Conveyance of Patients

I have just finished a discussion about the conveyance of patients who are detained under the Mental Health Act.  This is a subject which has now reached the political level because the UK Home Secretary indicated in her speech to the Police Federation conference in May 2012 that she wanted to try to ensure that police officers spend less time “escorting mental health patients”.  I know that she is looking at how this can be achieved in conjunction with the Department of Health.

There are various situations in which the police convey patients – some of them are inevitable, some of them potentially avoidable:

  1. Following a police led detention under the Act – s136 detention for example; or following the re-detention by the police of someone who is AWOL from hospital.
  2. Following an application for someone’s admission under the MHA – typically,  the sort of situation in which an Approved Mental Health Professional and one or two doctors have ‘sectioned’ someone and seek police support for conveyance of that detained person.
  3. Following a request that a psychiatric inpatient be transferred – typically, this may the need to transferred someone to another psychiatric unit or to A&E if an inpatient has urgent physical health problems.

Situation 1 is unavoidable – if the police detain someone and no other method of conveyance is available, then “you are where you are”.  The Mental Health Act Code of Practice states that conveyance of anyone detained under the Act should be done by non-police transport, wherever possible – so there is legal basis for asking the ambulance service to support you.  This is not only because what you think may be a mental health problem could be something else besides; but also it is concerned with ensuring the dignity of people who have not been arrested for an offence.  Their transportation should reflect this status as ‘patient’ rather than ‘suspect’.

In fairness to police services, some Ambulance Trusts have strong views about conveyance of mental health patients, especially following police detention.  One senior paramedic (not in my own force area’s ambulance service) once curtly asked me, “Do you really think that’s a good use of an intensive care unit on wheels?!”  I couldn’t give two hoots whether it is or not, if I’m honest: it is a legal requirement from the Code and I’d happily achieve non-police conveyance another way if there was an established mechanism by which to do so.  As there usually isn’t, you’ll be asked anyway.  If the NHS then want to say no, that’s up to them but I’ll be mentioning it to the Coroner should the need arise and they can explore the NHS commissioning and conveyance arrangements if they need to.  You can then explain Chapter 11 of the Code of Practice in the context of your decision.

Such legal situations would include: sections 135(1) (warrant to a place of safety), 136 (emergency removal to a place of safety), 18 (AWOL patients) and 138 (absconders from PoS detention).  If you don’t request an ambulance, you’ll never get one so why not try?  If you do try and fail – for whatever right or wrong reason – then it’s on the audit trail that you tried and this is key: Dorset Police and either Kent or Sussex Police (link to follow when found!) have each had situations in the last couple of years where they removed someone by police vehicle after detention in the above legal situations and the person died in transit.  I also have an example from my own force of a man who was detained by officers under s136 where it was perfectly reasonable of them to do so.  Because they called an ambulance to the scene, paramedics were able to do standard physical observations checks which included a blood sugar test and as they did this the man collapsed and was rushed to A&E.  Had he been taken to the police cells in a car, he probably would have collapsed in the holding area of the cell block and the A&E consultant who treated him suggested it was possible he may have died.  It turned out that he was an undiagnosed diabetic and has no mental disorder at all.

Situation 2 could be better planned – this includes the “Mental Health Act Assessment on Private Premises” situation.  I have a great deal of sympathy with AMHPs here.  They are required to co-ordinate assessments and then the admission if it is required, but they often don’t have access to the resources to make this happen.  In some situations where ambulance and police are required to convey, they find a “catch-22” ongoing where the police won’t even despatch an officer until the ambulance is there or vice versa.  Presumably this occurs because neither agency wants to then be told that the other emergency service has been diverted to [insert your preferred emergency here] and be asked to crack on unsupported.  Paramedics don’t want resistant, escape risks in the back of their ambulance; the police don’t want people with medical problems in their police cars.  Happy times for AMHPs.

