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Erasing History

Do you know what I mean by a ‘vanilla’ tweet? – the phrase refers to something fairly inoffensive on Twitter, quite bland information that doesn’t tell us a huge amount but whilst purports to inform. Something like, “Great meeting with partners about mental health – loads of work going on to keep you safe” or similar. Well, I’m bumping into a fair few of them on the subject of the Crisis Care Concordat and I have a couple of concerns arising from it -

  • Vanilla tweets – of themselves – don’t tell us much and they never, ever have.  I can see, however, that they may be infrequently necessary.
  • Vanilla tweets on the subject of the CCC imply little difficulty in resolving the thirty to fifty year evolution of problems in policing and mental health.

It’s almost as if history has been somewhat erased and it makes me wonder why we ever had any problems in this arena because just one or two meetings and we seem to be sorting it all out without much difficulty! This also strikes me as highly unlikely. Take it from me, it took five years of my life (that I’ll never get back) just to sort out section 136 Mental Health Act Place of Safety provision in one area. That’s before the subject of Liaison and Diversion (whatever that means); patients who are absent without leave; and the multitude of other problems that all areas face to one degree or another.

Principle amongst the ‘other things’ should the creation of a system that avoids the need for as much crisis care as possible, because help is available before people have ‘one foot off the bridge’, to quote the Mind report on crisis care.

CRISIS CARE CONCORDAT

You can look at the Crisis Care Concordat website for yourself if you want to read more about it or see the local progress mapped out for us all by the mental health charity, Mind.  They will be chivvying people along for progress updates towards the end of the year.

One problem with the Concordat always was that it simply puts into one handy document with a checklist and a schedule of work, all the issues that we know have been problematic for decades, imperatives for which already exist. This, as Winnie the Pooh said, is “a good thing” – if you want it summarised and neatly presented and for those professionals in policing and health who are relatively new to this, it’s a great tool to help you start benchmarking where you are and working out how to plug the gaps. However, if you’re familiar with the field, it’s all very last century in some respects. Some commentators asked upon publication, this stuff is already written down in range of documents – why do it again?

So the Concordat asks us to address crisis care and in some areas this will mean that everyone works out there is overuse of section 136 by the police and, even allowing for the overuse, under-provision of health based places of safety by the NHS. The Concordat would say you get these things into the Action Plan that is submitted with your Crisis Care Declaration in November 2014 and look to improve this position over time. So you’d probably train your officers better on the use of the power, consider a phone or street triage approach so you reduce usage and look at expanding provision. Sounds easy doesn’t it?! Here’s the problem —

We’ve known that these things needed doing for at least twenty years and there are already various statutory imperatives to do so – what does the Concordat give us that laws and statutory regulations didn’t?! If we can ignore statutory guidance on the Mental Health Act, what is it about the Concordat and its implications that we won’t ignore?

Well, the idea is that this will be driven a lead in a way that wasn’t previously there – this is “a good thing”. And there is no doubt that areas are now talking whereas previously, they weren’t – this is “a good thing”. Arising from discussions, some areas have filed their local Crisis Care Declaration, implying that they now have a jointly agreed action plan to allow progress in 2015 and beyond – “a good thing”. However, there are many more areas that don’t seem to be fairing quite as well.

IT’S GOOD TO TALK

I’m assuming that in some areas, these joint CCC meetings have led to some of the discussions that I had when you have culturally diverse organisations coming together to discuss issues. You get doctors and NHS managers who know comparatively little about the law, getting together with police officers who know little better to discuss issues that are bedevilled by the received wisdom and inherited thinking of generations of professionals who’ve gone before them. And they are having to do it with fairly dreadful data sets about ‘stuff’, in many cases.

In some ares, no-one fully knows how many section 136 detentions take place, where they go or what the outcomes are. There are myths and personal opinion abounding about what percentage of those detentions is ‘appropriate – despite the fact that no-one seems to be offering a definition of what is appropriate. No-one looks at how many section 136 detentions are ‘repeat’ detainees or how many were already known to the MH, perhaps indicating a breakdown in the care plan. No-one knows the percentage of people arrested for offences who are known to the MH trust and no-one seems to be trying to define what ‘diversion’ means in terms of when the police push ahead with a prosecution decision for an offence when they know the offender is mentally unwell, as opposed to when they don’t.

