police cars, handcuffs, uniforms and personal safety and first aid training.

      DO that exercise for mental health and you start to envisage inpatient and outpatient care; the application of legal frameworks around care for those who may not recognise the need for it; the assessment, admission and conveyance of patients, and the recovery of patients who are absent. Then, NHS managers should be thinking through the implications of those legal frameworks. It is not and it never, ever has been the case that the police alone are responsible for the coercion of vulnerable people, whether that be in the hospital or community setting. Parliament specifically took the time and trouble to legislate to say otherwise; and we must presume that this was the case for a reason.

      So I admit to wondering two things: 1) why do NHS managers structure their services as if to display a deliberate disregard for the will of Parliament by not preparing to give practical effect to its intentions? and 2) why do we always assume that it is acceptable for NHS organisations not to recruit, equip and train their staff to undertake the implications of the laws that apply to their duties, including the use of force in the community? Because I’m certain if the police took the view that they just wanted to disregard certain issues that parliament made (at least partly) theirs, there would be uproar. No-one is saying NHS professionals should be recoverying patients who are barricading themselves in their houses with weapons and threaten to kill whoever comes near them. But where the patient is passively resistant and able to be safely managed by a couple of nursing staff, possible assisted by paramedics and / or the police if it’s a bit more than passive resistance, why should we not expect this, given that there are obvious medical implications to restraining vulnerable people and that police personal safety tactics are not and were not designed for the purpose?

      The response you pose here is better directed at managers who took the decisions. I’m merely reflecting back the law of this country, towards those who bear responsibilities for implementing it and carrying it out.

      Posted by mentalhealthcop | March 8, 2014, 5:09 pm
      • Possibly for patients there are issues around more of the coercive powers being used b medical staff. If for example when someone is detained under a s136 the force is used by the police at least afterwards you aren’t having to relate to the people who have restrained you etc etc in a therapeutic way……..

        Posted by Judy | March 8, 2014, 8:12 pm
      • I find it ethically extremely interesting: a acceptance or belief in the occasional need to coerce other people and a preparedness to take the legal decisions around that view – but a resistance to actually doing it. It is a curious philosophy that sits behind such a contradiction, in my view.

        Posted by mentalhealthcop | March 8, 2014, 9:11 pm
      • I think your assertion that MH trust are in the business of “coercion of human beings” is somewhat disingenuous. Its like saying the role of the police is to just to arrest people. Of course coercion is a part of our remit, but it is a part that we are legally bound to avoid if at all possible and most definitely not the sole remit.

        I actually wrote a lengthy response about the NHS and how difficult it would be to return AWOL patients, but then realised I was missing the point entirely! I realised there were a significant number of patients who I’ve seen reported as AWOL and been somewhat embarrassed that our first response was to phone the police. The reality is that we are not, as you point out, resourced properly to do our job and have become insular in our thinking.

        I can’t imagine how distressing it must be to be acutely unwell and have the police turn up at your door to drag you back to hospital. There is clearly a huge gap in this response that should be filled by mental health staff, with the police as a partner to be called on as a last resort.

        Perhaps with the new concordat, commissioners will start to fund us to fill in these gaps but I won’t start holding my breath yet!

        As usual your blog has made me think and question my practice and I thank you for that.

        As an aside, there is a whole response to this that would focus on therapeutic relationships and nurses not
        being seen as arbiters of social control, and Is one that can’t be entirely dismissed, but that’s for another day!

        Posted by jim | March 10, 2014, 3:12 pm
  6. Additional thought – it worries me that there seems little oversight of deaths and incidents in mental health units, compared with similar in police custody. I think this needs rectifying urgently, if people have even if only de facto been deprived of their liberty then surely there is a major duty of care towards the individual, which needs rigorous oversight.. Spent a depressing half hour reading CQC reports on a selection of failing mental health units……..

    Posted by Judy | March 9, 2014, 5:22 pm

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