No big introduction, just crack on and read this. Written by Dr Jenny HOLMES, a Force Medical Examiner and Psychiatrist. Not all doctors appreciate what she has to say. Also bear in mind, this recent post by @NathanConstable – how many more deaths will we read about, before the penny drops? 😦
Today I have been at a conference full of eminent people in Manchester, discussing Policing and Mental Health. Police, Doctors, Psychiatric Nurses and many others along with those who have carried out important reports such as Lord Adebowale (who reviewed how the Metropolitan Police deal with mental health in the wake of several deaths and serious incidents). Lord BRADLEY was there to update on the progress of a National Liaison and Diversion service. And Drusilla SHARPLING who produced the HMIC report ‘A Criminal Use of Police Cells’ looking at s136 detentions
Drusilla said that having a person in a Police cell under s136 of the Mental Health Act who had not committed a crime’ was wholly unacceptable. All day we talked about how to make this stop.
The case of 39 year old Leon BRIGGS who died after being taken to a Police cell under a s136 detention by Bedfordshire Police last week was mentioned. Michael and I went for a drink afterwards to discuss all things Policing and Mental Health then as we parted company and I checked my phone I found out it had happened again via an announcement on Twitter by the IPCC. Yet again a young man of 33, Terry SMITH, detained by Surrey Police under s136 and taken to a Police cell had become ill and died.
Two cases in two weeks. Young men in their 30s. Detained by the Police to get them a mental health assessment and help. Yet somehow dead. We cannot comment or speculate beyond what is in the public domain but here are two tragedies that perhaps could have been prevented and my thought are with the families
It may be oversimplifying things but I have begun to think of these cases as being a deadly combination of factors which contribute to the risk of death:
MENTAL ILL-HEALTH / DISTURBED BEHAVIOUR + POLICE RESTRAINT + POLICE TRANSPORT + POLICE CELL = RISK OF DEATH
Looking at these in turn;
MENTAL ILL HEALTH / DISTURBED BEHAVIOUR
Mentally unwell people have poor physical health. We know that someone with a major mental illness such as schizophrenia dies on average 20 years before their peers. This is due to a combination of factors such as heavy smoking (psychiatric patients are some of the heaviest smokers left in society) leading to early emphysema and heart disease. Drugs such as olanzapine can cause people to gain large amounts of weight which can lead to diabetes. Some psychiatric drugs also alter the electrics of the heart making it more likely to stop suddenly.
The mentally unwell often misuse drugs and alcohol leading to further ill-health. Alcoholics can have oesophageal varices, massive swollen blood vessels in the gullet, caused by liver cirrhosis and waiting to burst and cause death at any time. Many people without mental illness also misuse drugs and alcohol.
Disturbed behaviour can arise in the context of intoxication alone, many stimulant drugs such as cocaine, amphetamines and the many ‘legal highs’ can produce symptoms such as a racing heart, raised body temperature, sweating, hallucinations and aggression. By the time the Police get involved the person’s body is often under immense strain, either from chronic illness and/or the acute effects of drugs and/or alcohol
The Police have a situation of risk to deal with. They are trained to deal with people who pose a risk to the public and to a lesser extent those who pose a risk of harm to themselves. They are not trained to assess medical risk. If I as a doctor was faced with this person in the street I could not fully assess the medical risk either. They are unknown to me, probably in a too agitated state to communicate and I have nothing more to go on than a visual inspection for injuries and obvious physical illness.
When the Police turn up its frightening. One or more blue lights screech up. Officers in protective clothing get out, on their belts they have batons / CS gas / pepper spray and increasingly a TASER. They approach the person, they do try verbal de-escalation but without success. Trust me, as a doctor who prides themselves on their verbal de-escalation skills that when I see people like this in Police cells, I often can’t de-escalate it myself.
The Police put a hand on and the person tenses up. Things can escalate rapidly. The Police have extensive training on the safe, proportionate and least restrictive use of force but force it still is with pain compliance techniques. The person is already frightened, many people who experience hallucinations and delusions whilst intoxicated or mentally unwell feel very frightened and paranoid and fear of the Police is often a feature. Things can escalate rapidly.
