Is A&E a Place of Safety?

ANYWHERE can be a Place of Safety under the Mental Health Act as long as the occupier is temporarily willing to receive the patient.  This is stated in s135(6) of the Mental Health Act.  Of course, the Act also declares that hospitals and police stations are places of safety (PoS); and the Code of Practice requires a joint protocol to exist which indicates which PoS should be used and in which circumstances.  So if a hospital A&E department agrees to accept someone for assessment, treatment – in what sense are they still not a Place of Safety?  It’s wordsmithery.

I’m not going to recall the story of an officer who once removed someone to a GP’s surgery to find the doctor happy to help and let his surgery be used.  Or the child who was taken home and assessed there once officers were happy it was clean and safe.

Of course, ideally, A&E would be used for medical emergencies and treatment of physical injury only; a psychiatric or dedicated PoS would be used for more or less everything else; and a police station only as a last resort.  But what if the middle option doesn’t exist at all; or it doesn’t work properly?  What if the police know, that resort to the cells may well be medically risky and potentially illegal?

We should remember: regardless of domestic law and local protocols, whatever ends up happening MUST survive contact with articles 2, 3 and 5 of the ECHR.  There have already been successful human rights based challenges around s136 and more are pending (MS v UK).  Statutory regulators have given direction to police forces that their acquiesance to inadequate local NHS arrangements would constitute a human rights breach in certain circumstances.  We also know, that attempting to get direct access to healthcare would make the difference when trying to decide whether or not officers were negligent.

Some people are potentially too ill to be in a police station, but not ill enough to be in A&E.

I can give multiple examples of incidents where officers have ‘done as they were told’ by their NHS areas who wrote protocols saying things like “The police station is the place of safety” or who documented such gems of clinical clarity as “people arrested under s136 who are violent or intoxicated should go to the cells”.  Such cases have ended very badly indeed, worst of all for patients.  We all know, alcohol can mask other problems and resistant behaviours can be symptomatic of all sorts of things.

BUT(!) before my colleagues in A&E point out – quite rightly – that A&E is (usually) not ‘designated’ as a PoS; that it is not equipped to act as a place of safety; that it is unsuitable as an environment and should only be used if patients have got additional medical problems or injuries that indicate A&E is appropriate.  I have this to say:

  • You could say all of that about police stations – few Chief Constables WANT their police custody blocks used as a PoS and there is probably more public material against the use of police stations than against the use of A&E.
  • The word ‘designated’ only appears four times in the whole Code of Practice and never in chapter 10 which discusses PoS protocols – the word doesn’t appear in s135(6) MHA at all.
  • Legally, there is no such thing as a designated or a non-designated PoS.
  • We know from published research, that approximately 15% of people who go to A&E have mental health problems.
  • We know that 5% of people who go to A&E are there JUST because of mental health problems.
  • We know that A&E have psychiatric liaison services, called by various names, but all who provide psychiatric assessment, including formal assessment for admission, if required.
  • So let’s not pretend that A&E do not do mental health.
  • We also know, that in some NHS areas, the managers of A&E Services do not know who the managers of MH services are, even though their frontline operational staff have daily contact and have to improvise integrated care pathways into secondary MH services where necessary.

I also understand that if areas had a properly commissioned, staffed and overseen PoS  service then such tensions as I’ve seen which appear to exist between A&E and the police may not exist at all.  In the absence of such a facility, or in the absence of being able to access it, police officers have been forced into various dilemmas, especially those of us who read Chapter 10 of the Code of Practice (Wales) and the Royal College Standards and then wondered why our experience bore no resemblance to this Nirvana described within.

Problematically, when A&E say “we’re not a place of safety” they are often undermined by their own decision-making.  If one arrested an elderly, female dementia patient and removed them to A&E asking for help from the NHS whilst explaining that the cells are full of howling drunks, robbers and rapists and that you’d really rather not subject your octogenarian to that environment, you’d probably get in.  <<< Real example.  So you are a PoS on some occasions?  OK, now I’m really confused: on what basis are we picking and choosing?  Do these decision survive contact with Equality Impact Assessments?!  Strikes me they probably wouldn’t!