Legal training in all the professions is parlous: I learned again this week having a child in an ‘adult’ place of safety is a safeguarding risk. What do we think is not a safeguarding risk about having a child in a police cell, not too far away from a masturbating drunk who is singing sex songs or threatening sexual violence to the custody officer? I can only imagine that in just some CCC discussions about certain issues, the myths and folklore are raging hard, with professionals of all kinds arguing they can’t do things they actually could do, that they shouldn’t be doing things that they’d prefer the other agency to do.

LET’S TALK ABOUT VULNERABLE PEOPLE

And nothing in this blog post so far is about vulnerable people is it? … their rights to effective police responses, accessible crisis care and dignity and respect for their human rights whilst in contact with the state? Those people who experience the indignity of being detained in the cells under s136 because they had the temerity to have a few drinks (or more) – to stop the voices in their head, or at least make them quieter. None of this includes references to the difficulties that some patients have in Accident & Emergency despite very obviously being there appropriately to access some kind of care that is otherwise unavailable and inaccessible. We’re not even talking about the ongoing extent to which our mental health care system is being increasingly criminalised by reliance upon the police and the justice system just to make extra sure that some face the extra stigma of having cops staring at them whilst the NHS do their thing with all that we know the feels like for some.

The Crisis Care Concordat will be examined next month for progress and as things stand just four areas out of 43 police forces and 57 mental health trusts have submitted a local declaration with an action plan. I’ve already heard that some areas feel they will be unable to submit anything by the November deadline. I’ve also heard that some relevant senior people have only not read the CCC, they hadn’t heard about it, as of a month or so ago. Quite remarkable, really. So we need to continue to raise awareness of its imperatives and remember, that most of them arise from existing laws and NHS guidelines anyway.

It’s what we should have been already doing – for some thirty years, actually!

If one or two CCC meetings is all it has taken to get complete agreement about what we need to do, then I’m thrilled. I’m also quite unconvinced.

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The Mental Health Cop blog

Badgewon the ConnectedCOPS ‘Top Cop’ Award for leveraging social media in policing.
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

ccawards2013 was highlighted by the Independent Commission on Policing & Mental Health
– was referenced in the UK Parliamentary debate on Policing & Mental Health
was commended by the Home Affairs Select Committee of the UK Parliament.

Nature

Something’s Not Quite Right

You may remember that in July the IPCC launched an inquiry into the death of a man in Sussex following an incident in Hayward’s Heath.  The family of the man who died following restraint have suggested he was tasered and subject to the use of pepper spray as officers appeared to disregard information that he suffered from epilepsy and a seizure was mistaken for violent behaviour.  Initial reports suggest he may also have suffered a heart attack either during restraint or once in the police vehicle.  Another tragedy for all involved, regardless of what the IPCC findings may be and I can only imagine what his family have been through.

Of course epilepsy is not traditionally viewed in medicine as a mental illness, despite the fact that for the purposes of nineteenth-century laws on insanity, it could be viewed as such.  So could diabetes, for that matter.  However, this incident links to concerns I have written about before for various reasons:  we know that epilepsy is one of those medical conditions flagged up, along with diabetes, Addison’s disease and others, as examples of non-mental health conditions where presentation could be interpreted by many people as indicators of a mental health problem.  We also know that some people who suffer seizures because of epilepsy occasionally exhibit quite marked, sometimes violent behaviours and it’s crucial officers know enough to stand the maximum chance of recognising this where it happens.

I’ve written many times on this blog about different opinions, incidents and anecdotes which show the difficulty in deconstructing behaviour at incidents into those inherently artificial categories of disease, distress or dissent.  And of course, nothing prevents those three things overlapping just to make the decision a harder one – about how those issues should be prioritised.  The story circulated on Twitter and amidst the expressions of regret at the human tragedy, commentators started to second-guess what the IPCC will discover during their inquiry – I would advise against such attempts given that no-one yet knows the full facts and already there are disputes about what occured.

Let the IPCC do their job, first!

So what remains of this blog is nothing whatsoever to do with the specific case, about which I know nothing beyond that reported in the media.  I want to address two broader issues -

  • The issue of particular awareness or training for particular medical conditions.
  • The issue of deconstructing behaviour into clear decisions about whether to this ‘this’, ‘that’ or ‘the other’.

