The Man in the Arena*

Here is a profoundly important example in practice of some of the decisions facing operational, front-line cops about their duties and obligations with regard to mental health patients once they have had contact.

Nicola Edgington is currently standing trial for murder.  It is relevant to point out that she had previously been tried for the murder of her mother in 2006 and was found guilty of manslaughter on the grounds of diminished responsibility.  Having then been detained in a secure unit under a restricted hospital order, she was discharged from detention under s42 of the Mental Health Act into forensic community care.  She was living in supported accommodation in Greenwich, London when the latest incident occurred in November 2011.

Last year I wrote a post about how the decision would be taken on whether or not to release a convicted killer back into a community model of care, when rumours floated about PC Nina MACKAY’s assailant being considered for release.  The same legal and risk assessment process would have applied in the build up to Nicola Edgington’s release in 2009.  I am interested in this post in neither the conclusion of the current trial nor in the whether the release decision in 2009 may or may not have been premature.

JUDGEMENT CALL

Prior to the attack, Nicola Edgington is known to have approached a taxi rank in Bexleyheath, south London and asked to be taken to the Queen Elizabeth Hospital.  When it emerged she didn’t have the money to pay the fare, the taxi driver called the police and there have been various reports.  They include that she was “pleading with the police to section her” and that she “begged him [a police officer] for help to get sectioned“.  << Of course, there is a distinct difference between the two things.

The police have a power under s136 of the Mental Health Act and I’ll come on in a moment to whether it could or should have been used; but asking for help to “get sectioned” is different and does not necessarily mean via section 136 MHA.  There are other routes to getting sectioned and in this particular example, the two officers took the lady to the Accident & Emergency Department of the QEH, without legally detaining her.

  • Could they have detained her under s136 of the Mental Health Act 1983? – very probably; almost certainly.
  • Should they have detained her under s136? – it is very far from clear.

Remember the grounds for detention? –

  • A constable finds in a place to which the public have access – check.
  • A person who appears to be suffering from mental disorder – check.
  • And who is in immediate need of care or control – check.
  • The constable may, if he thinks it necessaryhang on a minute
  • In her own interests or for the protection of others – STOP RIGHT THERE!

Nicola Edgington wanted help, the police were willing to take her to a 24/7 medical facility with liaison psychiatric services who can call upon MH professionals to provide whatever assessment and admission she needs.  So if she is willing to undertake the journey and engage with staff, is legally detaining her “necessary”?  Strictly speaking, perhaps not.  Why coerce someone through a process with which they are apparently willing to engage?

But doesn’t it depends what you mean by “necessary”?  Although not necessary to detain her at the taxi rank in order to secure her attendance at a medical facility for assessment, was it ‘necessary’ to ensure that a patient who can now be seen as erratic and in crisis, remained engaged in that process?  Earlier in the month, I wrote up a report after investigating a complaint against an officer where he was accused by a patient of failing to detain him MHA when at the time of this officer’s alleged neglect, the patient was busy getting into an ambulance to go willingly to A&E.

  • So why would the officer arrest you, in order to force you to do what you’re already doing very willingly?!
  • Should the police act to ensure that no matter what happens in the subsequent hours, the person remains to be assessed?
  • If the officers don’t arrest now, could they arrest later? Yes – s136 may be exercised in Accident & Emergency if it becomes necessary to do so and the patient decides to leave.

SHOULD I STAY OR SHOULD I GO?

So what I am interested in is the debate about “should I stay or should I go?”  Having arrived in Accident & Emergency with a patient who is not under arrest or in any condition of legal custody, the officers would have to think about whether they remain with the patient after arrival.  On the face of it, there is no legal obligation to remain.  Officers have exercised a duty of care in immediately removing the patient to hospital, but nothing explicitly demands their continued attendance.

Does it matter that the patient concerned was previously convicted of homicide – the manslaughter of her mother, committed whilst mentally ill?  Some may well argue that it does.  Certainly John COOPER QC put it to the police witnesses that they should have stayed there with the patient until she was assessed and he pressed them quite keenly about why no background check was done to establish previous risks.  It also emerged during his questioning of the officers that at one particular point they began to leave and Nicola followed them claiming that she did not want to wait on her own.  After sitting with her for a while further, the officers claimed to be satisfied that she would remain there and left.

