One Friday Night …

As my interest in mental health developed into just some knowledge around it, I noticed that the phone started to ring more frequently.  I now get around 20 emails a week asking something about mental health – often specific legal or procedural questions after jobs have proved difficult.

Sometimes it rings when I’m at home and for a range of different reasons, but it tends to be one of two types of officer ringing.  Senior investigating officers for serious crime inquiries involving mentally disorder offenders where a ‘sectioning’ process is proving difficult against a backdrop of PACE (custody) timelimites; OR duty inspectors to whom frontline officers have referred numerous types of problems needing answers and leadership.

One Friday night around 9pm the phone rang and it was a duty inspector on the phone, someone I know very well.  She’d been faced with an AMHP who was clearly dissatisfied with her final decision around a request for police support and felt she had nowhere else to go with it.  She quickly explained she was managing an extremely busy evening as duty inspector, having been at work for half of her shift, which would end at 3am.  For all intents and purposes, she had run out of police:  prisoners in custody, prisoners detained with a double-guard at hospital, crime scenes, 999 calls ongoing to which a small group of officers were responding, ‘job to job’ and intent on writing up all the paperwork at the end of the demand.

Somewhere in there, a call had come in for police to attend the ward of a general hospital to support mental health professionals who had ‘sectioned’ a man who now needed to be transferred to a mental health unit very nearby.  (I later calculated you could walk ‘door to door’ in approximately 7 minutes.)  The reason for the request for police officers was that upon being told he was to be transferred, the man had said “No, I’m not going there.  You’re not sectioning me.”  When I eventually got involved in this incident and asked various questions, I failed to establish what had been done, considered or tried, between “No” and the call to the police.  I need to be extra-clear here: the man was not violent, was not threatening violence and if there were any resistance or violence in his previous contact with mental health services, none of this was being disclosed to the police.

Initially, at around 8pm the police contact centre sergeant had explained that in light there being of no immediate risks or threats, there was little prospect of police support for ‘several hours’ because of other demands which had to be prioritised.  This had led to a further phone call asking to speak to the Duty Inspector who was promptly told by a bed manager that she was under an obligation to send officers to the hospital.  She again established that there was no violence, threats or attempts to abscond and explained that there was no prospect of this occurring any time before approximately 11pm, perhaps later.  That’s when legislation started to be quoted with an insistence that she was ‘obliged’.

She rang and I told her to leave it with me and police her area.  The three telephone conversations I had were some of the most revealing I’ve ever had: of the extent to which the law was being misrepresented to involve the police in Mental Health Act processes – I’ll leave you to decide whether it was deliberate misrepresentation or not:

The dialogue of that evening was repeated for my benefit, and I reconfirmed that sectioned patient was not violent and had not threatened to be.  The bed manager then said, “So in the circumstances, the police have to attend and move the person.”

“Setting aside the most important point, that there are no police free to actually do this, currently, could you tell me where’s that written down in English law?”

“What do you mean?”

“You’re telling me that we’re legally obligated and I’m asking you to tell me where this is demonstrated so I can look at it for myself.  If I’m honest, I disagree and I don’t believe what you’ve just said to be true.”

“Err, the AMHP at the hospital said that if she asks you to do it, you have to.”

“Perhaps you should get her to ring me then?”

Approximately fifteen minutes later the phone rang and the formality of summaries and checking questions were again completed.  The AMHP sounded fairly frustrated by this stage.  “I’ve been here for over 3hrs with this case and this man has needed to be moved since this afternoon!”

“Why wasn’t he moved this afternoon?”

“The police were not available!”

“Why does it need the police?  Where were the relevant mental health professionals this afternoon and why did they just go home without resolving this, expecting the gap to be plugged?  Three times this evening, I’m not hearing anything about violence or resistance or aggression.  I just keep being told that he’s said he’s not prepared to move.”

“Well, that’s right.”

“So what has been tried since then?”

“What do you mean?”

“I’m not sure how I can ask it another way.  Have you gathered a nurse or two and attempted to direct him – perhaps with hospital security nearby – or did you just ring the police?”

“I just rang the police.  I’m here on my own!”

“So where are the out of hours Crisis Team or community team, to support the process?  Your organisation employs thousands of people, literally.  It must be possible to get two or three nurses with right training who can come and encourage, persuade or even compel this man in the right way?!”

“Well it’s not possible … that’s not in the remit of the Crisis Team.”

