This is a picture of my son playing about with bits of my uniform: potentially, he’s the best human being ever to live, just like everybody else’s kids. Definitely, the best thing about my life on earth – getting to be his Dad.
I want to tell you a story about someone else’s child – because I admit that it got me quite upset bordering on angry and I often think about children’s mental health issues through the prism of being a dad. Wondering what I would do, how I would feel.
I went to work a while ago to find an email from an Acting Inspector, in the north of England, who had queries. His officers had been to a domestic address to support social workers who were present with a child / adolescent mental health nurse as part of routine community care and the child (10yrs old) had become aggressive. They had suggested the child with autism needed a mental health act assessment and called the police. There entailed a story that had me sitting staring into the mid-distance wondering what on earth we think we’re doing.
The police were asked to remove the child to A&E. Of course, there is no power whatsoever to do this as the child is in their private dwelling so s136 MHA cannot be used and no-one has sectioned the child. Parliament’s intentions around this scenario are that a s12 DR and an AMHP attend the home address and use s4 MHA for emergency assessment / admission. I suspect a reason why this was not done which I’ll leave until further into the story. So the social worker and CPN set about ‘persuading’ the parents of the child that he needed to go to hospital and they should take him to A&E. Quite why this is right, I’m not sure – the child was not physically injured or suffering from any obvious RED FLAG, they were ‘just’ perceived to be in need of MHA assessment. I can imagine if the child had been removed to A&E as a place of safety by the police, they would have been denied access to it. This has happened to countless cops over the years.
Nevertheless, the officers at the scene were implored to accompany them on the journey because of the violence exhibited and they agreed to do so. This is the first ‘error’ in my view, where they offered their arm to the mangle and started to get sucked into a nightmare. As I read the email telling the story, I got to this point and thought a certain thought, which I’m still keeping to myself until later.
THREE HOURS
Upon arrival at a busy A&E, the child was triaged and not turned away – social workers and psych nurses can get non injured MH patients into A&E, it’s only the police that struggle – and he was put into a normal cubicle that had been cleared of all equipment, including the bed. They were supplied with a chair and various ‘fitness mats’ for the floor. The A&E staff insisted that the police to stay because they had been told by the social worker of the previous violence at the home address. Standard warnings to the officers about the A&E not being able to detain or restrain were administered and they agreed.
We can all understand why they did: child in A&E who has been violent, who is upset and volatile and may run off, of course the police should stay!? That all having been said, we’re only in A&E in the first place because we haven’t put a legal framework around the child at their address and we’ve removed them to A&E despite them not suffering from any condition which would prompt removal there if they had been arrested under s136. I wonder why?!
A&E asked the s136 question at some stage, assuming that police plus volatile child with mental health problem and when they learned that the child was not so detained, they requested it. Officers had to explain that the legal criteria were not met, because the child had not been found in a place to which the public have access so an arrest now would still be illegal.
TWELVE HOURS
It was over twelve hours after initial attendance and a change of officers because of shift changeover before the AMHP and a CAMHS psychiatrist got there. The child was still volatile, despite his mother’s reassurances and a good manner by the officers. A&E were expressing frustration at everyone, some 8hrs after expiry of their 4hr target, that we still were relatively nowhere in bringing this process to an end. Assessment of the child led to a conclusion that they needed admission to hospital, detained under s2 of the Mental Health Act because they were a risk to themselves or others, volatile and unwilling to undertake voluntary admission. And here is the kernel of the story: where do we find a CAMHS bed? – nowhere. There are none.
BINGO! – this was coming from the minute we attended the house. We think the child needs admission; we know we haven’t got access to a CAMHS bed and it will be difficult (it usually is); we got to do something, this is ‘something’, so we’ll do this.
As the AMHP and the psychiatrist waved goodbye to the police and A&E staff saying, “We’ll identify a bed and get back to you” they left these emergency services with a nightmare. This child, in need of compulsory admission under the Mental Health Act, is in an A&E department with one of their parents, two cops and some A&E staff without a condition of legal detention around them as they have not been detained s136 and are not (yet) detained under s2 because no application has been completed and no other legal ground for detention exists. Personally, I’d have taken my son home at that stage as both I and he were legally free to leave. However, it had been implied that the boy could not leave because he’d been ‘sectioned’ … which of course he hadn’t, because no application had been made. (Article 5 ECHR anyone – detained by a process not prescribed by law?)
