This last week has brought a number of queries about the role of the police in restoring or maintaining order on psychiatric wards where disturbances have occured. This is a difficult and controversial subject because we have seen incidents on wards involving the police which have then become subject to protracted inquiries after deaths in police custody or following contact. Olaseni LEWIS and Kingsley BURRELL-BROWN are just two examples of ongoing enquiries where criminal investigations became necessary after tragic events.
So it is not unsurprising to learn that the police are becoming alive to the to the risks and sensitivities of intervening in medical settings where disturbances occur. And yet, there is an inverted point to be made here about parity of esteem: the police are frequently called to intervene in Accident & Emergency departments, despite the presence of security staff there. The police are often asked to intervene if disturbances occur on wards, whether involving patients or their families. I spent a phenomenal amount of time as a young PC in City Hospital in Birmingham dealing with crime and disorder that arose in those environments. This was a far greater amount of time than I ever spent at All Saint’s Hospital, which was the nineteenth century asylum in my area.
But these debates carry on —
I recently attended an event in another force where a Chief Inspector gave an overview of a situation in an acute admissions ward where a patient was reported to have taken hostages and threatened them and staff. When the police arrived, these two individuals had been released but there was now a barricade situation in the patient’s room. Staff in that unit had called the police and officers were firstly interested in what “tactical options” the NHS staff had.
So this gets in to the debate: to what extent should the response to or the management of disturbance on NHS wards be “a part of the job” for mental health nurses and other professionals? We know that mental health care will give rise to disturbances, because at least some of it is delivered coercively. There are very real legal disputes and frustrations in mental health care, which mean staff train and prepare – to an extent – to respond to that. We know that some NHS staff have control and restraint training. We know that institutions which provide higher levels of security also train to a higher standard and have intervention teams.
But this is not across the board – and for very good reason.
DIFFERENT MENTAL HEALTH UNITS
Mental health units differ in their constitution, their purpose and their levels of security. Even within a particular mental health unit, there are different kinds of wards. In the main local mental health unit – not a low, medium or high secure facility – there will be acute admissions wards as we as rehabilitation wards. There may be individual wards for particular conditions or split by gender or age. There may also be seclusion facilities and in some instances, a psychiatric intensive care unit. As new build facilities have opened in the last ten years or so, financed by various PFI schemes, we have seen the construction of some mixed estates – distinct areas within one building, providing different levels of care and security for different client groups.
So in some instances, within the same building, you have non-secure MH facilities, but one wing or ward may be designed to a more secure specification for a small number of low or medium secure patients. All of this affects who managers and staff will look at their extent of their role in the management of disturbances. It may be more readily expected that PICU staff prepare for the reality of managing disturbed behaviour compared to, let’s say, an elderly adult ward or a rehabilitation ward. So beyond the provision of staff with training in control and restraint for pre-planned interventions to medicate someone under Part IV of the Mental Health Act, there may be little further tactical capability to deal with disturbances in the less secure settings.
Contrast this with High Secure hospitals: Broadmoor, and Rampton; Ashworth and Carstairs – these units are able to mobile staff in protective equipment, much as the Prison Service do with their “Tornado” teams. Of course, it’s a debate to be had, about whether we see this as something the NHS should do or whether it is a role for the police.
There are different views on these issues: quite often genuinely held and argued for good reason in good faith.
The operational tension that can arise from these discussions sometimes occurs because two debates are occurring simultaneously. NHS staff, faced with a disturbance that they assess as being beyond their ability to cope call the police, the police then turn up and ask why it is beyond their ability to cope. In other words, NHS staff are asking for help in their operational reality; police officers are wondering why it is their operational reality and why thought hasn’t been given to equipping and training NHS staff to have options available to them. But this is to massively miss the point, isn’t it? – it’s like the police turning up to a car crash and putting the cause of the collision ahead of casualty management and public safety. You start to investigate the cause of the crash after you’ve prioritised the injured and started first aid, as well as having secured the scene of the collision as best you can. You start getting other 999 services there before you start interviewing a blameworthy driver about due care and attention.
It is certainly my view and that of others that there can always be situations that where there is a need for police support. It is also my view, that regardless of what NHS managers could or should have considered and what they might have done to better prepare or respond, if you have frightened staff and patients asking for help because situations have occured where there are threats or risks consistent with the type of thing the police would have responded to in acute medical settings or other places, then there are certain duties arising from that. I’ve written about this elsewhere. You are where you are, regardless of how you got there.
Suffice to say, most mental health units, that are not High Secure hospitals do not have tactical capabilities to deal with anything beyond verbal, minor or short-lived disturbances. That means it is the job of operational officers to decide how to best police what they are called to, and the job of senior officers to discuss with mental health trusts (and possibly CCGs) what activity is best done by police officers and what is best done by health professionals. I’m confident, if there were ever a scenario where a lethal or near-lethal threat emerged on a mental health ward, we would agree with the principle that the police should be involved. Where disturbances occur of a far less serious nature, there should be capability within our NHS to respond to that.
We know that front line professionals on both sides can get this wrong: stories exist within the NHS of police officers being too quick to say, “This is a matter for you and refusing to get involved.” NHS staff have been known to ring the police for trivial issues like a patient throwing a mug at a wall, breaking it. NB: not throwing a mug and engaging in any ongoing crime or disorder a one-off incident which was over just after it begun.
BARRICADES, WEAPONS AND HOSTAGES
Over the years, I have formed an impression that you can use the three criteria “Barricades, weapons and hostages” as a clue to things. Where any of these matters are present in an incident of disorder, there will be some kind of role for the police, not least because within such events you could well have criminal liability that may need investigating. Let us remember: there are legitimate concerns within the NHS about the police’s competence and willingness to investigate criminal offending. We know that a minority of offences on wards are reported to the police, so it is usually done because staff have thought through the incident enough to believe that the police should investigate.
But where we have barricades being erected in wards by patients stacking furniture behind doors and threatening to harm themselves or others; where we have hostages taken or weapons being brandished towards staff and other patients, this all sounds serious enough for me to want to be involved, even if it is just in support of NHS staff or to investigate the incident if criminal complaints are made. And if certain NHS establishments do have greater tactical ability to resolve disturbances then they can choose not to ring the police or cancel them.
So I’m sympathetic to the idea that senior managers and senior officers could be talking to each other more, about certain situations do not need to involve the police. Other situations are better led by health professionals appropriately trained and equipped and some situations should involve the police just as they would if they occured in other contexts. Within all of that, we need frontline staff to understand how that partnership works so that NHS staff to recognise that part of their role is the management of disturbances and calling the police about coffee mugs being thrown during one-off events is inappropriate. That said, police officers need to recognise that not all criminal justice responsibilties stop at the hospital wall and that it can be unrealistic to leave NHS dealing with barricades, hostages and weapons.
We need to remember: we are policing the world we actually do live in, not the world we would prefer to live in.
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