The Use of Force

To see any of the other Paramedic Series blogs, refer to the index:


This afternoon I did a lecture at the University of Worcester to a group of undergraduate, student paramedics.  This is one of four universities in the West Midlands for training student paramedics and I’d gone there full of ideas of what we’d discuss – all issues covered on the previous five blogs:

Somehow, and without planning to do so, I ended up involved in talking about self-defence and “reasonable force”, because the issue of personal safety came up in a question and it suddenly struck me that we’re about to send these young people into situations where – let’s be honest – they can face some awful abuse, provocation and violence.  In starting to think about the PARAMEDIC SERIES of blogs, I spoke to Ella Shaw who was once hit over the head with a lump of wood and had her hand broken by a person who she continued to care for despite the violence.  Let’s not forget: some ambulance services feel it is appropriate to issue “stab-vests” to their staff because of the risks they face.  It just makes me hold me head in my hands, on occasions.  So I want to make sure they’re as safe as possible especially if the police are not right there to deal with it.

And so – “do you know what you’re entitled to do to defend yourself?” seemed a relevant diversion when the subject came up at Worcester.

SECTION 3 OF THE CRIMINAL LAW ACT 1967

This is the law that allows EVERYONE to protect themselves when faced with an attack or personal violence: this is the law that is debated on the news whenever we get the those stories about what you can do to defend your home against burglars, etc., etc..  It states –

“A person may use such force as is reasonable in the circumstances in the prevention of crime, or in effecting or assisting in the lawful arrest of offenders or suspected offenders or of persons unlawfully at large.”

To paraphrase a judge from a recent court case who was asked what “reasonable doubt” meant, he answered “It is a doubt that is reasonable.  These are ordinary English words.”  The same applies here.  One student said, “If someone was trying to stab you, you’d be entitled to punch them in the face to stop them from getting you and then run away.” << What he said … as long as simply running away was not going to keep you safe.

The force anyone uses to defend themselves is judged in the particular context it was used.  I gave the example of a paramedic at an incident who was busy using scissors to cut clothing from a patient to access a wound and assess or apply the correct treatment.  If, whilst holding scissors, someone attacked you and your flinch-based, instinctive reaction in pushing out your hands to deflect the blow resulted in scissors hitting someone, it doesn’t mean you’ll be arrested for stabbing your assailant, even if they were injured.  Self-defence is judged in its context and if you assault a paramedic holding scissors, whilst they are not allowed to deliberately stab you, any claim to lawful defence of themselves would not be rendered useless because their instinctive reaction happened to involve an aspect which caused a more serious consequence.  If pushing someone away from you to keep yourself safe was lawful, pushing them backwards would still be lawful even if they tripped as they went backwards and then hit their head on the floor, fracturing their skull, for example.

DETAINING PATIENTS

On a different, but related issue, it is worth covering some law about the detention of patients under the Mental Health Act where paramedics are often brought into the situation for conveyance purposes.  When an Approved Mental Health Professional has ‘sectioned’ a patient under the Mental Health Act, they are obliged to convey that person to the identified hospital for admission.  They have a legal authority, under s6(1) of the Act, to “detain and convey” the patient and have “all the powers of a [police] constable” in order to do so.  Something of relevance to paramedics and police officers, is the concept of a “delegated authority” to detain and convey; and the legal concept of paramedics assisting police officers in the execution of their duty and vice versa.

Under s6(1) MHA, an AMHP may delegate their authority to detain and convey to anyone else.  It is quite frequent that this request will be made of police officers, especially if the AMHP has found that it will be reasonable to use force in order to effect the admission but equally, it could be made of paramedics.  There are a few things about this delegated authority that you need to know, whilst reminding you that different ambulance services have different policies about whether or not their staff will accept this legal option.

In some trusts, it is declared that paramedics will not become responsible for legalities around conveyance.  They will provide the vehicle, oversee the clinical wellbeing of the patient whilst in transit and support the detaining authority, but they will not detain / convey.  In other trust areas, paramedics are allowed to accept delegated authorities for low risk patients who are not resistant to being taken to hospital.  So it’s important to understand your area’s procedure.  It’s still worth knowing the following things however, to manage your discussions with AMHPs and police officers.

  • The AMHP who wishes to delegate their authority to someone else, may not compel anyone else to accept that authority.
  • Anyone who does choose to accept it then also assumes “all the powers of a [police] constable” with regard to that patient in that admission process.
  • In other words: they have a right to use reasonable force to effect the admission.
  • GET THE AUTHORITY IN WRITING:  by getting involved in the forcible admission of a patient who is resisting it, you may reasonable anticipate the need to justify anything that you do.
  • By virtue of para 11.10 of the MHA Code of Practice, the form of an AMHPs authorisation to detain / convey should be agreed in the joint protocol for your area on conveyance.  Usually, in writing.
  • By virtue of para 11.17 of the MHA Code of Practice, the AMHP who is requesting the (police or) paramedics to detain and convey should “provide” that authority to do so where the person is unwilling to be moved.

WHO GOES HANDS ON?

This all brings you and us to the question of who goes “hands on” with the unwilling patient?  It is commonly thought that this is a matter for the police.  After all, we’re trained to use force aren’t we and we’re the ones who are carrying batons, CS spray and occasionally tasers for resistant people.  What if the patient is concerned is 83yrs old and has diabetes, blood circulation issues and Alzheimer’s?  Are we still in the zone of thinking this is a police responsibility?

