“If You Leave, We’ll Call The Police!”

This blog is a response to a post by Sarah Bellamy, author of ‘A Carer’s Eyes’.  Her post “If you leave, we’ll call the police” concerns her partner, Chris, and his experiences in Accident and Emergency.  (Sarah has also written a follow-up post.)  It’s all about the duty of care to A&E patients who have mental health problems and what, if anything, A&E staff could or should do, to stop patients leaving – in what circumstances can they do so.  There has been a good debate on Twitter about this post, with professionals chipping in with various views but I want to give it more than 140 characters.

This story struck me, because of several incidents I am aware of in my area; one of which I was involved in.  The best example concerns a man who was taken to Accident & Emergency after an ambulance had been called to him.  He was self-harming, appeared suicidal and had a history of mental health problems and clinical depression.  During several hours in A&E, his cuts were cleaned and dressed, and arrangements were put in place to assess him under the Mental Health Act.

Whilst waiting for this to occur, the chap became increasingly agitated and anxious, he started saying he wanted to leave.  Staff did their best verbally to encourage him to stay, but he decided to go.  They let him leave or did not stop him and the police were not called.  The police did become involved in the incident, however: because 60 minutes later they were dealing with a man threatening to jump from the top of a multi-story car park and within 90 minutes of him leaving, they were dealing with a suicide by jumping.

Following the inquest, the hospital contacted the police to tighten up procedures around mentally ill or otherwise vulnerable patients absenting themselves from A&E.  They were very keen to be able to immediately report people who walked out – not that they need permission – but also wanted to talk about what, if anything their duty would be to keep people from leaving, where engaging any risks may be consistent with expectations upon nursing or healthcare assistants, security officers.

  • Patients in A&E are not considered hospital inpatients for the purposes of the Mental Health Act, so Doctors’ and Nurses’ holding powers cannot be used.
  • Only the police can instigate ss136 / 297 / a130 detentions, so that is not an option for the NHS or their security.
  • What about common law (doctrine of necessity) or the Mental Capacity Act 2005?

Well – it turns out that the Coroner had written a ‘Rule 43’ letter to the NHS Trust, requiring demonstration of tightened procedures, and closer liaison with the police for those cases where someone’s departure needed to be prevented but couldn’t be.

Clearly, NHS staff once they accept someone into their department and commence assessment and treatment, owe various legal duties to patients:  Human Rights duties around no deprivation of liberty (Article 5), inhumane treatment (Article 3), right to life (Article 2).  We’ve seen recently in the Rabone case, that human rights obligations around the right to life can extend to non-detained mental health patients, albeit Michelle Rabone was an admitted patient; but duties around risks, prevention would remain.  It is also true to say, these duties can conflict: what if there is doubt about whether the MCA would allow detention pending arrival of the police (art5) but there is a real fear if someone leaves they will kill themselves (art2)?

It is clear that in many circumstances, A&E staff would be obliged to let most patients leave if they wanted to.  People often walk out of A&E against medical advice – the mere fact of doing something ‘unwise’ does not immediately mean that someone lacks capacity to take the decision to leave.  Equally, capacity is situationally specific to the decision being taken:  at the same time, someone may have the capacity to decline a drink, but not to decline a course of medical treatment.  Quite possibly, that could come about because the consequences of not having a drink and zero or trivial, whilst declining medical treatment could be life-threatening.

So it is a complex business for A&E to make decisions about what, if anything they should do.  There have been various reports about integrating mental health care with physical healthcare, including from the Academy of Medical Royal Colleges.  The preface of this document states: “It is a matter of shame that this document is needed. But needed it most certainly is.” and goes on to detail common, regrettable problems in integration.  It recommends more training in mental health for A&E nurses, etc., and closer work with or the creation of liaison psychiatry services.

Meanwhile back in A&E: the duty of care owed to patients who are there, not least because of Human Rights obligations, could be covered by s44 of the Mental Capacity Act which creates a criminal offence of wilful neglect or ill-treatment of those who lack capacity.  It puts the police in tough position if families allege or officers suspect that someone who should have been prevented from leaving because of a lack of capacity was not prevented and nothing else done.  What if relatives make criminal complaints to the police so that such circumstances are fully investigated?

Capacity assessments are often required on individuals who come through A&E departments where decision-making is affected by mental health, drugs / alcohol, head injury; organic conditions such as dementia, etc..  And these things cannot be entirely separated from physical illness.

