Sectioning the Elderly

Alan Bailey from Greater Manchester suffered from Alzheimer’s and was sectioned under the Mental Health Act in March 2011.  He fell whilst in hospital in April 2011 and subsequently died – a true tragedy for him and for his family.

The manner of his being ‘sectioned’ under the Mental Health Act has featured in the Inquest into his death, which recorded a verdict of accidental death following his unconnected fall.  The Coroner has criticised a decision by a police officer to handcuff him whilst being moved to the ambulance that would convey him to hospital.  The officer claimed that he was attempting to undo the straps on the paramedic chair that was being used and that he had become resistant and agitated.  The force subsequently offered evidence that the risks of handcuffing (and presumably the implications for dignity) were weighted against the alternatives, which broadly would have consisted of manually handling him.

This all re-visits the debate about the use of force on vulnerable people after the Coroner is quoted as saying, “This is totally ridiculous officer” and saying that the handcuffing decision “beggars belief”.

I’ve posted about this in the last few months and won’t repeat all of that again.  Suffice to say, that I repeat my point about mental health professionals often stating that elderly adults are capable of inflicting serious injuries when they lash out or resist being compulsorily detained under the Act whilst suffering organic mental disorders like Alzheimer’s.  I know of older adult professionals who will say they have lifelong visible injuries and the officer’s job was to prevent such things.

I will restate the bigger questions this further example raises – but they are generic observations, not specific to Mr Bailey’s case:

  • Patients who are resistant, aggressive, violent or pose risks of escape (RAVE risks):
  • If it is decided that alternatives to compulsory admission cannot be achieved and / or are less safe than pursuing (coercive) admission; if attempts to achieve admission without use of force have been tried and have failed, who should be deployed to use force to reinforce that legal decision to ‘section’?
  • Some thoughts:
  • Is it always a police role and if so, is police training fit for such purposes?
  • If it should not always be a police role, who in the NHS is going to do it and when is the line crossed where it is argued it has become a police role?
  • Regardless of who does it, how does one move an octogenarian from “here” to “there” when they are perceived as posing a ‘RAVE risk’?
  • If the answer to the previous question should not include the word “handcuffs” or “proactive blanketting”, how does one move someone who does not want to be moved?
  • Are the alternatives to handcuffing safer? – these would include things like doing nothing at all, using manual handling to control arms, or legs?
  • What are the potential medical implications on the elderly of being manually restrained by a police officer?
  • Are NHS personal safety techniques for restraint more appropriate?
  • If so – why don’t the NHS deploy such staff to MHA assessments in support of AMHP?
  • Some areas never do this and refuse to consider it, because they argue that force in the community is a police responsibility.
  • They argue this, despite the fact that no such thing is written down in UK law.
  • Do we expect police officers to keep filling gaps in NHS services, using their training as it is outlined to them by the Home Office and then to face criticism for doing so in courts?

I fully understand, frankly I support, the concern of Mr Bailey’s daughter, Sandra Coombes.  She said, “I was particularly upset to hear the manner in which a frail, elderly man was handcuffed and held by straps to restrain him in an ambulance to hospital … not only the excessive use of force, but to send a policeman to accompany him was unbelievable.”

There we have it, and from the families of vulnerable patients – they would prefer the police not to be involved in the detention and admission of vulnerable people like Mr Bailey.

So how are we going to do it?! – especially against a backdrop of knowing that such escorting of patients is being looked at politically?

UPDATE >>> Since the original publication of the Manchester Evening News article, this has been picked up by the Daily Mail, also.  Sir Peter Fahy has replied to the criticism of HM Coroner for Stockport, saying “This is a medical issue and not a police issue.  Medical staff receive extensive training to deal with patients in this sort of situation and to recognise warning signs.  There is no way we can replicate this level of training.  Basically I do not want to have police officers trying to restrain elderly people in medical situations.  We are presently negotiating a new protocol with the NHS on police being called to deal with mental health issues.”

I will be going to Greater Manchester Police on Monday to talk to them and their NHS colleagues about exactly this issue.