THIRTY HOURS
This saga continued with various protests and escalation of concerns around bed access. Vicious rumour emerged at one stage of a CAMHS bed 100 miles away … but that faded amidst the AMHP not being able to square an out of area admission. Overnight, the child slept well enough with two cops still stood around them. Doing what, I’m not quite sure … it was insisted by the A&E nurses involved that only the police had any power to restrain the boy. Quite why they’d think this and tell the cops what legal authority they had I’m not sure – I don’t tell nurses when / how to provide medical care? <<< This could be me being sensitive about the appalling position everyone was left in. Reality is, no power whatsoever to restrain the child, unless they offend or start actively attempting to serious hurt themselves or others. Should they try to leave, s136 is still highly questionable as the whole story began with removing the child from a dwelling … the passage of many hours doesn’t change the fact that the police did not find him “in a place to which the public have access.”
The officers at one stage were so frustrated – the inspector acknowledges that he and his officers were starting to get very grumpy indeed – they decided to try to improvise a better, temporary solution. They established of themselves that the local s136 place of safety was empty. They tried to encourage the AMHP to have the child removed from A&E, admission made to that PoS hospital and the boy temporarily held there where he could at least be in a more secure location, with better facilities for him in terms of bed, shower, toilet, etc.. Denied. “That’s not what it’s for.” But what do we think A&E is for? Surely not for providing a poor quality sleeping area for held-but-not-held children who need MHA admission so they can sleep on a floor and struggle to get drinks, toilet access and have no access to proper cleaning facilities.
Read that paragraph again: we will continue to ‘hold’ a autistic child in an A&E without a clear legal authority to do so; where access to basic facilities is made complicated by a department full of drunks, road traffic collision victims and other members of the public with injuries whilst a mental health facility with CAMHS staff just a few miles away has a Place of Safety (the clue is in the name) which is currently empty and which is not used very often. I know it’s not in the textbook or the guidelines, but is it legal? Which is better for the child? Is it even in doubt?
THIRTY-TWO HOURS
Eventually, the child was admitted to children’s ward in a general hospital with two-to-one nursing and the police were ‘allowed’ by the NHS to leave (thanks). Illegal detention of the child over, he was seen by a CAMHS psychiatric consultant on the first morning after admission. Released from detention under the MHA after about 9 hours.
Read that paragraph again! After nearly a day and half of effort, resources and frustration he was released after fewer than nine hours. Great.
I’ve asked this before, but I’ll do so again – if any person who has been volatile and aggressive is assessed as being in need of admission to hospital and is a vulnerable condition of non-legal detention in an A&E department with two cops who cannot legally prevent them from leaving unless they commit a criminal offence – of what application to this scenario is s13 MHA, s140 MHA and the MHAC (now CQC) guidance. If these things are utterly meaningless, can we please see the guidance retracted and the law changed. And if they mean anything at all, can we please see the organisations who administer MHA admissions at least knowing about it and acknowledging it, potentially with regulators and inspectors doing their bit.
Meanwhile, the police officers involved are raising formal representations. It is not legally correct to say “If there are no beds, there are no beds.” It is self-evidentally obvious and yet legally irrelevant all at the same time. Whenever I read s13 MHA about the duties of the AMHP to make applications, I note it does not contain anything about beds, hospitals, willingness, etc.; we have legal duties here. It’s almost like saying “Teh cells are full, so we can’t arrest this bloke despite the fact he’s stabbed you.” I know it’s better to ensure a smooth run following application for admission and that the Code talks about this in Chapter 4, but if a smooth run is not possible and the only other option is a situation such as this and it’s glorious illegality, should we not try the bumpy route? As long as we get there in the end, with the patient’s interests first?
I couldn’t help but think: do this to my son, and I’ll be speaking to a solicitor in the morning.
Winner of the President’s Medal,
the Royal College of Psychiatrists.
Winner of the Mind Digital Media Award
All views 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.
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Mental Health Cop 
Well so many things wrong here its had to know where to start, why wasn’t the child assessed at home although i think i would of questioned why they felt a MHA assessment was required in the first place. There is no excuse for the assessment not taking place within 4 hours, shift changeovers or not. As an AMHP i would not of left when you are trying to get a bed you are ringing people that’s it, you may be arguing with lots of them but that’s no reason to leave. This situation is exactly what Section 140 is for. I hope the parents do get some good legal advice and sue all parties involved.
Thanks for the endorsement of the thrust of my thoughts … I was appalled. The inspector who raised it to me didn’t have MHA sections to deploy an arguement but his common sense meant his thinking was in exactly the right place. He raised these things and said the response from one of the AMHPs and certainly from a psychiatrist was one of being overwhelmingly patronised.
Thanks again – much appreciated!
My stepson is on the autistic spectrum. He doesn’t always make the best choices but this sort of scenario most certainly wouldn’t help him.
I probably wouldn’t have taken him to A&E to begin with but if I had I think I’d have taken him back home again pretty quickly too:
“Show me the relevant documentation or get out of the way. We’re going home.”