AWARENESS TRAINING

We hear requests for more police awareness training on mental health and following this incident and others like it there have been calls for more epilepsy awareness training.  A couple of comments also emerged in the discussion about autism training.  Here is a list of the various conditions I’ve heard mentioned during my career amidst suggestions that police officers should have raised awareness of that particular issues, above others.  Not all of them are mental health conditions but the others are conditions that officers may often mistake for indications of mental distress —

  • Schizophrenia
  • Bipolar
  • Alzheimer’s
  • Dementia
  • Depression
  • Post-natal depression
  • Autism
  • Apserger’s
  • Learning Disabilities
  • Personality Disorder
  • Anxiety Disorder
  • Acquired Brain Injury
  • Epilepsy
  • Diabetes
  • Stroke
  • …… plus awareness of how drugs and alcohol can confuse and conflate all of the above.

Quite a syllabus isn’t it?  When one asks the charities who represent those in our society who are affected by the above problems how much training would be required, you tend to get answers of between two and four hours.   There are fourteen conditions listed above – even at 2hrs per input that amounts to a week of training and at the end of such a course we would still need inputs about mental health and mental capacity law as well as the operational implications for the police of all of it.

You can’t do that in just one day! … so we’d already be looking at a course lasting a week and a half, if not two.

I have a more controversial question, however – to what extent do the above conditions make a difference to the way something should be policed?  If there is an answer to that then I see the relevance of training it – I’ve argued before that I see the point of specific autism awareness training for police officers because we know that where officers deal with incidents involving someone with autism there could be considerations that wouldn’t necessarily apply to other situations, if they can be accommodated.  I’m not sure if that could be said of all of the above conditions, however.  Would it matter to the policing of an emergency mental health incident whether someone who appeared to be in distress was psychotic because of schizophrenia or because of bipolar or because of Addison’s disease?  Probably not.

If police officers are going about things properly, they would be calling upon paramedics to support their decision-making about what needed to happen next where they have concerns about someone’s medical welfare.  But even this is a difficult balance to strike because police officers are not going to call an ambulance for everyone who is violent or resistant just to rule out encephalopathy or anything else.  But there is a point where no police officer with a first-aid certificate and any amount of enhanced mental health training is going to be the right person to be making certain clinical calls.

So where is that line?

DECONSTRUCTING BEHAVIOUR

The reality is that not every police officer in the United Kingdom is going to get a two-week mental health training course – and I would ask the question whether every one of them actually needed such a course.  I would argue a few need whatever we eventually decide is the most comprehensive training on offer and that most need a diluted version of that.

For many policing incidents, of course, an approach which starts with understanding particular conditions looks at things the wrong way ’round – officers are only occasionally asked to attend an incident where a family member is giving full information about medical or psychiatric history.  More frequently, we meet people and have to figure it all out for ourselves from scratch.  We often don’t know the person’s name when we first meet them and paramedics are rarely better off.  We simply don’t attend vast numbers of jobs where we know in advance which medical box someone fits into and even where we do things become more complicated when you introduce issues like drugs, alcohol and obviously, restraint.

And perhaps less obviously, some police incidents are going to be policed in exactly the same way irrespective of a mental health issue because it sometimes makes no difference to a police response whether someone is mentally unwell or not, at least to very initial handling of an incident.  All cases on their merits – everyone is an individual in those particular circumstances, whatever they may be.

I would argue that the police can be expected to make the obvious calls; but the more subtle things become the less reason there is to think the police are the right people to be deconstructing behaviour into clinical or non-clinical paradigms.  Clinical support is important and it isn’t always there, frankly.  That’s why I argue for greater involvement with our colleagues in the ambulance service and I suspect more integrated ways of working across those 999 agencies could bring enormous benefits, not just in the arena of mental health, but also domestic violence, night-time economy policing and so on.  It’s fair enough for police officers to see someone with a gaping, bleeding head injury and allow them to make the judgement about whether someone needs to go to A&E or not.  I say this because we would all hope an officer in that situation would agree that they should!  But it is far less reasonable when a knock to the head didn’t lead to any visible injury or any other sign of distress.  Does that mean everyone with a knock to the head goes to A&E? – no.  It means we need a combination of paramedics, healthcare support in custody and A&E as suite of options with good training on how far things should be escalated.

