Excited delirium

<<< UPDATED ON 31/01 – a Radio4 programme on Excited Delirium will be on iPlayer for a limited time and is a very worthwhile listen. >>>

The question of whether excited delirium (ED) is a real medical condition is way above my pay-grade.  But in reality, police officers find themselves refereeing an aetiological debate by arbitrating various doctors’ views.  Decisions about how to respond to someone suffering from this ‘syndrome’ contain no shades of grey: because ED (syndrome) is either a real medical condition which needs to be regarded as a medical and psychiatric emergency where life may be at risk, or it is not.

How does a police service give clear guidance where there remains an ongoing argument between clinicians who call for more research?  Well, where issues of clinical risk are concerned, it is perfectly proper to argue that the police should acknowledge their limitations and seek the correct advice from suitable professionals.

Internationally, clinicians have suggested that excited delirium has been ‘made up’ by the police, perhaps to medicalize excessive force and deflect liabilities for inappropriate restraint?  I’ve heard this argument made in the last month in my own police area.  Certainly, ED does not appear as a recognised disorder within in the international classifications of disease, the DSM-4 or the ICD-10; it is not due to appear within DSM-5.  There has also been significant caution urged in Canada against the use of the term, notably during the ‘Braidwood Inquiry’ conducted by a retired judge.

But for those police officers who find themselves patronised by clinicians who would seek the removal of ED patients to police cells without reference to medical authority, here is some more information regarding this supposed condition:

Paul COKER (London, 2005), Nadeem KHAN (Lancashire, 2007) Ricky PENFOLD (London, 2008) and Jason PEARCE (Shropshire, 2009) all died following which inquests ruled that they probably died from ED or complications arising from being restrained whilst suffering it.  Odisseas VEKIARIS (Melbourne, 2009) was ruled to have died from excited delirium according to the Victorian Coroner.  There have been further cases in Canada, New Zealand and the US and inquests (or equivalent hearings) considered medical and pathological evidence pertaining to the cause of death – before ruling individuals to have probably died from or following ED.

Simply put: whether this a real condition or not, is unclear; what contribution drugs or restraint may play is not clear.

So here are some further considerations for police officers and police forces when they are obliged to decide whether to listen to this doctor or that doctor:

  • The Independent Police Complaints Commission has given police forces recommendations to improve training and awareness of this condition: it is now a regular feature in police public order (riot) training, as well as in first-aid training and personal safety (restraint) training.
  • Guidelines produced by the National Policing Improvement Agency for the ‘Safer Detention’ of people arrested by the police, highlight that excited delirium is a medical emergency – pp31 and 51.
  • Guidelines produced by NPIA for ‘Police Responses to Mental Ill Health and Learning Disabilities’ which highlight that the condition is potentially life threatening and necessitates removal to A&E – pp54, 97 and 107.
  • Perhaps unsurprisingly, both sets of guidelines were produced after extensive consultation with medical professionals – the mental health guidance in particular is overtly and explicitly badged by the Department of Health.
  • The phenomenon is not restricted to police contact deaths, either:  as well as prison incidents, there have also been deaths in psychiatric detention which have led to the excited delirium question being raised and again ruled as relevant to a cause of death.
  • A joint psychiatric-pathology text has been published on the subject which states, “For all practical purposes, an acute psychiatric episode with agitation and violence is synonymous with excited delirium” warning that death can follow in minutes – p4.
  • Other medical work is available with a large number of reputable emergency physicians putting their names to it and to the need for further research,
  • The National Institute for Health and Clinical Excellence published statutory guidelines for the NHS in 2005 on the “Short-term management of disturbed / violent behaviour in in-patient settings and emergency departments.”  There are three separate academic references within it to ED in the context of restraint risks and it outlines various possible pharmacological interventions to mitigate clinical threats.  If the document envisages and advises on ADB-type presentations within NHS settings, surely where those manifest to the police the issue becomes one of how the police get the patient to a suitable medical location for those interventions to be considered, as quickly and safely as possible?]#
  • That none of the above present a definitive argument that ED is real; it clearly gives a basis for police forces to consider whether it may be.
  • It also gives a basis for police forces to consider how to approach situations where officers may be thinking about or required to engage in restraint situations.

So whilst there may doubt about ED as a real medical condition – indeed, it may be nothing more than a euphemism to describe any number of potential medical or non-medical presentations – there is no room to argue that the police can easily dismiss it.  Sufficient people argue it is a very real threat to the safety of people detained despite not being is not in relevant textbooks and not being acknowledged by all medical professionals.

Asking police officers to make these judgements about healthcare needs in dynamic, unfolding situations is not only unrealistic but potentially dangerous.  When more is known about ED, we can look at this again; but until that time every police constable in the UK has the legal right – actually the duty – to ensure that prior to taking violent people to the police cells, that it is medically appropriate to do so to avoid catastrophe for patients and their families.

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7 thoughts on “Excited delirium

  1. As a MH nurse of 29 yrs I have worked in a multitude of different psychiatric scenarios. I really welcome your endeavours in this blog. Pleased to contribute if asked. Steve

  2. Thanks again for an honest look at MH services and policing. You have changed my opinion totally by your honest appraisal of the Facts! Well done and thank you to the experts who
    have offered to help. Joined Up Thinking is breaking out!:o)

  3. Brilliant blog…I’m looking forward to reading more-will defo follow.Much admiration for what you’re doing by raising awareness of the issues the Police face and the limitations & restrictions placed on your practice. A great source of knowledge for other professionals and I will bear your observations,advice & knowledge in mind when I graduate to practice as a social worker…mentalhealthcop, Inspector Brown….a legend ;0)

  4. As a serving patrol Sergeant I was so concerned by the lack of practical support and guidance to the Police regarding mental health I researched it for a degree. Your thoughts and findings are spot on. This blog is highlighting the problems encountered by officers. My force is making advances but its so slow.
    Regards and well done Steve J

  5. Plenty of Guidance on health matters from DH is published but how much is implemented or seen as optional?
    The Mental Health Act is a Statutory requirement but often ignored & MH guidance in particular is overtly and explicitly badged by the Department of Health……but its left to Trusts to implement seemingly, if they feel like it! Whilst statutory Acts are a legal requirement…there is no hope of public challenge because of expense and no accountability of Trust management or DH level!
    Goodwill is key to whether success or failure in treatment!
    Well done for work you put into this, its certainly rattling some cages!!

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