“Seriously?!  It’s not the remit of the police either and it’s like us telling police officers they can arrest people but then not training them in how to deliver upon that in reality.  In any event, I’ve rung back to argue against this idea that the police are legally obliged.  Nothing in this incident currently is making it a priority over the volume of other calls currently being received.  The only free officers in the area are literally running from 999 call to 999 call.  The reality is, you can’t get the police for a few hours yet.  If that changes, they’ll let you know.  But it’s quite wrong to push against that decision by arguing they are obligated, because they are not.  As and when officers become free from other, higher priority calls, they will consider a request to support.”

“But the police ARE obliged: of course they are! This man has been sectioned and I need the police to move him, because he says he won’t go!!”

“You’ll need to tell me where that’s written down in law: that it must be a police matter purely because you say so.  This man is in YOUR legal custody if YOU’VE sectioned him.  this is by virtue of s137 of the Mental Health Act and your authority to detain and convey comes from s6.”

“I can delegate that the police move him.”  The smugness of the remark was almost unbearable.

“Yes, I understand that you can delegate under s6, but I also understand – if you actually read s6: all of it – that nothing in that section obliges the person to whom you would prefer to delegate, to accept your delegation or direction.  At the moment, for reasons explained, the police are not accepting it.  So the person remains in your custody, entitled to your duty of care.”

“No that’s not right.  Actually, can I ring you back?!”

Fifteen minutes later …

“I’ve spoken to a colleague” … she proceeded to read out all of s6 MHA from the Richard JONES Mental Health Act Manual. (The ‘MHA Manual’ is standard equipment for AMHPs: a textbook I have had cause question on a few occasions, not least because I’ve come across three different bits of written opinion from barristers which do not accord with this reference tool’s contents.) …  “just how do you want me to do it if you’re not going to help?!  I’ve got another MHA assessment to do!  If you won’t do it, I’ll have to leave him here to do my other assessment and if he walks out, it’s down to you.”

“But it’s not, though is it?  It’s down to your inability and that of one of the largest mental health trusts in Europe to pull on resources which are consistent with managing just one passively resistant patient.  Why can’t you ring your managers or MH trust managers to have someone authorise the necessary contingency arrangements?  You are a major health trust, you must have out of hours arrangements and some contingency planning?  And it’s only fair I inform you that I’m now going to record your threats to walk out and leave the man, in case that should become relevant during any investigation subsequently.”

“This is ridiculous.  We’re not trained, you’re the only ones who can use force.”

“Again, I’m afraid you misunderstand.  You have all the powers of a constable in this situation so you are simply not correct in law.  In fact, the police have no powers here whatsoever, until they accept your delegated authority, which we’re currently not accepting for the reasons given.  Therefore, as things stand YOU are the only one who can use force – or anyone you can persuade to accept your delegated authority which does not currently include us.”

“This is outrageous.  I’m going to have to leave him here.  I’ll record you’re refusing to help.”

“Yes, we are – but only temporarily and for the reasons given.”

I subsequently learned that the section papers were destroyed by the AMHP who did indeed walk out on the patient, leaving him on the ward.  This may or may not have been mentioned in the letter that was subsequently written.  Incidentally, the patient remained on that medical ward overnight and following a persuasive discussion with a subsequent AMHP the following morning went to the hospital without any problem at all – no force was used whatsoever.

Incidentally – conversations like this are more likely if AMHPs and police officers work in an area where managers have declined to ensure there is a local protocol which covers who will do what and when.  Police managers who try to do so may wish to reflect on why mental health services will sometimes train inpatient nurses to use control and restraint techniques which are deliberately designed to be therapeutically appropriate; whilst community nurses are most usually not trained.  I still cannot work out why this is the case when physical coercion may needed in both contexts.

______________________________________________________________________
The Mental Health Cop blog

Badgewon the ConnectedCOPS ‘Top Cop’ Award for leveraging social media in policing.
won the Digital Media Award from the UK’s leading mental health charity, Mind
– won a World of Mentalists #TWIMAward for the best in mental health blogs

ccawards2013 was highlighted by the Independent Commission on Policing & Mental Health
– was referenced in the UK Parliamentary debate on Policing & Mental Health
was commended by the Home Affairs Select Committee of the UK Parliament.

