Police

Voluntary Attendance

This post is about trying to ensure a non-prescriptive framework for how police officers should consider whether or not to detain someone under the Mental Health Act when it is legally possible to do so, as opposed to helping people access relevant services without detention.  So it is about two, frequently opposing philosophies: the principles of autonomy from the least restriction and of security from necesary control.

We know that where (UK) police officers encounter individuals who actively want to access some kind of healthcare support for their mental health problems, they traditionally have four options.  They are not always available because legal powers vary between public and private places and because 24/7 Crisis Team services usually only respond to patients already receiving mental health care.

Nevertheless, the four options are —

  1. Advise the person to contact their GP (primary care), in due course
  2. Advise the person to contact their MH CrisisTeam (secondary care), if one is available
  3. Assist someone is accessing Accident & Emergency (urgent, unscheduled care), more or less immediately
  4. Use legal provisions in the Mental Health Act 1983, if appropriate.

It does get us into all manner of problems where we think something needs to happen straight away because you have to decide whether to use the Mental Health Act in order to remove someone to a place of safety or whether to point them towards A&E or accompany them there.  This is a remarkably complex decision, as the rest of this post should explain.  It is made difficult by some important principles of law that creates a tension for the officer who might detain someone: a tension which you could almost always argue remains unresolved no matter which decision is taken.

NICOLA EDGINGTON

GreenwichThe most high-profile example of this decision – at least in my mind – was the decision taken in the case of Nicola EDGINGTON in south London in October 2011.  Metropolitan Police officers had accompanied her to an A&E deparment on a voluntary basis, without detaining her.  It must be said, in the first instance that it was questioned whether the officers could have legally detained her at all, having first encountered her in a private place.  That said, Nicola having exercised a free decision to move from that private place to A&E she then attempted to leave and the argument was suggested that Metropolitan Police officers should have detained her under s136 MHA at that point, particularly because she had a previous history of homicide and everyone accepted that she was worried she may kill or hurt someone.

She was not detained.  Having then remained in A&E for further mental health assessment she was admitted to a psychiatric unit as a voluntary patient and moved to a ward.  She then absented herself from that location and travelled to Bexleyheath where she attempted to kill Kerry CLARK, and then did kill Sally HODKIN.  I have previously written about this case if you want more detail on it and read about the IPCC investigation that looked at this decision-making.  Suffice to say, I’m now waiting to read the independent review of Nicola’s treatment and care when it is published by NHS England.

So we know from this and other cases, that police decisions to leave individuals in healthcare settings who may be a risk to themselves or others is precarious business.  But an ‘err on the side of caution’ approach directly conflicts with principles of handling people in the least restrictive way.  The ‘least restriction’ idea is a core principle of the Mental Health Act Code of Practice, outlined very early in that document and referenced through-out.  Any conversation about a decision to use mental health law – or about the particular manner in which it is applied – doesn’t last very long before officers are reminded about the need for least restriction.  It is an important part of the ethical application of the MHA, that restriction and restraint is only used when it is absolutely necessary to do so and the no more coercion and control is used that is absolutely necessary.  Anything less could represent a human rights violation.

So at the heart of this dilemma and the method by which any tension is managed is the following question:  Why would a police officer legally detain a person in order to compel that person into a process that they are willing to enter?  And the answer for me lies in the definition of the word ‘necessary’ and in the ability of services to make sure in some case that someone not only enters a process of assessment, but also finishes it.

WHAT DOES ‘NECESSARY’ MEAN?

Police officers are used to considering the word ‘necessary’ because every arrest made under criminal law carries with it the need for a necessity test, under section 24 of the the Police and Criminal Evidence Act.  When I joined the police, we used to talk about ‘arrestable offences’ and if you were suspected of having committed one you could be arrested for it and that arrest would be lawful.  The end.  So if you knew that an allegation of assault (ABH or GBH) had been made against and you turned up to the police station to have your say about the incident or help the police with their enquiries, you may be arrested.  This changed some years ago and it is now a legal requirement for the arresting officer to show why an arrest was actually ‘necessary’, against established legal criteria now made plain in the Act.

