There is, in my professional experience, a very distinct difference between restraining burglars or street robbers who have been arrested for offences and restraining patients who have been detained or re-detained under the Mental Health Act. The concepts of resistance or aggression may be similar; the instinct of a police officer to contain the risks that arise from resistance or aggression may be similar, but I’m beyond doubt that arresting criminals and detaining patients are qualitatively very different.
It is the very fact that the two enterprises are NOT the same thing, that renders a similar approach to each to be far too crude. It is also a false disctinction to differentiate based on the legal framework officers are applying: arrest for crime / detain MHA. The approach should be governed by what we know about the person being restrained: arresting a criminal suspect for an offence where we know of serious mental health problems is something to which the caution in this post should apply.
This is a very difficult subject and I’ve waited ages before addressing it, although I’ve alluded to the use of force and medical emergencies from the restraint of patients in mental health crisis before. We know there have been deaths in custody which have become political issues and which have brought about protest; and we know that there have been adverse outcomes from inquests and inquiries suggesting that policing, although complex and demanding, has not reached the necessary standard. And there are ongoing investigations.
But it’s not too difficult to conceive a different approach, albeit one that sits just outside the unilateral control of the police – and it rests not only upon policing, but upon those with clinical skills and better training around health and mental health. But we’re going to have to challenge some inherited thinking in policing and health to do it.
I’m about to make a massive generalisation for the purposes of drawing a distinction: your focus should be on the distinction, not the generalisation – it has been my operational experience that where the police are detaining resistant criminals after arresting them for offences, they’ll either resist until they know that they are properly caught and detained, and then they will desist into abusing you; OR, where offenders are drunk, may continue to physically resist, but are able to be quickly removed to a cell where they concentrate on banging the cell door to annoy everybody.
I realise that this is an extreme generalisation – but I pose it deliberately to contrast it with my experience of detaining and restraining resistant mental health patients: patients are often so fearful of being restrained that they either start fighting in fear of their lives AND / OR they may have underlying health conditions or drug / alcohol complexities which mean a high-impact restraint renders it a difficult and dangerous situation – and sometimes, this protracts for a significant period of time, because the underlying fear of being detained or the background health risks do not suddenly go away. Qualitatively, it is a very, very different kind of thing to arresting burglars and domestic violence offenders.
RESTRAINT AS A MEDICAL EMERGENCY
I’ve written loads on this blog that is intended to help police officers navigate difficult operational waters, but if they remember NOTHING else, I’d want them to remember this: >> the need for *ongoing*, especially-prolonged restraint of a psychiatric patient is a medical emergency – end of.
And this is NOT just my opinion: it has a basis in both medicine and law.
I’ve stressed, “ongoing”: when some restraint or coercion interventions start, patients often do decide to then comply with what is happening and the intervention can be scaled back or stopped entirely. It is when resistance begins and doesn’t stop that we need to start thinking clinically.
There are a few reasons for this.
- If patients are under the influence of drugs or alcohol as well as suffering a mental disorder, restraint can compound what is occurring to the patient physiologically – this is where people start talking about things like Excited Delirium and Acutely Disturbed Behaviour, controversial though those concepts are for some;
- There can be certain physiological side-effects to patients suddenly ceasing to take psychiatric medication like anti-psychotics – some patients are more affected than others and again, impact where it occurs can vary depending on (illegal) drugs / alcohol consumed; and restraint can exacerbate this;
- Mental health patients, on average, have much poorer physical health than the population as a whole – as a rough rule of thumb, add 10 years to a patient’s actual age and then start to comprehend how restraint would impact;
- Think of the intervention you are applying from the patient’s point of view: which may include, for example, paranoid delusions about who the police or what the police are trying to do – if you genuinely feared that restraint was something qualitatively different to what you were being told, however delusional that belief were, would you not resist in fear?
NOT JUST MY OPINION
During the Independent Inquiry into the Death of Rocky BENNETT, various expert medical witnesses and experts in restraint, talked of the ongoing need for restraint as a medical emergency. It talked about doing so, only in a context where there were doctors and nurses trained in the use of defibrillators, appropriate medication and who are knowledge about of things like the NICE Guidelines on Acutely Disturbed Behaviour (2004).
