Thank You For Messing Us About

A recent experience at work just had to become a blog – mainly because this is about the third time that this has happened to me.  Police resisted becoming involved in a mental health job – causing delay, inconvenience and frustration to the frontline professionals involved – and were then thanked for doing so, because the resistance and the escalation it caused brought to managers’ attention issues faced by frontline NHS staff.  This is something that frontline staff were grateful for, because their attempts to address the same problem were not, in their view, listened to or acted upon.

Officers were requested to attend a premises after a very elderly lady had been detained under the Mental Health Act.  The request was for officers to use reasonable force to coerce her to hospital, the AMHP having explained that she had to go because she’d been ‘sectioned’.  The lady did not agree on the need for it or the legalities of it, so reasonable attempts to persuade, encourage and direct having been tried and failed, the police were called.

The control room in the relevant area despatched officers to the address to assess the situation after the lady was described as verbally aggressive but quite rightly on the part of the police, there was a reluctance from the start.  I say this because the thought of two taser-equipped police officers, in stab vests with batons coercing an octogenarian from her home is not attractive.  Aren’t we supposed to use force in the ‘least restrictive’ way?!

Only this week, I’ve blogged on the back of publicity for an incident in Lincolnshire where the police use of force on a dementia patient was massively criticised, despite the fact that “significant levels of violence” were displayed and despite most people, including me, not knowing the full facts.  The internet was alive with a broader debate about whether the police should be the agency to coerce people at all, where it is in the context of MHA admission.  So today, my force were asked to coerce a substantially older patient who was verbally and passively resistant to admission.  At no stage had she attempted to hurt anyone.

The duty inspector in this particular area was quite clear to his staff: “We’re not going ‘hands on’ first.  That’s not our job.  If the NHS find that resistance to their attempts to move this lady escalates to violence towards them and they are at risk of being hurt, then we’ll assist.  But it’s not dignified for this woman to be dragged to hospital by the police when she’s probably fairly frightened by the prospect already.”  He deployed his officers to assess the situation, they tried verbally reasoning – as I’m sure the AMHP already had – but to no avail.

I got brought into this to advise the duty inspector on whether he was on safe grounds to continue to refuse?  His approach stacked up to me.  What happens if the officers say “OK, let’s crack on” and then restrain the patient only to break her arm – bearing in mind she was in her late 80s?  You can then see the headline, “Police break elderly dementia patient’s arm” and then we’re talking about policing again, rather than about decisions taken by the NHS – consciously or otherwise – to have no appropriately trained mental health resources available to the AMHP to avoid the use of the police.

Meanwhile, the AMHP who had been there several hours with someone in custody escalated the issue to an AMHP-lead in her area – why were the police not agreeing to this and what was she to do?  In the conversation I had with the AMHP-lead, I outlined that in my view there needs to be something in between the patient saying, “Sorry I’m not going” and the AMHP saying, “Call the police”. NHS Trusts often employ thousands of people, community based and inpatient based – why can’t they arrange to deploy two C&R trained staff?

I’ve said this before: if you want to be in the coercion business, you should expect to find yourself in situations in which you need to coerce.  A patient, once sectioned, is actually in the legal custody of the AMHP and parliament gave the AMHP “all the powers of a constable” in these situations for a reason.  This should be reflected in acceptance that there are at least some situations in which those powers should be used.  Yes, I know that the AMHP can delegate authority to anyone else: but they may not DIRECT anyone else to accept that delegated authority.  Again, we must presume that parliament legislated like this for a reason.  Low level, passive resistance would seem the place, as far as I’m concerned, to see AMHPs and / or their NHS or Local Authority colleagues using appropriate training to act for themselves.

To be clear: nothing that I’m writing here implies that anyone expects AMHPs or C&R trained nurses to manage serious aggravated resistance by patients intent on deliberately hurting NHS staff.

It took several more hours for the AMHP lead to attempt to engage senior managers to consider what, if any, contingencies could be accessed to deliver therapeutically relevant restraint and for that manager to then ask to speak to me.  By then it was nearly 5pm on a Friday afternoon so people were going home.  Senior managers had nothing in their toolbox, one presumes because nowhere in the planning of the delivery of mental health services was the ‘need to coerce after MHA assessment’ scenario considered.  And of course, no-one in that area had remembered to write and agree a local policy with the police on “MHA assessments in private premises.”  <<< This is a requirement of the Code of Practice to the Mental Health Act – oops.

