Whilst I Was In Bed …

<<< If there’s one thing from which I derive very real satisfaction, having blogged away now for six months, then it is emails from frontline officers saying how the blog material has come in useful in operational reality.  To get such a story as this one where it is clear a better patient outcome has been achieved for someone whilst I was lying in bed after NIGHTS is gold dust.  This feedback comes from Twitter’s @NathanConstable, a blogging / tweeting frontline police inspector who is worth a follow and does good blogs on policing issues. >>>

Your site has AGAIN proved invaluable today as I have quoted Paragraph 10.22 of the MHA Codes of Practice to a ward manager.

The Circumstances

A man was seen yesterday by a support worker, at home, who felt he needed an MHA assessment but he left the house before it could be jacked up and he was reported missing as she had concerns for him. He was located several hours later by police who detained him under 136.

He was conveyed to the PoS but they didn’t want him for a variety of reasons. Eventually the night Inspector went down there himself and told them he would be staying there whether they liked it or not.

As I came on at 0700hrs this morning and just three minutes into briefing, we had a call from the hospital saying that a patient was kicking off, that he had assaulted three members of staff and five of them were restraining him. I did not realise at this point that it was the same male.

My view at this stage was that this is something they need to be handling themselves with their appropriately trained staff.  However, when it became apparent that he was pre-section and still detained only on 136 I had to revisit that and I sent a unit with specific instructions NOT to remove him from the hospital unless it was absolutely necessary.  By this time the patient (still not assessed) had been moved into a secure room by the hospital staff and was no threat to anyone any more.

Apart from their initial unhappiness about our lack of attendance they were then extremely unhappy when the officers refused to take him away. This led to the Ward Manager calling me to discuss.

His view was that the hospital was not an appropriate place for him, they “couldn’t handle” him and he needed to be detained in a cell.  My response to that was that a police cell was not appropriate, the HAD handled him and he was now detained in an appropriate place of safety.

Not content with this the ward manager informed me that the room being used was not THE PoS. To which I quoted 10.22 and said he had effectively improvised one.

He persisted that by using the room it was denying its use to a hypothetical service user who might need it later.  He even went as far as to say that it would be on my head if a 80-year-old dementia sufferer ended up in police cells because they couldn’t use the room.

My answer to that was – why are you worrying about hypothetical “what ifs” rather than dealing with the service user you have in front of you?  If an 80yr-old dementia sufferer turned up I would improvise my own PoS and take her home rather than convey her to a cell.

The debate continued with him accusing me of thinking it was alright to assault staff.  I said that is not the case at all – his medical and clinical status is not yet ascertained so I don’t know whether his actions are criminal or not yet – if they are we will deal with them but that is not the priority right now – his assessment is.

Then he moved onto the fact that the patient was unlikely to be sectioned as he had been examined before. I asked him three questions.

Question – “What happens if he is Sectioned?”

Answer – “He stays in hospital.”

Question – “What happens if he isn’t?”

Answer – “He is released.”

Question – “What happens if he is so violent that the AMHPs cannot conduct the assessment or make valid assessment.”  …  it took him a while to admit that in that eventuality he would be detained for further assessment to which I said, “Two out of three of those scenarios involve him remaining in hospital and the other see’s him walking out. Where does a police cell come into this?”

I then explained that it wasn’t a question of having police officers involved – I was quite happy to supply a double crewed unit to ensure no crime was committed before or during the assessment. For me it was a question of WHERE this would take place and I would not, under any circumstances, take him to the police station now he was secured in a safe and secure room.

The ward manager reluctantly accepted this – which suggests to me that I was right.

The inevitable, “I will be making representations about this” came out but the question is – was I right? I think I was. I will accept that had I known he was pre-section in the first place that might have changed my initial “how quickly we got there” approach but not the eventual outcome.

The fact that seven hours later we are still there is something I have to accept. Their other problem was a refusal to change their schedule for the day.  Common sense dictates that they bump this guy to the top of the queue – and assess him – we know where we all are and the room is either utilised fully or he is released thereby freeing it up. Problem solved. Unfortunately they seem to have had a series of unavoidable meetings which is delaying the whole process.  What a surprise.