 

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21 thoughts on “One Friday Night …

  1. 26 April 2012

    Dear Mentalhealth Cop,
    Does anyone actually know the law regarding sectioning and police and public safety? I have been asking what happens where an AHMP has brought 2 doctors to make their recommendations but the Section 2 has not been completed at that time. The AHMP then does what you suggest could be done – goes with a nurse from the hospital with the patient in a wheelchair and the patient is wheeled from one hospital authority, a hospital trust where the patient was on ward, discharged and then taken INVOLUNTARILY to a different building run by a completely different health trust – a foundation NHS trust. Only after another 2 or so hours was the sectioning made. But what I have been trying to find out without any success, was whether this was actually legal, as I thought that the police had powers under Section 136 to remove a person from a public place to a place of safety.
    Does an NHS hospital ward count as a public place?
    And can the police place a person under Section 136 on a hospital ward to be removed from that hospital trust to a different hospital trust?
    I would be most grateful for your help and advice.
    Thank you so much,
    Rosemary

    1. Rosemary – A hospital ward is a place of safety. Police take persons TO a hospital ward as a place of safety. Usually the persons on a hospital ward have responsiblity of removing them to a different hospital trust, but I believe, and maybe the blog host can confirm, that if the person is threatening violence or harm, or is a danger, then police can assist under sec 140?

      1. When people discuss “What is a place of safety?” police and NHS usually approach this from two different angles and hence both and simultaneously right (in their own minds) and wrong (in the minds of the other party), thus creating a (potential) conflict.

        A place of safety is effectively defined TWICE for the purposes of these types of discussions – once by s135(6) MHA and also within your local PoS protocol, which should have been agreed and signed off by your senior officers / managers about how s135/6 get done in your area. Many such protocol documents in the UK do not reflect the nationally specified guidelines (see the Health Guidance available via the blog toolbar for more detail). These guidelines talk about PoS services existing preferably in hospitals, they talk about the standards to which they should operate (staffing, exclusion criteria, officers not have to remain in situ, etc., etc.;) and they take about oversight of their effectiveness, etc..

        So when you say a “ward is a place of safety” you are both right and wrong. You are right, that by virtue of it being part of a hospital, it is part of (what can be) a PoS. However, in all probability, it will not be specified as a PoS in your local protocol because this will normally be a psychiatric unit, an A&E department (which has an area set aside for the purpose) or a police station, depending on whether / how a PoS service has been commissioned by the PCT.

        In operational reality, officers will often be asked by NHS staff in what the law regards as a “Place of Safety” to remove people who are mentally ill to a “Place of Safety” and what they mean is, to a PoS which is designated in local arrangements. If this happenes to be the police station, it creates the perverse situation in which health staff want people with health issues to be removed to non-health building for health assessment and the identification of the appropriate pathway into care. You only have to read this paragraph back to yourself thinking as a police officer to see how bizarre it looks to.

        The operational reality is, that NHS buildings which are not designated as a place of safety in local protocols believe they are entitled to deny their undoubted legal status. This has brought about various kinds of problems on both sides and someone, we have reached a point where in some areas, the inability of NHS A&E, MH and Acute services to integrate.

        In fairness to them, this is for very practical reasons: police stations are “places of safety” in law, but we know that in practice Chief Constables only allow (PACE) designated police stations to be utilised as a PoS. Small police stations without custody facilities are not used as a rule. However, were an officer on foot patrol in a rural area to remove someone to such a small station whilst arrangements were put in place to arrange ambulance or police transport to a more appropriate designated PoS, there is nothing illegal in so doing. Moreoever, if the officer called for an AMHP / FME to attend that place and it ended being possible and quicker to arrange assessment there without moving them on, nothing prevents it being acceptable, subject to safety / dignity being managed, etc..

        So it should be anticipated that if you try to push against NHS staff to utilise a non-designated place as a PoS, you should expect a push back and however outrageous that may appear to be, it probably comes back to whether or not the local protocol is in fact based upon properly commissioned arrangements in the NHS for the pathways that patients need when detained and it should reflect the fact that some patients need detaining under s136 in their own interests and for the protection of others, notwithstanding that they are already standing in an NHS facility.

        Does that make sense?! – tried to give it a full answer, because it is an oft-raised point.

      2. Thank you. That was a very detailed response. It’s obviously not as clear cut as it could be. I do though still believe that the NHS try and get out of their responsibilites if they can pass the buck to someone else. Its just that no-one wants to take responsiblity. At the end of the day, they are the health professionals not us. We don’t ask them to help us with our crime solving or arrests, so why do we end up having to take responsibility too often for the sick and mentally ill? I know that doesn’t sound very compassionate, but with resources as they are that’s how I feel.

    2. Thank you both very much for these explanations. It is very important that we understand NATIONALLY what these local PoS are as clearly it changes according to where you are.

      Coupled with the “Localism” and “Big Society” I rather fear that we are becoming a “splinter group society” where national policies no longer exist.