So we understand about ‘necessity’ and it’s implied and inherent links to the least restriction principle.

Let me amplify these points with real examples:

Officers encounter an elderly man who is confused and disoriented.  Some enquiries reveal that he is almost certainly a missing person from a neighbouring police area and he is out in winter, obviously very cold.  An ambulance turns up at the officers’ request and checks him over they state that they need to take him to A&E to get him checked over medically and the police area from which he is missing are telling his relatives he’s been found and his wife and son are now heading to the A&E concerned.

The man is happy to go to A&E and not resisting at all, saying he’d welcome a cup of tea.  The grounds for s136 were undoubtedly met:  he was “believed to be suffering a mental disorder, in immediate need of care in his own interests.”  This is one version of the definition of s136.  Was he detained? – NO.  Did he need to be? – NO.

Police officers encounter a young woman in her twenties who is asking for help and saying that she “needs to be sectioned”.  She wants to be assessed and admitted to hospital for a period of time and has a history of suicide attempts, including a serious overdose and significant injury after self-harm.  She has also been considered a high-risk missing person after having previously self-presented to A&E departments and having left in a suicidal state before being the Crisis Team arrived to assess her needs.

Although the woman is happy to go to A&E on a voluntary basis, there is the potential that this decision could change, especially if there is a protracted wait for the Crisis Team.  Should she leave, there could be a significant risk to her wellbeing based upon background factors.  Could she have been detained? – YES.  Was she detained? – YES, because this ensures she remains detained pending the assessment outcome and ensures her various legal rights are in place.

In this latter case, if officers had not legally detained her under the MHA, she may either have been left at A&E and again become a potentially high-risk missing person should she leave; OR officers would have still remained in hospital to ensure she didn’t leave hospital, not having legally detained her.  So she would have been detained in fact, but not in law - and I’ll guess that no thought would have been given to her legal rights under s131 MHA or PACE.

VOLUNTARY ATTENDANCE

A&ESo you’re the police officer at the incident and let’s assume that all four options mentioned at the start of this post are open to you as possibilities:  you can advise contact with the person’s GP or Crisis Team; or you could offer to assist someone to access A&E or you could use section 136 of the Mental Health Act.

For me, the first three options are only available where risks and threats involved mean that we need to be sure that someone will complete the process of assessment.  This may include suicide risks, someone who has taken an overdose, someone who has previously sought help and then disengaged before being seen in circumstance of some concern that need to be avoided.

Of course, something like street or telephone triage with mental health services may render an instinct to detain null and void so any decision taken must be based upon the fullest available information.  But necessity needs to be judged in terms of whether the risks of a person not remaining engaged to complete an assessment are so serious as to need negating.  If they are not so serious, then principles of least restriction should mean that sign-posting, referral or voluntary attendance are perfectly proportionate responses to incidents.  We all accept and understand that physical injury or illness does not always require immediate A&E attention and so it is true of mental health issues.

_______________________________________________________________________________

BadgeThe Mental Health Cop blog
– won the Digital Media Award from the UK’s leading mental health charity, Mind
– won a World of Mentalists #TWIMAward for the best in mental health blogs
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23 thoughts on “Voluntary Attendance

  1. 12 August 2014

    Dear Mentalhealthcop,

    Like you I have been concerned about the provision of services in Royal Borough of Greenwich in 2011.

    I have asked the following questions of Royal Borough of Greenwich and they have kindly agreed to see what data and answers they can give me:

    1] Did Royal Borough of Greenwich have any social responsibility towards Nicola Edgington before she killed Sally Hodkin?

    2] What did Royal Borough of Greenwich do to help Nicola Edgington and her family before she killed Sally Hodkin?

