Locked Up For Being Ill

It is my massive pleasure to publish a guest blog from Dr Jenny HOLMES who is a psychiatrist, a police doctor and works with the Faculty of Forensic and Legal Medicine.  That combination of background and experience should indicate that what you are about to read is an insightful, thoughtful contribution to the fallout from Monday night’s episode of Panorama.  You can follow Dr HOLMES on Twitter – she is @NorthWestDoc and I’m grateful she has found time to write this piece for us all.

I had high hopes for this programme. It started well, a realistic portrayal of Custody: not an especially busy period, just regular shifts. The Police came across as human, empathic, doing the best they could with blunt tools.  Equally their tired frustration as they tried to secure advice and assessment from Mental Health Services.

The programme lost its way a bit, tried to tell too many personal stories and there wasn’t enough time to do justice to everything. The debate between Irene Curtis and the Clinical Director of the Mental Health Trust was highly edited and became polarized with the disagreement between them of the practicalities of using A&E as a Place of Safety.

Equally the Street Triage segment came across as the Police providing a fast car for a crisis mental health response: s136 could not have been used in this instance as it was a private dwelling.  The crisis could have been managed by dispatching an ambulance to bring the woman to Accident and Emergency for assessment by the Crisis Team and the Police Officer could have been sent to deal with core Police business.  I don’t doubt the Street Triage model will help drive down s136s and I do believe such reductions need to be health driven.  Good liaison between Health and the Police both in advance for repeat s136 cases and in real time as we see in Street Triage will reduce unnecessary detentions.

PROFESSIONAL RESPONSES

The response of fellow Mental Health Professionals on Twitter during the subsequent #mhpolchat discussion really surprised me.  Many felt that the people portrayed were probably not mentally ill and would not hit the threshold for services hence were primarily a Police problem.  If we look at points of entry in to health systems we don’t see these attitudes applied elsewhere. Accident and Emergency nurses don’t block the entry of ambulance patients with arbitrary exclusion criteria. Nor do General Practitioners: beyond a triage of urgency patients enjoy open access to a medical/nursing opinion as to whether they require investigations/referral onwards/admission etc.

The NHS Commissioners who are currently looking at Offender Health Pathways also see Police Custody as a potential point of entry into Health and it makes sense that if you treat health problems such as substance misuse and mental illness which have a strong link to criminality or the criminal justice system you can reduce re-offending and drive down demand and cost.

The “25%” that the Police talk about are a complex mix of mental health (both acute and coincidental), substance misuse, physical ill-health, social and emotional crisis etc.  I find it pretty challenging as a doctor working out what’s what in these complex people so how on earth do we expect the Police to?

I also need to be clear that the Police are not asking Health to take on their problems.  I’m never asked to make a quick arrest, interview witnesses or secure a scene when I’m the duty doctor in Custody.  They are an organisation whose raison d’etre is crime: the Home Secretary repeatedly tells them that their job is “to reduce crime, nothing more, nothing less.”  Whilst this may be a touch simplistic, it influences the mind-set of officers at all levels whose performance is often assessed against crime activity in their area and on the investigation of crime.

When they encounter someone on the street and there is a criminal offence they make judgements about whether to arrest for it or apply discretion. That’s what they are trained to do.  To exercise s136 they need to suspect a mental disorder, broadly defined.  An individual Officer will exercise his or her power of arrest many thousand times in a career and section 136 only a handful of times. Once a person is in custody under arrest all they want from Health is a timely opinion on the person’s needs and close partnership working to determine whether an individual and the public at large may benefit from them being diverted from the Criminal Justice pathway.  In my experience that’s less than 10% of people at point of arrest who may also still need a plan of support around their health needs even if they are diverted.

PLACE OF SAFETY OPTIONS

What’s the big deal about not using Police cells as a place of Safety for s136?  Let’s look at the arguments: Firstly it criminalises the mentally ill.  Yes, from a purist perspective but someone taken to Accident and Emergency still appears to all intents and purposes to everyone else to be under arrest.

Secondly it can worsen the mental state. The Panorama programme certainly showed how difficult the environment is.  But it also showed real compassion and care from Police Officers.  I have seen Police staff bring in bags of clothes for the homeless. Feed them up.  Provide extra blankets.  So yes it might worsen the mental state and if the custody suite is busy it’s a noisy, scary place and the staff are pushed for time.

