The Force Medical Examiner, or Forensic Medical Examiner, is the doctor who comes into police custody suites to undertake various medical functions. The terminology for these professionals has changed over the years and is now officially the “Approved Healthcare Professional” which is helpfully confusing when I want to discuss AHPs in the context of functions they must undertake with AMHPs (Approved Mental Health Professionals under the Mental Health Act)!
For that reason, I’m going to persist with the outdated term, “FME”!
When I joined the police, the FMEs were a load of local doctors, mostly GPs, who were on a rota. My station and two others had four of them and they were in each subsequent 7 day period “first choice” then “fourth choice” then “third choice” etc.. Many of them earned more from being an FME than they did from being a GP because they worked about 24/7 for a week, then had two weeks ‘off’ (because 3rd and 4th were rarely called) and then a week of being called ‘occasionally’.
Presumably because of cost and some debate about skills, training and clinical governance, somewhere around 2002, my force contracted a private provider to undertake all medical functions in the custody office and elsewhere, introducing nurses for certain functions rather than doctors.
The FME has an interesting role with regards to s136 and it varies across the country. Legally, once someone has been detained by the police and removed to any place of safety, they must be seen by a “Registered Medical Practitioner” and an AMHP. The RMP needs to be a doctor and there is no specific requirement that they be “s12 approved“. Section 12 approval relates to doctors who are declared to have “special experience in the diagnosis or treatment of mental disorder”. Many functions for doctors under the Mental Health Act 1983 require a “s12 doctor” but s136 MHA is not one of them. In fact, many FMEs in fact ARE “section 12 approved”.
The Mental Health Act Code of Practice states that the RMP should ideally be s12 approved, but stops short of mandating it.
Force Medical Examiners being used outside police custody
Sometimes, local s136 policies specify that even where a person is removed to an NHS place of safety, the FME should still be involved in the s136 assessment. There are a few problems with this which then emerge in reality.
Firstly, some force contracts with their medical provider, do not cover it and therefore some FMEs are told by their contracted employer not to undertake such functions. Assessment under s136 MHA is a statutory responsibility for the NHS and therefore, the NHS should ensure that the commissioning of PoS services ensures the availability of whatever kind of DR they believe is the most appropriate. This has caused tensions and problems, because it sometimes only became known that FMEs were involved, once contracted medical companies were overseeing FME schemes.
It turns out, RMPs can claim a statutory fee for s136 and MHA assessments, so plenty of FMEs were happy to do it. But then some NHS areas started trying to suggest that as the doctor “worked for the police”, the police should pay that bill. Err, no.
I have recently been looking for a reference which I’m sure I once read in the Code of Practice to the MHA, which indicated that PCTs should not rely for the delivery of services upon third-party organisations that are not directly commissioned. Contracted police FME services are one such example, where reliance by the NHS on a service they did not commission and do not control, can lead to operational problems. PCTs must ensure they have answer to “how s136 gets done.”
I suspect some of this may change in the future when the NHS takes overall commissioning responsibility for healthcare in police custody, at the point of writing this, it remains true.
Force Medical Examiners in police custody
FMEs have been used in various ways for s136 assessments in the cells. In some forces, the local authority WANT the FME to get involved in a ‘screening assessment’ before the AMHP is notified, ostensibly so that the FME gets rid of any s136 detention which is obviously inappropriate. In other areas, the local authority specific DO NOT want the FME to make any decisions whatsoever around s136 MHA, because they want to bring their own RMP, usually off the “section 12 approved” rota.
Each of these scenarios poses a different, interesting question: if the FME is screening people out, on what basis are they doing so? I ask because I know that some doctors think the question to ask of s136 patients is whether they are ‘sectionable’ under the Mental Health Act. In fact, the purpose of s136 assessment is not (just) to establish whether the person is ‘sectionable’, but “whether they are mentally disorder for the purposes of the Mental Health Act” and to identify subsequently necessary care pathways. These could be inpatient OR outpatient pathways.
The second quandary is interesting: if the FME gets to police custody with a view to doing “FME things” and staying ‘out’ of the s136 process – police want FMEs to confirm fitness to be detained in the police cells, levels of safety observations which will be undertaken whilst the person is there, helping with decisions around whether they need removal to A&E for any purpose perhaps after a physical examination – what then happens if the FME who is an RMP thinks the person is “not mentally disordered within the meaning of the act”? The Codes of Practice to the MHA and to the Police and Criminal Evidence Act 1984 both state that if an RMP believes the person is “not mentally disordered” etc., then the person should be released and s136 comes to an end. To detain beyond that point would be illegal; a false imprisonment by the police.
However, in more than one joint operating protocol that I have read, the policy states that no-one detained under s136 MHA in a place of safety will be released until they have been seen by both a doctor AND an AMHP. Which could amount to a false imprisonment, in some cases.
I also know of local protocols where the local authority want the FME totally removed for the s136 process, even where they are in police cells. This usually stems from a history of incidents where the local authority found that FME decisions were way off mark, leading to the unnecessary release of people who were quite unwell. But of course, the custody sergeant is obliged to call an FME for reasons above, that are nothing to do with s136. Safer Detention guidelines and PACE require it.
I understand the importance of the AMHP role in s136 assessments. Not only do AMHPs make arrangements for full MHA assessment if the “s136 assessment” indicates compulsory admission to hospital may be needed. Also, even where admission may not be necessary but where the person detained is suffering from mental disorder within the meaning of the Act, the AMHPs role is to ensure the relevant community follow-up. This may take one of many forms, including referral to the patient’s own GP, or community based mental health services.
So a tension in police custody can emerge, depending on how local s136 protocols are drafted: the custody officer is responsible for managing this tension and my advice is this:
- Notify the FME for assessment as soon as practicable after ‘detention authorised’.
- Notify the AMHP as soon as practicable after ‘detention authorised’ of the s136 detention in your cells and give the FMEs estimate time of arrival. The AMHP can then choose whether or not to be present at the same time, as preferred by the CoP MHA.
- If the FME arrives first and assesses the person to any degree, the question to ask is, “Is this person mentally disordered within the meaning of the MHA?”
- If yes – continue to detain for the AMHP.
- If no – section s136 has been brought to an end by virtue of this assessment. Unless you think for good reason that the Doctor is way-off in their conclusion, in which case contact your on-call senior FME (most forces have this) and notify the AMHP.
Footnote: “Not mentally disordered” after removal to A&E
The references highlighted above about RMPs indicating that someone is not mentally disordered has one further consequence that is worthy of mention in this context, although it is not about FMEs. Where a person has been removed to A&E – presumably because of additional RED FLAG injury / illness which makes this necessary – it could be that an A&E doctor states that a person is “not mentally disordered …” etc.. Where this occurs, it again raises the question of whether s136 should be brought to an end, irrespective of whether the AMHP has arrived or been notified of the detention and undertake an interview.
After much discussion on this point it comes back to the Code of Practice to the MHA (para 10.33): “If the doctor sees the person first and concludes that they have a mental disorder and that, while compulsory admission to hospital is not necessary, they may still need treatment or care (whether in or out of hospital), the person should still be seen by an AMHP.”
The Mental Health Cop blog
– won 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
– 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.