Here are two things that we learned today —
1. One of HM Coroner’s Courts ruled that unnecessary force ‘more than minimally’ contributed to the death of a man with mental health problems in police custody.
2. Earlier failures to monitor refusal to take prescribed medication and to arrange a mental health or Mental Health Act assessment, ‘more than minimally’ contributed to the death of a patient in police custody.
There is something in the police officer inside me wants to focus on point two. After all, had the failure to take prescribed medication been followed up earlier, perhaps via greater support or a Mental Health Act assessment, the police intervention which involved unnecessary force may not have become necessary at all. Surely it’s about ‘upstream interventions’ by other agencies – in this case mental health services?
I’ve given away before, that I think this is a complete red-herring. Policing only exists at all because sometimes people don’t do what we’d expect them to do and this includes professionals omissions leading to a need for the police service to act, as well as to personal failures which require arrests and criminal investigations. Whether rightly or wrongly, whether through system or personal failure, or whether it is just “one of those things”, the police service will again in the future be called to a situation involving someone with mental health problems who is exhibiting resistant, aggressive or violent behaviour; possibly in the context of being restrained under arrest or to prevent their escape from somewhere, like a mental health facility, for example. We need to know what we’re doing.
So let me tell you something about the story of Rocky Bennett not least because it is not a ‘police’ story. David ‘Rocky’ Bennett died in a Norfolk mental health unit in 1998 after a restraint related intervention by NHS staff. There was subsequently an inquiry into his death, not least because of various obvious racial connotations to the incident – it may be argued to be the ‘Stephen Lawrence Inquiry’ for the NHS, which explored the concept of ‘institutional racism’.
Rocky had been racially abused on his ward by another patient during the course of a day and his representations for protection from this led to a perverse decision that he would be moved to another ward. Not the perpetrator. He resisted this and was restrained. He was held in the prone position for a long period of time and died before he was moved.
Here are various things that were said during the Inquiry:
- Any patient who required physical restraint was by definition in a medical emergency – p52.
- Wherever a mentally ill patient is detained there should be a fully equipped resuscitation trolley;
- There should also be people who were capable of giving drugs and using the equipment, including a defibrillator. – p55.
- There should be a doctor in every place where mentally ill patients are detained, or if that is not possible foolproof arrangements should be in place twenty-four hours a day to ensure that a doctor will attend within twenty minutes – p55.
Read those again and think about the medical implications of the police service picking up violent, resistant patients – irrespective of whether there could or should have been any form of ‘upstream intervention’ – and then think about the clinical care that will be provided in custody. We couldn’t deliver on any of this – not even nearly. Think about the physiological implications of restraint, especially where it may potentially continue for more than a few minutes now that you’ve reflected upon this incident and upon the news today.
We can debate this stuff all day long, but actually it always comes back down to this – whether you’ve arrested a vulnerable detainee under s136 of the Mental Health Act OR whether you’ve arrested someone for a criminal offence who you know to be mentally ill:
- Arrest – for s136 or the offence, as appropriate.
- Ambulance – call one every time!
- Assess – their medical needs before you do anything else.
- RED FLAGS go to the nearest A&E
- No RED FLAGS go to the psychiatric place of safety
- When everything else has failed, and if no appropriate alternative can be identified, the police station is the last resort.
I would submit, that this model, described more fully elsewhere on this blog will ensure that the best is done, to assess and respond to whatever medical or psychiatric issues are presented by detainees with complex needs. Being frank, attempts to follow this model will also ensure that even if any part of the NHS find themselves unable to be sufficiently responsive, the officers will be able to show that they have done all they reasonably could do to access medical care, to discharge their legal duty of care.
But the main point here is that of restraint: restraint is frequent business for police officers, probably far more frequent than it is for mental health professionals. More important still, restraint of patients with complex medical presentations – perhaps complicated further by drugs and / or alcohol – is fundamentally different in nature to the restraint of burglars or shoplifters. it needs to be seen as such.
This is why policy leads in police services need to be aware of the existence of NICE guidelines on these issues*. We need to give the opportunity to the NHS to implement them, where they can relate to patients who have been detained by the police. Again, being frank – I’ve dropped these guidelines onto the toes of various NHS professionals, including A&E staff and psychiatric nurses. Most of them haven’t heard of these guidelines, but that’s their issue, not mine.
If you take nothing else from this blog – take this: the need for ongoing restraint of a mental health patient is a medical emergency – a RED FLAG – and the person should be removed to Accident & Emergency for assessment. This is not my view, it is the view of the A&E Consultant who drew up the RED FLAG list that forms part of my area’s place of safety arrangements. We didn’t just take his word for it either: we took his list to every A&E department in my force area and explained what it was; we also took it to the Strategic Health Authority. They all just nodded and agreed it so there are centuries of professional experience in emergency medicine saying that this is right!
Incidentally: guess which one of these two findings is all over twitter and the press? … and guess which one is not?
*NB: when this post was first published, the hyperlink to NICE Guidelines was to a 2005 document which has since been withdrawn and is no longer publicly available. For the sake of the substantive point being made, I have linked to the updated guidance which was published in 2015 but not in force at the time of the original post.
Winner of the President’s Medal, the Royal College of Psychiatrists.
Winner of the Mind Digital Media Award
All opinions expressed are my own – they do not represent the views of any organisation. (c) Michael Brown, 2012
I try to keep this blog up to date, but inevitably over time, amendments to the law as well as court rulings and other findings from inquests and complaints processes mean it is difficult to ensure all the articles and pages remain current. Please ensure you check all legal issues in particular and take appropriate professional advice where necessary.