____________________________________________________________________
The Mental Health Cop blog

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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
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10 thoughts on “Sectioning the Elderly

  1. 4 July 2012
    Dear Mental Health Cop,
    I am very concerned indeed to read your posting, as it seems that the entire set-up is for people to be seized from their homes rather than people being actively given support in their own homes.
    To me this is tragic and obscene.

  2. This is not an answer to the strategic issues of deciding who should be responsible for the application of force in community medical situations. However, again I do feel that given most sections are planned over a number of hours, we have the opportunity to discuss with families and other concerned parties exactly what will happen and what it will be like for the patient and their families.

    Rather than shie away from the discussing the prospect of having to use force we should surely be covering the posibility in our conversations with families and discussing how this might happen in practice.

    This seems a much more sensitive way of dealing with a difficult situation than being surprised later that someone is shocked at seeing their parent or grandparent manhandled into a waiting vehicle.

    1. I agree – although the newspaper article covers criticism by the Coroner, directly unconnected to the police, which was aimed at the mental health professionals who brought forward a planned assessment by 24hrs, in circumstances in which Mr Bailey’s daughter was unable to attend.

      The “strategic” issues are best answered by proper commissioning of healthcare services to include the operational reality that if you are professionally absorbed in the business of coercion, you should develop and deploy a capacity to coerce. Should you fail to plan for that eventually, you put your frontline staff in a terrible position.

      AMHPs especially are vulnerable, because they have all the powers of a police officer with none of the training and backup and all cops know this … with lower level risk patients, it is therefore perfectly possible to ask “If Parliament gave you these powers, please describe the kind of situation in which you use them, if it’s not this one?” etc., etc..

      I think most Mental Health Act Assessments are inadequately planned, at least from my perspective as a police officer: under-sharing of risk information; lack of notice for them occuring; failure on the part of senior NHS or LA managers to ensure that AMHPs can call upon the non-police resources that they may need to achieve the operational objective.

      I agree with you.

  3. Thank you for a well balanced article. Like you, I make no criticism of the officer concerned who used the handcuffs. I am critical of whoever it was in GMP who accepted the request fo the police to attend and deployed the officer in the first place. By accepting this task the officer was placed in an invidious position and he appears to have responded only in accordance with his training in methods to deal with violent offenders.

    The Chief Constable should not be prevaricating, if local negotiation with the NHS is stalling then the CC should pul the plug and instruct his control room staff not to accept such requests for assistance until such time as the protocol is agreed.

    The use of handcuffs to control prisoners who present a violent threat or risk of escape is acceptable, any minor injuries caused to such prisoners’ wrists is acceptable and is a product only of the individual’s resistance. If handcuffs were an appropriate restraint to use on patients in ambulances then paramedics would be issued with them; not a likely scenario I would suggest.

    1. The irony is, that the NHS came to my police station to take custody of a patient who had absconded and brought handcuffs with them! … and that patient wasn’t even resisting being returned!

      Your comments are great as far as they go and I totally support what you’re getting at: in practice, the duty inspector would refuse on the grounds you state, then the mental health professionals would find themselves in an invidious position where escalation to their managers would yield nothing practical because the services aren’t commissioned in that way and then the situation would either escalate to violence or there would be claims that it was about to or had escalated and the police would KEEP being asked to reconsider their refusal.

      I recently did EXACTLY this on my area where I was extremely comfortable with my refusal (which I’d do again) and the calls and representations just kept on coming and coming and coming until there were claims that the MH professionals were at risk. I’m not necessarily certain that they were because various police officers who got sucked into that situation found themselves looking at an elderly patient who they would not agree was violent. Then the NHS observed that the presence of uniforms had calmed the situation down and if the police left, it would escalate again. Then they utterly refused to do anything at all, leaving the police with the decision: regardless of how outrageous the planning and handling of this situation is, would we rather be criticised for trying to do something to get this (legally detained) person to hospital, or continuing to refuse until such time as the AMHP walks away and then tries to criticise the police for refusing to do what we COULD have done, but which he didn’t do because we took a view that we should not HAVE to do it.

      There is a point where I think, you made your stand, esclate, desist and decline to cause sufficient agitatino in the NHS super-structure, but ultimately you have to keep people safe. Doing os recently opened various doors to managers who didn’t realise the reality in their area.

      But I absolutely DO agree with you: a tactical refusal is often required and can work wonders.