However there are three main reasons I believe we MUST have Health Based Places of Safety. Firstly a proportion of these people will have serious physical health concerns. Diabetes, Liver failure, Sepsis, Head injuries……there must be a safety net so we don’t miss these cases.

Secondly the dangers of restraint.  There are too many deaths of mentally ill people after Police restraint.  Health Guidelines emphasise the need for Immediate Life Support trained health staff to manage restraint in psychiatric facilities. That there must be a review of physical and mental health within two hours of restraint.  Police restraint techniques rely on pain compliance and this does not work in the mentally ill but worsens the situation.  Let’s get them to an appropriate health facility, by health transport and keep them safe.

Thirdly s136s contain a large proportion of people who have health needs who need health solutions.  In my area the ‘hit rate’ for s136s is that 20% are admitted either detained under a s2 or 3 of the Mental Health Act or informally.  Another 30% get some sort of mental health follow up. The rest usually have some recommendations made to attend their GP, access addiction services, third sector services etc. In areas where health have really focused on partnership working around s136s the percentages are even better with 80 % or more getting admission/follow up.

Its World Suicide Prevention Day today. David in the programme had lots of factors that made him high risk for completed suicide: male, living alone, estranged from child, alcohol misuse and previous self-harm. So finally I want to quote from the National Institute of Clinical Excellence’s Guidelines on Self Harm for Healthcare Professionals.

People who have self-harmed should be treated with the same compassion, dignity and respect as everyone else using healthcare services. Judgemental or negative staff attitudes towards those who have self-harmed can contribute to poor experiences of care, and may also lead to further self-harm. People who have self-harmed should have an initial assessment of physical health, mental state, social circumstances and risks of repetition or suicide. This can identify if a person is at immediate physical risk, so that steps can be taken to reduce this risk, including referral for more urgent care if needed

A comprehensive psychological assessment should be carried out each time a person presents with an episode of self-harm. This is aimed at identifying why it has happened. The assessment can also start a therapeutic relationship with the healthcare professional and be used to develop an effective management plan

Last night I saw distressed people who had self-harmed or had strong suicidal ideation, some of whom had called the Police themselves, in Police stations. If they had called an ambulance they may have got care in accordance with the NICE Guidelines. As a Psychiatrist part of my job is to advocate for some of them most vulnerable people in society.  It’s not acceptable to me that there is such disparity of care just because a person has ended up with a Police response to their self-harming behaviour and distress.


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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9 thoughts on “Locked Up For Being Ill

  1. Hi, agree with the comments made. As a mental health professional who works with S136 and clients on an almost daily basis, I am we’ll aware of the constraints on both services.
    The panorama programme, I felt, did loose its way as it progressed. The misrepresentation of the nurse attending with police to potentially 136 in a private dwelling, etc doesn’t help the public understand how they can gain help in real situations.
    To call an ambulance will be to release the police but tie up and over stretch the already over worked a and e services and there has been much talk in the news this week about this. What will a and e do? Get security to stand with the clients, possibly restrain and then call the police for help?
    The answer- who knows. All services are receiving cuts in labour and funds meaning police, ambulance and hospitals are working at their limits. And hence why assessment and response times from mental health services is beyond the agreed limits too. The person stuck in the middle is the client in distress whose need is immediate and is sometimes managed in appropriately due to systemic deficits in organisations.

    1. This has certainly made me sit back and think! On reflection, my opinion and views regarding the programme were very much based around the limitations of existing service provision and commissioning agreements. Your point about A&E not make these kind of judgement calls said it all! A good reminder of remembering our public’s needs and not the limitations of our service provision
      Thank you.
      Zoe Grant.

