I have referred during a few posts to the practice in some Places of Safety of staff ‘screening’ patients before agreeing to their entry with the use of a breathalyser. Time for a specific post about it, following it coming up on Twitter in the context of discussing Section 136 and Alcohol.
The police have understood for years that mental health or Mental Health Act assessment can be impaired by alcohol. Whilst the practice of assessing someone for full admission under the MHA whilst patients are under the influence of alcohol is NOT prohibited, Chapter 4 of the Code of Practice does suggest it should be carefully considered against the potential to delay an assessment. << This is important … I have heard numerous AMHPs and other mental health professionals state that you cannot – ever – assess patients whilst they are intoxicated. This is simply wrong, both in law and in practice. It may be preferrable to wait, but it is not obligatory. And of course there is a difference between someone who has ‘had a drink’ and someone who is ‘intoxicated’ or ‘drunk’.
I want to start off by re-sounding a quick alarm bell towards the police use of section 136 – there are some areas of the UK and some officers where use of this important authority is quite inappropriate. Some officers arrest people who are drunk when there are no reasonable grounds to suspect any additional mental illness. Officers’ observations of drunk people which are unaccompanied by additional information to suggest a real mental health problem, are usually insufficient for officers to be confident that section 136 is the right approach. Forces need to work on this, through decent training to operational officers. That said, mental health professionals need to understand that where officers do know that they are dealing with someone with a mental health history, section 136 is not off-limits because of the current presentation involving alcohol. This would exclude dual diagnosis patients from healthcare and potentially prevent other masked healthcare concerns being brought to the swift attention of paramedics or other healthcare staff.
That now having been said! – I have heard senior psychiatrists suggest that breathalysers should be mandatory before an NHS trust agrees to ‘allow’ someone to enter a place of safety. I’ve heard other senior psychiatrists describe the practice as – and I quote it, because I wrote it down at the time! – “Fairly disgusting if you think about it.” … and if we are going to do it, bearing in mind there is no legal power to insist that a patient submits to a screening test, what are we going to do with the reading it provides? What is the threshold to be applied and to what purpose?
And what do we think it is telling us?!
Are we saying that the reading, measured in micrograms of alcohol per 100ml of breath, will then determine access or will it just be indicative as to how much someone has consumed and roughly how long it may be advisable to delay an assessment? Is it really ethical to conduct these tests in a car park outside the PoS?! – yes, it does happen.
- How alcohol affects people will vary from person to person
- How alcohol affects the same person will vary from time to time
Some Place of Safety services who use breathalysers as a screening tool for entry, use the drink drive limit as the cut off point – 35ug /100ml breath. This is about two pints of beer / lager for most people or a large glass of wine. Others use 50ug or some use double the drink drive limit of 70ug. Why such variation?! Where’s the evidence base for one limit over another and how does it impact upon the s136 population it affects? The truth is, we do not know because it is not researched.
DRINK DRIVE LIMITS
The drink drive limit is set on the basis that most people will be sufficiently affected in their ability to drive if they are over the limit, that it is not worth the risk in allowing them to do so. It does NOT equate with being ‘drunk’ for the purposes of other law. For example, I would say that most people I have ever arrested for drink-driving were not ‘drunk’ – but they were definitely over the legal limit. They were neither ‘incapable’ nor ‘disorderly’, for example and could not have been arrested for those offences – but they were still over the limit and I would not want them to drive past my son’s school at 4pm.
So I would argue, and there are enough psychiatrists and other doctors who would argue likewise, that a screening breath test tells you nothing of relevance to the decisions you are trying to make about whether someone is fit enough to undergo mental health assessment. I was moderately over the drink drive limit a few times on my recent holiday as South Africa produces very nice red wine … I’d never have driven a car whilst exploring the Boschendal but I would question whether I was ever so intoxicated that I couldn’t account for myself or my medical history had the need arisen.
And we also know that someone who is alcohol dependent can be taken to a very dangerous place, medically, if they are suddenly forced to completely sober up. We see police doctors ‘prescribing’ alcohol to a few detainees on occasions to ensure that they don’t sober up entirely. There is a police force in England who had a near-tragic event in their custody after the NHS excluded a mentally ill, alcohol-dependent chap who had been detained under s136. Fortunately for the Chief Constable, his custody sergeant was switched on and got him to A&E quickly.
EXCLUSION TO THE CELLS
Of course, if the presumption of health professionals is that failure of such tests will lead to exclusion to the police’s cells until sufficient sobriety has returned, then they should think again. We know that alcohol can mask other healthcare problems – diabetes, head injury, epilepsy. We can name the people who have suffered untoward events in custody because of such an approach to alcohol which is too casual. We also know, that patients who are resistant being excluded to the cells can also lead to untoward events and illegality. We all know the cross over between alcohol / resistance and mental health in s136 detentions. Any custody sergeant worth their salt would be aware of para 9.5 and Annex H to Code C of PACE which covers the sergeant’s duty to ensure that people with unmet health needs get appropriate clinical attention. Whilst this often involves calling the privately contracted FME, it could also involve calling an ambulance and / or transferring someone to hospital. That is the difficult judgement call that custody sergeants with first-aid certificates have to make every time someone becomes detained.
An A&E Doctor once said to me, regarding the development of sound protocols for clinical care in A&E, “We wouldn’t assume that someone’s potenitally bizarre or disruptive behaviour was attributable to alcohol, until we had ruled out everything else. This includes diabetes, head injury and loads more besides. Only when we are happy that those are not a risk, would we write someone off as simply ‘drunk’.” The police service should be wary about deviating from this approach in custody and we should certainly NOT assume that the application of exclusion criteria by a psychiatric Place of Safety has been done following a proper triage by paramedics and a physical assessment, etc..
A tweeter this morning informed that when they ring their PoS service to inform them of an arrest, the first question asked is, “Have they been drinking or violent?” If the answer to either is, “Yes” then they refuse admission. Presumably because a telephone conversation with a police controller is sufficient insight and examination of the patient to be confident that is a safe decision?
The Mental Health Cop blog
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