Putting Your Arm in the Mangle

Policing some mental health issues is can be like putting your arm in a mangle: you sometimes want to try and avoid it if you can, you fear that if you do it at all, you’ll get pulled in far more than you originally hoped and that there could be a degree of pain and disorientation involved as you all of a sudden wonder how you’re in up to the shoulder.  Let me explain!! >>>

We know that in theory, many responsibilities around the operation of mental health law, ideally sit with health services.  This could cover arrangements around assessment for admission to hospital, transportation issues; and all kinds of circumstances where restraint is needed.  In practice, they often cannot or do not sit with health and / or social care professionals and there are a variety of reasons for this.  Sometimes, it is a lack of commissioning or contingency arrangements; othertimes it is unpredictable events and occasionally it is down to lack of training or even a lack of legal knowledge about what it is possible or necessary.

For example, the Code of Practice to the MHA requires commissioners in England to ensure they have commissioned appropriate transport arrangements for the movement of patients – there are comparable provisions elsewhere in the UK Codes of Practice.

Clearly, if a patient was suddenly seriously injured or ill in a psychiatric facility, it may be necessary in a hurry to ask for police support to assist in transferring to A&E because of escape risks or risks to others, because treatment cannot be delayed at all.  Othertimes, the need to move patients from here to there can be planned in advance or delayed until appropriate non-police conveyance is arranged.  Some mental health providers have limited access to transport other than their ambulance service and not all MH trusts feel they get an adequate response.  Equally, I’ve heard ambulance services argue that the way in which they are commissioned does not involve them providing transport for every kind of MH related transport scenario and police support is sought for the want of alternatives.

Most situations like this involve mental health staff with a genuine need to move patients and officers having an instinctive reaction that the need for movement is perfectly valid enough.  The debate is whether or not to put your arm in the mangle.

Not all of these situations involve “RAVE risks” – this is my ‘rough rule of thumb’ to cue whether or not the police should be involved in essentially health or social care situations.  Hence it is not always clear why the police may have been called.  That having been said, I have heard several non-police opinions that even where “RAVE risks” are involved for detained patients, mental health providers should still have arrangements, if necessary through contingency planning and escalation to duty managers, to effect the movement of resistant patients from here to there without resorting to the police, unless that need emerges unpredictably and needs rapid response.

I have posted previously on being called to a psychiatric facility to face a request that a violent patient be restrained so that they can either be forcibly medicated under law AND / OR moved to another mental health unit that has a seclusion facility.  Such requests are not an everyday occurance, but nor are they rare.  These situations are loaded with risk.

There are risks associated with restraint of psychaitric patients.  Not only have questions been asked (by counsel who gave legal advice to a UK police force) about whether the law allows the police to restrain patients for the purposes of allowing nurses or doctors to forcibly medicate, there are problems with understanding the underlying risk factors associated with it.

We know from research, that the physical health and wellbeing of those who live with severe and enduring mental illness is poorer than those who live without.  We know that life expectency is significantly reduced by 10 or 15 years; sometimes more.  Therefore the restraint of man in his early 40s, ostensibly fit and healthy, could be akin to the restraint of a 60yr old man.  We – police or psychiatric staff – should therefore enter into those situations with caution:

  • What are the potentially unknown risks? – poor physical health, underlying health problems, complexities around drug / alcohol (ab)use.
  • What is the exit strategy from restraint? – you can’t just KEEP restraining somebody, under anyone’s guidelines.  How are we getting out of it? Are psychaitrists going to use rapid-tranquilisation, seclusion or can we turn techniques to RESTRAIN into a condition where we CONTAIN once any immediate threats are mitigated (ie, weapons)?
  • What happens next? – what is the plan for moving from that condition just after restraint ends to the police withdrawing entirely from the situation and the situation returning to ‘normality’, even this is a ‘new normality’?

LET ME BE COMPLETELY CLEAR: I am not suggesting that whilst the risks around the reason for caling the police prevail, that we slip the kettle on an discuss ad nauseum a load of contingencies when time may be of the essence.  But planning and joint operating protocols around calling the police to psychiatric facilities should include advance consideration of this kind of thing.

  • What happens if we’re asking the police to restrain for meds?
  • What happens if we’re asking the police to restrain for transfer?
  • Where does the transport come from? – Ambulance, other secure transport provider or police?
  • What influences that decision?
  • Has this been commissioned / agreed in advance?
  • Who does the escort – NB the police should NEVER do this alone.
  • I’m told that NHS guidelines also state if the patient was sedated prior to transfer, they should be accompanied by a Doctor. <<< Can any NHS staff tell me if this is correct, please?
  • WHO IS IN CHARGE OF ALL OF THIS? – the NHS or the Police?

I am going to blog later about something else that has massively influenced my thinking on policing and mental health: Black Swan Theory.  In short, this is the study of high impact, low probability events, originally in the financial sector.  Characteristics of such financial events are that they were not predicted, they are low probability and high impact and after the fact, they become rationalised as if they were predictable.

This is what policing and mental health can be: it’s often the case following controversial incidents of contact death and restraint – or the controversial use of force – that inquiries reveal unknown, unpredicted, unpredictable events.  They almost always allude to a cluster of variables which in hindsight, make the events somewhat predictable when in fact, they often were not.

As such, may be we need to think about all this a bit more to develop a robustness against ‘negative’ Black Swan events – and so that we don’t put our arm in the mangle?

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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