    3] Did Royal Borough of Greenwich Social Services have any hand whatsoever in obtaining any services whatsoever for Nicola Edgington either directly or indirectly before she killed Sally Hodkin?

    4] Was Oxleas NHS Foundation Trust partnered with Royal Borough of Greenwich at any time to provide help to Nicola Edgington and her family before she killed Sally Hodkin?

    5] Was the Pan London policy to protect the community in force at Royal Borough of Greenwich at the time that Nicola Edgington killed Sally Hodkin?

    6] What safeguarding measures to protect the community were in place at Royal Borough of Greenwich at the time that Nicola Edgington killed Sally Hodkin?

    7] What measures were in place at Royal Borough of Greenwich to protect anyone with known mental health problems before Nicola Edgington killed Sally HODKIN?

    8] What serious case review has been undertaken by Royal Borough of Greenwich in the wake of Sally Hodkin’s killingr by Nicola Edgington?

    9] What lessons have been learned by Royal Borough of Greenwich in the wake of Sally Hodkin”s killing by Nicola Edgington?

    10] What new policies have been implemented by Royal Borough of Greenwich to protect the community from danger posed by people with mental health problems?

    Your posts have inspired me, Mentalhealthcop.

    Thank you so much.

    Rosemary Cantwell

  2. 12 August 2014

    Dear Mentalhealthcop

    I made request for information, inter alia, from the Care Quality Commission in respect of the use of the Mental Health Act 1983:

    “WHAT IS THE LAW REGARDING A PERSON NOT BEING FORMALLY DETAINED

    What is the law regarding a person not being formally detained under Section 2?

    Does the person have the RIGHT to refuse admittance into a mental health facility, even if a medical recommendation has been made by both a Section 12 Doctor and a relevant clinician but no Section been applied?

    I ask because I wish to know what is the precise law regarding detaining a person who, even if recommendations have been made and an AHMP is in the process of making a formal assessment based on these recommendations. Is the person legally entitled to refuse to go into detention UNTIL the Section 2 of the Mental Health Act 1983/2007 or Section 3 of the Mental Health Act 1983/2007 is registered and therefore legally binding?

    It seems to me to be a possible lacuna in the law.

    For if a person can be in a pre-admission suite, and not formally sectioned, is it not legally possible for the person to claim abduction if forcibly / coerced /removed to a mental health facility?

    Is it not the law that a Section 135 has to be produced to remove someone from their residence or private property?

    Or a Section 136 has to be produced to remove someone from a public place such as a hospital?

    And if so, this has to be applied for? Do both have to be done through Magistrates? Or can an AHMP made an affidavit? What precisely is the legal requirement in England?

    SAFEGUARDING
    How are patients being fully protected by the your Care Quality Commission’s policies of safeguarding?

    How doe the Care Quality Commission protect your Care Quality Commission employees and safeguard them?”

    I would be most interested in your own thoughts, please, Mentalhealthcop.

    Thank you very much for all your insightfulness.

    Rosemary Cantwell

  3. I enjoy your articles but I was wondering why you deemed it correct to accept a mental health blogger award with a crossed eyed emoji in a straitjacket? Hardly a symbol you’d expect from an organisation seemingly hell bent on de-stigmatising the stigma. Not trying to be pedantic or anything, it is a genuine question.

      1. I hadn’t noticed but the yellow ‘smiley’ (emoji on phones and tablets) in the Mind banner does indeed appear to be in a strait jacket. Very strange.

  4. Thank you for this article. I would like to add that, while the Police Force is fairly consistent across the country, unfortunately the NHS and services provided by it are not. This is where hypothetical scenarios tend to struggle.

    For example, I would consider it strange to take someone to A&E if they are experiencing a mental health crisis in the absence of a need for treatment for a physical health problem. They will get seen by Mental Health professionals there but it’s not a recommended pathway.

