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Personal Responsibility

I’m going to have to be careful about the tone of this one: it just mind end up sounding a bit like a lecture or a telling-off!  And I should be clear that this post is not just aimed at professionals in policing – what I am about to say is of applicability to anyone who has to deliver their profession within the constraints and opportunities of our mental health and capacity laws.

So whilst trying not to sound like Mr GILBERT from the Inbetweeners, here goes —

If you are a professional reading this, you will have taken many decisions in your career which are, fundamentally, legal decisions.  Section 136 MHA detentions; decisions about whether to grant leave under the MHA and recall a patient from it; the application of the Mental Capacity Act or issues around the application for and execution of warrants.  There are countless other examples.  Of course, the origins of these decisions may well be based on practice judgements, health and safety considerations or the attempts to prevent harm but as soon as you get into this territory you will come up against legal considerations. So we need to know the law.

So here’s the rub: we actually have to know the law, which means we might have to study it. Here’s another rub: whether or not we have a training course on offer, we might still have to know the law, which means we might have to study it. Finally, here’s a real spoiler: whether or not we know the law and whether or not you have studied it, you’re still accountable to it. Ignorance is no excuse, etc., etc..

STANDARDS OF KNOWLEDGE

My personal view, is that the standard of legal knowledge across the professions is actually quite shocking.  I am prepared to be so blunt because I actually don’t think this is the fault of individual professionals.  I know that I had my views early in my career about police training, but I have subsequently come to think that legal training within various mental health professionals is far from great.  The only real exception I make to this generalisation is the training given to AMHPs, because they are legally warranted and professionally examined on the Mental Health Act.  It doesn’t prevent the occasional myth pervading that professional group, but their legal knowledge is usually spot on.

I’ve noted a few times on previous posts that I get loads of queries via social media or email about mental health law each week and and most of them are really quite basic. “What is a s37 patient?”; “Have I got a power of entry for this situation?”; “I had a job the other night, whose responsibility is to do this?”

Of course, some questions are more elementary for some professionals than others. A while ago medium secure unit in another area to mine reported a ‘voluntary’ patient missing and told us “The Secretary of State has issued an order for his return to this hospital.” This information is actually very confusing about the legal status of this patient and what, precisely the police are allowed to do if or when they find the man.  It seemed to me that there could be contradiction or confusion within the request.  Since the local police area were asking officers across the force area, including mine, to attend various addresses and search for the man, I asked the duty inspector for the hospital’s area to enquire of the reporting nurse, “We’re just trying to clarify police powers here: is this a conditionally discharged patient and is this ‘order’ you’re on about a warrant from the MoJ under s42(3) of the Act?”

Silence on the phone line.

Now this probably won’t mean much to your average response officer as conditionally discharged patients being recalled is so comparatively rare that most officers will go a whole career without encountering the situation – it’s only the fifth or sixth that I’d ever been connected to in the real world.  Nurses working on medium secure units will see this far more frequently and as they are an important link to ensure that the police are properly briefed on these situations, it’s important they understand their powers.  Most crucially, the word ‘voluntary’ should never have been used in this context: the police have no powers over voluntary patients, unless we encounter them in public places and feel that section 136 should be applied. So can you imagine if this man – who it turned out had been a serious sex offender leading up to his hospitalization – were found by the police in a private address (where they would have no powers) and left there because of confusion as to his precise legal status?  Imagine the horror if he offended after police contact with that opportunity to re-detain him having been missed?!  It’s too awful for words.

It turns out that our guess was correct: he had previously been in hospital as a restricted patient and then conditionally discharged under s42 MHA. For whatever reason to do with his care, he had been recalled to hospital and would again become a restricted patient.  So at last we understood what we could and couldn’t do.

This is not a knock at an individual nurse tasked with phoning the police: it is just the more potentially consequential tale from the last few months to highlight the point. There could have been the story of the woman who had been assessed under the MHA and an AMHP had applied for admission to hospital. She had not travelled to hospital on the night of the application and the following day, staff attended her home address to convey her to hospital and she refused to open the door. Could the police just force entry? …. not with a warrant we can’t, no.  There could have been the one about the police being asked to physically coerce the Community Treatment Order patient back to hospital before anyone had served a recall notice.  The list goes on.

The police are potentially worse: perhaps you’d expect that because although mental health is core police business we know that we’re not quite there yet with the provision of training.  This week alone, “What’s a s37 patient?”, “Can we force entry to re-detain a s3 patient?”, “Can’t we just use s17 of PACE instead of getting a warrant?”.