UNREALISTIC EXPECTATIONS

The same principle holds true with diabetes or epilepsy: if a person has collapsed to the floor and appears to have slipped into a coma, we would expect officers to spot that and react, irrespective of whether they knew it was caused by diabetes or whether they were quite unsure.  But where someone is disoriented but conscious, slightly incoherent and confused, would we immediately say “suspect diabetes” when a similar presentation could arise from other conditions?  Probably not, unless given information from someone at the scene.  Some years ago, just after West Midlands Police started routinely calling ambulances to all detentions made under s136 of the Mental Health Act, there was an incident that showed how precarious this all gets -

A gentleman outside a pub brought to police attention because of concerns by a member of the public about him being in the “confused, disoriented” category.  He didn’t appear to be drunk and enquiries confirmed he hadn’t been in the pub and officers formed the view he may be suffering a mental health problem.  They detained him under s136 and called an ambulance – he promptly collapsed in the back of it and was rushed to A&E has his blood sugar levels had fallen through the floor.  He was entirely undiagnosed – he had absolutely no knowledge at all that he had diabetes and after not eating properly that day he found himself in some medical difficulty.

Of course, it must be said that the police have got a bit of form in some high-profile incidents for not making use of information and people available to them who could better help them to understand certain situations.  This was true in the so-called ‘ZH’ autism case in London.  In certain other cases, family and professionals have claimed to have given the police information that should have been seen as relevant and it was ignored or disregarded.  If true, this is quite damming and officers must bear in mind how useful information and advice is from people who know those were are interacting with.

However, on the main issue here of officers’ recognition of medical issues cutting across mental health and other conditions I have to wonder whether the best we might be able to hope for, is not something which approaches diagnosis or specialist awareness of particular conditions, but an ability to have a general sense that ‘something’s not quite right here’ with a set of standard approaches to keep people safe and engaging with clinical professionals of whatever kind, as soon as possible?

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The Mental Health Cop blog

Badgewon the ConnectedCOPS ‘Top Cop’ Award for leveraging social media in policing.
won the Digital Media Award from the UK’s leading mental health charity, Mind
ccawards2013 – won a World of Mentalists #TWIMAward for the best in mental health blogs

was highlighted by the Independent Commission on Policing & Mental Health
– was referenced in the UK Parliamentary debate on Policing & Mental Health
was commended by the Home Affairs Select Committee of the UK Parliament.

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A Longitudinal View

Contemplate the idea that a vulnerable person with mental health problems is arrested for a not-especially-serious offence.  In custody the Force Medical Examiner suggests they are seriously unwell and may need admission to hospital under the Mental Health Act.  An AMHP and a psychiatrist join the FME in assessing the person formally and it is decided that he or she requires admission to hospital under s2 MHA for assessment of their supposed mental disorder.

What now happens to the offence?

Well – if it was not-especially-serious and the person has never really been in trouble before, is there any public interest in prosecuting the offence? Probably not – maybe there would be utility in it if the offence had been murder but where the investigation had been into shoplifting or a minor assault, government policy suggests – in Home Office Circular 66/1990 – that diversion from justice is in order.

What if it were not the first arrest?

If someone is being repeatedly arrested, things may change.  If the last arrest was also for minor matters and it was several years ago it may not but surely, if diversion has occured a handful of times or more, over a few of months or even years and there is an emerging pattern of admission-recovery-discharge-disengagement-crisis-arrest for ever-more-serious-or-more-frequent offences, then another approach may be justified? Certainly, more careful consideration is justified!

What if we’ve now seen a fifth person assaulted and / or a history of absconding from whichever mental health unit they were admitted to after diversion?  Does it matter when determining whether someone should be or could be charged that they are sectionable under the MHA? – not necessarily.  What if, within the arrests for offences, there are one or more detentions under section 136 MHA – diversion away from arrest – that also indicate a revolving door and an indication of rising levels of risk?

What if offences are escalating in seriousness?

We agreed above that if a one-off offence had involved a murder, the fact that someone is ‘sectionable’ wouldn’t prevent a prosecution.  So somewhere between shoplifting and murder there appears to be a line – before this line we argue there is little public interest and seek to divert someone into health and social care services; afterwards we consider prosecution.

Incidentally, can we keep trying to find another word for ‘diversion’?! – diversion is NOT what this interface between mental health and criminal justice consistently does!  I know the current government pilots are called ‘liaison and diversion’ but no-one seems to be able to answer this:

When are we liaising, when are we diverting; who is making this decision and how?!

PHILIP SIMELANE

Last month, we saw the publication of a report into the treatment and care of Philip SIMELANE in the lead up to the killing of Christina EDKINS in Birmingham in March 2013.  You may remember the case because it was a very high-profile tragedy that touched us all and the heartache arising from it has been compounded by the report which indicated that Christina’s death was preventable.  The report makes 51 recommendations to various agencies, including the police and CPS and I was very interested in it making case specific agency recommendations and broader, ‘national’ recommendations.  In particular, I was fascinated by the suggestion that custody sergeants need to take a ‘longitudinal view’ of offending behaviour when suspects with mental health problems are in custody – fascinated because I’ve argued this for years, on this BLOG and elsewhere.