      However the rejection of local Mayors gives me hope that Whitehall and not Town Hall will prevail – but it needs to be reinforced.

      1. Whilst there may be local variation, all PoS services should be predicated upon national guidelines in the CoP and RCPsych standards and various other sources. Perfectly possible to challenege local arrangements that fail to meet these standards to a point where local variation should not lead to sub-standard services. But those who campaign for standards should try and engage CQC or similar who are starting to look at this, I’m told.

  2. The section papers were destroyed???!!!
    Oh I do hope there is a law covering that… and this individual feels it’s full force.

  3. Another great and illuminating post. It highlights a number of things to me:
    – The importance of the work some forces are doing to join up thinking at strategic level between Health Care Commissioners and Senior Police officers.

    – The skills gap that prevents some mental health staff (and this extends to other health practioners too) actually having a conversation with another human being! In this case policy/law/bureaucracy seems to have completely blinded the health staff (and to an extent the busy police inspector) to the simple basic need to talk to the patient.

    Both the inspector and the AMHP seem to have been stretched to their limit and as the result thinking only in terms of policy and procedure, rather than the actual practical nuts and bolts of what was required, and who should do the work.

    It is easy to see this as a triumph of the police over the failure of the health professionals to take responsibility for their role in this situation. I don’t see it like that. I see it as an example of a (commonly occurring) failure to support and equip the people who make things happen on the frontline. Having law and policy is great so long as we equip the doers to do the doing.

    1. I think this is a really insightful comment. Of course, it alludes to that discussion about whether the police become obligated if the doers are not equipped to do the ‘doing’. And of course, the AMHP from the subsequent day showed that it took no police and no force, but some good communicative skills to make the required outcome a reality.

      I agree with your point, except to the extent that it is a matter of extreme frustration to all frontline staff that roles / remits are inadequately defined and then usually, each organisation will assume a remit that is not agree by the other agency – this kind of thing works both ways and is not just about the policing side of it.

      Really insightful comment.

      1. Agree with a lot of the comments made but one point is that in most cases the AMHP is employed by the Local Authority and Mental Health Trust staff Ambulance Trust staff and general hospital staff are often uncooperative when it comes to conveying patients despite having local protocols in place. In that case what do people suggest the AMHP does ?

      2. There are then: call the police and take their chance that they’re free and willing to muck in. Before / after: get MH commissioners to integrate their commission in a way which ensures the AMHP has resources upon which to call when this situation emerges.

        A failure to plan (by the MH commissioner) does not create any kind of legal duty for the police to plug gaps and from situation to situation it will vary as to whether they can / should.

        Difficult: but it’s ultimately about EVERYONE shouting loud that in many, many areas of the UK, NHS commissioning authorities are not ensuring that basic gaps in service provision get plugged and it would be my personal opinion that this is becuase aroudn 50% of them don’t understand the issue involved and a larger figure have no interest in the issue involved.

        That’s why, in my view, we keep getting cases in the courts the bring the NHS into a harsh reality which looks a little bit like what the rest of us thought should have been happening all along: RABONE and SAVAGE are just two such examples.

        None of this means the police are perfect! … but unless we say to the police: “These are your responsibilities – A / B / C – and these are not – X / Y / Z” … we’ll continue to struggle, unless X / Y / Z is getting addressed by MH commissioners and operational managers.

        It must surely amaze the public that the NHS – an organisation of a million people – can’t produce two or three C&R nurses in a community setting to section a passively resistant patient?

        Final point: I fully recognise the position in which the AMHP is placed, and don’t diminish the frustration these kind of jobs / responses cause. However, I remain convinced that as long as the police keep mucking in with X / Y / Z, we’ll see no progress.

  4. Wow , it seems like a tough call for the police. I think that its difficult for both parties and I guess some times responsiblity can become confusing. On the other hand, I think that all other options should have been done before calling the police! I just hope that the patient is bettter which what’s important!

  5. This is what happened to a friend of mine in New Zealand who had 111 called on him after being interrupted prior to a suicide attempt involving non-violent means. He was in a calm state, there was no threat of difficulty or violence, he just wanted to help – ie. professional, medical help. The police were sent to pick him up, and initially transport him to a police station (!) before they were turned around halfway and diverted to a hospital.

    Having also interviewed a senior police superintendent on police responses to mental distress callouts, it seems clear that a lot of buck-passing goes on, and police are expected to deal with situations that they both (a) aren’t qualified to respond to and (b) aren’t really needed for.

    Like you said in another post, I think there needs to be some more education in the other direction – letting health professionals know what police procedures and obligations are.