This whole blog post is a TOTAL AND UTTER RED-HERRING because instead of A&E and the police getting at each other, not supporting each other; arguing about the minutiae of legal terminology neither are qualified to handle and contorting the Act and Code to support their particular point of view, the actual point is busy being missed:  properly commissioned, established and resourced Places of Safety in dedicated facilities which operate to nationally agreed standards.

Other debates are white noise.


IMG_0053IMG_0052Winner of the President’s Medal from
the Royal College of Psychiatrists.

Winner of the Mind Digital Media Award.


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26 thoughts on “Is A&E a Place of Safety?

  1. As a mere MOP my handle on this is as follows: accident and emergency covers events such as fractures, heart attacks, penetrating injuries. I don’t want A&E staff to be handling MH issues. I want them to be bone-smiths. And, in my pain and distress, I want to feel comfortable and safe myself.

    A threatened suicide may well be an emergency but it should be dealt with elsewhere. I realise that this is your point. Where is this mythical ‘elsewhere’? Where is this pleasant Place of Safety? For I wish those with MH problems to be as comfortable and secure as I desire to be myself.

    Oh, and whilst I want A&E to be a place for speedy treatment and (hopefully) discharge I also have a vision of a police force (yes, force) which has as its principal mission the apprehending of criminals rather than the supporting of the vulnerable or coaxing the intoxicated out of town centres. You know the sort of thing – drivers on their mobiles, speeding drivers, burglars, racist attackers et al. I don’t know who is best equipped to deal with MH issues but I see no reason why anybody believes the police should be particularly good at it nor why they should be required to be.

    In short, I’m stumped.

  2. But where do potentially suicidal patients go? eg there was the “flagship” Barnes unit at Oxford John Radcliffe hospital, where patients who self harmed had access to emergency psychiatric assessments and could be detained and placed under protection of Section 2 for treatment and observation…..yet thats been closed….as have many specialist centres!
    Fact is for far too long people with mental illness have been left to deteriorate at an alarming rate whilst services applaud their “Early Intervention Services”, “Community Mental Health Teams” and “Dual Diagnosis” treatment….all of which are sadly left either lacking in specialist training or just not implemented!
    I also want a safe A&E dept where I will be treated professionally. I also want a safe area for confused vulnerable people but I dont believe withdrawing suicide indicators is a professional approach to what no doubt is a difficult “hot potato”.
    Please don’t just leave all to police, we are talking ill people not always criminals.
    Duty of Care is with NHS Mental Health Services ….. improve early intervention services, treat early and reduce rate of damage and injury!

  3. An excellent blog, getting straight to the point. Maybe one question can help cut to the core:

    “Is a mental health emergency a health or a policing issue at heart?”

    We all know the answer, and so health services must provide suitable PoS.

    1. I agree with you to a point but actually I have to say that it is a joint issue. Police have a responsibility to protect the safety of the public which includes protecting someone in mental crisis from themselves and others. I have no problem with this whatsoever. The difficulty then arrises that having taken on that initial responisibility actually we are now looking at a healthcare issue and actually healthcare services may say “well it was your decision to arrest them not ours so why do we now have to deal with it” Of course they would never really say that – not out loud anyway! But they may have a point when the police detain people who are actually just very drunk or intoxicated which has created the impression of a mental disorder. We are lucky in our area to be well served by hospital places of safety, unfortunately they may be easier to access than custody sometimes and so Police have been guilty of using them to deal with the drunk an/or intoxicated by detaining under S136. Of course, Police then become very unpopular so we have a lot to do to improve that impression. Effective joint working to ensure appropriate use of S136 is of paramount importance. But rightly said properly resourced hosptial places of safety or any other health setting places of safety have got to be high on the priority list for Commissioners.

  4. Having experienced both AnE and police stations they are both impractical and dangerous places for people in mental distress.

    I have been taken to a n e only to be told by the crisis team, you don’t want to go in to hospital, people kill themselves in hospital. I have sat in A n E all night long completly out of it to be discharged after seeing a crisis team.

    However, my most harrowing experience has to be at a police station. Although I was not a criminal I was treated like one. Instead of being offered an appropriate adult by the duty Sargent I was offered a duty solicitor, I laughed and said, why would I need one of them, I haven’t done anything wrong?

