Mental Health in A&E

There has been some posting and tweeting recently about mental health in A&E, and very interesting it is too.  Against a backdrop of questions about what A&E can do, what they can’t do; what care they give for people who self-present or are brought in by ambulance.  Amidst such conversations during the work I did on trying to develop Mental Health Act places of safety for those detained under ss135/6 (or s297 / a130) I wondered about the extent of mental health presentations to A&E.

NB: I wish I could now re-find the on-line research article which gave these stats(!) but I remember the proportions anyway – if I land upon it, I’ll put the hyperlink in here! You can tell I’m not an academic!

The article studied presentations to major A&Es over a certain period.  There were two statistics from the sample which settled the question of mental health.

  • 1 in 6 of all patients presenting to A&E had some form of mental health presentation;
  • 1 in 3 of those were present in A&E just because of their mental health problems.
  • Therefore!
  • 5%+ of A&E volumes in the sample were mental health only;
  • 15%+ had mental health problems as a part of the overall picture.

This is why I find it unusual to read reports like that from the Academy of Medical Royal Colleges which talks about how usual it is for there to be little training for nursing / medical staff in A&E.  For 15% of the demand?

Several times in my career my officers and I have been faced with the following situation, not unlike those considered by Sarah Bellamy in her posts about her partner Chris.  (Post one and post two):

A person has presented to A&E or been taken there by someone other than the police because of mental health problems which may or may not have included medical issues wuch as injury, overdose, self-harm:  remember, the ambulance service’s only option for a mental health call is “A&E” because they have no pathway to other parts of the NHS.

Once there, A&E commence triage and if need be arrange a mental health act assessment.  Prior to the assessment taking place, or having taken place and admission being necessary a bed having not been found, the person becomes unwilling to stay – I’ll be frank: this usually occurs at a point where they have waited a period of time that would start to test most people’s patience.  Eight or nine hours is not uncommon; more has been known.

The person having then decided to leave the department, a phone call is put in to the police reporting a high risk missing person.  Immediate thought by me: what does ‘high risk’ mean with regard to the legal ability (or duty?) of A&E to consider trying to prevent the person leaving … especially for example if a patient has already been deemed in need of admission under the MHA?  If the risks associated with the person leaving were so high, why aren’t security usually found in attendance and / or why haven’t the police already been called?

(I need to acknowledge here, that police responses to such requests can be unhelpful – nonsense such as “not a public place” and “already in a place of safety” get trotted out.)

Cue police activity and within half an hour or so the patient has been found.  Let’s imagine they are found in a public place, they can either persuade the patient to return, or detain them under s136 / s297 / s130.  Let’s imagine they find them in a private dwelling because they went straight home – they can do nothing other than inform NHS services of the patients whereabouts.  Of course in the latter situation, A&E will no longer be interested in the practical problems of the police having no legal powers at all, because they are now a police responsibility; MH services will provide their usual response when police call for assistance to a private premises.

If one does persuade the person to return or uses s136 / s297 / s130 to enable it to occur, the response at A&E will be telling.  Once you arrive back, they will almost certainly (in my operational experience) refuse to have the person returned to them.  “What do you want to do with the person?”  “Arrest them under s136 but they can’t come back in here.” “Seriously?!  They were here for nine hours and now they’re banned?  For being mentally ill and frustrated at waiting times / bed unavailability.”  I used to worry about this course more when in practice it meant banishment to the cells because of there being no NHS place of safety in existence.

It has made me wonder in my more frustrated moments why A&E don’t have a routine policy of ringing the police every time they have a mental health presentation asking for the person to be arrested.  This sounds extremely facetious, doesn’t it?  But think the law through:  s136 and similar powers can be used if the person ‘is in a place to which the public have access, appears to be suffering from mental disorder and is in immediate need of care (or control) in their own interests (or for the protection of others).’  Taking that paraphrase as it stands, one could argue this applies to anyone banging on the door of A&E for help.

All of this is a red-herring though:  whether or not NHS Places of Safety exists and operate effectively in any area, there are going to be problems.  The variety of demands – the types of incident – which lead to the need for access to community mental health crisis services, A&E services or emergency services like police or ambulance are not integrated.  These organisations are not one coordinated system and they have conflicting operating models which leave gaps and create tension.

