The College of Emergency medicine today published a mental health toolkit, to assist acute trusts’ Emergency Departments in understanding the overlaps with mental health and improving liaison psychiatry services for the benefit of us all. A comparatively short document in an accessible format, I opened it up and searched for the phrase “place of safety” which I couldn’t find. I then searched for the word “police” and it brought me directly to section 11: which also includes a link to Royal College of Psychiatry Standards on s136:
“All areas in England will have a multi-agency policy for section 136 patients. There should be an appendix relating to the use of emergency departments. It is prudent to ensure that this is appropriate for your local service, and that the ED is only used for 136 patients who have an acute healthcare need. Otherwise mental health services should provide an assessment suite, or where necessary the patient should be taken into police custody. The policy should also include a strategy to ensure that acceptable time frames for a mental health act (MHA) assessment are established, with provision for police to remain with the patient if they are managed in the ED. The police should stay until a MHA assessment has been completed.”
Based upon that, I want to talk about para 10.21 and 10.22 to the Code of Practice to the Mental Health Act.
- Para 10.21 – A police station should be used as a place of safety only on an exceptional basis. It may be necessary to do so because the person’s behaviour would pose an unmanageably high risk to other patients, staff or users of a healthcare setting. It is preferable for a person thought to be suffering from a mental disorder to be detained in a hospital or other healthcare setting where mental health services are provided (subject, of course, to any urgent physical healthcare needs they may have).
- Para 10.22 – A police station should not be assumed to be the automatic second choice if the first choice place of safety is not immediately available. Other available options, such as a residential care home or the home of a relative or friend of the person who is willing to accept them temporarily, should also be considered. (My emphasis.)
And let’s not revisit the nonsense that A&E is not a place of safety. Of course it is: whenever they agree to temporarily receive a patient and by virtue of them being hospitals. And we understand that A&E can be a distressing environment that can exacerbate symptoms. What do we think happens in police custody when the masturbating drunks are singing songs and we’re dragging in the offenders who are screaming obscenities at the custody officer, wishing cancer upon their families? Not a great place to be if you’re mentally unwell. Has anyone asked patients where they would rather be if it came to a choice – it often does: the CEM document does talk about service-user engagement, after all.
THE BROADER PICTURE
Emergency Departments remain entitled to decline to provide healthcare to patients on an individual basis, if they wish. It is also true to say that police officers are under a duty to ensure that their management decisions of people they detain, survive contact with all legal realities – including human rights realities. Nothing in UK law prevents police officers asking ED to provide assessment and care for people detained if the officer believes that would be appropriate, or potentially just less inappropriate than the other options. Let’s remember: policing mental health events amidst a health service whose over-funcationalisation is as severe as is represented in this CEM document, it is often a matter of choosing the least-worst option. It’s also relevant to add, that if you detain an elderly person under s136 – perhaps a dementia patient – and remove her to A&E explaining that the cells are rammed full of screaming drunks, A&E usually makes itself available – the very practice of our NHS in this area doesn’t live up to the statements of the kind we see here.
I know that this sounds exceptionally subversive: encouraging officers to go against what a place of safety protocol may say; against what an eminent body like the Royal College of Psychiatrists might have in their s136 standards or the CEM in their mental health toolkit. It is really not intended to be: but it is intended to ensure that English and Welsh police officers (different CoP in Scotland / Northern Ireland) are aware that they are not bound by this, despite the phrasing in the document above and there are some – not all, just some – situations in which the law will require them to know this and act upon their legal responsibilities. It is in our oath of office that a police officer’s first duty is to the law.
This blog has listed several instances of individual police officers falling foul of laws where they have acquiesced to broadly preferred policy positions like this one. “Do as you’re told and don’t be awkward” appears to me to be the implication. That’s fine as long as it works, but such generalised statements of the kind we’ve found here and in some areas’ “Place of Safety” policies mean nothing when the impact of particular cases is being assessed by the IPCC and the courts after untoward events. We have seen before police officers criminally prosecuted for “doing as they’re told” by NHS organisations and for not agitating to access needed supports like ED or the Ambulance Service. We’ve seen other legal challenges brought and adverse inquest verdicts – not least in the case of Sean Rigg. From the Metropolitan Police’s point of view, the operational ‘answer’ to the detention of Sean Rigg, was to undertake the restraint differently and for a shorter period of time; to get an ambulance to him as soon as possible and get him to A&E. Whether or not A&E would agree with this, either in principle or in practice …
Finally, the last time I had doubt about whether it was appropriate to remain in the Emergency Department with a s136 case, it involved a patient who was also physically injured and had been sedated by ED doctors in order to stablise his position to give appropriate care. Staff were demanding police officers remain there – as suggested by this document – but I was managing TWO simultaneous firearms incidents in the middle of the night and we had officers elsewhere involved in responding to a serious sexual offence. I ordered the officers at ED to leave – I don’t often have to “order” anything, but the officers needed the ability to tell NHS staff that they were being directed by a more senior officer and were obliged to comply.
I actually did think about our “national decision-making model” and my own force’s statement of values to guide this decision and of all the things I would be prepared to justify to my Chief Constable if things went awry in any of my legal duties in those four significant policing events, it was the decision to leave a sedated patient in the care of medical staff who have security nearby whilst we cordoned three large areas to protect the public from firearms threats and preserved the scene of a serious crime.
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.
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