    Because I was deemed a suicide risk I was then taken to a side room and ordered to strip, put in a paper suit and taken to a police cell. When you are feeling worthless already and trying to cling on to any sense of self, to have all your clothes and possessions taken from you including your glasses (so you are blind) is dehumanising and lead to a further deterioration in my condition. I was technically on suicide watch, but they forgot about me, and it was only by luck that I am still here today.

    I was delusional, and was convinced because of my context that I had hurt someone and because there was no one here that I knew that must have been someone close to me.

    By the time the doctor seen me i was in such a state that I was nearly sectioned, but yet again, after investigation I was discharged and let go. Ironically I remember that the police doctor said that when i had been given my glasses and clothes back and it had been explained what was going on I was much calmer and happier.

    We are not criminals, we should not be sitting in a n e for hours on end. I know that in other countries you can go to a hospital and stay there if you feel the need. After all I am the best judge of my health am I not?

    That being said, the police themselves, i have no fault at allwith… They demonstrated more care understanding and attention throughout all my period of ill health than doctors and nurses ever could. Yes, the ones with the least mental health training I found to be the best at being able to cope with it.

    1. Thanks for posting all of that – I’m only advocating A&E when there are additional medical problems that need such treatment and care. Also, I’m so heart-warmed to read your last paragraph the likes of which I’ve heard or read more than once. The dehumanising process you describe is all too familiar, but reflects the fact that outside of their human qualities, the police are totally unable to provide proper care for individuals and it is all too often the only way to be sure you can keep people safe. I know that’s no reparation for you, but having policed for years, it’s all about keeping people safe when you’re inherently unable to predict and manage the psychiatric or medical or self-harm risks.

      Thanks again for sharing, I’m really glad you did.

      1. Ditto from another Cop. We feel so bad when we are obliged to detain someone who is clearly very unwell in a police cell. Trust me whey I tell you that I and our estemed blogger and others like us are working tirelessly to make improvements.

    2. Im a student nurse been on both sides of the coin as a service user. When I was at my worst
      and pretty angry with a&e staff due to hearing them talk about me. I was shouting sarcastically and being pretty rude so only option was police cells as no 136 suite. Staff were amazingly kind
      was told when I got there you are in no way here as a criminal we’re just keeping you safe. cell door left open someone watching me all times and allowed magazines to read and staff bought me a macdonalds and kfc and Starbucks went into an inpatient unit on section 2 but when out 2 months later took them lots of chocolate and vouchers to buy Starbucks

  5. Hi, just dropped by to add to this fascinating discussion. Yes, I agree, a ‘place of safety’ can, in theory be anywhere. I’m horrified to hear stories of people who are clearly ill being held in cells where there is no identified risk to healthcare staff or other patients. As dhared earlier, it can only dehumanise people in distress and create more fear around the common experience of mental distress.

    Not all places are lucky to have survivor led crisis centres, like the one we have in Leeds.
    Please take a look at their website as an example of best practice http://www.lslcs.org.uk/

    Similarly, not everywhere has a dedicated s136 suite where people can be brought by police for crisis assessment. These services seem so vital to the humane treatment of mental distress, yet may be vulnerable to the cuts being experienced as the NHS tries to make record efficiencies which have never before been effected by any health service anywhere.

    I recently made a Facebook page which I used to list services available for people in distress over the Christmas period, please see https://www.facebook.com/LeedsMentalHealthXmas.

    Perhaps this could be developed by others in areas of the country where they live- services are slightly different everywhere, although some national services are routinely available to people in crisis (NHS Direct, out of hours GP, Samaritans helpline and email, SANE Forum)

    Please continue to share your insights, which I am always interested in. Let’s hope that by sharing our different perspectives service users, carers, and people who work in all the services they need can communicate better about how we can improve what is provided.