Perceptions in the quality in the service received by those in need will be determined by the efficacy of the system to flow seamlessly from one part to another.  Currently, there are obstacles of various types scattered left right and centre because the service provision for such cases is functionalised into as many as eight different organisations who do not necessarily know or talk to each other.

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13 thoughts on “Mental Health in A&E

  1. I agree entirely with your view on this. All of this comes down to lack of cross-organisational planning and quick and efficient responses from acute and MH services. As you rightly say, if someone’s going to be hanging around A&E for hours waiting to be assessed then they’ll be off.
    Attitude, politics, policy and responses are the cornerstones of the problem here not necessarily the law.
    I remember having exactly the same problem-talk discussions about the sames issues in practice 15 years ago. This culture of care is being handed from one generation of professional to the other. How things will ever move on and change for the good of the mental health patient in A&E is utterly beyond me. I and my colleagues in the teaching room do our absolute best to challenge these issues and discuss effective use of law and good practice but this is often responded to by a by a delegate saying, “yes, but in the real world…” as if it’s some kind of defence for poor practice. We all persevere…and periodically despair.

    1. Thanks Matt! – great minds, eh?! Your point about generational attitudes and breaking cultures is spot on and the police are no different. Like you say, shame it takes tragedies or legal action or some other profound trigger to make people hear what is being said anyway.

      Meanwhile in the real world … 😉

  2. There will be little chance of ‘cross-organisational planning and quick and efficient responses from acute and MH services’ in the brand new NHS. The responses of A&E staff, police and mental health services is already so varied – I’ve seen it from my own experiences as a patient and advocating on behalf of other people – with individuals (across agencies) willing to do that bit extra just to support the people involved, whilst others are either wrapped up in the procedures (as they see them) or ignorant of basic mental health issues. Whilst we (rightly) fight to get rid of mental health stigma in public life the basic need for joined up working in many services is failing patients / service users – people! With the new commissioning arrangements fragmenting services even more, this is going to be nearly impossible to crack – and as Matt says the culture of care has been passed down over years so is already ingrained. I am also at a loss as to what to do (unless it involved more complete reorganisation) and even serious incident reviews / reports etc seem to just stack up on shelves. With more acute bed closures coming up, there is going to be even more pressure on A&E as an entry / re-entry point for mental health services. In the real world, I will put my concerns across to my own local services and hope that progress can be made. But the real world is a very strange place indeed…

    1. Agree to a degree: I think if we all just learned the law, we’d see what is implied … I can’t get passed the attitude of “we can’t stop them leaving” when there is a clear legal framework implying otherwise. Not just Article 2, but MCA etc., etc.. Cultural attitudes change when pressure is sufficient to make it happen, whether through tragic events, training, re-organisation or whatever.

  3. As you rightly say the problems arise from: (long list coming – no particualr priority) lack of awareness and training, poor understanding of the law/s and the guidance published, personal and professional prejudices, officious gate-keeping, lack of resources, lack of organisational planning, fear of negative media coverage, absence of “no blame culture”, poor responses from individuals across all public services, frequent changes to organisations and policies. I include in this the very different views – and likely complaints – of service users and their carers/ family/ friends, i.e. should we have “detained” or not. My personal experience is that depending on the individuals on duty (most notably the managers) we either work well together to solve difficult situations and across organisations support each other and the vulnerable person OR get into hot water and unhelpful battles. I have had some amazingly positive experiences in difficult situations of cross-agency working to the benefit of the service user as well as some that have given me many sleepless nights and feelings of despair.
    I want to be hopeful, but my fear is that in the curent climate of financial cuts and ever more reduced resources “divide and conquer” mentality rather than co-operation will become more common, i.e. blame another service, police officer, health professional, “obstructive” family member, rather than acknowledge we are all working under impossible constraints with a growing number of the public experiencing mental distress – for exactly the same reasons we are.
    Still going to keep on trying.

  4. As you say “meanwhile in the real world”
    A man presents, according to National Suicide Prevention Strategy, as in the nationally recognized highest risk group for successful suicide being “Young, male with a violent self harm history” ….however short! At Emergency psychiatric assessment, sent away with a leaflet and asked to present again if feeling suicidal…..which is why he was there in first place!
    Age 29, died August 2005 and having just listened to a Radio 4 programme entitled “Dr Tell me the Truth” here I am almost 7 years later still looking for answers!
    Clearly there was system failure as four members of Trusts SMT left (for other NHS Jobs and whole Board stepped down) PHSO also says “Clearly your son was failed by NHS” and “The follow up to his death was also clearly not good enough”……and who follow up the death?….the PHSO!!! I really dont want to apportion blame but must have accountability.
    Beggars belief!