The outcome was, he’s been detained under s2 MHA and admitted.  I doubt I have heard the last of this one!

My Comments

Was this duty inspector right?  Feel free to add your own comments to this post.  For me, certainly.

He has provided a response which ensured ongoing security to prevent further assaults and whether or not the NIGHT shift should or could have left resources at the PoS to prevent assaults from occurring in the first place, is not clear in terms of the risk background.  But that is not an issue for this inspector.

It is quite right to point out, that PoS solutions can be improvised notwithstanding what a PoS protocol stipulates the designated places to be and para 10.22 obliges the police AND the NHS to think of the alternatives.  This may not be “textbook”: it might not be what all NHS staff think is the right thing – but we’ve all got personal views on this stuff, haven’t we?  It was lawful, reasonable and ethical and it probably caused a faster assessment of MH need in a more appropriate place than if the police had just got back in their box and done as they were told.  Of course, had they done so, I’ve got various medical and legal situations playing out in my head which would have rendered acquiescence questionable.

Let’s not forget the criteria for use of a police station is “unmanageably high risk” and the officer points out, they managed it and then were supported by the police thereafter.  Let’s also remember: the Royal College of Psychiatrists Standards on s136 indicate that people detained should be taken to and left with NHS services “even where they are disturbed” (p8).  That ongoing police support was provided may be considered ‘extra’ to support a service that doesn’t function as agreed by relevant national agencies.  We should also remember that the recommendations of the Rocky Bennet Inquiry indicated that where psychaitric patients are in need of ongoing restraint, they should be detained a place with access to a Doctor and defibrilator.  That include no police station that I’m aware of.

It is for that reason that I smiled when I read the paragraph above “You’ve effectively improvised one.”  Can we doubt the commitment to investigate the assaults against staff or ensure they are not repeated?  Not really.  Removing the man to a police cell doesn’t un-assault the staff; nor does it ensure fast assessment of need.  Providing two cops to remain at the unit keeps the situation from re-escalating and represents a recognition from the police that the risks have raised and that whatever the rights and wrongs of the way the service is commissioned or the fact that staff would potentially prefer to operate outside the law and national guidance, the police have done the right thing in my humble view.

____________________________________________________________________
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

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– 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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17 thoughts on “Whilst I Was In Bed …

  1. Seems reasonable enough to me. Having said that though I’ve also been nurse in charge of acute psych in similair situations and I can appreciate the ward manager’s frustration too.

    The real problem isn’t with the police though but with the difficulties inherent in running a ward that may well be understaffed and over capacity.

    None of that makes it an automatic ‘removal by police’ issue though.

    Cheers,

    Stuart

  2. The Duty Inspector is right. I agree the problem is lack of resources to manage NHS PoSs effectively. Staff for the PoS are usually pulled from the ward in my experience leaving the ward short staffed. This is not acceptable.

  3. What was the persons state of intoxication? I’ve had cops swear blind the person is sober, yet when the alcometer comes out they’re over 3 1/2 times the clinical limit for MHA, (the patient that is, not the police!)

    In that scenario, the correct option (or at least one option) does involve police cells.

    1. Out of curiosity, what is the ‘clinical limit’ for the MHA? I’ve never ever heard of this before, despite many conversations about the NHS wanting to breathalysing patients.

      Really happy, always have been, to say that the police sometime misuse the power of s136 in some forces. I know of some forces who wholly abuse it. That having been said, it’s lawful to arrest s136 even where someone has had a drink and / or is very intoxicated and I’ve got a cracking story of where someone’s death may well have been avoided if only the police had done exactly that and then got assertive with a resistant NHS.