  6. Wordsmithery indeed, of course an A&E Dept can be a safe place for people in need of support, undoubtedly it should be less dehumanising than the experience so eloquently described above, but as also described above a busy City Centre A&E Dept sometimes is not the most pleasant of environments and it certainly is not the nirvana envisaged by the Code of Practice or Royal College. The truth of the debate is in your last 2 paragraphs; commisioning a properly equipped, resourced and supported PoS should be a priority for all PCT’s/ GP Consortia, but is it and will it be? That’s up to all of us, before we become one of the 1in4 who will suffer MH problems in life. In times of pressure on budgets Acute Hospitals may well change their stance and actively seek to be a preferred site for PoS’s after all as you address above, they are where people with physical injuries need to be and should be better than Police Stations in terms of environment, understanding and pathways to MH services. In the meantime Police Officers A&E Staff & to a lesser extent Healthcare Security officers will be left doing their best to support individuals in crisis who are at risk of becoming victims of beaurocracy as well as of illness and stigma.

    1. You know what – I am just not so sure. Of course we have to have sufficient dedicated places of safety within hosptial settings. However, perhaps the Acute Trusts should be looking at areas within A&E that can provide a place of safety for those occassions where someone has to be treated for illness or injury as well. It makes no moral or ethical sense at all for a person who is so unwell to have to be in the continued company of police while at the A&E and then subjected to a transfer out of the hospital – possibly into custody in order to have a MHA assessment. What happened to NICE guidlaines about treating the whole person? When are we going to stop number crunching and start considering the dignity and welbeing of human beings?

  7. I have only read a couple of posts on your blog, although it raises some interesting points for paramedics.

    We are given minimal training on this subject which makes it difficult for us to liaise with our colleagues in blue, when there is minor injury in the MH patient.

    As the Paramedic profession matures, we are increasingly seeing specialist paramedics. Trauma and medical patients are represented by critical care and emergency care paramedics. We have the ability to bypass Emergency Departments for acute strokes and certain types of heart attack. Is there a case for the provision of out of hospital assessment by specialist ‘psychiatric paramedics’, who can recommend the appropriate care pathway?

    Tj
    MCPara
    @meditude

    1. Maybe that would help: all comes back to the main point, however – whether those care pathways exist in the first place; and / or whether they invent non-clinical exclusion criteria to justify not having to accept a responsibility (with or without police support, assessed against risk) for providing oversight and care, ahead of assessment of need.

      Many tragic stories which commence with police interaction, become tragedies because that infrastructure didn’t exist at all or because it didn’t operate to anything like nationally expected standards. So we could give specialist training to police (which might happen) or to paramedics and it won’t make much difference at all to patient care (although it may make a difference to how those professionals defend their attempts to do the right thing.)

      What do you think?

      1. I think paramedics are ideally placed to ensure the correct care pathway is made. We have good relations (mainly) with you guys as you watch our back a lot. We also have good relations (mainly) with A & E staff. We should also be adept at communicating in all variety of situations including as a patient’s advocate to consultant level hospital staff and to patients on the street.

        With specialist MH training everyone would know that we were the people to advise the specialist generalists (jack of all trades) and would also be able to provide continuity of care throughout a pathway.

        All would win. The patient would get a better care experience, ambo could free up a crew, police would know that they had avoided a cell being taken up and ED would have on the spot advice if they were the initial place of safety or, if ED was bypassed, it’s 1 less bed space taken up. Because all three services benefit, the cost could be divided, increasing the cost benefit. Bean counters happy!

        If the infrastructure wasn’t in place, EDs would soon kick up as ambo fines them for a delayed handover and psych paramedics complete incident reports for inappropriate care.

      2. WooHoo!!! With you all the way!

        Any skepticism on my part is not the idea, only the reality that MH Commissioners (who I’m told don’t talk to acute care or A&E commissioners very often) would listen to your cogent argument as merely say, “What was the middle bit?!”

        Top idea – as long as paramedics also get the message that suitability for the cells is not connected to violence or alcohol or drugs … too many deaths in custody have been connected to people being condemned to the cells (for the want of other alternatives) when in reality they needed a care pathway that could handle their complex needs, inc challenging behaviour, intoxication and mental health.

        You fancy writing a blog on your psych paramedic idea?! Never thought of it before … :-))

  8. Surely the point is that ED’s provide initial rapid assessment and stabilisation for medical/surgical and trauma patients before getting a specialist involved to provide the ongoing care the same should be true for mental health patients. Once the need for mental health specialist care is identified it should be provided in a safe and calm environment which does not mean sitting for hours in the middle of a busy ED but should mean being transferred to a safe, appropriately staffed mental health assessment facility.

