“Exclusion criteria” is my term for those aspects of someone’s presentation which often mean a person detained under s135/6 of the Mental Health Act are denied access to a Place of Safety in a psychiatric setting with a presumption that it will be possible, legal and safe to detain them in police cells. (Occasionally, a PoS is within a dedicated part of A&E, established for the purpose of MH assessment and I include them here.)
I have come across the following exclusion criteria:
- Learning disabilities.
If you examine samples of people detained the above would amount to some 40 – 60% of the total, depending on your sample – I’ve sampled it at least ten times. The justifications for such exclusions are usually given, as follows:
- Drugs / alcohol: you cannot assess someone under the MHA when they are under the influence of substances. Fine: doesn’t mean it’s medically appropriate to have them in a police cell, though. 17% of deaths in custody involve drugs, alcohol and mental illness and 5% of deaths are people detained under s136. Let’s think about what we’re doing before we exclude to the cells.
- Aggression: it is not safe to have violent patients in A&E or in a psychiatric unit and they should be in the cells until they calm down. Again, I understand this. But what if the person is so floridly psychotic as to need constant restraint to prevent head-banging or self-harm? NICE guidelines for this cannot be applied in a cell block and the experts who gave evidence at the Rocky BENNETT Inquiry described the need for ongoing restraint as a medical emergency.
- Children: it has been said, that there are safeguarding issues to having children in an ‘adult’ setting and it is to be avoided. This is not correct, if the PoS involved is a distinct facility within an MH ward. What are the safeguarding risks if the only people that child will come into contact with are trained, vetted professionals and / or their own parents / families?
- Learning disabilities: I’ve heard it argued that where the police detain someone with a learning disability, that person should be excluded from the PoS and either taken to the cells or LD services should establish their own PoS facility. How do the police tell whether someone has an LD or an MH problem? What if they have co-mobidity?
As I bounced off these debates I was more or less breathless. How can the answer to a notional, theoretical safeguarding risk to a child be to put them in a cell block where quite possibly some man will be under arrest for raping boys or possessing indecent images and where at any moment whilst the child is being moved around the cell block to the Doctors room, the toilets or showers the local response team might drag in a violent drunk or domestic violence offender who wants to fight the world? <<< That’s a safeguarding issue.
How intoxicated is intoxicated? Some areas use Breathalyzers to determine the answer; but some are zero tolerance – any alcohol at all and you can’t come in; others use the drink / drive limit, others use double the drink / drive limit. Some don’t use Breathalyzers at all because the senior service psychiatrist has said, “It’s pretty disgusting if you think about it. What is it actually telling you?!”
Three pints of beer in one person will render them quite intoxicated; with others it won’t touch the sides and whilst neither could drive a vehicle lawfully, one of them may well be able to hold a sufficiently cogent conversation with an AMHP to be assessed under s136.
Aggression is a really difficult one: the police are always very keen to lock violent people in cells and keep people safe. The problem comes whether that action is consistent with keeping the detainee safe. The tragedies which have befallen individuals and their families include those which involve violence which is symptomatic of a medical emergency; or which requires ongoing restraint which causes further medical problems, perhaps because of underlying poor health or previous medical problems.
These are the reasons why protocols on s136 need to include sensible mitigation of medical risks before we condemn intoxicated and / or violent detainees to the cells; and it is why mainstream mental health services need to have proper pathways to their LD and CAMHS services, for those occasions where those services’ patients are detained and removed to a place of safety.
This means about six to eight organisations getting around the table to trash it out and it has happened in the real world and it works well with ongoing support across the organisational boundaries.