Should I Stay or Should I Go?

Should the police remain at a place of safety once they have arrived at the location? – to be clear at the outset, I’m referring to the psychiatric place of safety to which most people are removed.  I am not referring to A&E when it used because of additional medical emergency or physical injury – the open nature of that environment means officers should remain until the person is either discharged entirely from s136 following assessment or transferred to the main place of safety.

There is nothing whatsoever in the Mental Health Act or the Code of Practice (Wales) to the Mental Health Act which answers this question – and everything else is guidance and opinion.  This question is a sticking point in how place of safety processes work.  I was chuffed to see the BLOG getting a mention on a nurses’ internet forum following which a (student?) nurse made a comment which prompts this post: “In theory the police should remain with the person until this is completed … now that we insist they remain with them until it has been decided whether or not further input is required they are reluctant.”

Of course the police are reluctant, not least because there is no legal basis at all for this claim.  And even if this question is addressed morally rather than legally, it is probably fair to remark that the public would wish to see their police deployed in way that means they are not remaining with patients in hospital pending assessment unless the patient poses a risk to staff where it’s obviously vital that the police protect their colleagues in the NHS.

But it is clearly understood that because of the extent of assaults on NHS mental health professionals – 68% of all assaults on NHS staff are on MH professionals – support from the police is needed in some cases.

Here’s the problem:  responses to undertake assessments of patients who are removed to a place of safety are often measured in hours and half-days.  Average response time to the place of safety in my home area (not my force) is over eight hours and the mental health provider refuses to allow the police to use the facility at all unless the chief constable agrees that two officers will remain at that location with the patient throughout the entire duration.  That PoS facility has no nurse to meet, greet and triage the patient and so the irony of the arrangements is that if the police had removed the person to the cells, they would have been seen by a police doctor within 90 minutes (average) – the place of safety facility in my home area quite effectively delays access to necessary healthcare.

And of course this comes at a cost.  When you have two large towns covered by four police officers at night and two of them are twenty-five miles away ‘guarding’ a non-resistant mental health patient – the PoS cannot be used for anyone who is violent – it means there is, for example, less capacity to respond to calls to Accident & Emergency that drunk patients are being aggressive towards staff.

One police force in the north of England were kind enough to share with me a copy of the legal advice they had received from a barrister on this very point.  They sought counsel’s advice on their obligations to remain and he was very clear:  “None whatsoever, in law, unless remaining there is necessary to prevent crime or protect life.”

So what’s the way forward?

As ever, local protocols should reflect the core roles of each agency and the Royal College Guidelines.  Parliament did not make it an obligation upon the police to remain in all situations, the Code of Practice implies there will be some situations where the police do and some where they do not, and the Royal College Standards clearly envisage the police leaving even in some situations where patients are ‘disturbed’.  Ultimately it all comes back to proper commissioning and resourcing of Place of Safety facilities which sits with PCTs.

In time-honoured tradition I prefer the compromise that all patients removed to a PoS are risk categorised as LOW, MEDIUM or HIGH.  Low risk patients are an NHS responsibility, once they police have arrived, researched background and risk and provided a full handover of information to the NHS.  High risk patients are a joint responsibility – medium risks cases should be judged case by case dependent upon the professionals involved and the patient.

Where dispute remains about whether the police stay, my force operates to the rule that we stay if we asked to do so, but if the attending officers disagree with the need for it, the case is referred to managers at the time and if still unresolved, the next day for review.  Working on the principle that there should be objective risk information to which nurses should be able to point to justify that request; some nurses have had feedback about inappropriate retention of the police.  Equally, some officers have had feedback following an insistence upon leaving when the nurse had not agreed.  This mechanism is proving over time, to build trust and lead to fewer disputes than when the process first began.

Perhaps a way of summarising all of this, it to observe that it is not for the police to staff and resource NHS places of safety because they PCT would prefer not to do so; but it is for the police to protect the professionals who work there from very real risks of assault.

AFTERTHOUGHT –  just in case any healthcare professional reading this is thinking, “But I don’t have legal authority to keep the person in a PoS for assessment, only the police can do that”.  Yes you do – s136(2) MHA.  If patients are asking to leave, keep the door shut, if they start to get aggressive because of this, then the risks have raised at least to medium so call the police back.

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10 thoughts on “Should I Stay or Should I Go?

  1. A lot of people dont realise that the local policy for dealing with S136 patients are usualy onlone anyway (http://www.mhsc.nhs.uk/media/1842/Section%20136%20Joint%20Policy.pdf) this includes MH staff. Our agreed place of safety is a room in A&E that doesnt close, and I mean close not lock as its a swing door. When we gete ther we fill in a risk assesment, based on a points system, to see if we should stay or not. The problem is staff are never happy when we can leave and say “We wont stop them leaving. Then we’ll just report them missing”

    Try telling them that it’s there responsibilty to prevent them leaving and they look at you like you’ve stamped on an orphans toys!

    Having said that the staff at our local MH hospital dont even know their own polcies that are pinnedon the wall of their offices so I wont hold my breath on change anytime soon.