    1. I don’t disagree with that but the additional point also is that such “safe and calm” environments as you describe often don’t exist; where they do exist they can be picky and choosy and inevitably they pick and choose easy cases which implying an organisation view that the removal of the others to the cells should occur. Laws state that this should be the last resort and that other options should be considered so whilst accepting that there will be occasions where the cells are used because clinical supervision pending assessment is not required and there is no medical emergency, etc.; or where unusual levels of demand mean a operating PoS service cannot match demands, there will be occasions – there have been occasions – where using the cells has contributed to serious untoward events.

      Where officers are faced with all the right options, you are spot on … where those options don’t exist or are denied or do not work properly, there will be situations where improvising is required and this could involve asking A&E whilst acknowledging their right to decline. Cell blocks have every potential to be even worse places than a busy A&E department for a range of reasons and we can name the patients who have come to harm despite the police doing everything within their power to properly supervise them in custody and we can show how this has lead to legal liabilities, human rights violations and complaints for both the police and the NHS. We can also show, that where A&Es have declined to support someone in what I might call an ‘improvised pathway’, that Coroners have criticised them for their non-response.

      This debate is missing the primary point: places of safety in apprppriate settings usuall don’t exist or work properly – THAT is what needs fixing. Until then, the police and A&E can find themselves pointing at each other when really we should be jointly asking questions of PCTs and MH Trusts. You know as well as I do, that MH responses to your department for patients is often excessive.

  9. I came across this site as one does trawling the internet and as a person with serious mental health problems who has ended up in a cell on a section 136 a few times I found it interesting reading. My experience comes mostly from the Sussex area where there is a well known suicide spot and only one section 136 room/place of safety provided by the NHS nearby. When that is in use the default is a cell – terrifying in many senses of the word as i get claustrophobia. I have been stripped searched before now which is degrading especially when you are distressed. I have all possessions removed including glasses and watch. I am just left there not knowing the time and staring at the 4 walls which seem to get ever closer. I have ended up in such distress that I am curled up in a ball on the solid floor sobbing for hours (that was my 36 hour stay) with cell staff refusing to call the nurse so I could get something to relieve the distress. When I once asked why it was taking so long for an assessment to happen I was told to stop moaning as it was my own fault I was there in the first place.

    In short a police cell is certainly not the right place to take a distressed person who is no risk to others and for sure A&E would be so much better. I have begged to be taken somewhere else except the custody centre but the officers are just doing what they are told. I do agree though that I have received more kindness over the years from police officers than mental health practitioners. Just occasionally though an officer has displayed a complete lack of understanding mental health issues such as the officer who berated me for wasting police time when I went home against medical advice and when I went upstairs followed me up and continued telling me off even though by then I was sobbing on my bed.

    It’s time to stop a police cell ever being considered for those in distress that are not violent. It can only make things worse for the suicidal person sitting alone with little human contact apart from the opening and closing of the viewing door. You need human contact and understanding. I have got to the point now where I would rather die than be locked up ever again. On a lighter note the food is awful! None of the meals on offer are suitable for me and I end up eating bowls of flakes.

    1. Everything about this comment rings true, to me. You’re right, often there is no other option available to officers and we have the heartache, quite genuinely, of knowing that what we’re being forced to put people through is not helping or potentially making things worse.

      I’m glad you’ve received kindness from police officers – I often hear that officers are very professional and compassionate, notwithstanding the structures they’re operating in. I hope things are getting better for you now.

      1. Thanks for the reply. Things are not really better for me and with the mental health services not knowing how else to help me it quite often is left to the police to pick up the pieces and in fact my local crisis helpline actively points those of us in distress calling in in the direction of the emergency services which is really unacceptable. After all they’re the ones with the training in mental health and all the police can do is point the person in crisis back to the mental health services or section 136 to a cell which is where we came in. Quite often a hospital bed is offered but then none is available and off I go again as I’ve got no help and the police get called back out. It is not my intention to be a nuisance to the police and I feel really guilty about all of this.

        The whole system including the police custody makes me feel that I’m being punished for being ill and having never having had anything to do with the police in my life before it has become a nightmare.

