I’m just going to focus on two reports this month which are worthy of note for different reasons but which both relate to the management of risks and the use of restraint:
The first comes from Mind following an investigation into the nature and extent of restraint in mental health hospitals; the second is a joint inspection from Her Majesty’s Inspectorates of Constabulary and Prisons along with the Care Quality Commission and the Health Inspectorate for Wales on the use of police cells as a place of safety. These two reports are two sides of a coin and should be considered together.
Before I start on all that, don’t forget that BBC3’s season of coverage on mental health started on Monday night. You should watch “Don’t Call Me Crazy” on the BBC’s iPlayer – it is about patients in an adolescent mental health unit in Manchester and I thought it was really thought-provoking for a range of reasons under consideration in this newsletter. Issues around restraint are played out on this programme. Further episodes in coming weeks.
It is fifteen years since the death of Rocky BENNETT. He died in a Norwich mental health unit in 1998 after staff attempted to move him against his wishes following him being racially abused by another patient. The controversy surrounding his death led to an independent inquiry and the subsequent report was something of a “Stephen LAWRENCE” report for the NHS, because alongside the inquiry’s substantive investigation into the events which led to a restraint-death, there was an under-current of institutional racism. Why was he the one moved, not the racist aggressor? When the report into his death was published it made a variety of recommendations not all of which have been implemented. Fifteen years on, Mind decided to investigate the extent of it all through Freedom of Information requests.
Obviously, Mind have reported on the answers they were given by mental health trusts. I always start reading these things with a large bucket of salt by my side because I have seen enough poor recording of “stuff” in health and policing to be skeptical about data. That said, what was reported back was interesting enough:
Note on the numbers that follow: there are 54 mental health trusts in England – three of them provided no answer to the investigation at all. Because trusts record different things in different ways, they could not all answer every question posed to them.
- 39,883 incidents of restraint in 47 mental health trusts – this ranged from 38 restraints in one trust to 3,346 in another.
- 3,439 incidents of face-down restraint in 27 trusts – 4 mental health trusts reported no use of face-down restraint; another recorded 923 which is a quarter of the total.
- 4,300 incidents of restraint for medication in 31 trusts – 1 trust reported 1 incident and another reported 592.
- 361 incidents of the police being involved in restraint in 27 trusts – 100 of these were in just one trust and only three reported never using the police.
Interesting, isn’t it?! I must say: I don’t believe the figure about the police at all. When you look at particular areas, it amounts to such low prevalence compare to stories you’ll hear in a police briefing room.
This is important stuff, because it speaks of organisational culture. It is also important to policing because we know that there are ongoing inquiries and legal proceedings following incidents where officers were called into mental health hospitals because of violence-related issues which led to restraint. I agree with this report, that we need national guidelines and expectations.
I would end by saying that I would have loved all of this data to be cross-referenced against two other pieces of information –
- Staffing levels – were the wards who engaged in this restraint up to the required level in terms of staff numbers.
- Staff training – were those staff on duty sufficiently trained in control and restraint to undertake this.
I routinely ask these questions when my team are called to attend wards in case the background is something I need to report or the context is something which influences my handling of any request made of the police. I am yet to get a “Yes” to either question.
HMIC / CQC REPORT
I didn’t blog on this report when it came out – having read it, I couldn’t think of much to say that I haven’t already written about on this blog. Suffice to say here, that I wasn’t especially thrilled with it. I’m not sure it told us anything we didn’t already know; I’m not convinced it takes us particularly forward although it does make good recommendations (the clue is in the name) about commissioning and oversight of services.
The one thing I would highlight was that the report failed to call, as the IPCC had in their 2008 report, for a complete end to the use of police cells as a place of safety. This report calls for a clearer definition of when police cells should be used “in exceptional circumstances”. It focussed upon the phrase “unmanageably high risk” as indicating the situation in which it would be appropriate for the cells to be used.
I have five things to say about that, although I could say more –
- Michael POWELL
- Sean RIGG
- Olaseni LEWIS
- Kingsley BURRELL-BROWN
- James HERBERT
All examples of the police having contact with individuals who at the time were presenting in a way that would have seen them captured by the definition of “unmanageably high risk”, as considered by the NHS. Bear in mind, that last week I was contacted by a senior MH nurse giving an example of professional strife they have become embroiled in because of their decision to accept a calm, compliant patient into an NHS place of safety. This nurses manager’s took exception to the decision purely on the grounds of a well-known history of violence towards NHS staff.
On that occasion, because of that background of risk, police officers willingly remained at the PoS in support in case anything escalated and nothing did. Now that nurse is having professional difficulty even though nothing went wrong, no-one was hurt or even threatened and a patient was assessed in a dignified way and admitted under the Mental Health Act.
TWO SIDES OF A COIN
We need to see the two above reports as opposite sides of the same issue: the safety of patients in contact with the state. We are reading about restraint in hospitals, including the involvement of the police to move people, administer meds and we are concerned and calling for health inspectorates or regulators to do more to reduce restraint and the 1,000 injuries that resulted from it. Then in the next breath we are seeing the reinforcement of a framework that wants to see patients excluded from therapeatuic environments and potentially restrained – how else can a custody sergeant stop a vulnerable person from hitting their head off a cell wall, for example?
Eventually, we are going to learn that highly resistant or aggressive behaviour should be treated as a medical emergency – you can’t handle medical emergencies in small concrete rooms with a first-aid kit. We need to “get” the highly counter-intuitive truth that some, just some, patients who are presenting risks to themselves and to others need to be taken into the healthcare system, not excluded from it. We need to build our health service and police service to accommodate this and work together in time-critical ways. Lord ADEBOWALE said so in his recent report; and Coroners have said so in their inquest judgements. It will be received wisdom at some stage in the future that restraint can be clinically-attributable and how quickly this point is grasped and realised will determine how many untoward events and controversial inquiries we have between now and then.
The NICE Guidelines on Acutely Disturbed Behaviour are not mentioned within this report. I wondered why not, bearing in mind that they tell us important things about clinical responses to resistant or agitated patients?
If you want to start delivering health equality between physical and mental health care problems then understand this: if a patient at a road-traffic collision was agitated or outright aggressive because they had hit their head during the incident and had become cognitively impaired and aggressive as a result, you would NOT see them excluded to police cells. You do not get taken to police cells for any other medical reason than mental health disorders and for as long as you do, it will be impossible to argue that we have parity. it is about discrimination, pure and simple.
Ongoing assertions that some mental health patients should be excluded from healthcare fails to learn the lessons from the above cases about clinical risks leading up to detention or arising from restraint and it puts people at risk. Any custody sergeant worth their salt would remember para 10.22 to the Code of Practice to the Mental Health Act at this stage; along with para 9.5 and Annex H to Code C of PACE in making decision in this context. We also need to remember the case of MS v UK. The patient in that case was “an unmanageably high risk” and the court ruled his detention in police custody became illegal. The likelihood of further MS v UK cases is greater now than when the case actually occured in 2004, because some areas have halved – yes, halved – the number of acute inpatient beds against real-terms budget increases of 59% in the last ten years.
This report doesn’t take full account of the laws and guidelines that govern us – in my personal view. I also think it a shame that South Africa and India can reach a position in the 21st century where their equivalent legal authority to s136 cannot, by law, lead to removal to a police station.
Why can’t the United Kingdom do this?
Winner of the Mind Digital Media Award.