So there’s it is >>> having established there was absolutely no other way to get the job done, the police did the right thing and attended to coerce, paramedics and AMHP in support.  It had reached the point that unless the police did it, the AMHP would have chosen to walk away because of an inability to complete the task.  Obviously, no-one was going to leave an 80-odd year old woman in her address alone when she posed a risk to herself.

Predictably it took nothing more than an officer taking her by the arm, pulling her gently to her feet whilst telling her to sit in a wheelchair whilst trying to calm her verbal distress at being moved.  The sergeant involved explained that it was “barely any resistance at all” to get the job done.  Why could that not be done by an AMHP a paramedic or a CPN?  No reason at all, if we’re honest.

This story is far from rare: the point I’m making in this post is the AMHP-lead saying this: “You resisting in this way has caused this to get escalated to senior managers, I’ve been able to register this matter as a clinical incident and the Chief Executive will hear about this.  It may be that the police resisting this will cause managers to discuss things frontline staff have raised for years, but which haven’t been addressed.” <<< Read the paragraph again and think about it.

So – we think we got thanked for taking the trouble to cause significant inconvenience and delay to a frontline AMHP – albeit we checked at every stage and repeatedly that the AMHP wasn’t at risk or the lady’s health deteriorating.  The AMHP was aware that any sudden change in the situation ring 999 for police and / or ambulance.  One can only hope that next week, people take seriously that there are important discussions to be had about how we make the processes of coercive sectioning as dignified and humane as it can be, balanced against managing risks and threats which may, from time to time, require the police.

UPDATE >>> Since publishing this blog a few hours ago, I have already had AMHPs and other mental health professionals from other areas ‘nodding’ at the above including an Older Adults Psychiatrist suggesting that this is a police force quite rightly putting dignity first.  One MH professional pointed out that in their area, the police would not have been called because there is a commissioned service upon which to call in this situation.  This needs to be wider practice.

____________________________________________________________________
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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22 thoughts on “Thank You For Messing Us About

  1. I’ve been in similar situations many times. Sometimes (as I’m sure you know) a ‘uniform’ can help conveyance – sometimes a police uniform, sometimes paramedics or sometimes a family member or known GP/care coordinator.
    As an AMHP I see it as absolutely paramount that the conveyance is accomplished with dignity and humanity and certainly don’t want to see any physicality or force when not necessary.
    The problems come when you have exhausted all these possibilities and you re-evaluate risk levels. Yes, the person has been assessed as needing admission but are there any situations when you can delay the conveyance and have these conversations at another time or try and collate different resources? It’s not always possible.

    What really is needed is proper discussions of these situations BEFORE they happen – by the people who actually do the assessments – rather than the managers who might not raise the same issues that we see, however much we feedback after incidents.

    I’m sympathetic to the AMHP in your scenario because I’ve been in exactly the same situation and have raised it with my senior managers when we had a refusal (for exactly the same reasons) to convey – but nothing was set in motion to prevent it happening again.

    That’s the shame. One off incidents will pass and everyone will nod and say ‘something needs to be done’ but it will take a SCR for anything to actually change. You just hope, as a practitioner, the roulette wheel of fate doesn’t land on you when that situation does and will present itself.

    Not very comforting.

  2. Most ambulance crews are now trained to deal with passive aggression and can take people be the arm and put them in a wheel chair etc. Most won’t ‘just incase’ and call the police. As you’ve already said its the lack of pre-planning that causes these problems.

    These kind of incidents will increase because whereas in the past the police would just do what was asked the prevalence of litigation and lack of resource means that’s no longer the case.

    1. Agreed: I’ve just been wondering what the HSE would think about an organisation who know they need to coerce but have taken no steps to arrange to do so and rely upon third-party organisations in the way they commission services – a breach of the CoP. Just saying.

  3. The taxi service of health care, not that I agree the police should never be involved within mental health unless for reasons of criminality. Its a right from The Equality Act 2010, Protected Characteristics, hold a belief to refuse that what is a non science, from the DSM, read the book, its a non science, psychiatry has no rights upon those that disagree. Mental capacity – claim that we all somehow loose a right to science when a sufferer of “confusion” would laughable not for the detrimental activity of a monopoly service provider.

    The Senior was within their legal rights to refuse, and verbal agressiveness is in the eyes of many legal professionals assertiveness.