  2. In most cases police do not stay with patients in our local area A+E and we would not expect them too but within office hours we would expect to respond within the hour. One of our ongoing issues is that although we have a designated place of safety at local psych hospital staffing of it was not funded so we rely on the ward it adjoins a PICU to have staff available which has left police officers hesitant to leave. Sorting this issue would solve a lot of the problems and not just locally

  3. A question or at least a thought!!
    If a pt is detained by an Officer under s136 and am ambulance has been called as per local guidance and best practice then does that Officer need to travel with the pt and why?
    I know in the first instance everyone says YES, but why? The power is never discharged; just certain events take over that render in no longer in place – once at a POS if all are in agreement then the Officer will leave anyhow and the person remains under s136 – in effect the power has been delegated to an agreeable other by mutual discussion –
    My rationale here is one to assist the police – if I were a solo Officer in a rural area and an ambulance was conveying the detainee to the s136 suite then I would currently have to travel in the ambulance, maybe for well over an hour, with a pt who is low risk and compliant (but still resisted voluntary removal hence the s136), or the medical issue may have resolved the perceived mental illness once the paramedics have provided appropriate treatment. I would then be miles out of my patch, with no vehicle (this was left on scene), in need of transport to get back to my vehicle and in this case as soon as I arrived at s136 suite I handed over to the team whom were happy for me to leave – so why could I not just hand over to the paramedics if of course they were willing to convey – I could then save hours and provide my services for where they are needed!

    Would appreciate some thoughts here – do we just do things because we accept it sometimes as that’s the way it has always been done???!!!

    1. The answers is generally thought to lie in the distinction between s136(1) and s136(2) — the first sub-section is the power to detain someone and remove them to a place of safety. The wording makes this clear that such a power is reserved exclusively to “constables”. The second sub-section relates to the power to keep somone detained at a PoS once they have arrived there and it merely says that once a person has been conveyed to a PoS “they may bve detained there for up to 72hrs” without specifying that they may be detained by a constable.

      Therefore, much legal interpretation has agreed that only the police can make the original detention and (legally) convey to the PoS: anyone party to the running of that PoS can detain the person once they have arrived there.

      I don’t think this is an example of that just being how we’ve always done it – I actually think the law specifies this approach. Does that help?!

      1. It does make sense indeed . Can an ambulance be deemed as a POS? If it can (any other suitable place the occupant is willing to temporarily receive – s135 (ss6) MHA 1983 ) then would you agree the power can then be delegated under the amended 2007 ACT to transfer onwards at the bequest of the constable for further assessment, namely the ambulance be the first assessment to eliminate health ( as a hospital would be prior to onward journey to psychiatric pos) ??

  4. Hi this does fit in with email i have sent you surrounding A&E , the trust I work for does not have a 136 Suite of a place of safety for mental health patients. Such a place does exist in a building external to Main Accident and Emergency department which i feel does throw confusion to Police officers who attend Accident and emergency when detained person requires treatment. It should be highlighted that general nursing staff don’t have the power to transfer care and responsibility from Police so they can leave

    again it would appear that local policy somewhat grays out actual legislation due to interpretation through need

  5. underrescourcing of the pos suites is a major problem. Ours is attached to the main ward with all 20 patients and only one extra hca to deal with any 136. I’ve had shifts where I have had to effectively close the 136 suite to police due to the acuity on the ward being so high and therefore risk to the lifes of our current patients that to manage a 136 would be dangerous to the other service . This obviously puts a massive strain on the police. There are only two 136 suites in our county and they are in different towns 50 miles apart. Both managed and operated by mental health wards and therefore staffing coming out of the wards. Most would say that this is under resourcing but the nature of mental health wards is that on one shift it can be fine and safe to run on 7 staff and on others the ward is so risky and chaotic that 10 staff would not be enough to contain the risks. And where we do try and get in extra staff when needed this does not always take into account shifts where it start off calm and ends with 4 service users on 1.1 ( this does happen). The best option Ive seen in our trust but in a different county is where a mini 136 ward is set up with its own permanent staffing. The police know the ward has 4 spaces and permanently rostered staff to manage it wether there are service users or not. Police happy / Nurses happy as the unexpected 136 can literally turn a ward with attached 136 from chaotic to dangerous.

    1. All organisations have challenges to face in resourcing things that are important, but which are only required occasionally and which therefore, can’t have permanent staffing on 24/7 standby. Many seem to manage it, including the NHS so I do admit to wondering why NHS MH services can’t in this area of their activity. If we can’t get MH nurses around people in crisis, what can we do?

  6. I am a very experienced Mental Health Nurse, for the majority of my career I have worked in “frontline” settings. I have spent the past 3 years working in A&E in a busy inner London hospital. I have to say my experience is a mixed bag, as with all professions you will always come across good, well informed and caring staff and equally those that make you wonder why they are doing the job in the first place – I refer here both to nurses and officers. On the whole it is the former, what did make me a little alarmed was a rare occurernce, a patient had been placed on S136 and bought to ED for medical clearance – confusion entailed as ED staff questioned “Sam, this “psych” patient is she yours”, it transpired no she was not she was in fact on 136 but the officers had gone AWOL, this is however an usual occrence.
    I have to say that I have seen a big improvemenet in the way in which the MET in my area work with patients who are mentally unwell. Yes I agree that members of the public would rather officers are freed up but there are times their back up is needed. I also agree that we are facing a huge shortage in staffing in MH services, daily I am met with extreme difficulties in finding psychiatric beds for my patients who are in crisis and need them; personally I blame the government and senior managers who are running and commisioning services, they do not understand how services need to be run and staffed – so please bear this in mind, please don’t be quick to blame staff running the PoS, they are under extreme pressure and get very little support from their managers.

    1. I can assure you I do understand that – but it only takes me so far. Ultimately, I need to get staff, officers and the public all making sure that managers and commissioners understand this and the police continuing to absorb the consequences of NHS decisions is a) not sustainable and b) a sure way to ensure problems remain hidden from NHS managers.

      Nine of this means I don’t also recognise the problems created by the police if exactly the kind you mention. 👍🏼

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