Two things happened to me recently to cause my head a brief period of cognitive dissonance as I unwound from my LATE shift last night. I recently went to work to find a person in the cells who had not long been arrested under section 136 of the Mental Health Act. I noticed when I got home from work yesterday, a Twitter remark from an A&E Consultant questioning why he and his staff should have to put with aggressive behaviour from the public and being shouted at?
These two things got me thinking –
EMERGENCY MENTAL HEALTH CARE
The person detained under s136 had been removed to the cells because the Place of Safety in the area concerned had been telephoned by the police control room after arrest to notify them that officers would be heading towards them with a detainee and were asked, “Have they been violent?” In fairness, the person concerned had displayed some agitated behaviour. Actually, they were screaming very loudly in distress and had been doing so before the police arrived – that’s the reason the police were called in the first place: members of the public concerned about the individual and their behaviour in a public place.
When detained by the officers, the person had been resistant – frankly, very frightened by what was going on – and had been handcuffed by the officers in order to maintain the safety of the person. There is one other dimension to the incident I’m afraid I can’t recount as it would potentially be an identifiable factor, but I’d ask you to just believe that it would be something causing additional distress and the officers had to manage that too.
The phone call lead to the receiving nurse saying that because violence was an exclusion criteria, the person could not be taken to the place of safety and would need to be removed to the cells. Paragraph 10.22 MHA CoP anyone? (This is now paragrah 16.38 under the new Code of Practice – see below).
EMERGENCY PHYSICAL HEALTH CARE
Meanwhile, in Accident & Emergency in another part of the UK, our Consultant colleague is being shouted at by aggressive patients and their family members whilst attempting to deliver healthcare. Why should they have to put up with that? Why, indeed, DO they put with that?!
So, I asked him! Various responses to his question “Why do we put up with it?” came back with clinical reasons and an underlying fear of rare events leading to professional misconduct allegations, etc.. Maybe the aggression was attributable to underlying organic disease and premature dismissal of the patient for their opprobrious behaviour could lead to undiagnosed disaster? Even though this is a rare possibility, it is a possibility and goes a long way to explaining why A&E staff suck up a level of personal abuse and threats that most of us wouldn’t stand for: even in the face of threats to their safety, they are attempting to assess their potential and their professional need to care. Perhaps they’ll have A&E security standing nearby and sometimes they will call the police and staff will continue to treat people even after assaults have occurred – believe it or not.
If you want to see this for real, look at the case of Christopher ALDER in Humberside. The events leading to the police arresting Mr ALDER who subsequently died in the police station, was that A&E dismissed him without adequately evaluating a head injury that had been sustained when he was assaulted.
So here’s my question for place of safety services who decline to accept patients following a third-party telephone triage because of violence that they haven’t seen:
How much violence is too much violence, where’s the evidence base for that line being drawn and how do you know whether or not the violence is clinically attributable? Where is the level of anxiety about undiagnosed, unidentified threats leading to professional disaster that appears to exist in A&E? How do you tell all of this when you’re not actually seeing the patient but are speaking to a police control room operator who isn’t with the patient either? Are we ever going to get that right, except by chance?!
Actually, one of my main objections is that it wasn’t violence at all, it was resistance predicated upon very real fear and a case of being very, very “shouty”. The fear in this person was no less real for the fact that it was all clinically attributable to psychosis – in the opinion of the s12 Doctor who saw the person in custody. All were agreed: police custody was making things worse but because we still have a level of “Doctor knows best” respect for our NHS, the officers concerned had removed that person to the cells.
My questions when I took over as duty inspector included –
- Was the person transferred from arrest to custody by ambulance? – if not, why not?! See Chapters 10 and 11 of the MHA Code of Practice.
- Has anyone asked the question about “RED FLAGS“?
- If the detainee has not been seen by any healthcare professional, can we be sure they are safe in custody? – if so, how?! Remember: almost half of all deaths in custody involve people with mental health problems, often complicated by drugs and / or alcohol.
- Unless the FME is getting out of their car in the police station car park, should we not think about transferring the person to hospital?
As it happened, the FME was nearby and the first thing he said after examining the person was “being here is making it worse”. There were reports of psychosis, hallucinations and paranoia – fear that officers were going to inflict injury or death, a total lack of communication with anyone in custody. I mean that literally. There were suggestions that sedation may be required.
The first thing I did, was send two officers to custody and tell the custody sergeant to ring the relevant area’s place of safety to inform them that the doctor had authorised a transfer to them because the person was not violent and was being made worse and being made to suffer in custody. Within a couple of hours of being detained, they were in that area’s PoS facility and any ongoing concerns for staff safety arising from the patient’s presentation would be mitigated by officers remaining at the PoS to support NHS staff.
Of course, we’d also “breached the protocol” by transferring someone to a PoS in another area – the person’s home area. Normally, everything happens in the local authority area where the police detention occurred. Oops! – but of course, no laws were broken in doing so, everyone agreed it was right and it expedited the persons MHA assessment.
Incidentally, I got shouted at and very personally abused last night by a young man who took a dim view of police actions at a job, but then we are trained and empowered to deal with this in a variety of ways. I couldn’t manage to get myself into the position the young man had suggested whilst wearing a protective vest so I just ignored him and cracked on … but our colleagues in the NHS don’t have that luxury.
So the cognitive dissonance is at the organisational level of the NHS: how can we think it is simultaneously OK to dismiss some patients to police cells for resistant or aggressive behaviour that has not gone anywhere near a healthcare professional AND think it acceptable that NHS staff continue to suffer abuse and assaults because of fears that such obnoxious conduct may have an underlying clinical cause?
Leave it with you …
Update on 01st April 2015 – since writing this article, a new Code of Practice has come into effect in England. It doesn’t substantially alter the post but certain reference numbers have changed. My summary post about the new Code of Practice (2015) is here, the new Reference Guide is here and the full document is here. The Code of Practice (Wales) remains unchanged.
The Mental Health Cop blog
– won the ConnectedCOPS ‘Top Cop’ Award for leveraging social media in policing.
– 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
– was highlighted by the Independent Commission on Policing & Mental Health
– was referenced in the UK Parliamentary debate on Policing & Mental Health
– was commended by the Home Affairs Select Committee of the UK Parliament.