    Time police officers walked away from barbaric and inhumane professionals that do treat police as a taxi service and lesser of their service users – within a court, is it possible to define no choice to be a service? Possible to be a service user from force? Once the drugs are applied then becomes modern slavery and do we agree to that service provision? Stand at the parliament chaps (depressives) with the whips and apply the treatment from the butt to remove the disease.

    1. Quite simply, that’s not what the Equality Act says – although the words to justify that view are there if you only want to read part of it. And I have read it, with more than one reason in mind, but including this.

  4. I do agree with the broad thrust of your argument that there should be other resources to coerce detained patients to hospital. My main frustration is when ambulance staff refuse to help me as the AMHP to use very minimal force such as the police used here (which is well within ambulance staff training and competence). It reminds we when I was in a very similar situation when a very frail old woman was refusing to go to hospital. There was no active resistance but she wasnt going. The ambulance said they couldn’t lay hands on her. I explained they could use force under my authorisation or wait several hours for the police. They very gently picked her up and put her into their chair, wrapped her up in a blanket, strapped her and in a very dignified manner took her to the ambulance. Best result all round. I could have not done that on my own.

    I do feel that ambulance staff are best placed to support the AMHP these situations. However, I am often told “we cannot use force, it would be assault” which is clearly wrong. It is the duty of the NHS to provide the means to convey detained patients to hospital which must include the means to use appropriate and proportionate force, only using the police when there is signficant RAVE risks you have discussed before. In my area the ambulance service are commissioned by the PCT to convey detained patients so they should provide all the resources required to do that task!

    This is an NHS commissioning problem which can only get worse with cuts and the dismantling of PCTs.

    1. I don’t just agree with your broad thrust, I agree with every word, Simon! Again, I think if we met in a pub, we’d reach agreement very quickly on most things and head for the bar to talk about other matters of life and death! 🙂

  5. This is such an important topic because the way people are treated in these situations not only affects them in the present, but also affects the treatment & support they’ll accept in the future. And not just with relation to people with dementia. I’ve recently been involved, in effect as a lay person,with supporting a young person who is terrified of going in an ambulance, or police car or going to A&E or into hospital because of a series of traumatic experiences in the past. These experiences are very real & cause panic attacks & flashbacks, which then cause further trauma. They weren’t the result of anything actually done by the emergency services, but more a result of a series of events which all add up to enormous distress & in which, because the services were involved, they are now bound up with it in her mind. They have also caused the feeling that it’s pointless going into hospital because of poor care & neglect when there in the past and that there is, therefore, absolutely no appropriate support out there for her. Having gradually got to know her & her story this seems to me an absolutely logical conclusion for her to have reached. However, her behaviour is viewed by services as ‘acting out’ and refusing to engage. And the answer from mental health services on 3 occassions in the past month has been to send in police and/or ambulance staff. She had not been detained, but was told she had been assessed as meeting the criteria for detention. So, scarce police & ambulance resources have been wasted & a very vulnerable young person has been left, in effect, with no access to services, even more convinced that no-one can help her and even more determined to keep her head down for fear of it happening again. In my view there is no risk to anyone in any of this except to herself. And at times that risk has been overwhelming. In fact she did make an attempt on her life and is still experiencing physical symptoms which are very likely the result. What has led to this life threatening situation (& potentially a life of chronic illness) is not anything done by uniformed officers – but the fact that appropriately trained & resourced NHS services were not available. This all starts much, much earlier than the point of crisis. We need some joined up thinking about how we identify & support people who are at risk of crisis and how we design crisis services that are humane and, therefore, effective. Uniformed services should, in my view, only be a very last resort, and I totally support their resistance at being ‘used’ in any other way.

    1. Brilliant thanks for that.

      “This all starts much, much earlier than the point of crisis. We need some joined up thinking about how we identify & support people who are at risk of crisis and how we design crisis services that are humane and, therefore, effective.”

      I will set this to music, later today.

  6. It is a credit to the Police that all of the aspects of the person’s dignity, fears and need for reassurance were factored into the assessment of the appropriate course of action. Having been on both sides of such a scenario, it is concerning that, as you say, there is no consideration of contingency between patient refusal and enforcement of their removal under MHA.

    1. I think sometimes that sometimes people ofter think that a “Hands On” approch is better as it makes life easier and that your in control but my thoughts are that sometimes just talking to someone and show understanding can make a difference. I know this can’t always be the case but sometimes people kick of because they are scared and thats how they deal with being scared.