  5. Another informative article that stimulated interesting talking points both locally and on the blog.
    There is one point I wish to raise and seek some clarity. It is point I have seen mentioned several times often briefly without further discussion. The issue is about police powers to access people I their own homes. Your line “Let’s imagine they find them in a private dwelling because they went straight home – they (the police) can do nothing other than inform NHS services of the patients whereabouts”, is this really true? Are there not options to access the home using a warrant, s135(2). Also is it not permissible for a police officer to enter a property where they suspect someone is at ‘immediate’ risk. I guess some of the difficulty with the latter point is determining the ‘immediacy’ and unless there are obvious signs it can leave the police considering subjective responses. And is there an argument that by definition the person has been detained that risk has already been established (not sure about this one). There were a few stories banded around the office about police saying “can you smell gas” and “did I hear someone scream”, as some ruse to gain access, I suspect (and hope) that these are urban myths with colleagues all reporting to know ‘someone’ who this happened to!

    Ultimately I guess my point is that if these things are permissible (warrants and accessing if risk is present) maybe this could be made explicit or it may lead readers confused and of the belief there are no options.

    1. I’m afraid that this IS true, unless there is a criminal offence being committed OR it is anticipated that there will be a breach of the peace; OR the Mental Capacity Act is of application, which is possible, but unlikely and better used by health than police.

      So it is true for several kinds of situation, not just the one in this post:

      1. True for patients who leave A&E before treatment or before being ‘sectioned’; of course, sectioned means a written application HAS BEEN MADE to the detaining hospital and if someone leaves AFTER that, then they are AWOL. If the medical recommendations have been done are we’re busy hunting for a bed, the person is not yet sectioned, therefore not yet AWOL.

      2. True for informal or voluntary patients who leave hospital without notification or permission and are ‘missing’ but become found in a dwelling; it’s all very well that they’re ‘supposed’ to be in hospital, but the method of recovery for both is an AMHP and DR sectioning them under s4 (or s2/3 if two DRs available).

      3. True for police attendance in a private dwelling for other matters to which they are called and find themselves in a private dwelling dealing with a mental health situation. See below.

      Warrants under s135(2) relate to recovery of people who are AWOL from being detained patients, or AWOL because they have failed to surrender to a revoked CTO, etc.. You cannot secure a s135(2) warrant for any of the three situations above. Where you go on the query “by definition the person has been detained” and risk is established: of course, it’s worth pointing out that it’s not the police and sometimes not the police at all, who have the powers to mitigate risks. MH services, AMHPs, etc., often have them INSTEAD, or as well but whether local areas will deploy their people in a way that gives them a chance of using them varies enormously!

      Regarding the immediate risk: the police do have a power to force entry to premises under s17 Police and Criminal Evidence Act to ‘save life and limb’ but the court ruled in the case of D’Souza v DPP (1992 – on the law resources page of the blog) that this was a high threshold, where life is genuinely and literally at risk. Concerns for welfare, even serious ones are insufficient to use s17 PACE. And this power is to force entry: what do you do once you’re in? Criminal Offence or breach of the peace powers available, MCA if criteria met – unlikely and better decided by health.

      So if a police officer dealing with any of the three things lsited above, feels action must be taken, they can verbally encourage, persaude, ask, even try to use a forceful verbal style to ‘direct’ or ‘command’ people to do things, but if that fails there are no powers of coercion unless the person is committing a criminal offence or unless the officers anticipate a breach of the peace (defined in R v HOWELL is ‘immiment risk of violence’. Some have even argued it must be an immiment risk of violence to OTHERS, not to self.)

      The options in a private dwelling are:

      1. Verbally manage to attempt to secure an outcome.
      2. Call other professionals who can put in place the legal structures for coercion if grounds are met. This might involve one or more from: ambulance, AMHP, CrisisTeam, Out-of-Hours GP.
      3. These health or social care professionals may assist in determining whether the Mental Capacity Act is of application.
      4. Arrest for crime or for a breach if the peace, if possible.
      5. If those fail or do not apply – there are no grounds for intervention BY THE POLICE. Of course MH can attend at their leisure (with or without police support) to do so.