    In an admission situation, even if the person is willing to be admitted, asking for admission and admission is appropriate then they still need to demonstrate they have capacity to consent. Lack of capacity would equal a Mental Health Act assessment. I don’t know the case above but, if there are concerns around risk with informally admitted ward patients then the Hospital staff have options to prevent a person leaving such as a nurses power to detain. I’m not sure a 136 is appropriate in the case of someone asking for admission (an AMHP is the best person to answer this) but every case is highly individual and individuals themselves are never static in time.

    Two examples I have encountered are these: An obvious s136 (suicidal, on a bridge) is not detained and I am called to assess with the officer assigned to the team for the shift. The person is referred to services, EDT provide accommodation overnight and he is seen by services the following morning. He is able to access the home treatment team during the night if he requires this. The assessment is transparent and officers are happy that the risks are well managed. It would have been very appropriate to detain and the 136 suite would have no problem accepting such a case however it was unnecessary.

    Another case, a woman has ransacked her home, officers aren’t sure why she has done so but call for assessment. Having gleaned a comprehensive history from our NHS systems, my assessment is very brief and a MHA assessment is called. Yes, there was an hour wait but the lady was detained under section 2.

    I suppose my point is this, in the absence of a joined up and responsive multi-agency team (Police, Mental Health, Ambulance, Substance misuse etc) we are limited in our safe options. The more we work together the more options open up. Transparency is key along with a clear vision of our goals for each case we see.

    I believe it would be good to meet you if ever you are in our area. I think you will see a very different provision of services than those you describe, I’m sure you would revisit your four options above.

    1. Regarding taking someone to A&E, in our area the only recommendation for out of hours is to go to the Urgent Treatment Centre. It would be great if there was something else. I am rather concerned about how the decision not to detain someone is taken – the whole point of powers under s136 is so that someone can be kept safe until they can be properly assessed. In your example above there seems to be an informal assessment carried out that someone isn’t that suicidal when the evidence suggests they are – would be interested in how that judgement is made and how you can be comfortable they won’t change their mind overnight……and who would carry the can if they decided to walk out and jump off the bridge later that night? The police or mental health services….

      1. The same way MH teams allow people to be informal in-patients having been detained under 136, it is a judment call. To be honest many of the cases I see where police allow voluntarily attendance is where they had no powers to execute in the first place for example the person was located in a private property.

      2. Hi Judy, I understand your concern, however, I would stand by the assessment and action plan with great confidence. I believe it was entirely the correct decision for that case, at that time.
        You’re right, there is always going to be potential for someone to actually do harm to themselves
        The key part of any assessment is recognition that there is a great difference between feeling like life is too difficult to carry on with, how a person may communicate their struggle (the bridge) and their true intentions to actually end their life.
        The young man had no real intentions to commit the act but he was finding life hard to carry on with. He didn’t know another way to shout help and believed it was all hopeless. The key thing is that he received the help he needed, he discovered that there are people out there who care and the message he was communicating was heard and understood. I doubt entirely that an admission would have proven of any benefit to the person we were with, it would not have solved any of the problems which were causing his feelings of hopelessness.

        I agree too that services differ across areas. A&E would be inappropriate most of the time in our area but other areas have this as part of the pathway. We also have Intoxication Observation beds in our substance misuse unit funded by A&E to relieve pressure, this is another great option for people who aren’t able to maintain their own safety.

    2. 13 August 2014
      Dear Mentalhealthcop
      How refreshing your transparency is.
      I received a response from a police force referring to my requests for information that they now deem these topics as vexatious if I should refer to them again:

      “•Sally Hodkin
      •MPS Mental Health policies, practices and procedures
      •Any other request relating to or stemming from Mental Health issues”

      Have you had anything like this?

      Thank you for championing transparency.

