One vacuum into which the police have frequently been drawn is the area of urgent transfers between NHS hospitals. Transfers from a mental health unit to Accident & Emergency or another mental health unit. There are pitfalls to be anticipated in these kinds of requests and a legal framework in the background of incidents that is often worth knowing about. But to focus minds, it is worth remembering there are ongoing criminal inquiries into police officers and into mental health professionals arising from urgent transfers of patients between NHS facilities – there are liabilities to be encountered here, in Health & Safety or human rights law, as well as civil and criminal liabilities that may arise from the way in which the Code of Practice to the Mental Health Act may be violated.
So we need to get this right!
It is the responsibility of the Clinical Commissioning Group for each area to ensure that it has commissioned appropriate methods of conveyance for patients of all kinds, and this includes mental health patients. How the CCG goes about doing this is a matter for them, but typically they will group together with surrounding CCGs and commission their 999 ambulance service on a regional basis. They will also have to have regard to other situations of conveyance, for example the patient transport services which transfer non-urgent, immobile patients from home to hospital for outpatient clinics or, within our area of interest, the conveyance of patients subject to mental health law in the variety of circumstances that emerge.
These duties are made clear in Chapter 11 of the Code of Practice to the Mental Health Act 1983 and a starter for ten here, should be that the urgency in situation should probably involve a threat to life to become something where the police get involved, thus triggering our legal duty to protect life.
PREDICTING FORSEEABLE DEMAND
It is a predictable feature of providing mental health care that from time to time, patients will need to be moved somewhat urgently. We know for example that patients detained in hospital under the MHA are far more likely to have poorer than average physical health so problems such as heart attacks, respiratory problems or strokes are not impossible events. We also know that some patients self-harm or take an overdose and they may do so whilst on authorised periods of section 17 leave. The extent of this may require hospital assessment and treatment in A&E. It is also predictable that as patient care continues there will be a need to move someone from a unit that has become unsuitable to a more appropriate one. This will include transferring a person to a setting that has more or less security as risks to them and others alter over time.
As a general rule, such transfers should not involve the police. Apart from the over-riding principles of the Code of Practice stipulating that transfer should ensure dignity for the patient, it all comes back to many types of demand being foreseeable. We may not know on which day a detained patient is going to need transfer to a medium secure facility from a Psychiatric Intensive Care Unit but we know it will happen. So when the need arises, how will it happen without necessarily involving the police as an automatic response? That is what we should be asking now, if we’re not already.
URGENT TRANSFERS TO A&E
By definition, most people attending A&E do not know that they are going to need to go until the something bad happens. If someone suffers a potentially life-threatening emergency like a heart attack, it is going to be a 999 ambulance involved in the transfer and, in theory at least, staff will accompany that patient. But you can already see why the police are sometimes drawn into this kind of situation – if need is truly urgent and there are security implications beyond the ability of staff to manage, then time may not be available to have long discussions about where extra staff can be found. This leads officers into difficult territory about whether get involved and how to extract themselves from the situation if they do.
There is no obvious legal barrier to the police becoming involved in this kind of situation in extremis. A person detained under the MHA is in legal custody and officers assisting NHS staff may use reasonable force to ensure that someone being transferred remains in legal custody. The urgent nature of some transfers may mean officers become involved initially to ensure that access to emergency care is not denied or delayed and that NHS managers then identify staff to take over from them at A&E or even upon admission to a general hospital ward. This is the kind of things duty inspectors end up having to discuss. At what point is it reasonable for the police to expect NHS managers and staff to have identified a plan arising from which officers are released back to their other duties. I know of a scenario like this where the police ended up remaining on a hospital ward for three days.
Bear in mind that these last two paragraphs could have been written with regard to a section 3 patient with little risk history and where police support is sought purely because a ward was understaffed and had too few nurses available to accompany the patient. Equally, it could have been written about a Part III MHA patient, convicted and sentenced by a criminal court to a restricted hospital order in a medium secure unit who represents a significant risk to the public – police officers may be needed to keep someone safely and securely contained, at least initially.
In these kinds of incidents, I have seen and heard of requests that arise purely from under-staffing on wards. It wasn’t that the police per se, were required – it was that nurses attending A&E with one patient leaves dangerously low levels of staff on the ward of the mental health unit. There are two things that could be said about this —
The police service could take the view that it is not their responsibility to plug gaps and refuse to attend; OR we could recognise that there is a situation in which we could potentially contribute to saving someone’s life and then row about the bureaucracy and politics of it all just as soon as that person is in A&E receiving assessment and treatment. All situations will turn on their merits but police and NHS supervisors should begin to work together just as soon as any PCs have jumped on board an ambulance and they should work out the medium term plan for exiting the police from the situation.
URGENT TRANSFERS BETWEEN MENTAL HEALTH UNITS
Urgent transfer requests are also often seen in between mental health units. In my experience, this usually occurs where someone has been initially admitted to a ward which is then deemed unsuitable for a patient’s needs and where greater security and better staffing ratios are necessary to provide effective care. We sometimes see police officers called to these situations where patients have again become “unmanageable” in the opinion of staff caring for them and the dangers involved in transferring them via ambulance are too great to countenance.
There have been several incidents where officers have been called to disturbances on mental health wards and found that staff are involved in restraint and either wish to forced medication on a patient or have already done so and a clinical decision has been made to transfer to another kind of unit or to place a patient in seclusion. Where medication to sedate someone has been administered, there some particularly important issues to bear in mind if officers are even vaguely thinking of becoming involved.
The first point to make with regard to any patient who has been sedated, is that there is a particular requirement in the Mental Health Act Code of Practice: paragraph 11.5 makes it very clear, “Patients who have been sedated before being conveyed should always be accompanied by a health professional who is knowledgeable in the care of such patients, is able to identify and respond to any physical distress which may occur and has access to the necessary emergency equipment to do so.” Paramedics will normally not regard themselves as ‘suitable’ professionals – there are issues around the drugs they are licensed to administer and the issue of not wanting to supervise patients where the dosage of medication was administered by someone else where it involves estimates about patients and travelling time.
Ambulance services often refuse to convey sedated patients where the trust who seek support for conveyance are not supplying a doctor or suitable nurse. It is perfectly proper to suggest that the police should do likewise and for even more reasons. << This is the stuff of inquiries.
It is a perfectly valid position to say that the police should not be involved in these issues at all unless there is a risk to life.
Now, in an ideal world the police would not be called to any of these kinds of incidents. But I don’t live in or police an ideal world. There are going to be some situations where the correct judgement is going to be for the police to get involved – either because someone really does need to be in A&E as quickly as possible and there isn’t time to debate public sector cuts and staffing levels that may or may not satisfy the CQC. That having been acknowledged, it is incumbent upon NHS managers to plan for foreseeable demand and where officers have concerns about whether this has been done, it is perfectly proper to flag up the incident via their inspector and ask for it to be reviewed. It always comes back to whether CCGs have properly commissioned appropriate conveyance pathways but even then, events may dictate a dynamic decision has to be taken to get involved to keep people safe and / or prevent yet more calls for service to a mental health facility which is struggling to cope. Do the right thing to keep people safe – argue about it afterwards.
This blog arises in part from email queries that were waiting for me upon return to work after Christmas, so it’s clearly an ongoing issue and the pitfalls worth avoiding.
And I will end by saying this, again – conveyancing is what you do when you buy and sell a house; conveyance is what you do when you move people and stuff. 🙂
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