What happens where the conveyance is required not just because of a need to move someone, but a need to move someone who is presenting risks to safety – either their own or that of others?  Although unclear about why the police would be called to convey someone who is compliant, I can understand why an AMHP may want the police because of what I’ve previously called RAVE risks.  But what precisely is the role?  Where does the potential for harm turn a situation where the police are in the background, in support of an AMHP, to one where they take the lead in the physical coercion of someone who is presenting actual violence and danger?  I’ve posted elsewhere about debates that go on about the coercion of patients – should it always be a role for the police or should mental health services have trained staff available?  Obviously this question links directly into the subsequently necessary question of conveyance and who will do it.

However, this again often comes back to commissioning.  In many areas, as well as designing services in a way which means control or restraint trained staff are not available there are often no planned arrangements for achieving conveyance of patients after MHA detention – it is a question of asking and hoping for a 999 ambulance to be available.  You can easily see why AMHPs with actual patients in the real world turn to the police for help.  In some areas they have arranged the non-999 vehicles to undertake this task, with a ‘bookable’ system.  In other areas, few in number, there are contractual arrangements with a private organisation who can be requested by the AMHP for conveyance, including staff with some capacity to manage resistant patients.

Situation 3 is arguably not a police responsibility – except where urgent risks need to be mitigated.  The Code of Practice clearly states that it is the responsibility of Primary Care Trusts to ensure they have properly commissioned arrangements for conveyance of patients.  This is an area of business where some police forces have just issued a fairly blunt directive: we do not convey patients between psychiatric units, ever.  Such direction is not just about demand on resources which could be prioritized elsewhere.  It is also about questioning whether the police are the correct people to make urgent transfers of detained patients.  What kind of medical or paramedical supervision is needed?  In whose legal custody is the person if they are being moved by the police and / or ambulance service and / or doctors and / or nurses?  Who is in charge of this where medical risks have blended into safety risks?! What do we do with disagreements about transfer?!!  It goes on …

SEDATED PATIENTS

One point to make very clear, is that there have been incidents where police officers and paramedics are asked to transfer detained MHA patients who have been sedated – para 11.5 of the MHA CoP states, “Patients who have been sedated before being conveyed should always be accompanied by a health professional who is knowledgeable in the care of such patients, is able to identify and respond to any physical distress which may occur and has access to the necessary emergency equipment to do so.”  Paramedics I have spoken to do not usually regard themselves as ‘suitable’ professionals.  There are issues around what drugs they are licensed to administer and the issue of not wanting to supervise patients where the dosage of medication was administered by someone else where it involves estimates about patients and travelling time.

Ambulance services often refuse to convey sedated patients where the trust who seek support for conveyance are not supplying a doctor or suitable nurse.  It is perfectly proper to suggest that the police should do likewise for even more reasons.

Some requests for transfer arise from the fact that a patient’s condition warrants a different type of mental health unit.  For example, a patient initially admitted to a Psychiatric Intensive Care Unit may need to be moved to medium secure care.  A patient on an acute admissions ward, may need to be secluded but the hospital or clinic in which they are detained may not have a seclusion facility or it may not be available.  There is a legitimate difficulty in gauging where police responsibilities lie and I’m going to make a specific post out of the considerations that may apply to the ‘rapid transfer’ of a patient to another psychiatric unit where mental health professionals are seeking police support in a hurry because of unmanageable risks.  For now, I just keep coming back to a question I’ve asked inpatient nursing or medical staff when faced with these requests:  “before we get police officers and paramedics to improvise their way through this, what contingency arrangements do you have access to through your managers?”  Too often the answer is: “None.”  Actually and quite frankly: I’ve never known the answer be anything other than “None.”

And can I end by just saying this – conveyancing is what you do when you buy and sell a house; conveyance is about the movement of people or stuff! 😉

____________________________________________________________________
The Mental Health Cop blog

Badgewon the ConnectedCOPS ‘Top Cop’ Award for leveraging social media in policing.
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– 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
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10 thoughts on “Conveyance of Patients

  1. An excellent evaluation of some of the problems we face as paramedics. We get told one thing (the pt has been sectioned) we arrive to find no HCP on scene, psych has left & we’re expected to transport on the basis of a scrap of paper the psych left! No thanks!