  2. We have asked for assessment of our son since he was 4 to no avail at 13 they found out he had dspraxia bullied at school and outside I said there is something more to this at college discovered dyslexia he quit college then grandparents both died within a week became withdrawn and moved out suffered depression and anxiety attacks in April we got him home tried to get help from gp wouldn’t talk to me as by now 17 on the anniversary of grandparents death he slowly declined till one night he left with a knife fearing for him I called police he was arrested but mental health called had some visits from mental health but he canceled them but he did attend an assessment they are looking into aspergers. On Monday he was in court while waiting he curled up and laid his head on my husband’s knee he is going to probation mental health for pre sentence report then back to court in October getting a criminal record is what it’s taken to get our son help he is 18

  3. People who present as David and Tyler in the Panorama programme did are prime examples of the different ways that people perceive mental health. To the ‘layman’ and i would guess most non MH professionals they clearly had a mental disorder. To most MH professionals ( that i have spoken to who watched the programme) they are emotionally disturbed, angry, under the influence but not mentally ill. The ‘proof’ would be in their comparatively calm presentations once the effects of substances had worn off. However a police cell just winds them up further and allows them to cause more damage to themselves (hard walls, lots of noise and other stimulus as well as a captive audience to loudly vent their frustration and anger to).
    The answer is simple, at least to me. In my area it would involve an 8 bed (it is not unusual to have that many waiting up and down the county either for assessment or for in-patient beds) Place of Safety unit, lots of staff (overtime/stand by could be used to ensure staff can respond as required), minimal facilities as no one is going to be there longer then 48 hours and each room would be to the same spec as found in a PICU. It would be attached to the main Psych unit so quick access to Docs if meds are needed urgently. Your Tylers and Dave’s are likely to calm down more rapidly in this type of environment, if on a section 136 they can be assessed rapidly as soon as they present in a manner that makes an assessment possible (note not when their blood/alcohol level is below the drink drive limit). If not assessed as having a mental disorder then the police could be informed as they may wish to interview about possible criminal offences committed while under the influence. I don’t see that the use of a Place of safety should allow an offender to ‘get away’ with crime.
    I have a dream…….

    1. And to be fair to you, I share your dream! Warmed my heart to read that – because my fundamental reaction to the reaction, as it were – we can’t unpack what’s going on very quickly (ie, minutes). It’s going to take a few hours and I’m only interested in maximising the potential to keep people safe whilst they sober up and calm down, or not, and get a timely assessment.

      Total agreement.

    2. Very true #genowens. I too have the same dream of such a unit. Only then can people get the assessment appropriately in the right environment. My friend was texting me throughout in dismay at Tyler and Dave, I however was not in agreement of the acute state and once I pointed that once substances out of their systems they went home, she began to see the point of my argument. The cells are no place for people to be seen.

    3. One extra thing I’d add to that observation, is something around the number of people I’ve met who present as Tyler and David did, who do not calm down after intoxicatants have worn off, or who were not significantly intoxicated in the first place. People who only continue to get worse after their arrival and whose onward movement into appropriate care is made more complicated by their presentation and the inability of a lot of NHS areas to accommodate and care for them in a timely way. High profile events are there to see: the man in MS v UK being the very best example of this. (And that was not an isolated case: I have met several MS-type patients in police custody, including one very recently who was banished to the cells for being acutely unwell and who spent over 55hrs worrying the hell out of my for all the illegalities and indignities that were being inflicted.

      And therefore my main point about Panorama, as that it was all very well AMHPs and others shouting at the television about substance induced behavioural problems amongst people who were not severely and enduringly mentally ill. My point is, there is absolutely NO WAY a police officer can be expected to tell the difference. Which is why your unit, as envisaged, seems like an appropriate dream.

  4. I am a voice hearer with no diagnosis.

    I take no drugs legal or illegal.

    Some think the doctor’s diagnosis are often WRONG

    Some think the psychiatric drugs cause huge problems as does the Mental Health system

    I would recommend Pat Bracken’s Copenhagen talk and the Schizophrenia report
    ( which I have signposted below )

    What would you like for yourself, what are your dreams and aspirations ?

    EAT WELL, SLEEP WELL, EXERCISE, TAKE NOTICE, KEEP LEARNING,
    YOUR RELATIONSHIP WITH THE PLANET IS SO IMPORTANT,
    DRINK 6 CUPS OF WATER OR HERBAL TEA EACH DAY

    with support you can come off the drugs but I know from family and friends
    how scary the psychiatric system can be, be kind to yourself you are a good person.

    Here is some up-to-date information which I hope you will find useful
    This is another disturbing terrible case to do with the mental
    health system in the UK

    http://www.bbc.co.uk/news/uk-england-birmingham-21904422

    It is not an illness to hear voices or hallucinate
    1 in 20 hear voices or hallucinate

    For more information contact
    HVN, Limbrick Centre, Limbrick Road, Sheffield,S6 2PE
    Tel: 0114 271 8210
    Email : nhvn@hotmail.co.uk Website : http://www.hearing-voices.org/

    Hearing voices network also publish 4 magazines a year with very interesting articles !