In other words, we should not look at each arrest and the potential appropriateness of diversion on an isolated basis – we should take a broader view of the risk / threat issues based upon a full understanding of offending, detentions and other health information of various kinds.

Disclaimer:  Despite being a West Midlands Police officer I do not know anything about this case beyond that which can be read in the media.  I was not involved in any way in the investigation or any of the previous arrests of Mr SIMELANE.  I know nothing more than you.

What the report seems to be saying, is that where offenders with mental health problems come in to custody repeatedly, amidst a background of their families asking for their loved ones to be helped and supported because of mental health problems, the police and mental health services should look more closely at whether or not prosecution becomes necessary, given that this particular vulnerable person is arrested for offences more than once or twice and the latter stages they seem to indicate a concerning level or risk posed to people other than the patient.  The police should consider all the previous arrests, detentions under the MHA  as well as any other information that is available. This may include information about whether patients engage with mental health services or whether they abscond from admission under the MHA. It’s relevant, obviously!

What’s the point of doing again, something which has been tried already and failed? Little or none, say a lot of people. That said, if the offences are not escalating especially severely and if the it is not recurring especially frequently, then this dilemma can become difficult and very subjective.

INADVERTANTLY BUILDING RISK

If this report says anything to me, it says that we need to rethink our whole approach to ‘diversion’ (whatever that means).  We need to remember that most people who offend whilst they are mentally ill do not offend because they are mentally ill.  As such, one question that policy makers are yet to answer in anything like a convincing way is why we have special pre-charge arrangements for offenders with mental health problems when we lack equivalent options for any other particular groups, except children.  Why are mentally disordered offenders distinct from other vulnerable adult groups, including those with addictions and substance misuse issues?  Why do we build a criminal justice system with mechanisms that allow for the compulsion of mentally disordered offenders and then try as hard as we can not to use it, even in circumstances where we know that less restrictive options have been tried and failed or are wholly inappropriate?

This approach builds invisible risk into our criminal justice and mental health interface.  It means that risk assessment of offenders in the future is less likely to take full account of risks known about today, because we’ve seen through cases like this how little previous contact with mental health and criminal justice will influence how offenders in custody are handled.

One other thing appeared within the report which concerend me, despite it’s intuitive nature: and it concerns the issue at the heart of many a homicide related treatment inquiry – information sharing.  It was pointed out that whilst Philip SIMELANE was in custody he was assessed by doctors and nurses of various kinds and that this inforamtion was not routinely shared with his NHS clinical carers.  As such, when NHS professionals were making risk related assessments about his mental health, they were unable to take advantage of this information and the report recommends the kind of routine information exchange that seems intuititive

SENSITIVE PERSONAL DATA

Of course, people are entitled to have their personal data protected and medical information is confidential just as criminal convinctions and police intelligence is confidential.  Information that comes into the hands of the police (or their contracted medical providers) can only be routeinly shared with other people – the NHS – with the consent of the person concerned or where the criteria in the Data Protection Act 1998 are satisifed for disclosure without consent.

Buit the opposite is also true! … information and crime and offending which is known to the NHS can only be shared with the police, with consent, unless the criteria for disclosure without consent are met.  So if a patient admits he has been stealing food from supermarkets whilst sleeping rough living in crisis, this remains confidential between patient and doctor unless the patient wants that informtaion disclosed – and who would?!

But if we’re going to get the police and the NHS into the routine sharing of what the law calls sensitive personal data, then we need to make sure that we are doing it lawfully.  What if someone in custody for offence wants NOTHING of their arrest or health information made known to anyone else? – what if they were asked for consent to disclose and expressly stated they did not consent?  Where is the lawful basis for disclosure?  In many cases there would be one.  In some, there would not.

As with everything important in life: no generalisations and all cases on their individual merits.

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The Mental Health Cop blog

Badgewon the ConnectedCOPS ‘Top Cop’ Award for leveraging social media in policing.
won the Digital Media Award from the UK’s leading mental health charity, Mind
ccawards2013 – won a World of Mentalists #TWIMAward for the best in mental health blogs

was highlighted by the Independent Commission on Policing & Mental Health
– was referenced in the UK Parliamentary debate on Policing & Mental Health
was commended by the Home Affairs Select Committee of the UK Parliament.