Police forces have been known to say things to the effect of “This person is not actively resisting admission” and decline to be the first agent to use force.  This could sound like a petulant refusal, couldn’t it?  We should remember that police training in personal safety issues is predicated upon verbal communications followed by the use of techniques which involve the deliberate application of pain – justifiable in some situations, but are they really appropriate to the elderly dementia patient?  Well, the MHA Code of Practice talks about the restraint of inpatients in hospital and makes as point saying that “pain compliance techniques” should be avoided.  We’ve seen police involvement in the restraint ot dementia patients become criticised in the courts and in the media.

This does not amount to the police saying “leave it with you” – but it should involve consideration between the AMHP, the police and any other professionals on hand about how we proceed.  There is a very real risk about the use of force by the police on vulnerable people: the use of techniques which involve pain may result in injury and other subsequent psychological problems – it is not to be undertaken casually.  That is why a discussion about how things will proceed is always useful and I know senior paramedics who have talked about their potential to do what they call “proactive blanketing” to help in the management of patients who are passively resistant to being detained and conveyed.  And the police should support this or other approaches where possible because whatever level of force is used, it has to be the “least restrictive” thing in the circumstances.  It’s at least arguable that uniformed, stab-vested police officers using pain compliance techniques on the elderly would fail this test.

FURTHER READING

Don’t forget three methods of using this blog to find out more:

  • There is a full index of over 500 posts on all manner of topics.
  • There is a series of “Quick Guides” originally intended for police officers, but some will be of interest to paramedics.
  • There is a “search” facility in the top right hand corner: by entering any keywords on policing / mental health will bring up the relevant posts, including entering sections of the MHA like “s136″.

To see any of the other paramedic blogs, refer to the index:

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.


IMG_0053IMG_0052Winner of the President’s Medal from
the Royal College of Psychiatrists.

Winner of the Mind Digital Media Award.


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6 thoughts on “The Use of Force

  1. I fully agree with your sentiment that Home Office approved techniques for restraint are really rather unsuitable for the detention of the above mentioned OAP, unfortunately Paramedics are not taught to restrain and it’s only through the judicious application of blankets or other, similar, fudging that Paramedics can retain physical control if needed.

    I would however disagree with one of your sentences: “Let’s not forget: some ambulance services feel it is appropriate to issue “stab-vests” to their staff because of the risks they face.” The issue is not that some trusts feel it’s appropriate to issue such PPE, but that others feel it is appropriate to *not* issue such equipment. Paramedics have to, by the very nature of their job, get very close to any number of people removing the option of space as a defence – because people are so very close the only line of protection left may be a vest (acknowledging of course the limitations of such armour). I would be much happier working in some situations with a vest but I don’t even have the option.

    1. All good points – and you should be clear that I’m not suggesting “get on with it”, I’m suggesting a partnership approach but it may interest you (and various) AMHPs to know that legal opinion around the use of police officers suggests that a blanket use of them (no pun intended) to be the agent of coercion may not be legal, especially where the patient concerned is a mildly and passively resistant patient who poses little active threat.

      But good points, well made.

      1. I wouldn’t routinely demand police attend for such a pt, after all even more unfamiliar faces won’t help the situation at all. What would be useful would be formal, safe, training for times when it’s appropriate for paramedics to restrain/not suitable for police to restrain. I would expect mental health workers who section people to have similar training.

  2. Paramedics in the north west ARE taught simple restraint techniques they just choose not to use them and claim they’re not allowed to. Then police get called.

  3. We managed to get a patient to stay on the trolley by telling her that only our driver could undo the trolley straps, and he was in the front.
    We also put her own duvet over her, as she was much happier with that than a blanket.
    This resulted in a safe, if slightly surreal journey to the local Elderly Mental Health Unit with the patient and her friend who had come with her for support singing “Daisy, Daisy, I’m half Crazy….” all the way there.
    The mental health nurse who met us obviously knew his job – “Hello Mavis (or whatever) – shall we find somewhere you can have a cup of tea…yes, of course you can bring your duvet…”

    I had a query about this job, though – did the warrants for removing someone from their home (135?) just come in as part of the 2006 revision, or was there something similar before? The patient wouldn’t have been safe staying there, as she lived alone, and kept lighting her gas heater then letting it go out, or putting stuff on top of it.

    It probably was that long ago, and I remember the AMHP having a lively discussion with police control by phone about the fact that yes, she could ask them to come and assist in removing the lady from her home, as all the persuasion we could muster wasn’t working.
    She ended up phoning an inspector friend (I think), and getting them to explain things to Control – from what I remember, I think a bit of listening to recordings, followed by education, was about to follow…

    2 lovely policemen came, and between them helped the lady into our ambulance, with a little bit of gentle force. They asked if we wanted them to travel, but we were happy for them not to.

    We had all the paperwork- I think it was a Section 2 and an authority to convey form, plus the doctor’s admission letter – “section” paperwork and letter stayed at the MHUnit with the patient, authority to covey went with our patient report form into our archive just in case.
    As a VAS volunteer crew, we don’t get that many mental health jobs, so all info is useful.

  4. Note to self – read all blog posts before replying to one – I THINK you may have answered this in the “what is an AMHP” post… 🙂

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