    After much ringing round, Dr off duty now and it turns out the pt isn’ sectioned anyway.
    Because I discovered MHC via Twitter I’ve been able to use your resources to point me in t right direction a couple of times. A new approach has to be found. We’re working together on the big stuff like contingency planning, we should be able to at the operational level to carry out small scale joint op

    If we can’t have psychiatric paramedics, maybe a case for ambulance HART to assist? As for transporting sedated patients, critical care paramedics should be more than able to assist. South East Coast Ambulance Service have a particularly good CCP setup.

    Tj

    @meditude

    1. Dear Mental Health Cop and Tj,

      I am very concerned about the opaqueness of the Mental health legislation and how people who are NOT sectioned are forcibly “captured” and taken hostage from a surgical ward of an acute hospital into a mental health facility where the admissions states it is standard under A and E from home, and that level observation stated “INF”. This is so worrying. Is it illegal?

      1. Unfortunately as a paramedic I specialise in out of hospital emergencies, so I can’t really comment on your case. My case ended up OK as the pt ended up consenting to transport to hospital to be assessed.

        Part of our problem is having to deal with patients with minimal training. This is something I personally address by reading blogs like MHC and reading peer reviewed journals, amongst others.

        Take care,

        Tj

        @meditude

  2. I work in a medium secure unit and we have had to transfer patients due to deterioration of mental health from other units to our own as quickly as possible. Management and frontline staff quickly confer on the best way of transfer and discuss staffing levels and staffing types. As much information as possible is gathered about the individual and experienced staff are used to affect transfer if the other unit cannot facilitate. All our staff have undertaken control and restraint techniques but our preferred method is to talk to individuals and give as much reassurance as possible, not only are people suffering from deterioration of mental health but they are bound to be anxious and agitated about moving to a strange place. This is one reason that it is better for us to affect the move, they can meet people who are going to work with them. For most people in this position the police no matter how nice and supportive they may be are often seen as “the enemy” as prior interactions may have been percieved as being negative. Even if there is a large risk we would prefer to patients as roles for people with mental health issues can be much more set in stone as regards to what they do ie police arrest you for wrong doing. We like to know that there are people we can call on but surely we should at least try to do our jobs.

    1. I think we’re both saying the same thing and I’m grateful for the comment because it rather backs up my own view from someone who works in that field. I know that the commissioned transportation arrangements in each area vary and perhaps unsurprisingly, it is areas without fully developed pathways to secure transfer who call upon the police more frequently – at least that is my experience of it.

      Thanks again – enjoyed your comment.

  3. 20 October 2012

    Dear MentalHealthCop

    I am returning to you for help please regarding this vexed issue of conveyance.

    If a person is in hospital on a surgical ward and then has a recommendation by 2 doctors – both Section 12 – and an assessment by an AMHP who is employed by the Local Social Services Authority and works as a Deputy Manager at the local mental health trust where such patient is to go in, is this a conflict of interest that is barred by the Mental Health Act 2007 as this AMHP would surely could not be seen to be “neutral” as the AMHP would depend on the viability of the mental health trust to keep having new patients brought in by the AMHP to keep the job at the Trust especially where such AMHP might be then appointed by the Trust to be the new patient’s care co-ordinator?

    I am asking this in the hypothetical but I would be very glad of your help please.

    Thank you so much for your excellent blog – it is so very helpful.

    Best wishes,

    Rosemary

    1. Sorry for a delayed response: been on annual leave.

      It’s not a conflict of interest as far as I’m aware – AMHPs, when operating in that capacity, are strictly and legally independent in their decision making and this is written in to the Mental Health Act. Of course, I understand why there could be a perception that legal authorities are NOT discharged independently, despite this requirement, but then that could be said of all legal officials, including police officers, UK Borders staff, HMRC, etc., etc..

      Does that help?!

  4. As somone who has had a very very recent near death in transit in a police van, I wish ambulance had taken them to 136 suite!

  5. What are your thoughts on conveying patients who have been subject to s136 for example and who have not been detained and upon discharge who should convey…as i understand it, there is no legal basis for conveying someone after the assessment. What happens to the elderly and others who may still be vulnerable and who may not ahve any family or friends to support????

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