Government legislation website – www.legislation.gov.uk
8 thoughts on “Mental Health Restraint”
We, the police, are not always good at joining dots to see the bigger picture. We provide first aid training to front line staff, its content is limited to whatever the HSE say it should be. We provide additional first aid training to officers whose role may inflict major trauma – I’m thinking of firearms officers, but there is clearly a gap in training officers to identify what you elegantly describe as ‘red flags’, where there is no physical trauma but there are high levels of psycholgical trauma that may lead to major bodily systems failure.
2 August 2012
Thank you again for all your blogs – they are excellent and thought-provoking.
“Joined-up thinking” used to be the political mantra a few years ago, but is rarely heard now.
It seems to me that the entire service provision in the United Kingdom needs to be revisited.
This includes inter alia:
Education from cradle to grave
Health provision from cradle to grave
Law – a Robert Peel consolidation of laws into a manageable and comprehensible Code for the Citizens of the UK so that we do not find ourselves unwittingly breaking a law which we do not even know existed – and I take this from a discussion on television broadcast a few weeks ago by an eminent lawyer who said some of these laws have 1200 subsections and is unworkable
Policing by consent of the citizenry of the United Kingdom and that the people who tread the thin blue line be both supported by the citizenry but also be regulated by the citizenry so that people can express both their satisfaction and dissatisfaction in a public forum, so that we can all work together to get consensual policing, for police put their own lives on the line to protect us in violent situations.
Judicial System – judges must be made accountable to the citizenry of the UK, as they seem to make perverse judgements which cannot be challenged except by other judges
Unfortunately following a recent incident it’s clear that the NHS have no contingency options when it comes to restraint in the community. When a risk assessment was completed by police following a 135 (1) warrant it was decided that the use of force would wouldn’t be appropriate by untrained officers and that MH staff with control and restraint techniques would be better placed to remove the patient (pensioner with a heart condition). Following, several hours of escalation on both sides we were told they couldn’t come out as they’re not trained to do it in the community.
So there you have it THERE IS NO PLAN B! If the police say NO it doesn’t get done.
Unfortunately following a recent incident it’s clear that the NHS have no contingency options when it comes to restraint in the community. When a risk assessment was completed by police following a 135 (1) warrant it was decided that the use of force wouldn’t be appropriate by untrained officers and that MH staff with control and restraint techniques would be better placed to remove the patient (pensioner with a heart condition). Following, several hours of escalation on both sides we were told they couldn’t come out as they’re not trained to do it in the community.
So there you have it THERE IS NO PLAN B! If the police say NO it doesn’t get done.
from this thread: http://www.guardian.co.uk/commentisfree/2012/aug/04/samantha-rigg-david-sean-riggs-death
“Samantha I understand your pain & I do not wish to absolve the Police from blame, as they deserve it, but from an objective outside view I see your brother’s death as a massive fail from the health service. I would not assign any individual blame as I do not know why the health service failed, it could have been due to resource issues, who knows, but the facts are that your brother was a recognised vulnerable adult living in a supported Hostel for people with mental health issues. The Hostel staff signalled the need for intervention & no intervention was made.
There was a massive fail here, your brother should not have died in custody because he should not have been in custody in the first place. You have to tell the whole story.”
It IS resources and it IS NHS failure. I’ve argued with cops in the street in the middle of the night over who should carry the risk in a mental health assessment scenario. Truth is, they were RIGHT and we were wrong, but resources dictate that we are one assessing nurse and one band 3 support worker as the *entire* night provision across three metropolitan boroughs of some 500,000 people.
… and on the night in question, there was NO capacity for inpatient admissions across the whole regional sector. Something’s got to give.
Throughout my life I have always supported our Police and encouraged others to do the same – sometimes to the point where my and my family has been placed in danger. If we ask people to do the work of a Police Officer we have the responsibility to so support them. However, this is a much wider issue than has been presented here. The issue that ought to be addressed, not only in the Police services but everywhere that people are detained involuntarily is whether “Control & Restraint” is a reasonable and proper response to people suffering a crisis in their behaviour? It is, without any doubt, a shameful thing that within our caring services people are taught to use the same techniques of “Control & Restraint” that our armed forces and the Police are taught.
“Control & Restraint” is a method of controlling people through the deliberate use of pain; it inherently contains certain techniques that will lead to injury or even the death of some on whom it is practiced; it should never, under any circumstances, be an option for someone in the caring professions to use. There are alternatives, such as “RESPECT” – which is used in mental health services in North East Lincolnshire and is being introduced by a number of other progressive and caring Trusts nationally.
As to whether it is a suitable method for the Police may be another matter, however there is one example of a small national Police force introducing it. Still, all investigations into these deaths where C&R is used should take a careful look at the alternatives. Maybe the Police should have C&R as a possible response at the last resort but it should not be the first & only method available to them. I cannot immagine how actually being involved in killing another person in this sort of situation can impact our Police Officers but we should be providing them with other techniques that in many situations would mean that the dangerous C&R does not need to be used.
“Rocky had been racially abused on his ward by another patient during the course of a day and his representations for protection from this led to a perverse decision that he would be moved to another ward. Not the perpetrator. ”
pages 16-17 of the inquiry (http://www.irr.org.uk/pdf/bennett_inquiry.pdf) give an accurate account of the events of the evening and explain the thinking behind the decision
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