        I am a passionate campaigner to get better help and understanding for those of us with mental health problems and I was impressed by this site. I spent a good half hour once speaking with an officer before he took me to a proper place of safety that time. He wanted to know what it was like to feel suicidal etc. It’s people like him who want to go one step beyond the call of duty that will make a difference.

  10. I work for a charity that supports people at risk of suicide. We cannot provide 24 hour support for large numbers and there are times when we have so many clients that we need to take a client to a safe place because we feel their risk is too high to go home. I always take to A&E and wait with them until they see a doctor to find out whether they are going to be admitted on grounds of risk and assessed by psych liaison in the hospital the next day , or whether the crisis team are going to assess them in A&E that night. Tonight the A&E doctor told me I should have called the police to do a 136 at our crisis centre. Our client has never used statutory services before (he has come from overseas and doesn’t even have a GP here yet) but they expected me to call the police and have him taken under a section and detained in a 136 suite when I know he has a terror of being trapped or contained. The doc said A&E wasn’t a place of safety. Well it’s a hell of a lot safer than his other plan of going to the top of a very tall building and jumping off. He is doing okay and we are supporting him.

    1. Words fail me … whether or not A&E is a place of safety (it is) doesn’t matter in your scenario because you’re not a police officer and you poor client is not detained. I despair at the lack of training and the ability of such bureacracy to get in the way of patient care.

  11. Mike – I’m late to this discussion, as it ties in to your posting on Webley v St George – Reading the statutory construction carefully, I’d put it to you that an A&E is ALWAYS a place of safety for S135 or 136 patients, as is any hospital –

    the reason I say this is that s136 (1) refers to a place of safety: “within the meaning of section 135 above.”

    Now, S135 States: “In this section “place of safety” means residential accommodation provided by a local social services authority under Part III of the National Assistance Act 1948 […],[5] a hospital as defined by this Act, a police station, [an independent hospital or care home][6] for mentally disordered persons or any other suitable place the occupier of which is willing temporarily to receive the patient.”

    and for avoidance of doubt – S145 states:
    Interpretation
    145.—(1) In this Act, unless the context otherwise requires – “hospital” means—
    (a) any health service hospital within the meaning of the [National Health Service Act 2006 or the National Health Service (Wales) Act 2006];[6] and
    (b) any accommodation provided by a local authority and used as a hospital by or on behalf of the Secretary of State under that Act; [; and
    (c) any hospital as defined by section 206 of the National Health Service (Wales) Act 2006 which is vested in a Local Health Board;][1]

    Get that – “a hospital as defined by this Act” – like a police station – IS a place of safety, whether they like it or not, they are de-facto places of safety – the final element “the occupier of which is willing temporarily to receive the patient.” is a separate element, it ONLY applies to “or any other suitable place” – the statutory construction does not allow a police station or a hospital to qualify themselves as willing to receive the patient, this only applies to ‘other suitable places’, the hospital and police station are always a place of safety.

    Now, in case you’re doubting me so far, there’s another mention and interpretation of “place of safety” within the 1983 act, in S55 that says:

    55 Interpretation of Part III.
    (1)In this Part of this Act—
    “place of safety”, in relation to a person who is not a child or young person, means any police station, prison or remand centre, or any hospital the managers of which are willing temporarily to receive him…”

    However, this definition applies ONLY to part III of the act – concerning prisoners under remand or prison sentence, it does not apply to part X of the act, where S135 and 136 is.

    This clearly shows that only in the context of a prison patient does the hospital have to be willing to temporarily receive the patient – the same qualification does not apply to the definition of a hospital as place of safety for patients under S135 or 136, where they must therefore ALWAYS qualify as places of safety, whether they are willing to receive them or not.

  12. Hi, as a long standing custody officer, it has always caused me great concern having to detain vulnerable people under S136, a lot has been said already, so I won’t labour the point that a police station shouldn’t be an automatic choice for mental health assessments. One question I would ask though, is; Is there any guidance on what facilities a POS should provide? Obviously it should be more than a bunk, a plastic covered mattress and a toilet. Treating people with dignity needs sympathetic infrastructure. Thoughts please?

    1. Yes – it’s listed in the Royal College of Psychiatry Standards (2011) which are linked under the resources section of this BLOG (above). You’re instinct is correct – they’re way in excess of what a custody office could provide.

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