In my area about two years ago, a man jumped from a bridge over the motorway network.  He’d had a drink, but wasn’t drunk and he had a history of depression and this was (to him) a serious suicide attempt.  He broke his leg particularly badly in the fall and suffered other physical injuries less serious than that.  When he arrived in A&E he attempted to decline all treatment maintaining that he wanted to be allowed to die and was making remarkable efforts to try and leave.  The medical staff got into their assessment of capacity and took the view that he lacked the capacity to take the decision to leave, because the alcohol and his mental health prevented him from fully understanding the consequences and they detained him using hospital security.  They also called police back to A&E and requested he be detained under s136 for full MHA assessment.  He was sectioned to an orthopeadic ward as his leg injury needed an operation.

So, it really isn’t as simple as saying that if someone wants to leave A&E that they can unless the police have got them under arrest.  A&E would get this completely if you gave them the example of an extremely confused 87yr old dementia patient in their night-clothes found wandering who was picked up by the ambulance service and brought in.  If she tried to walk out into the night, they’d put a gentle arm around and stop her from doing so.  They may well also be calling security or police, but they’d do something and they would be right to do so if the opposite was to let a dementia patient wander off.

No-one is suggesting that A&E should be sitting on people (although I have dashed to A&E after a 999 call to see hospital security doing exactly that – most recently to stop a alcoholic from drinking the A&E hand-gel when they knew that his medical condition was so developed following decades of abuse that alcohol could well kill him.)  But there are duties of care, and these are not necessarily fully understood because in some areas I know, the senior MH managers and the senior Acute Trust managers don’t know each other.  I’ve also seen each of them refuse to meet each other and the police to try and draw services together, for these kinds of things.

I found those conversations involving refusal – they were asked directly to do so – utterly breathtaking.

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16 thoughts on ““If You Leave, We’ll Call The Police!”

  1. As I’ve seen this myself (as a patient on receiving end and also how my ex was dismissed when he was suicidal and had my vulnerable son with him), WHY exactly does this happen? Why does A&E see it as not their problem and instead gives in? Is there an attitude there beneath everything that they only deal with medical issues rather than mental ones (although as you point out, if it was an ‘old dear’ with dementia they’d be a lot more sympathetic)?

    In my case it was an undiagnosed auto-immune reaction (I was in the middle of a flare) and other than try to get me to drink tea and eat biscuits, they just let me out the following day with no supervision. I could have gone anywhere after that…and I’m staggered they let me out, but I got the distinct impression I wasn’t their problem – I was just taking up bedspace.

    Worrying.

  2. Given this some thought today and while its impossible to stop every tragedy tighter procedures can be put in place at every A+E as in if they suspect a patient is affected by a mental disorder appropriate professionals should be called immediately. There is no excuse for several hours of delay and i would agree A+E staff have a duty of care. During are initial training and at refreshers we are always reminded that its better to be explaining to a judge why you acted in a manner allegedly outside of the law than to a coroner at a inquest. perhaps the law could be changed to class patients been treated in A+E as inpatients it seems illogical to me that the police can take someone to there on Section136 and they can be detained there but a partner, paramedic or anyone else can bring someone in who appears to have a mental disorder and trained staff from psych liaison, crisis resolution team cant detain if they agree until a AMHP and sec12 doctor can attend

  3. Whilst in some cases, leaving A+E may require a police response, there are also others where calling the police is used as a threat and punishment for any degree of non-compliance. It’s much the same situation as where voluntary psychiatric inpatients don’t have the same access to advocates as sectioned patients do, yet are threatened with sectioning if they attempt to discharge themselves.

    I wonder how you, as a police officer, feel about being used as a threat. Do you feel that most calls regarding people leaving A+E are appropriate? Or do you frequently encounter patients with MH issues but enough capacity to decide to decline treatment?

    1. Don’t necessarily mind being used as a threat, but only where that is a proportionate, legal, appropriate and necessary course. My objection, is that it often isn’t, said by professionals who misunderstand the law and set themselves up by threatening things that the police can not or should not do.

      I think about half of calls regarding people leaving A&E either relate to situations which could have been prevented in the first place, or which relate to people who left and need no follow up. Most MH patients we meet have capacity to decide for themselves what they want (and legaly we must assume this to be true) and if there was doubt, I’d put them in contact with a healthcare professional to determine capacity.

      Does that help?!