  6. I think there are two main issues here, Mental Health and Justice, both of which were compromised in the original case which you describe. I write expert reports in psychopharmacology and psychotoxicology and I have had a few cases in the past couple of years of cases where patients have been admitted to hospital with, or have progressively developed, violent behaviour which has not been addressed adequately by the nursing staff, has often been exacerbated by the hospital security staff and then the police have been involved. Once the latter has occurred the patient becomes even more threatened and perhaps more violent leading to an allegation of assault on an officer.

    Ultimately, if the police are involved this may lead to a prosecution of the patient, a traumatic experience for the individual with the possibility of imprisonment and, if justice is done, an expensive trial followed by acquittal. The police and CPS should not have to decide on the mental health issues involved since that is the job of the hospital. The prisons are already widely populated with patients with mental disorders and prison overcrowding should not be further stretched by imprisonment of those whose only offence is that they are ill or have been affected by their medications.

    I spent the first fifteen years of my career carrying out psychopharmacological research in psychiatric hospitals and specifically in one unit which worked to investigate short cycle manic-depressive disorders (now known as bipolar disorders). We therefore from time to time had significant disorder on the ward because it sometimes happened that if one patient started to behave aggressively, some of the others kicked off as well. The nursing staff were well trained: they controlled the situation with no injury to the patients or themselves and the only times I recall police being on the premises were when from time to time a patient wandered off and was returned to the hospital after (s)he was found in the nearby town.

    I have had recent experience also of cases in which ambulance crew make complaints of assault against their patients and involve the police when they should themselves be capable of calming the situation and passing the patient on to the relevant hospital.

    It seems to be that the health service has abrogated responsibility for patients who may become violent, as a result of mental disease, medication or just plain circumstance. I appreciate that hospitals feel that their staff should not be subject to confrontation and violence but hospitals are a place of great emotion and it should be part of the aethos that they can cope with emotion including violently expressed emotion. Calling in police should be the last resort and not the first. Clearly, if an armed intruder is found, or someone is trying to interfere with patients, that is a different matter

    In my opinion nursing staff and indeed medical staff, are inadequately trained in dealing with the difficult patient and they are therefore likely to call in police support at an inappropriately early stage leading to a rapidly escalating situation. This is a failure of training but unfortunately those in the managerial positions are of a generation who have also not been properly trained in this respect and are likely to pass on this attitude to junior staff.

    1. WOW! I’ll have to read that a few times and then do some wider reading to take in the implications of what you’ve written.

      I’m really grateful that you have, though! Sounds like there could be a load going on beneath the surface that I hadn’t yet considered.

      That’s why I’m really grateful for the comment – many thanks indeed!

      1. Keep up the good work and let me know if I can help. I am only just getting to grips with social networking so please excuse any inconsistencies or lack of response. In fact yours was the first blog to which I have ever responded so it is rather surpirising to me to get a response!!! Best wishes

        NJB

  7. I have found in my job with the police that the NHS use us as a resource when they themselves are short of staff or just don’t know what to do.
    I have had a case where a mental health staff member wanted police assistance transferring a non violent patient to a facility as a colleague was due to go off duty and they had no-one else to help them. They have out of hours teams but don’t seem to want to use them! They use the police all the time and when you explain to them about lack of police resources; their responsiblities and our obligations under the MHA, they just argue the case with you. It is so frustrating at times, and if you don’t oblige them, some of them can show quite an agressive manner towards you. I know they suffer from lack of resources, but so do we, and they shouldn’t just use the Police to fill gaps in their lack of resources.
    It makes me mad!
    Thanks for a great blog by the way. It has been shared in my workplace and I am learning a lot from it.

  8. I had a similar set of conversations with our local place of safety.

    Patient had been detained s136 sectioned and then we were requested to transfer the patient to a hospital some two hours drive away at midnight as this is where the patient lived and the AMHP had arranged the bed.

    Numerous phone calls excuses, threats and being told they would not allow officers to leave!

    Patient had been verbally but not physically aggressive.

    I refused to assist in the transport as we were fully committed and suggested it was a matter where they would have to gather together appropriate staff but I’m the mean time if there was problem at the unit where the patient became too violent for them to deal with we would return to ensure their safety.

    This is where I left it as it was well past my home time and I can only assume the NHS staff resolved the matter in the end.

    Is there any legislation which backs up this course of action?

    (or policy it was in WMP area)

    Cheers

    Chris.

  9. Ridiculous situation. The AMHP in the case above was being awkward and lazy. Or incompetent.

    How were they allowed to get away with destroying the paperwork?

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