The list goes on – legal training all ’round.

PERSONAL RESPONSIBILITY

Here is a list of resources to help, but you might have to read and internalize them! —

  • What do all the sections mean? - each important section of the Act, summarised into one or two sentences.
  • Quick Guides – covering very common and some not-so-common scenarios under the MHA / MCA.
  • Knowledge Check - one post which summarises into around 500 words the most crucial information.
  • But you might have to actually read it and internalize it! – try doing it as an act of studying, rather than trying grab information at jobs when pressure is on.

I was remembering recently that the police legal syllabus doesn’t include very information on mental health. The Blackstone’s Manuals (2015) don’t include more than passing reference to the Mental Health Act.  They certainly don’t include detailed knowledge of the Mental Health or Mental Capacity Acts into the legal syllabus that is the basis of the first part of both the sergeants’ and inspectors’ promotion exams.  The examination is based upon surveys of operational supervisors as to what knowledge is needed and yet mental health doesn’t feature at all, despite it being daily business!  I would estimate I get several dozen queries a week about what different legal structures mean or what police powers are implied.  I can’t imagine how many officers with such queries don’t raise them.

The hope behind the above resources was that they would allow quick reference about the sections of the Act and what those sections mean officers can do.

We have seen that the police are only going to be as good as the information they are given. Most MHA related scenarios for the police are not instigated BY the police – the obvious exception being section 136 MHA which most officers understand pretty well. Otherwise, the police are almost always acting in support of or on behalf of mental health professionals who will need to ensure police officers are properly briefed to be able to act quickly, professionally and legally.

This is important stuff and it may well mean that each of us needs to spend at least a couple of hours (or more!) actually reading the law itself, taking personal responsibility for ensuring we are well positioned to discharge our responsibilities and to work in partnership with each other.

Over to you!

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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

– was highlighted by the Independent Commission on Policing & Mental Health

– was highlighted in the UK Parliamentary debate on Policing & Mental Health

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.

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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
– was highlighted by the Independent Commission on Policing & Mental Health
– was highlighted in the UK Parliamentary debate on Policing & Mental Health

Police

Are We Failing Police Officers?

TRIGGER WARNING:  this post discusses suicide and mental ill-health very specifically amongst police officers – those affected by these issues should carefully consider whether or not to read on.  There is support available via the links and phone numbers at the bottom of this page, if needed.

Two separate news articles from opposite sides of our planet caught my attention this week: each of them referring to suicide and mental distress amongst police officers.  In the state of Victoria in Australia, the Chief Commissioner has set up two separate, but clearly related, external inquiries into police deaths and depression.  These reviews emerged after seven police officers in the last two and a half years took their own lives.  Set against a workforce of over twelve and a half thousand, that number may not seem large but that department estimate that as many as thirty officers are currently at risk of suicide.

Meanwhile, a police sergeant in Toronto took his own life after leaving a suicide note specifically attributing his decision to work-related issues and his battle with PTSD.  His family is calling for the inquest to examine the officer’s claims against a background that includes other police suicides and a former police sergeant’s criticism of the support he received for PTSD.  And let’s face it: these two countries are not alone and this issue does not just affect police officers. There are more deaths of US police officers after suicide than after homicide each year.  Queries a year or two ago to Her Majesty’s Inspectorate of Constabulary revealed that police forces here do not collate data on suicides, but we know there have recently been several and that policing in the UK is considered one of the higher-risk professions.

So, are we failing police officers? … or emergency first responders?

POLICING AND MENTAL ILL-HEALTH

Mental ill-health in policing generally is a subject we don’t discuss very much: having asked these men and woman to go and do a pile of stuff the rest of us wouldn’t do, it should come as no surprise that the police, like paramedics, are four times as likely to suffer from stress, depression and anxiety when compared to the population as a whole.  When I do talks that touch on the broad subject of mental health and policing, you often find questions asked about mental health in policing.  You don’t have to look hard to find something to say, either – individual anecdotes of suicides by serving officers, perceptions of in-house support and more general comments about the extent to which we don’t seem to have fully understood this.  We know from research that acute levels of stress in policing are probably connected to non-negligible levels of mental illness.