      1. For me I dont mind it being threatened where needs be but there is never any attempt to even talk to Chris about why he wants to leave or listen to him for a bit, they might be able to be kind enough to him get him to stay. For me it’s too easy to flippantly go ‘oh if he leaves we will call the police’
        I think I will blog the other side to this, the plenty of times he has walked out and no one need do anything, for example he’s self harmed and doesnt want to wait, for me this is unwise but nothing I would think he NEED seeing for.
        Micheal? Do you get called by wards? This isnt just A&E staff I have had this problem with its medical wards as well.

      2. Yes it does and it certainly tallies up with my experiences of it from the other end. It must be frustrating for you and potentially leads to MH patints distrusting you, even in situations where you are needed.

  4. As a staff nurse involved with people who want to leave hospital following self harm or self poisoning, we cannot and will not forcefully make someone stay who wants to go. We can be done for assault. We can talk to them and try and persuade them but if it’s a busy are as it probably was in A and E and the pt has been waiting for hours and they want to leave, trying to get them to stay is time consuming and often futile. That is why staff nurses have no time for patients with mental health problems. I’m not saying its right I’m just saying how it is. Yes they have a duty of care but if someone refuses to be treated there is not a lot we can do.
    I was lucky enough to have a very compassionate staff nurse look after me in A and E after an OD who took the time to speak to me and try and sort me out but if it had been any of the other staff members then I would have been discharged after sleeping it off with no intervention.
    It’s sad but the policies are there to a) protect the patient from physical abuse and b) protect the nurse from assault and/or compromising their pin number.
    I have persuaded people to stay before now only for them to be discharged behind my back as soon as its turned with no help offered and it breaks my heart. Mental health care in this country is poor but the patient has to be willing to co operate or it’ll amount to nothing and a waste of resources.

    1. That’s up to you, but know this: if someone lacks capacity to take the decision to leave and does so in circumstances where it is clearly not in their best interests to do so, it is at least arguable that anyone who fails to act in those best interests could be guilty of a criminal offence (s44 MCA). So it’s important that NHS staff know their law – which too often, they don’t. Whether watching them leave whilst ringing the police is sufficient to satisfy the duty of care owed, will vary case by case. This is not my view, it’s what Coroner’s and Courts HAVE said already when others amongst your colleagues took that view.

  5. This story is all to familiar! My sister has been suffering with bipolar, and a personality disorder, she self harms, has attempted sucide on at least 15 occasions, she was discharged on Wednesday from a
    ‘treatment’ facility, by Sunday she had taken 2 weeks of medication which they discharged her with, she is now again in the hospital for treatment only to no doubt walk out and the process starts again, the mental health team have a lot to answer for, why would they give her so much medication to leave with knowing her history, I believe Essex mental health are not performing their duty of care!!!!!

    1. I’m sorry to hear this – not least because Essex mental health services have previously faced human rights challenges and been found wanting after inadequate care of patients even before it gets to the point of discharge. I do hope your sister is OK and that things improve.

      1. I’m not surprised they have problems there. Their system clearly does not work, I know these problems are not easily fixed, though I do expect them not to put her in harms way! She has a large amount of medication and to give her two weeks worth is just plain discraceful! Thank you she is back in ‘the lakes’

  6. Going to the ER or A&E as you call it over there in the UK is not always the answer. I was reading a forum post by a member who had just lost her father to Cancer and she was saying when she went to A&e and told a nurse she felt suicda that so called nurse told her to jump in front of a bus. Then when she complain the hospital manager did NOTHING about it. ER staff are just not qualified to deal with some problems. Here in the US It’s the same in New York. Far beter to go to your own doctor or mental health crisis center than go to ER.
    Cindy.

  7. If somebody with mental health problems is admitted to hospital with a physical illness, as my friend was (without being told by doctors that he was seriously ill,) he tried to leave but was physically attacked by Police in order to prevent him from doing so, is this assault? Police physically attacked a seriously ill man without provocation. All that needed to happen was for the medical staff to explain the situation from the word go. Surely this isn’t right?

  8. After police leave a 136 patient in the safe place (for example a hospital 136 room with external door locks) does sc 136 MHA authorise hospital security to continue that persons detention there up to the 72 hours? Can they engage the door locks to prevent that person from leaving?

    1. Yes, because where a person has been removed to a Place of Safety under the Act they may be detained there for up to 72hrs, according to s136(2). It doesn’t stipulate that this can only be done by the police and various worthy opinions suggest that anyone who is a proper party to the operation of that police of safety may keep the person detained. Including by locking and refusing to open the door.

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