We’ve seen during some critical incidents, that police officers were too slow to get people out of a prone position; too quick to use a police vehicle for the conveyance of that person, including over long-distances; unprepared to call paramedics for a range of reasons that may partly be attributed to (false?) presumptions that they wouldn’t attend anyway; and far too quick to fall victim of the inherited thinking that has prevailed for years that anyone who is violent should always be taken to the cells. This is where we get it wrong:
Resistance, aggression and violence can be attributable to any number of things: head or brain injuries, some of which won’t necessarily be visible; diabetes; epilepsy, strokes. Or it can be a natural reaction to paranoid delusions or auditory hallucinations – we need to know more before we start thinking “more force, police vehicles and cell blocks.” The stakes are too high.
THE ROLE OF THE AMBULANCE SERVICE
We have seen criticism arising from police officers who are engaged in restraint of seriously resistant patients not calling paramedics to the scene. Although paramedics are not licensed to carry the kinds of medications which the above-mentioned NICE Guidelines talk about, like benzodiazepines, they are in a position to administer some medications that may help and have other kit to monitor a patients condition. They are also positioned to oversee clinical wellbeing and of course to react to any untoward developments that occur whilst in transit. We’ve known patients suffer heart attacks and slip into diabetic comas in police vehicles after detention by the police under the MHA – previous conditions that no-one knew about where a paramedic with a bag of kit would have been quite handy to provide a swift-reaction.
It is these cases I think about when I hear that some ambulance trusts are pejoratively asking the police, “Why on earth do you need an ‘intensive-care-unit-on-wheels’ for someone who is ‘just’ mentally ill?!” << This is a question I was actually asked several years ago by a senior paramedic. And there are two answers to it –
- Firstly – because I haven’t got a Scoobie-Doo whether the person I think is mentally ill is mentally ill or not because I’m a police officer; the first rule of good mental health assessment is to rule-out physical causation before concluding mental disorder and cops are not going to do basic obs like heart-rate, blood pressure, blood sugars, etc..
- Secondly – because the Code of Practice and the Royal College standards say this is the way it gets done – they amount to agreed statutory and professional standards signed up to nationally by everyone who is important. There is something here about patient dignity and reducing stigma in how we do what we do.
We should remember this – the Code of Practice to the Mental Health Act requires conveyance to be done by ambulance (as the only practical alternative to police transport which is criminalising) and where this is not possible, it is suggested good practice that a paramedic travels in the police vehicle with the patient. Only recently, there was a scenario on my team where a first-responder paramedic indicated quick removal was needed and as the situation occured near to a major A&E, he got into the police car with police officers and the patient; whilst another officer drove his ambulance service car to the hospital for him so he wasn’t stranded afterwards.
It is also relevant to point out, that within the Safer Detention guidelines for the police, which pertain to detention in police custody, it talks about officers having awareness of conditions like Excited Delirium and the necessary responses = Accident & Emergency.
So, we can all name the cases where we have heard or even seen CCTV, of high-impact restraint by several police officers. There is a sound basis for thinking clinically where this is believed to be attributable to a mental disorder, especially where drugs / alcohol are involved and call an ambulance. In the West Midlands, where I can’t praise West Midlands Ambulance Service enough for their approach to this stuff, we have an agreed set of criteria, known as RED FLAGS, which then trigger consideration of removal to Accident & Emergency. The need for ongoing restraint, amidst concerns about excited delirium, are RED FLAGS under this process which then allow the NHS in quick time to consider whether application of NICE Guidelines should apply, or whether another pathway into care is necessary.
As the risks of not getting this right are grave and have previously involved criminal investigation and indeed, prosecution of police officers and potentially in the future of health staff, it is important we don’t get caught in the over-functionalised thinking that has previously believed we can sort this out at the road-side or at a police station. The stakes are too high, the underlying causation invisible and we are playing Russian roulette with people if we get outside our skill sets and gamble the odds. In risk assessment, high-impact but low probability events – let’s be honest, most high-impact restraint does not lead to death, prosecution or untoward events – should be treated seriously and mitigated against in just the same way that fear of stroke or fears of heart-attack would be.
Any other approach is discrimination against some extremely vulnerable, however challenging, people at a very risky time.
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