      Assuming for just a minute – I accept it is a total assumption that may not be right in your particular case – that the person was a known mental health patient OR that he did have unmet mental health needs: we as a society need to move past this thing that it’s OK to detain people in the cells until sober. It’s a bloody dangerous thing to do: it is a perverse form of Russian Roulette with that patient. Apart from the fact that this is not necessarily even lawful (because of various legal requirements on police stations that people get ‘appropriate clinical attention’ which could NEVER been ensured in police cells and to ensure humane and non-degrading treatment) it is a kind of action which stacks the predictors towards a death in custody because alcohol could be masking any number of things, especially so the more alcohol has been consumed.

      Any custody sergeant worth their salt would refuse or resist detention in the cells for this kind of stuff until EVERYTHING else has been tried and this would include NHS PoS, A&E and any other improvised alternative. It is also worth reminding every mental health professional who wants to decline someone’s reception in a psychiatric place of safety by saying, “Take him to the cells” that they are breaching the Code of Practice which seems to be an important document in every regard: except where it relates to NHS obligations to ensure an appropriate environment in terms of that person’s dignity and clinical welfare. The same arguments go for violence: it can be symptomatic of any number of other issues.

      I restate my original caveat that of course, forces need to do more around training to ensure correct use of the power: to ensure that s136 is not used on drunk people without obvious, objective evidence or information that the person has mental health problems; to ensure that it is not used where substantive criminal offence powers should be used. But alcohol or violence to the cells: not until NHS profesisonals whose names I’ve recorded have REFUSED to allow me to do otherwise and I’m left with no choice.

      If this response feels a touch agitated, it isn’t intended to be: but it IS true to say that failures to do exactly this in the past have lead to police officers being criminallly prosecuted for neglect or civilly prosecuted for various kinds of tort of violation. There’s no way I or my officers are going through this, because the NHS would prefer the Code of Practice breached arising from deliberate decisions not to commission their PoS service properly.

      Police cells, by law, are for those who pose an “unmanageable high risk”. This will rarely arise because it will almost always be possible to put enough cops in a PoS or A&E to make any risks “manageable”. Just my opinion – but then it’s my legal detention and my duty of care and my backside on the line.

      1. It’s interesting that this issue gets all of us examining our positions and somewhat exercised. I’d hazard this type of argument takes place up and down the country all the time.

        My social work colleagues use the drink drive BAC limits as a ‘rule of thumb’ for MHA assessment. This is obviously bendable: ie if a chronic alcoholic blows in a little over 1. Tolerance is taken into account and 2. By the time the assessment team have been assembled they may be within range. Suffice to say that in the instance of someone showing gross motor impairment and blowing 0.150, few psychiatrists would attempt to assess – UNLESS there was prior knowledge of the person. What we’re talking about here is a ‘cold’ S136 – fresh off the street, not previously known to services.

        So my question is: If no clinical assessment has taken place, how can the MH services fail in their obligations to a person’s clinical welfare under the Code of Practice? We can’t make a judgement on their clinical need, because whatever that need may or may not be, right now it’s submerged under a litre of vodka.

        If they are in physical danger as a result of acute intoxication, the place they need to be is A&E.

        Again this is my take only and i contribute to this discussion with a genuine willingness to stand corrected.

        On a matter more related to the original post, night shifts are skeletally staffed for good reason – you can’t have a full compliment on duty when 99% of the time our people are medded and bedded and all is (relatively) settled. I’m interested to know what police procedures are for unforseen emergencies where huge resource needs to be drawn down at short notice – how do you muster force in the middle of the night? I ask because it might be something that the NHS could learn from. Being resource-strapped out of hours is a ridiculous (unethical? illegal?) basis for falling one side or the other in judging clinical need.

        Many thanks

      2. Police services have internal procedures for raising large numbers of staff within a single force and for forces supporting each other in what is called ‘mutual aid’. So if my police area had a murder with a large scene at 0230hrs, we’d ‘mobilise’ surrounding police areas in my force.