Within a few hours she had been seen and arrangements were being made to admit her as a voluntary patient to a nearby mental health ward – so the officers were not the only people convinced that she was a willing participant in a process to arrange her admission.  It has emerged during the trial on 24th January that whilst waiting for those arrangements to come into effect, she rang 999 and informed operators that she felt as she did prior to killing her mother.  She subsequently left the unit and bought a knife, attacking the first victim who managed to resist and fight back, disarming her.  She then stole a knife from a butcher’s shop and killed her second victim.  To describe this as a tragedy for all involved, is to understate the matter enormously.

20 / 20 HINDSIGHT

This is exactly the kind of debate that gets police officers going.  My sergeants and I recently discussed this at length having had three such cases on our team in the last week.  “Did we PNC and FLINTS check any of them?”  Apparently we did – all three.  “Did we remain at A&E after arrival?”  No, not in any case.  What would have happened if any of those people had then committed a serious offence?  Our approach would have been questioned, no doubt.

  • Are we saying that all people removed to A&E by the police should be PNC checked? … or just the mentally ill?
  • Are we saying that we should stay with all patients in A&E until the MH assessment process is completed?
  • Do we do this every time – and even where this risks criminalising an 80yr old dementia patient?
  • What are the dynamics here? – we wouldn’t do this with physical or medically unwell patients so is this a further example of stigma, discrimination and presumptions of violence in mental health care?
  • If we are saying, “No, you don’t have to stay with all mental health patients”, how are defining the divide?  Which ones are we staying with?
  • Is it just those with a homicide conviction, or would GBH convictions also count towards attracting a police chaperone?
  • What about violence to property or are we only interested in violence against people?

This situation is a tough judgement call.  Once you hear that Nicola Edgington is a mental health patient with a previous homicide conviction, it is hard to countenance why the police would even think about leaving her unaccompanied.  But at that time, she was engaging in something and not just because of the police being present.  The officers formed a view and made a decision that they could leave and she remained there for a couple of hours.  When she was formally assessed under the MHA, the AMHP and Doctors could have sectioned her and caused her detention to be framed by law.  They did not.

Not only with police powers of arrest, but also with medical applications of the Mental Health Act, the law requires professionals to operate against ‘necessity criteria’, ‘least restrictive’ principles and the way in which these principles are explained and framed by guidance (usually in Codes of Practice – are not black and white.  They are endless shades of grey.

So if we are going to trace history backwards to look for intervention opportunities ahead of this second serious offence, why go back to the officers at the taxi rank and not to the AMHP and Doctors who assessed her after the police had left and / or to the psychiatrists and officials from the Ministry of Justice who released her in 2009?  Just asking.

* The Man in the Arena is the title given to an excerpt from a speech by President Theodore Roosevelt (a former Police Commissioner of the New York Police Department).  The speech was made in the Sorbornne, University of Paris, in April 1910.

“It is not the critic who counts; not the man who points out how the strong man stumbles, or where the doer of deeds could have done them better. The credit belongs to the man who is actually in the arena, whose face is marred by dust and sweat and blood; who strives valiantly; who errs, who comes short again and again, because there is no effort without error and shortcoming; but who does actually strive to do the deeds; who knows great enthusiasms, the great devotions; who spends himself in a worthy cause; who at the best knows in the end the triumph of high achievement, and who at the worst, if he fails, at least fails while daring greatly, so that his place shall never be with those cold and timid souls who neither know victory nor defeat.”

______________________________________________________________________

The Mental Health Cop blog

Badgewon 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

ccawards2013 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.

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14 thoughts on “The Man in the Arena*

  1. Probably for another post altogether, but this reminds me of the Sabina Eriksson case. (Swedish twins on M6) She also went on to kill after being released. Perhaps worth a mention or discussion?

  2. Its worth considering why officers want or need to leave the hospital? Is it personal choice based on officers wanting to “do something else” or is it more likely that there are controllers or supervisors saying “we have three early responses to resource, we need to clear you”?

    1. Well, it is acknowledged that the officers did not know at the point where they left Nicola that they were dealing with someone who had previously committed a homicide. Obviously, this comes down to them not undertaking a PNC check in the circumstances which reasonable people may take a view was right or wrong.

      But given that they did not know the background and given the patient’s apparent willingness to engage, it would probably be a combination of a few reasons.including those you mention.

  3. I am really sorry but this is just awful. No member of the public would be able to use the excuse I did not know they would have to enjoy the full rigours of the criminal justice system for what ever they did no know.