      Rosemary Cantwell

  5. can you assist with my question on where police powers cease please? having been detained for assessment, do the police powers stop when the assessment starts or do they continue until the assessment is complete? sorry if this is an obvious answer…. its not to a number of my colleagues :(

    1. If you mean when detained on s136 for assessment, then it ends either at the end of the AMHP making “arrangements for treatment or care” OR it ends when the Place of Safety safety take over the detention of the patient pending assessment.

      Ideally, when you take the person to the PoS for assessment, the nursing staff should then take over the detention and release the police pending the assessment occuring. Only where there are risk-specific reasons should the police remain at the PoS and where they do, their role continues until the risks reduce and staff take over or until any necessary arrangements are made.

      Arrangements will either be: the AMHP is admitting the patient to hospital, so the police role continues (if they are still involved) until the patient is safely admitted; OR the AMHP will refer the person to community services or their GP and then police role ends when the patient is released from detention.

      Does that help?!

      1. Sorry for delay i didn’t get notified you had replied :-(

        Does this help? Well yes and no. You seem to be stating that the powers cease after assessment…… but earlier if directed by nursing staff. This is a surprise to me as i understood we were relieved of our detention power when the assessment began!! From what you are telling me i cant see any situation where we should be leaving prior to the assessment being completed? A person presenting as being compliant at the start of an assessment can change their view during, this would leave us in a difficult situation if they were presenting well and were not threatening or have previously attempted self harm.
        Surely we should, even in such resource driven times be staying with or near the ‘detained’ person until assessment complete.
        Really appreciate your view on this. You can use my email if you would prefer?

  6. Locally, which is always the key, our designated PoS is a semi secure locked area which should have an available care assistant. When the AMHP arrives they carry out a joint risk assessment with the officer(s) about the need for them to remain.

    The AMHP can take custody of the individual from the police and the individual remains detained until the assessment is complete (or 72 hours has passed from arrival).
    Circumstances where I would not be happy to accept responsibility for custody, and they would therefore need to remain, would be unmanageable violent behaviours (or evidence of significant risk of same) or the absence of a care assistant. The latter is a resource issue which then has to be addressed and I understand the police are very unhappy about this, however I can’t leave an individual who is considered to be disturbed/vulnerable/unwell wandering around the unit on their own while I make the various arrangements required for the assessment.

    The attitude of officers varies and their are many occasions when they don’t even ask to leave. Tea/coffee and comfy chairs certainly help.

    1. I should point out this quite often results in the police remaining for both the duration of the assessment and then afterwards, once the individual is liable to be detained, to assist with conveyance.

    2. And when those situations present, do you flag to NHS managers that the pathway didn’t work as the nationally agreed standards say it should because they have under-resources their facility? If not, why not, given it’s a health and safety near miss. << not trying to be funny, they are genuine questions because otherwise managers won't know and there is evidence of ignorance at commissioning manager and provider manager levels.

      1. Yes, there is a form completed for every s136 which goes to a monitoring group un any case, but my first course of action is to request someone from a local ward, although that’s not the safest option. If the police have to remain solely because I am short of staff then I complete an incident report and then encourage them to do the same to their bosses.
        Its not entirely about cash: It’s hard to recruit staff to be on call for a pittance to spend hours alone with individuals who are quite disturbed. It’s a real issue. If a patient is nursed 1:1 on a ward then they would only expected to do this for an hour at a time with an individual whose risks have been fully assessed. In context the police will only do this in pairs.

      2. Maybe, your police – I know many cases where just one officer has remained. There is no rule that says it must be two police officers. More examples of areas policies making things up as they go?

      3. I do, again local policy, in line with CoP, is conveyance with an ambulance crew, however they quite often won’t take someone without a police escort, especially if the police are already in attendance. It’s all very well delegating, but they have to accept.
        Always find it bizarre when the ambulance crew and police officers negotiate that the police will follow behind in their car, as I generally do that anyway.

      4. So the police often stay because the NHS is understaffed and then because the have police stayed, the ambulance crew won’t act without police support – sounds like a great system!

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