Assessing Intoxicated Patients – part 2

This is a continuation of a previous post >>> Part 1.

  • If you demand total sobriety from some patients – absolutely zero alcohol in someone’s system before MHA assessment – where does this leave those with a dual diagnosis, who are alcohol dependent, and whose health would be put at risk by enforced withdrawal? – let’s be honest, with some people who are alcohol dependent, it could kill them.
  • If you breathalyse patients as a condition of entry to a Place of Safety, which threshold are we using? – some use 35ug / 100ml which is the drink-drive limit; some use 0ug / 100ml; others use 50ug / 100ml – where is the evidence based medicine behind these limits and the research?
  • A senior psychiatrist in Wales, present to represent the Royal College of Psychiatrists at s136 meeting I attended in Cardiff some years ago, described the practice of breathalysing patients as a condition of entry as “pretty disgusting if you think about it: clinically meaningless, morally repugnant and potentially dangerous.”  <<<  I can quote this because I wrote it down immediately and have used it many times to other psychiatrists.
  • If you are excluding someone from an NHS facility on this basis, are you assuming that it will be appropriate, legal and safe to detain them in a police station; and that any such decision is not accountable to the courts in the context of subsequently adverse consequences? – I’m thinking now of corporate manslaughter legislation, as well as potential human rights consequences under various Articles of the ECHR.

The fact is, the Code of Practice (England / Wales / Scotland / Northern Ireland) does NOT ban assessment under the appropriate mental health law, purely because of someone being under the influence of alcohol and it is not always medically appropriate to sober up in the cells.  And as ever, we should not have one organisation forcing upon another a state of affairs that is unconscionable.  Cross agency support is vital.

The English Code of Practice for example actually goes so far as to say, (para 4.55) that “if it is not realistic to wait [to stave the effects of alcohol], because of the patient’s disturbed behaviour and the urgency of the case, the assessment will have to be based on whatever information the AMHP can obtain from reliable sources.”

So it is possible, however unpreferrable.  <<< That is my only point.  Because it raises the question of when or why not?  And that is a matter for the AMHP.

I know of several Places of Safety who will refuse point-blank to allow anyone access to their facility if under the influence of alcohol.  At all: full stop. Others will say that they will not, but in practice will allow it if someone is not drunk, but has just ‘had a drink’.  In fairness to the NHS, I know that they are nervous about trying to set something up where it is not just black and white – in some areas the police have previously taken the ‘michael’ and immediately started using them as a drunk tank.  This is highly inappropriate.

Alcohol can sometimes mean that someone should be removed to A&E:  either because consumption has reached dangerously high levels or because it is believed (by paramedics?) to be masking something else that needs ruling out.  Things like head injury, diabetes and so on.

We do understand in the police that people who are drunk sometimes need to ‘sleep it off’ and that this will involve police custody.  However, focus over recent years on the circumstances in which it may well be medically dangerous to leave someone in a police station cell for hours even with constant supervision by a police officer whilst they ‘sober up’, has actually contributed to a reduction in the number of deaths in custody over the last 10yrs or so.

As 17% of all police contact deaths are people in custody with a combination of drugs, alcohol and mental health problems – 5% are people arrested under s136 – it is vital for senior managers who write and review local protocols to make sure that the NHS do not simply erect ‘exclusion criteria’ on alcohol.

If they do and a custody sergeant worth their salt has read PACE Code C, they will remark upon para 9.5 and Annex H in their custody record as they transfer the person directly to A&E, which of course would be quite legal.  Whether it would be legally for A&E or the NHS to decline a patient believed to be in medical need would be something for a court to decide.  If done in good faith it would be a necessary and proper mitigation by a custody sergeant of what could, quite possibly, be invisible risks way beyond their competence.

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6 thoughts on “Assessing Intoxicated Patients – part 2

  1. we do not use a breathalyser test and i would agree that it could easily give the wrong impression i have always thought of it as part of my role to assess the persons ability to comprehend whats going on and attempt to gather information from other sources. If its safe to wait until they are no longer intoxicated then fine but personally i would rather i was accused of getting it wrong than not assessing someone and it resulting in a SUI and as you pointed out a fairly large minority of people we encounter are never completely free of alcohol and/or other substances

  2. I think an optional breathaliser/drugs test could be a good idea – I have personally been locked up in the cells overnight rather than taken to A&E (crisis team called police as suicidal) because I was “clearly on drugs”.
    A drugs test would have shown that I clearly WASN’T.
    I wonder how often this happens?

    1. I think you may be a bit ahead of the science just in the sense that if takes different kinds of kit to test for different substances (Class A versus Cannabis, etc.) and obviously testing brings up results whether or not those drugs are attributable to illegal abuse, or legal prescription. Not opposed to the idea, though.

  3. I have never been 136’d, instead each time I have been arrested for breach of the peace, taken to the cells, left in there for hours with nobody telling me whats happening, then seeing the police doctor who said I will get a follow up call from the crisis team …. is this normal procedure?

    1. It depends and this answer is a general one, because obviously I don’t know the specifics of your case … but it would partly depend on where you were detained – s136 can’t be used in a private place; and partly because the officer may or may not have suspected that mental ill health was a feature. It may have only become known later. That said, if an officer did suspect mental disorder in a public place, I would expect s136 to be the legal mechanism used. As for the hours of delay in police custody: that could be due to response times by the NHS, intoxication of someone detained, availability of DRs to do any necessary MHA assessment.

  4. After being through almost all of this very recently (apart from the s136) I can’t begin to explain what it’s like. The police are better at dealing with this than the NHS. Being mentally impaired, drunk and having allegations made against me in my house, then being assaulted meant I was detained in a cell to sober up and give a statement. I’m not the only person who was scared – got threatened with sectioning, got hit in his face, called the police and then ended up shivering in a cell because he was too scared. The policemen were not to blame – but please know how hard it is to be assaulted and because you’re threatened by family with sectioning the result is 18 hours in the cell, no probs, but no resolution. And the very best mental health workers are the police.. the allegations against me were serious I had to drop the charges and because I was withdrawing from alcohol I really couldn’t stand up for myself. But that’s cool – thankfully this wasn’t just me – and thanks. If I get assaulted in my house do I need to sober up before I call the police would sum up in one phrase what’s up.

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