  4. I have a real worry that we are close if not overdue to having a police contact death after a S135 sectioning where for the majority of cases it could be argued IMHO for the most part the police are not the most ideal agency to assist with removal/detention.

    Of the options available to officers for restraint they either have limb restraints, wrist locks or handcuffs. The most common and perhaps indeed the most suitable is that of a set of handcuffs. Wrist locks are going to be difficult to use on someone in the back of an ambulance, limb restraints are not really for use on the arms – it still leaves the hands free to move around. There are no other options available to them.

    The amount of S135 jobs I have been present for and assisted with you could count on one hand, fortunately I have never had to resort to any force but I can see that the officer in this case has been put into a very difficult position. One one side he has a duty to protect the medical staff present, the patient and indeed himself and with the limited options available to him (as above) he has decided which one is most appropriate and used it. The other side is I am sure that officer is human and can see that he really would not want to handcuff an elderly dementia sufferer, I would be lying if I said that I don’t know officers (thankfully contrary to media belief they are quite rare) who use force more often than others but I am sure even those officers would think twice handcuffing in these circumstances unless they had no other option.

    The police assisting S135’s and the like has obviously been going on longer than I have been a police officer, I have not seen any mention of the NHS changing their outlook and saying that they will deploy appropriate staff where the risk has been deemed to be low or manageable it just seems like the stock request is to ring the police and get them involved. I doubt the family nor the patient really want us there.

  5. Sounds as if the response was proportionate. The poor chap was probably exceedingly agitated by this time and flailing around in frustration and alarm. You’d think the NHS staff would have some skills in de-escalation. Let’s say they DID but their strategies weren’t effective in this instance. Poor police officer. A bunch of articulate professionals claiming to be in fear of their lives (slight exaggeration) and a frightened old chap who didn’t want to be taken away.

    What was he to do? I don’t expect we know much about the prior cajoling and persuading. The headlines are made by the final handcuffing and not what may have preceded it.

    If the NHS staff remain obdurate and won’t act I don’t know what the police are to do except muddle through as best they can. I have been involved in one sectioning but that wasn’t met with resistance so……I’ve been fortunate. You surely have to anticipate trouble though and I’ve have thought it is the mental health professionals who should be planning for that.

    I don’t suppose many people become police officers to spend their days restraining the elderly and confused.

  6. I believe the real problem is how is “vulnerable” defined as there is no precise legal definition.

    Depending upon which law one quotes, it is possible to be “vulnerable” simply by being “frail”. But what is the definition of “frailty”? If a person is ill, that person is frail by the very nature of the illness but does this mean that this person becomes classified as “vulnerable”?

  7. As always I am unable to argue against the accuracy and logic of your argument Michael. Clearly where patients wether acute or Mental Health need to be moved then this should be an NHS responsibility. Where patients decline and resist that relocation it MAY be appropriate to seek support from the police where the healthcare staff cannot safely manage that transfer. What is true is that NHS staff are woefully inadequately trained to deal with violence & aggression whether intentional or “clinical” violence which is often attempts by patients to communicate their anxiety, fear or an unmet clinical need. People still think the NHS is one organisation, it’s not, it’s over 400, ten times the number of police forces in the UK. The only nationally consistent training course in dealing with aggression is the Conflict Resolution Training programme (CRT) which itself does not address how staff can physically manage aggression. Some (non MH) trusts are starting to acknowledge this training is insufficient and are delivering physical intervention training. Most MH trusts have delivered restraint training for several years to meet NICE guidance and more recently CQC Outcome 7. Personally I don’t believe handcuffs are appropriate to manage “clinical” violence, I’m more comfortable with Velcro strap style devices or staff physically managing a persons limbs subject to suitable legal position, training, risk assessment, equipment and vehicles being used to reduce the physical and mental health risks and minimise the compromise of a persons dignity. Are the NHS there yet? Nowhere near. Is there pressure for them to achieve this? Inu opinion probably not enough but the pressure caused by tragic cases such as this, from senior police officers, coroners and concerned and passionate professionals from police, health and social care can lead to a change in outlook which should lead to tragedy s becoming a learning point from history rather than a sadly predictable and reoccurring example of a failure in healthcare.

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