  7. reading quickly the above and its comments I have the impression that this is (yet another) illustration of to current state of the MHS where, like the NHS in general, too many mangers impose themselves on front-line services. In general terms the cuts are anathema but in practical terms the MHS is over-managed to the point of paralysis at a time of need?

  8. Hi,

    I’ve been doing some quiet background digging since discovering your blog. I hadn’t come across the bit about delegated authority to remove using reasonable restraint etc.

    Is there a link to this as I would definitely use this option in future!

    Tj

    @meditude

    1. Not sure if there’s a ‘link’ as such, but s6 of the MHA is here: http://www.mentalhealthlaw.co.uk/MHA_1983_s6 This is the AMHPs authority to detain / convey, and they can authorise – not order – others to do so. Ambulance, when someone is sectioned, can take hold of someone, sufficient to try and guide them into a wheelchair, etc., and use what a paramedic I know well calls “proactive blanketing” whilst moving them. Obviously, if escalates to outright violence that becomes a police matter.

      Many ambo think that to do so with someone who is ‘sectioned’ would be a criminal assault which it very definitely is not.

      1. I agree with Meditude. Your quote seems to me to be misleading. I cannot see where it says they have the powers of a constable. I agree it gives the applicant authority to “take and convey” but if one is to resist in such circumstances as you describe (a situation I have been in several times) then one needs to be correctly armed.

        I do enjoy reading your posts and have learned much as a result. Even in this instance you have inspired at least two people to do further research. Bravo.

    1. I have received a comment on this piece from an individual whose identity reveals the area involved in this case. As I have deliberately sought to avoid doing so – precisely because there is nothing about this incident which is specific to the area, it is a far wider problem – I am publishing it unaltered but under my own name: –

      “Those of us who know about the circumstances of this sad case know the at the original description is an extremely partial and biased description of the facts. All we were trying to do was to get the Police to follow both the code of practice as at 11.17-25 and the local policy in asking for humane police assitance to get a resisting person to hospital.”

      1. If one reads the Code of Practice sections mentioned above – I’ve pasted some of them, below and the ones I have not pasted don’t alter the point I’m trying to make – there is nothing within it which makes the physical coercion of this patient and exclusively police responsibility and as the duty inspector’s remarks show, the police were not refusing to be involved, just resisting being the agency of both first and last resort.

        If there were a local policy on these matters, it is one that is unknown to several local police officers who asked about its existence / contents, some of whom have asked repeatedly to see it, outside of this incident.

        In so far as comments of bias and partiality are concerned, I spoke with “both sides” during this incident, one of which described the matter as a “battle zone” – the piece refers to verbal aggression and shouting on the part of the patient – and the other described it as a resistant patient who was upset and distressed. No-one described the patient at any stage (to me at least) in a way that could be characterised as ‘dangerous’ or ‘violent’.

        11.17 If the patient is likely to be unwilling to be moved, the applicant should provide the people who are to convey the patient (including any ambulance staff or police officers involved) with authority to convey the patient. It is that authorisation which confers on them the legal power to transport the patient against their will, using reasonable force if necessary, and to prevent them absconding en route.
        11.18 If the patient’s behaviour is likely to be violent or dangerous, the police should be asked to assist in accordance with locally agreed arrangements. Where practicable, given the risk involved, an ambulance service (or similar) vehicle should be used even where the police
        are assisting.
        11.19 The locally agreed arrangements should set out what assistance the police will provide to AMHPs and health services in transporting patients safely. …

        The offer of support from the point where someone other than the police went ‘hands on’ was there from the start. And of course, the police did do this in the end, once we had reached a point where we could evidence little other option, having taken all reasonable steps to escalate this to find an alternative. When it emerged that there was not one, it was done.

  9. Out of interest, did the AMHP or local MH managers consider the use of the local crisis team to assist? I’m interested as a MH nurse in a crisis team & a trainee AMHP.

    1. Whether it went through their head prior to rejection of the idea – I don’t know; it was certainly not mentioned as an option in any discussion I had. I am given to understand the some MH trusts simply have NO resources to physically coerce, where this is needed. The rely entirely upon police officers being willing or able to do so.

      Interested in your perspective as an psych nurse training as an AMHP because since the 2007 Act allowed training of a wider group, I’ve been intrigued to see different perspectives on the AMHP role, especially potentially from someone who is likely to have had restraint training, such as a psych nurse.

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