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A POLICE-LEAD INCIDENT
In many important respects, the police are still wrestling with the nature and extent of their role around managing issues involving mental ill-health. Whilst a few officers stick to the view that it is “not police work”, more officers recognise that it is daily police business for a range of valid reasons. Given that mental ill-health is connected to at least twenty percent of police demand, police forces and individual officers should be taking it seriously and looking to improve their knowledge and understanding.
Section 136 MHA – This is the police power to detain someone in a place to which the public have access who is in immediate need of care or control, in their own interests or for the protection of others and to remove them to a place of safety. This enables an assessment by an Approved Mental Health Professional and a Registered Medical Practitioner. Where police officers detain a person under s136, they either will be thinking or they should be thinking about ambulance. Let me explain why:
Police officers have faced enormous criticism where they have failed to recognise clinically significant features in patients they have detained; this has also included officers misunderstanding the nature of clinical issues, like mistaking diabetes for mental illness. There have been several high-profile deaths in custody and other serious events, where officers were criticised and in some rare cases, criminally prosecuted, arising from these mistakes and misunderstandings. For those reasons, the police service have started to assert the requirements within the Code of Practice to the Mental Health Act, which stipulates non-police methods of conveyance for those who are detained – para 10.17 and Chapter 11 refers to it being about the dignity of the patient in ensuring that they are conveyed in the most humane way.
However, the main reason the police want to see paramedics at s136 jobs, is your clinical skills. It is not only around the potential that we could misunderstand something, although that is vital – it is also around the bone of contention that arises when police officers take people to Accident & Emergency under s136. A&E traditionally have not seen themselves as “a place of safety” (see below) and this is simply not a tenable position – because anywhere, including my mother’s house, can be a place of safety if they are temporarily willing to receive a patient. It is more about police officers (and now paramedics) understanding what would make A&E the appropriate place to take someone who had been detained because some people quite simply need to be in A&E and it’s impossible to physical have the patient without also legally having the patient . It is also far ‘easier’ to convince an A&E triage nurse that you’re not just “trying it on” if a paramedic is there, talking the medical talk, about why it’s appropriate.
In the West Midlands, we asked the NHS to specify what kinds of clinical conditions should trigger removal to A&E because of an acute need. An A&E consultant put together a list of what became known as RED FLAGS and all 11 A&Es agreed them as the basis upon which to go to A&E before anywhere else. Paramedics have proven key to ensuring that RED FLAGS are properly identified after use of s136 and we can cite at least three examples of lives having been saved that may otherwise have become deaths in police custody.
Finally – where a police officer has detained someone s136, they cannot hand the patient over to you and leave it with you: they should accompany the person to whichever place of safety is deemed most appropriate as the person remains in police custody until they are delivered into the detention of someone who is willing to take ongoing responsibility for detention and arrangement appropriate assessment – this will never be paramedics and will only be A&E is some very limited circumstances.
A Place of Safety – the legal decision about where someone is removed to after detention under s136 (or s135, which is covered in the next blog) rests with the police officer who detained the person, although it’s going to be a brave cop who goes against the advice of a paramedic or any other medical professional who may have been involved. A PoS is defined in s135(6) MHA as being “residential accommodation provided by the Local Social Services Authority, a hospital, a police station or any other place temporarily willing to receive the person.” So anywhere can be a place of safety, in theory – whether they get used as such in practice will depend upon your local s136 or PoS protocol.
It is worth knowing about Para 10.22 of the Code of Practice to the MHA when wrestling with the moralities of where officers might be thinking about taking someone. This paragraph imposes a duty not to automatically consider the police station to be the first or even the second choice location for a PoS: “other options should be considered before using the police station as last resort“. So it has been known that if accessing a PoS is proving difficult, attempts could be made to ‘improvise’ through the situation by taking someone to their own home or to a relative’s. It might not be in the local s136 protocol, but it’s not illegal either.
OTHER DETENTION AND CONVEYANCE
Section 18 MHA – this is the authority afforded to police officers (and AMHPs) to re-detain someone who is Absent WithOut Leave (AWOL) from hospital under the MHA. Many of the issues that officers should consider upon re-detaining someone who is AWOL, will be similar to those for s136, mentioned above. Taking someone (back) into custody means an assessment of risks and medical need will be necessary and again, officers have been prosecuted for alleged neglect where they have failed to call for an ambulance or react to the clinical risks in play when they find patients.
Patients can become AWOL in a range of circumstances but most the common situations involve patients who were detained under the MHA in hospital and have either left without permission or have failed to return from a period of agreed leave. It can also involved situations where patients on Community Treatment Orders, have been recalled to hospital. In all of these situations, and more besides, officers may want to seek your support to identify whether A&E is required and to convey the patient. I’m going to write about the ‘politics’ of this in another “Paramedic Series” blog, because it is well understood by the police that there are debates about whether this is an appropriate use of a 999 ambulance and that views of Ambulance Service managers are not consistent on these issues.
Section 6(1) – When a patient is ‘sectioned’ by an AMHP, the patients becomes “in legal custody” and the AMHP may then “detain and convey” that patient to hospital – against their will, if need be. Most usually, especially if force will be required, the AMHP will look to the police to undertake that task and the police will say, “Call an ambulance.” The AMHPs authority under s6(1) may be delegated to others, including police officers and paramedics, to convey the patient and keep them detained – they simply need to authorise those other professionals to act. If you become involved in a situation where, along with police officers, you are conveying a patient to hospital who has been ‘sectioned’, then the officers certainly and potentially the paramedics, will be authorised to “detain and convey”.
Urgent Transfers – In some areas, it is commonly assumed that if an urgent transfer is required of a patient from one psychiatric unit to another, that the police can be used, especially where the patient to be moved is aggressive or resistant. Police forces are increasingly resisting this approach, not only by citing the Code of Practice issues mentioned above, but also by pointing out the difficulties that can be unwittingly encountered. In particular, where transfers are sought because patients have become aggressive, it raises the question of how patient safety will be managed in the journey – does the request to transfer people mean implicitly that a patient should be restrained? – we all know the risks associated with protracted restraint. What about transferring patients who may have been forcibly medicated by a psychiatrist before the transfer? – well one issue that has arisen several times, is the question of whether the psychiatrist or a nurse will be travelling with the patient to the new location in order to ensure that any ongoing need for medication is attended to. Obviously as a paramedics you are not licensed to administer some of the medication that psychiatrists would use to sedate a patient and I’m reliably informed by paramedics that when a patient is sedated during transfer and the Code of Practice demands that they be supervised by an appropriate professional, this does not include paramedics / technicians. Police officers are extremely unlikely to know this! – please give them a nudge and help them make appropriate representations if transfers in which we become jointly involved start to look like this!
In the next blog, I’m going to cover issues around the Mental Capacity Act and the undertaking of pre-planned Mental Health Act assessments in someone’s home.
Don’t forget three methods of using this blog to find out more:
- There is a full index of over 5300 posts on all manner of topics.
- There is a series of “QuickGuides” originally intended for police officers, but some will be of interest to paramedics.
- There is a “Search” facility in the top right hand corner: any keywords on policing / mental health will bring up the relevant posts.
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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