        We’d mobile in multiples of 1 Sgt and 7 PCs; if we mobilse three of those we get an inspector too; if we mobilse three inspectors (riots) we add a ‘Bronze Commander’; two bronzes get a ‘Silver Commander’ and the Gold Commander is notified. Gold can then ‘erect further ‘silver commands’ as needed. So during the Birmingham riots 2011, we quickly went to Silver and Gold and Gold eventually carved WMP into two distinct ‘silver’ commands. With all those resources needed, we didn’t just mobilise West Midlands Police areas to Birmingham, we also mobilsed surrounding police forces to help.

        So an analagy could be, you have a restraint situation and you call upon staff from nearby wards; if you need more in a hurry, you may have to ring the police but you could then potentially ‘mobilse’ other NHS resrouces (community MH teams or crisis teams).

        I know they might argue that they were busy doing community visits, but Staffordshire Police were busy policing Staffordshire when West Midlands Police said, “We need 50 officers to help police Birmingham”. I think some describe this as a ‘tidal model’ of staffing.

        I understand the point you’re making about alcohol and you rightly point there is a level where A&E is needed. My point is, that where that threshold is not yet met, because it is still possible that there are clinical risks in someone being in a conrete police room being watched by a detention officer, they should remain in the place of safety under nurse obs until assessed.

        Of course, I repeat that I totally understand this is all contingent upon the police using the power responsibly and the NHS having confidence that this is the case; but it is also about the NHS understanding that most PoS provision is not established to survive contact with the reality that someone s136 detentions involve people with MH issues who are also drunk, and aggressive and that some of those are drunk / aggressive with accompanying risks if not medical supervised until assessed.

        IMHO comes back to Commissioning properly and I have met several MH commissioners who could not care less about this and do not understand the risks this business presents to their organisation because they haven’t (yet) been required to stand in a Coroner’s Court and account for them.

        I’m just waiting for the first Corporate Manslaughter case.

      3. Radio Rental,

        Is it the blood or breath limit you use as a ‘rule of thumb’?

        What legal right do you have to take either sample and what do you do if they refuse to provide?

        How do you calibrate the breath kits (which are notoriously inaccurate)?

        How do you know it’s not a medical issue that causes the person to ‘fail’ the intoxilizer test?

        Can you support this ‘rule of thumb’ with some medical evidence (even vague research paper will do)?

        Would it not be better to monitor the patient from the start to see how their behaviour changes as the alcohol wears off? It would be a bit like the police asking the victim of rape to submit to a breath test then refusing to help because they blew twice the driving limit.

        Turning people away on the spurious grounds of being too intoxicated can, and does, have fatal consequences.

        http://www.bbc.co.uk/news/uk-england-manchester-13620452

  4. Hi Sectioned Detention

    First off, for clarity i’m not a duty NIC so hold no direct responsibility for accepting or rejecting 136’s. I’m a frontline prac & observably close to admissions decisions but the accountability of the final call is not for me – thankfully! Scenarios like this inevitably cause much furrowing of brows and everyone dives into joint service level agreements for guidance.

    I’ll try respond to your points within the limits of my knowledge:

    1. blood alcohol content measured by breath sample on handheld alcometer
    2. not entirely sure but we do it if we get a strong smell of alcohol or the person is unsteady – we’re doing it for a clinical reason not a legal one, there is no legal consequence attached to the provision of the sample obviously. we do saliva tests for common street drugs too. People refuse that all the time, it’s not a barrier to admission.
    3. they are inaccurate but we need an indication. i’d suggest accuracy is not nearly so important when the person isn’t in charge of a one ton killing machine.
    4. could well be, we’re using the alcometer as only one indicator of intoxication.
    5. nope stumped me there. It’s more driven by the AMHP who in turn is guided by the docs. if psychs refuse to assess within a certain (inaccurate) range of intoxication, nursing staff have no input to that, evidence base or not. the options are for the police while the person sobers up: stay put at PoS, go to A&E, release and carry the risk or take back to cells.

    Maybe there DOES need to be clearer guidance on this.

    wow that is a shocking case you linked to. reminds me of a very similar situation at a direct access hostel i worked at pre-qual back when, person absents themselves from their room and plants themselves outside the front door in a fit of pique. we tried everything to get them back in, they were loading up on whiskey and methadone (so respiratory depressant x 2) and lost consciousness on the doorstep. it was january and sub-zero. the critical difference is we called an ambulance straight away.