What are the medical risks? Well firstly we have a person who we know may be in poor physical health. Acute intoxication carries a risk of sudden death. The restraint process can bring a person from standing to the floor, often with a bang. NICE guidance states that falls from heights over a metre ( and most people are 1.6 metres at least) carries a risk of serious head injury and a CT scan should be considered. Prone restraint (where the person is lying face down) can be particularly dangerous if prolonged. This is the position people are put in to apply handcuffs to the rear. Add obesity to prone restraint and the risks of asphyxiation are even greater.
The person’s body is absolutely flooded with chemicals such as adrenaline, perhaps through the effects of drugs and alcohol and certainly through fear. The body’s chemistry begins to change, perhaps with the blood becoming overloaded with potassium which can stop the heart. We know acute stress can cause heart attacks. A person who already takes medication that affects the heart’s electricity is doubly susceptible.
As way of comparison when people are restrained by psychiatric staff a nurse trained to Intermediate Life Support is supposed to monitor the medical condition and a doctors review should be sought urgently.
I am no expert in this. But I know that such persons often get transported in caged vehicles for the safety of the officers. By this time the person is controlled but will have handcuffs and possibly leg restraints ( Velcro straps) It can be difficult to maintain a sitting position in a caged vehicle and the person may get into further awkward positions aggravating the risks of positional asphyxia. Particularly if they are drunk. The worst near miss I saw of positional asphyxia was a drunk teenager, overweight, who had fallen asleep on the toilet with his head slumped forward, this had obstructed his airway and he was blue ( we woke him up and he was fine).
There is no ability to monitor medical condition in Police transport and no one trained to do it and it is usually a quick trip to the Custody Suite. In rural areas the distances can be substantial increasing the risks.
Once the person gets to Custody hopefully the restraint will be removed and things get a little safer. However some damage may be done; injuries sustained during restraint, a heart under strain, abnormal blood biochemistry. Custody Suites do have nurses and access to doctors. Some Custodies have a nurse there all the time: with most it is a mobile service with a response time of up to an hour in a City and much longer in rural areas. The Custody nurse comes armed with a blood pressure machine, a temperature, a saturation monitor, a blood glucose machine and that’s it. There might be some oxygen available and all suites should have a defibrillator which custody staff are also trained to use. We can’t do blood tests/x-rays/ECGs (heart tracings)/CT scans etc. We can’t drill holes in someone’s skull to remove the blood clot that is about to kill them, caused when they fell to the floor. We are not an Accident and Emergency Department. And if we decide to transfer the person to hospital we have to wait for an ambulance involving more delay.
I have blogged before about how these cases, if not starting as a medical emergency, can rapidly become one. The two deaths tell us that alone. November 2013 should never happen again. The answer is simple to me – get Health into the pathway right at the early stages.
I met PC Alex Crisp today who is rightly proud of the new Leicestershire Street Triage Scheme. He would argue that if he had turned up with a psychiatric nurse that the situation may have been different and they could have de-escalated it and kept things safe. That may be right but I know from years as a Police Doctor (FME) that many of these cases cannot be quickly verbally de -escalated. I have spent many a long night trying to engage a highly agitated, intoxicated person in a cell.
I do have doubts about the street triage model because of the physical ill health risks and was glad to hear that Alex would have no hesitation in summoning a paramedic to assist in these cases.
These cases must have a rapid paramedic response at scene and Health transport supported by the Police as necessary. I believe they should all then go to Health Based Places of Safety and hope this blog illustrates why: even without taking into account Drusilla SHARPLING’s views that from a legal and ethical perspective a cell should never be used
In eighteen months’ time my eldest son hopes to go to University. The late teens is a time of risk for men’s mental health and also a time when they can drink excessively and experiment with drugs. If my son is found one night in a highly agitated and intoxicated state in the middle of the road by a Police Officer I would be grateful if they applied discretion and applied s136 instead of arresting him, perhaps jeopardising his future career. I will jump in my car and drive through the night to pick him up from a hospital and take him home and look after him.
I don’t want to arrive at the hospital and be directed to the mortuary – let’s stop this deadly equation ever happening again.
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