    The HVN website features some of the HVN groups across the UK

    The local group I am involved with (in Richmond Surrey ) is as follows :-

    11:30 am at the Richmond Royal on Thursdays please contact

    0203 513 3200 for more information
    FREE to attend for as long as you like
    FREE cup of tea and biscuits!

    ALL WELCOME we are just a friendship group

    Other useful web links:-

    Postpsychiatry -Reaching beyond the technological paradigm in mental health by Dr Pat Bracken on YOUtube

    http://www.swlstg-tr.nhs.uk/news-and-media/events/hearing-voices/

    Ben Goldacre books ( Bad Pharma and Bad science) and the Schizophrenia commission report

    make very interesting reading.The Schizophrenia report is available through the link above for your
    information. I also have the following quotes from various people :-

    There is also a good piece in the British Journal of Psychiatry

    Dr Pat Bracken sent me a copy of the article :-

    “Psychiatry beyond the current paradigm”

    For medical staff it can be accessed via the following link:-

    http://bjp.rcpsych.org/content/201/6/430.full

    For non medical colleagues, you can get a copy of the article from me (via email).

    It is a brilliant article which mentions the HVN and
    challenges CBT, the NICE recommendations and of course
    ECT treatment, if I have read the article correctly.

    The article was written by approximately 29 people,
    some of whom are (I think) members of the critical Psychiatry network.

    Their website :-
    http://www.criticalpsychiatry.co.uk/

    To quote from the article:-

    There is also evidence that many patients who are not active
    in the service user movement find psychiatric interventions
    problematic and sometimes harmful. In their study of users’ views
    of services, Rogers etal found that many service users did not
    really value the technical expertise of the professionals. Instead,
    they were more concerned with the human aspects of their
    encounters such as being listened to, taken seriously, and treated
    with dignity, kindness and respect.

    To quote from Prof. MichealaAmering:-

    While the complex,as well as polarized, discussions about recovery are
    both fruitful and necessary, I would like to suggest that in order to
    meet the challenges outlined by these debates we might profit from a
    simple formulation for our efforts. To guarantee
    the human rights of people who come in contact with psychiatry could be
    the main focus for all of us in the international mental health
    community , be it as peers , clinicians, family and friends, advocates,
    therapists or in our research work as scientists.
    Such a focus might have far reaching implications.

    To paraphrase from the HVN magazine autumn edition 2012, Twinkle O’Sullivan.

    Twinkle describes lying to the people “in control” about ECT and voices
    because the “ECT treatment” was so bad.

    This is a powerful campaign as well :-

    http://www.mind.org.uk/crisiscare/restraint?utm_medium=email&utm_source=Mind+-+CharityEmail&utm_campaign=2708392_Mind+campaigner+bulletin+June+2013&utm_content=restraintinyourarea&dm_i=CZC,1M1T4,7XHDXM,5LCO7,1

    I have problems with some approaches that are suggested

    I do not talk out loud to my voices ( I did scream for hours once and it was scary )

    I speak to them without speaking out loud,
    so I talk but do not make any noise out loud

    You can ask your voices a simple question :-

    “are you a person , you do not have say”

    The answer is often that they are people

    Some in the Hearing voices group I attend are so kind

    and they say you DO NOT have to work out who your voices represent

    If it is non controlling positive telepathy then making other vulnerable

    people, as we all are, pretend to be people they are not in the voices

    could cause them huge problems

    MY biography sent to the “Psychiatry beyond the current paradigm” conference in Nottingham

    I am a 53 years old survivor of the mental health system.

    I am a voice hearer with no diagnosis.
    I take no drugs legal or illegal.

    I have not visited a doctor in ages and I am not ill.

    My sister is also a voice hearer, but she has not been so lucky.

    I have hallucinated since childhood.

    I believe the voices to be other people, I can chat to my voices without speaking out loud
    I try to provide accurate information into the voices and I am very uncomfortable with
    some advice given to voice hearers in reality.

    I attend a voice hearing group in Richmond Surrey , which I went to my MP to keep open.

    The group has had a psychologist and an occupational therapist available at different time.

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