      I may blog about this to clarify it all, if you suggest that needs doing. If these things were permissible, I would have made it clear because first and foremost this blog is about information / support for Police Officers to get things right and avoid getting things wrong.

      I love the stories about “can you smell gas”, “did you hear someone scream”. Every cop has heard them, used them in jest when faced with a frustrating situation where one would hope to be able to enter a premises by force but lacks the legal power. Can say with integrity, I’ve never heard of this being done in the real world to justify an unlawful entry.

  6. Maybe a fuller blog is needed although I get what you’re saying. I used the wrong part of S135 to illustrate my point, what was meant was that should access subsequently be needed to a private dwelling of a person leaving A&E for the purpose of assessing under the Act then a warrant could potentially be secured allowing access to the police. And not withstanding all your points about immediate risks and the D’Souza case the police can access a property albeit with an increased degree of caution if they suspect life and limb are at stake.
    I’m at risk of being pedantic (or very wrong or both) but my concern on first reading the blog was that it might give the impression to nurses in A&E or Crisis teams that there would be no point in calling you guys as you were impotent to act in all cases where there is a person in a private dwelling who may be at risk.
    I’ll go away now 😉

    1. No need to go away(!) – this is what the blog is for: engagement. Need for fuller blog duly noted, it shall be done, but not tonight, Josephine. Equally at risk of being pedantic, but I’d just a couple of points.

      1. The police can only access a property with permission – unless there’s a crime or breach of the peace, potentially including thsi life / limb thing we’re on about.
      2. I’m not saying and didn’t say, that “there’s no point”, I admit I’m (deliberately) trying to educate about the very potential impotence of the police. Calling the police may well work a complete treat; but in circumstances where it does not, or can not, the position created for the officers is massively frustrating.
      3. Once the police are there, responsible for it all but unable to engage AMHPs or Ambulance or CrisisTeams or CMHT and so on; it becomes an extremely unconscionable position – responsible but impotent to affect potentially necessary action.

      Finally, police can’t get a s135(1) warrant if it were needed to effect an assessment, only an AMHP can. In my own operational experience, the likelihood of getting an AMHP in these three circumstances to get a warrant following the police being called to the situations is zero. I have, quite literally, never known it happen and I’ve asked dozens of times.

      Like the debate: keep it coming, but I’ll do a blog post for certain.

      1. Never known an out of hours 135(1) warrant in all my time either (around 10 years). Nor do our Social Services or Mental Health Trust know how to get one if police call or who would take the lead. I know because I’ve spent the past 2 months trying to find out.

        Last night I was asked to visit the home address of Dave*. Dave is a serious alcoholic and had called an ambulance after self harming and cutting his wrist deeper than planned. In A&E he was triaged and after 2 hours started to get the shakes so went home to get a drink without telling staff. I’d rang the staff and asked “if had he told them he was leaving if they would have stopped him” ie relied on the MCA they said no. So ultimately police were called because a discharge form hadn’t been filled in.
        Anyway inside the house Dave has cut his wrist again but didn’t want to go back to hospital. The cuts weren’t serious enough for him to bleed to death be needed stitches IMO but he understood the consequences of not going to hospital so had the mantel capacity to refuse treatment. In order to at least get some treatment for Dave I called the hospital back and asked if they could arrange for a community nurse to attend to possibly stitch and dress the wound. I thought it was a win win plan but I was met with indignation. Apparently if he won’t go them they won’t come to him. Also, they don’t have a duty of care because he’d only been triaged and he was now my problem.

        I’m part way throughaking a complaint about the way the hospital dealt with the incident but I’m not holding my breath about any changes.

        Names changed etc

  7. Why is it that we have so many different and competing “systems” when in the old days it was the Welfare State and the Police and the Courts and the Government and Parliament.

    Privatisation of civil servants and now talks of privatisation of policing is unbelievable. What price safeguarding of society?

    Our police are rightly deserving our full support. Why is it being suggested that the policing can be done by private firms? It is NOT right. We need the independence of the police for fairness and accountability.

    I do not like the idea as mooted by Mrs May.

  8. I have limited experience of this, but in theory don’t the A & E need a 136 suite, or equivalent? The place I worked became really angry about 136 calls because the only suite available was in a different hospital within the Trust. In answer to Section Detained, unfortunately hospital services don’t necessarily provide community nursing, but they should have least have tried to help refer it somebody relevant.

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