If you spend even a short amount of time on social media, you will bump into numerous examples of current and former officers living with mental health issues and plenty of those will say that they felt unsupported at key times.  It must be said, that prevalence of distress and suicide risk has been linked in some instances with criminal or disciplinary procedures against officers so it is always going to be difficult in some cases to be both impartial prosecutor and supportive employer.  I’m aware of several legal actions ongoing by former officers under employment law for alleged failures in a duty of care or because they have alleged failures to support employees suffering from mental distress or give proper regard to mental ill-health when it comes to personnel processes.  Of course, mental health problems are classified for the purposes of the Equality Act as protected characteristics.  Officers who experience mental health problems at work are – in theory, at least – no different to officers who become physically disabled after an assault or accident.  And as with physical health problems, disability can arise for all manner of reasons, including work related reasons.

So where is the narrative that talks about police work as a line of work that can carry a cost in terms of mental health?

Asking this question is not to ignore that other professions – including other emergency first-responders – are also at raised risk of inflicting psychological distress upon their staff.  In particular, rates of PTSD in police officers (and in other first-responders) are concerning.  More concerning still, are the support mechanisms available in many cases.  We know that amidst public sector cuts, some police forces are having to reduce the counselling and other support that is able to be offered to staff and that NHS support for counselling and CBT can involve as much as an eighteen month wait.

POLICE SICKNESS

NSYThe demographics of recruitment and retention don’t help trends in police suicide and mental ill-health.  Reporting on suicide in the population as a whole puts young and early middle-aged men right in the danger zone, when it comes to predicting overall probabilities.  The Samaritans produced a very comprehensive report on suicide in the UK and Ireland this year and it provides detail on age and other demographic factors.

So in a profession that is still comprised mainly of men, the profession-level risks become amplified and obvious.  Every time I read initiatives about male mental health, I must admit I think about my predominantly male colleagues up against a culture that suggests you should be able to cope and a structure that may struggle to support you anyway.

You can see clues about police culture all around and much academic time has been given over to studying it.  Suffice to say here: none of the seven police officers in Victoria who took their own lives sought help from their employer.  So where suicide is the leading cause of death generally in men from certain age groups, we should be concerned about the risk of suicide in a profession that has higher than average rates of psychological distress and mental disorder and which is predominatly male.  Of course, female officers are affected too and whilst female suicide rates are much lower than those for men, female rates of self-harm are much higher.  It means we need think about how staff may be differently affected and think way beyond suicide.

The above report from the police in Victoria is not the first to make the claim that more days are lost to sickness in the police to mental health and other psychological problems than to physical health problems.  And sickness days lost to stress, depression and anxiety is on the rise.  Reports suggest that since 2010, sickness arising from mental health and psychological problems is up significantly.  In the North East of England, three police forces reported percentage rises of 260%, 122% and 37% compared to three years previously.  Even a 37% rise is significant and despite my efforts, I couldn’t find a news article suggesting that any UK police force had seen a decrease.  Let me know if you find one.

It’s worth noting the emphasis placed by forces upon the potential for personal circumstances to give rise to this trend.  In response to the story of north-east forces as well as elsewhere, senior officers have been keen to stress this and of course, that will be part of it.  But it must be said, there seems to be a lack of acknowledgement of the role that police work pays in causing distress and illness amongst officers.  In 2007, psychological problems were listed at the top of those reasons that cause long-term absence in a report by the Health and Safety Executive.  It would be really interesting to read an up to date version of this report.

IT’S TIME TO CHANGE

For some while now, I’ve felt that we need to see the development of a charitable organisation specifically aimed at supporting police officers (or 999 personnel as a whole) suffering from psychological distress and mental health problems.  I keep seeing the effort, the work and the impact of Combat Stress in drawing attention to and supporting our Armed Forces Veterans.  The issues in policing and emergency services work being different, with obvious overlaps, it strikes me that there is a gap that needs filling.  So it seems we could be doing a whole lot more and talking about this would be a good start – the Time To Change initiative has long since focussed its message on the importance of an open dialogue about mental health problems, but they also highlighted that policing is in the top two professional groups to be comparatively unaffected by its campaigns.  Yet how many times have we heard police officers who have found themselves living in distress say something similar to, “I would have thought I was the sort of person to affected by mental health problems.”

There is the knuckle of the problem – there is no type of person.  It’s about the broader human condition and the way we live our lives.  In my humble opinion.

Are we failing police officers? – let’s just say we have a long way to go.  Who’s protecting the protectors?

NB:  if you have been affected by the issues in this post, you can talk to the Samaritans for the price of a local phone call on 08457 909090.

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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
– was highlighted by the Independent Commission on Policing & Mental Health
– was highlighted in the UK Parliamentary debate on Policing & Mental Health