The history of disasters in policing and mental health arise from the fact that the police actually did exactly what the NHS explicitly sought or implicitly wanted them to do. Therefore, putting NHS staff alongside police officers, whilst it may bring very real benefits to some, will also bring an extra pressure dynamic to bear on operational officers at some critical times.
Imagine the scenario: there is a call from a desperate relative on 999. Their loved one has been living in crisis for several days and has been drinking throughout the afternoon. The triage car and other officers attends this call because there is a significant history about this patient that is known and it is in every sense a proper mental health emergency. Whilst the police officer is driving them there on “blues and twos” the police dispatcher is relaying a summary of attendances, warning markers and so on. We know that the person has previously been sectioned, that they’ve been AWOL whilst detained and have been detained at that location. We know that they have been resistant on arrest and that they’ve been drinking vodka today. Upon arrival, this man is in the street and his elderly relatives are asking for help. No amount of “tactical communication” is working – he is either too unwell, too drunk or both for either the nurse or the officer to persuade them out of the road. The triage car agree, he will have to be detained in his own interests.
Leave aside the debate which could immediately occur about whether to detain s136 or for a drunkenness-related offence, let’s just agree that the person will be detained. Where do we now go?
If you look at various section 136 policies around the UK, it will say, because of alcohol and aggression and the risk history involved, the man should be taken to the cells. We can only imagine the nurse would encourage this course of action being right there at the scene and knowing that this is what the joint protocol says. After all, we can’t assess the person under the Mental Health Act until the alcohol has worn off, can we? He needs to “sober up somewhere”, right?
What about physical healthcare needs? – what about the possibility that the person is suffering an underlying problem that is being masked or fogged by alcohol and aggression? How do we take that into account and – no offence to any mental health nurses anywhere in the UK – the triage car nurse would not be trained in the pre-hospital urgent care like our 999 colleagues in green. Remember, mental health nurses are (usually) not dual trained as general nurses. Would they carry with them, blood pressure cuffs, blood sugar testing equipment, thermometer, etc.? I realise that mental health nurses can / do physically examine patients, my question is “will they?” I’ll be frank: mental health nurse or not, I’d probably still be calling an ambulance – chapter 11 of the MHA Code of Practice stands.
How do we get the person to wherever they will be detained? – in most of the 11 ambulance services in the United Kingdom, they wouldn’t attend such a call anyway for various bureaucratic and on occasion discriminatory reasons. I’m pleased to say, the ambulance service where I work “get this” completely and would almost certainly attend, priority of unusual demands permitting. But yet again, knowing they may not feel obliged or able to attend, is no excuse for then doing the wrong thing – chapter 11 of the MHA Code of Practice stands.
You see the reason I have a deep, underlying fear of what is being suggested is not because I think it will fail to bring any benefits. I think there will be loads of benefits in terms of information sharing, s136 avoidance and I genuinely welcome that and more. Having said that, I can think of other, less resource intensive and probably cheaper ways of doing the same thing, but I do welcome it.
My deepest fear arises from the fact that the above case is not hypothetical: it is the real story of a UK death in police custody where the NHS actively wanted a police cell to be used for a patient who had received no pre-hospital triage and whose intoxicated, aggressive presentation led to a fast decision – a hasty one – that the only possible place we could remove the man to was police custody. The custody sergeant who did not resist that course of action by recognising the clinical threats involved was disciplined for gross misconduct.
I had some difficult writing this post, for two reasons –
- Firstly, I couldn’t think which death in custody story to use for the “hypothetical” point – there were several candidate stories to make the same point;
- Secondly, I am really conscious that it appears to be flying in the face of the thrust of the street triage initiative.
DECISION-MAKING AMIDST UNCERTAINTY
What I know from the work I’ve done over the last ten years on policing and mental health, is that we must equip our police officers to make the correct decision under pressure, which will sometimes, just occasionally, mean resisting the NHS and doing what they don’t want us to do. The reason we know this is because we could list the prosecutions where officers have faced criminal charges of neglect arising from “doing as they’re asked”.
Various cases over just the last ten years, many of them highlighted on this blog, show that the NHS has not commissioned and integrated itself to react to the number or nature of mental health emergencies that this country generates – this is precisely why the CQC have just yesterday announced a thematic inspection of emergency mental health care. When I get back from holiday, I am going to write a blog for their attention, specific to my view on that whole business.
But for here and now, for the debate following the announcement of street triage: we have to define the problem we’re trying to solve before identifying the solution. You could solve the “inappropriate s136” problem any number of ways without having to pay a nurse to stop the cop from doing the wrong thing. << This is the very raison d’être of at least one triage scheme already running – the NHS don’t trust their police to get it right, so they resourcing an opportunity to stop them from getting it wrong. Why not just train them to get it right?! Is it because we still haven’t defined what “right” actually means for s136? … probably. We know from reading the joint HMIC / CQC report on police cells as a place of safety and from the CQC annual reviews of the Mental Health Act that those who need to know about the police mental health interface don’t actually understand it.
We all know that the volume of calls to the police could be far better managed with mental health support through information sharing and joint working. What I’m less convinced of, is that these joint working arrangements will take proper account of things that the NHS have historically been unable to brigade: the urgent, emergency reaction to unknown clinical risks, involving intoxication and aggression.
And again, we see the trap being fallen into – this stuff will not go wrong very often, but when it does go wrong it will go really, really, wrong. Bearing in mind that nurses also have very different training around the use of force and restraint, I’m also concerned that we will see again, nurses flagging concerns about the use of force even where officers are acting in a text-book fashion, according to their training. We’ve seen this in the Olaseni LEWIS case and others: we’ll see it again until somebody defines the problem we’re trying to fix and designs the solution to fix that problem.
I’m not hoping to fix the problem to which “street triage” is the answer – for that, you need to fix CrisisTeam services as a whole and it will take more than free security and a lift from the police. Street triage is “pulling people out of the river”. Eventually, as Desmond TUTU rightly said, “we have to get upstream and work out why they’re falling in.”
I worry that untoward events will still occur; and that in hindsight, they will appear quite predictable.
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