Cheers,
Stuart
Agree with the theme of your frustration and comments and thank you for the interesting post. What an awful situation for everyone to be in. Just wanted to highlight that you won’t find anything in s13 about the AMHP finding a bed. Its not the AMHP or the local authorities role to find a bed – its the job of the NHS Trust. I realise that may sound like passing the buck, but one of the main roles of the AMHP is to bring a social perspective to what could otherwise be a very medical process. The AMHP has no authority to find a bed or to authorise out of area beds – again job of the NHS Trust. This can be muddled sometimes as AMHPs work within these same Trusts, but this is not a responsibility usually devolved to them and very important to put pressure on the Trusts to find a bed – as you say ‘there are no beds’ is not a good enough answer in any respect. Mark
I’ve re-read what I wrote and I didn’t claim it was the AMHPs responsibility to identify the bed and I’m aware it sits with the doctor. I specifically pointed out that s13 doesn’t contain reference to beds because you know, as I do, that the criteria don’t include availability of beds.
It is so interesting to read how this can work on your side of the pond. I’m befuddled by how complicated this situation was.
By the way, your son is a really cute guy!
So much is wrong……and your child is your child no matter what age they are! Thank you for your empathetic approach. Lucky lad and lucky Dad
Speaking in a personal capacity as a CAMHS nurse with experience of working in an in-patient unit, I can empathise with the sense of frustration that emanates from this story, and I agree that legal processes can be mis-used to deal with children with autistic spectrum conditions. However, there are wider factors in the mix that may complicate the issue as well, and in my opinion young people with with these conditions are disadvantaged by a lack of suitable service provision, especially in terms of admission into acute CAMHS services .
Emergency CAMHS admissions for young people with Autism and Aspergers often come about because things have reached crisis point at home, and can be very unsettling for children who find it difficult coping with changes to their daily routines at the best of times. Once they have been admitted, staff often grumble about how it’s an ‘inappropriate admission’ for an acute assessment unit. Finally, in terms of assessment and/or treatment, it’s limited what can be done in terms of medical interventions because Autism/Aspergers are life-long conditions that don’t respond to medication. In these cases, once they have settled down from the initial disruption of admission, the best way to help is to work together with the family as a whole to implement behavioural management strategies that help everyone cope with the sometimes challenging behaviour that can be associated with autistic spectrum disorders. However, such strategies are best done in the community, meaning that other than sometimes providing a brief respite for parents & carers, in-patient admission is rarely in the child’s long-term interests.
The example you cite shows clearly how young people with autistic spectrum disorders can be let down by mis-use of the Mental Health Act, but I worry that it goes beyond legal issues. Better service provision and training for all professionals working in this area so they can better help chuildren with these conditions would be most welcome.
Thanks for saying so … I haven’t so much got a problem with the bed issue – OK, I’ve got a small one, because the NHS constantly seems to run at capacity which is inherently inefficient when managing complex, unpredictable demands – it’s more about the way in which it was originally managed. There was a clear intention to detain the child for assessment with an initial view that admission was needed. So the options were get an AMHP / DR out and use s4, or get a 135(1) warrant and remove to a proper place of safety where you’ve got 72hrs.
Leaving aside the issue of whether areas have PoS services that accept children, this would have been much better than messing about in A&E, in my humble view. Thanks again, appreciate the comment.
Nope. Read it. Don’t get it.
People were there to help but the lad wasn’t keen. Why didn’t they just sod off? What has this to do with police? Sure he was aggressive but he’s frustrated/frightened/autistic. Back off. Go away. Make sure the mother knows she has someone to turn to if there’s a REAL problem but get the hell out of there.
FAR too many visitors in the home in the first place. Bound to destabilise the kid. The professionals caused the problem. This was meant to be routine? Well, he wasn’t in the mood that day. Dear God, anyone who works with autistic kids for 5 minutes could suss that.
Nothing to do with the police. What a performance! Waste of resources and the lad and family will be hard pressed to trust any of the professionals again. Sorry and all that but social workers?! Waste of space. Oh, and CAMHS aren’t always that great. Has to be said.
Caveat: these are my personal views and do not reflect the views of my employer or the author of this blog. #SosueME
I was shocked at reading this blog. I feel sorry for the child who was treated horribly by all sounds of it. I mean I have worked with children with aurtism and have a family members and I know how hard they can be to lookafter but to put the child through that is shocking. I hope they get good legal actio.
Great blog. Also for that Revolving Doors .http://www.revolving-doors.org.uk/news–blog/blog/spark-guest-blog/guest-blog-from-michael-brown/. Both reproduced here [http://www.aopm.co.uk/latest-blogs]. With thanks.
Cheers! – thanks for that. 🙂