Mental Health Restraint

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.

1. RED FLAGS go to the nearest A&E
2. No RED FLAGS go to the psychiatric place of safety
3. 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.

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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

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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