    1. So which offence did the officers commit that would allow them to be prosecuted? There is no law that officers who assist unwell people to hospital where no offence has been committed MUST do a background check on them.

      My position on this is: HAD they known, they should have detained s136. Because they did not know, their actions are understandable even if you don’t agree with them – which I don’t. Everything else is a broader debate about matters of policy. Would you not agree?

  4. Even if they had used Section 136 MHA, at the point they decided to let her be a voluntary patient there would have been no need for the police to stay anyway so why would the outcome have been any different? Or are they saying we should continue to wait and escort a voluntary patient to the ward?

  5. Good post – I have 2 issues (or questions) here.

    1. We don’t have the context of her first contact with police, eg was she threatening suicide or harm to others? That is the first thing as a supervisor that I ask my officers as it affects whether I tell them to stay or not.

    2. At what point in the procedure did the 999 call take place with the female saying she felt like killing (if that’s what she said)? Again if not detained and in benefit of hindsight that should have triggered a police response until sectioned or transported.

    While the legislation is complex and grey, in my opinion is all about risk- if you leave a voluntary patient they invariably become a high risk missing person- that’s what officers should be thinking before leaving someone alone. I am usually happy with leaving them with family providing there is no violence

    1. The newspapers have not been over-flowing with detail about that first contact but I have read nothing to say she was actually violent or threatening – merely that she pleaded with the police, either to ‘section’ her or help her get sectioned.

      The 999 calls took place after the police left and I’ve heard that the content described how she was feeling – like she did before she killed her mother – but it didn’t state whether or not she had threatened again to kill.

      I agree with you about the correct focus being upon managing risks. The issue for me is that the risks were not known because of no PNC check and that we all know of loads of examples where the police have done exactly this sort of thing with non-offending, non-threatening patients and would not have felt inclined to do a background check.

      Your post did pop up twice – hope you don’t mind, I just deleted the second one.

  6. So the police probably got her to A&E about 5pm, and she walked out of the Mental Health unit the next morning around 7am?
    I can understand criticism of the police if it had been 7pm, but MH staff had over 12 hours to work out whether she might do something or not.
    Looking* at the 2 facilities mentioned in the newspaper article, the Bracton Centre where her community treatment was being managed, and Oxleas House at the QEH, where she got admitted -these are both managed by the same trust, so surely when they type her name into the computer some background should come up!
    This should have flagged to the staff that she might need to be detained.
    *(what did we do before Google)

  7. As you so rightly say this is a tough call. There is a problem inherent in analysing such a case in that on any given day with a slight change in circumstances the outcomes could be completely different. Commentators need to bear this in mind. Once one knows this woman’s background as you have said ‘they should have detained her’. I have no idea as to the information that the officers might have had access to that would have helped them in their decision making but I do wonder whether information technology could have / should have helped?

  8. Police should have PNC checked and they would have discovered she had murdered her mother. They didn’t.

    1. Which means the police now have to PNC check everyone they come in to contact with who seeks help for their mental health condition and there can be no complaints about stigmatisation when this occurs, causes interactions to last longer and leads to more use of s136 MHA, which as you rightly assert on another comment, can end up on a DBS check (new name for CRB). Or, we let officers make judgements as they do in so many things they deal with.

      End of the day: Nicola remained in that A&E until assessed by the NHS an admitted as a patient. It was from the status of being an inpatient that she absconded to kill (again). Had the officers detained 136 and remained with her until admitted, she could (would?) have still absconded to kill.

      1. No, where have I said that everyone the police come into contact with due to mental health problems should be PNC checked?! Some should be. Judgement call, as you say – in this case, one I think was wrong. She had stated that she had killed someone before and felt she would again.
        I acknowledged that the hospital were at fault but had she turned up surrounded by police, they might have made sure she didn’t.

      2. Yes, we think it’s wrong now because we know she was previously convicted of homicide. What was it about her, her demeanour or the incident which indicated prior to the police leaving A&E that she needed to be PNC checked? Most cops I know have dealt with dozens, if not hundreds, of people in similar circumstances and we often don’t PNC check and admit we may not have done so here.

        So what – precisely – was it about her that meant she should have been PNC checked and “surrounded by police” up to the point where they left her in A&E? They absolutely KNEW about her background by the time *they* made the decision not to section her and to admit her to a ward.

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