    1. Why have more guidance? So much guidance on mental health and this stuff is already ignored, more is pointless. You should try asking A&E or MH nurses about NICE guideliness on short-term violence; or self-harm. You might as well ask your binman …

      1. Here’s an article that illustrates the inexactitude we’re talking about:

        http://pb.rcpsych.org/content/26/12/468.3

        “If the findings from our survey accurately reflect actual clinical practice, then intoxicated patients, some with suicidal ideation or other mental health problems, are being sent away without an assessment. This raises the question of who is responsible. Psychiatric cover in A&E departments is very variable: in some, but by no means all, teams of psychiatric liaison nurses staff A&E departments and emergency psychiatric clinics. Part of their role is to assist in the detection, assessment and management of alcohol dependent patients (Royal College of Physicians, 2001). Clearly there is ignorance over the use of the Mental Health Act, which can be used where there is a comorbid psychiatric disorder. Our findings support those of McCaffery et al and suggest a need for care protocols for when intoxicated patients present. We agree that there is a need for greater clarity on the management of such patients at both the local and national level.”

      2. I think that massively backs up the point being made by the police and the answer is not cops having a pop after an arrest or other frontline debate but a recognition by commissioners across mental health, acute care, ambulance etc., that they need to properly integrate their commissioning and they should meet their police officers to work where the police rightly do fit into it to support the above where that is appropriate and necessary.

      3. Oh, and of course: psych liaison teams won’t touch people who are under arrest by the police in all areas where I’ve been able to ask. So for those under s136 or under arrest for an offence whilst mentally ill, are denied access to such healthcare on those grounds alone.

  5. So mentally ill people aren’t allowed a few drinks, but someone who gets a physical injury while intoxicated is treated?! Discrimination is rife in the system against the mentally ill…

    I’m interested in the idea of actually testing people’s alcohol limits though… what’s the usual procedure for this? I have been turned away from mental health help after a distressing incident because I was ‘intoxicated’. I was, however, already known to mental health services, perfectly coherent/alert, and had just suffered an experience that would have been traumatic in any circumstances. They used the alcohol as an excuse not to treat me; despite knowing this incresed risk of suicide (and had a friend not stepped in, almost certianly would have in this situation.) I understand them not wanting to confuse intoxication with signs of mental illness; but if you’re known to them they should have a pretty good idea of what’s what! and should definitely make sure you’re safe until sober enough to be assessed.
    I’ve also been declared ‘clearly on drugs’ by a police dr in the cells, and thus refused a mental health assesment. Fortunately the officers involved weren’t convinced and kept the cell door open with someone sat there all night (was in about 12hrs). Despite this, I was never given a proper mental health assesment as when the dr came to reassess in the morning, he said there was nothing wrong with me (a couple of weeks later I was admitted to a psych ward). How could this happen? I had originally been arrested under ‘breach of the peace’, in my own home, because the MH crisis team had called the cops for a welfare check!

    Furthur adding to this distressing situation was that having been declared perfectly healthy, the sgt in charge (presumably annoyed at taking an officer off duty all night to watch me) decided to come and scream in my face, including shouting at me to “stop shaking or i’ll lock you up for another 12 hours”. All because of that stupid dr!
    (for they record, I spoke to this sgt a few days later and he was ott nice, think someone had a word!)

  6. Interesting debate. The patient was not drunk.
    I also disagree with the comment from Radio Rental that intoxication automatically means police cells. That is something which has developed as “local practice” and has become common procedure as a result. I believe that the actual circumstances where police cells are a necessity are few and far between and where the patient is “wholly unmanageable.”
    Just because they are over the limit and cannot be accurately assessed at THAT moment does not mean they should be banged up in a police cell. They are not criminals. Once the alcohol has worn off they can be assessed but the proper place for patients (unless wholly unmanageable) is in a hospital – sober or otherwise.

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