Somewhat Exasperating

I sometimes think we’re getting somewhere with this stuff and then quite unexpectedly, I come across apparently minor and incidental things which make me suspect all the progress we think we’re seeing is an illusion – somehow apparent because of cosmetic changes that seem both intuitive and convincing.

  • If we build a load of place of safety services and get 97% of people into them whilst 3% of people go to the cells, surely we can make massive claims of moving forwards?
  • If we get clinical decision-making to the point of detention, surely we can influence not just whether someone is detained, but also the pathway (or route) that they take whether detained or not?
  • If we have mental health provision in police custody and at the Magistrates Court, surely we can prevent unnecessary access to the criminal justice system?

Why wouldn’t we do all of this?! – it makes sense, doesn’t it? Well it’s not just what you do – it’s also how you do it.

LEGAL PROFESSIONALS

When I ask police officers what they would do in the event they instigated use of section 136 and were then advised by a mental health nurse or paramedic to remove someone to the cells because of highly resistant, aggressive behaviour – very possibly brought on by an immense overwhelming fear for that person of what the officers are actually trying to do – I am yet to find an example of an officer who knows when it would be wise, legal and in furtherance of proper guidelines around the dignified medical management of people to ignore that advice.

Yes, ignore it. Disregard it and plough another path.

I also sometimes ask police officers and mental health nurses whether they can conceive a situation in which someone wants to access a form of support or assessment and is willing to go with police, ambulance or mental health services and where this should also be disregarded. Why would you choose a legalised restrictive route when there appears to be another, less-restrictive option available which the mental health nurse or paramedic would like to follow? I cannot recall answers that reflect the learning from some tragic events we’ve seen where the key issue was whether someone who needed assessment and care finished it. Easy enough to start something on a voluntary basis, but what if the consent of acquiesance is removed before the process finishes?

When is it acceptable to take that risk and when should we not gamble with the issues – and who decides?

It is with enourmous distress that I keep reading and hearing of some influential people and some professionals operating in the new schemes we are seeing who are actively pushing the proposition that people who are “violent” (their words) need to be removed to police cells after the use of s136. Because where else would you take a resistant or frightened person suffering from mental distress?! Of course, I will speculate that the people who advocate such things have never spent years of their lives battling and campaigning on behalf of a deceased loved one for answer to why their sons, brothers and fathers died in the custody of the state; they’ve probably never been interviewed under criminal caution by the IPCC, prosecuted in the Crown Court for criminal offences ranging from assault to misconduct in public office; they they have probably never seen their Chief Executive officers being personally criminally investigated for Corporate Manslaughter arising from policies that raise the risks of deaths in custody.

It’s such an intuitive argument isn’t it? — the police lock up violent people in cells, this is a violent person ergo they must be taken to the cells. But it’s actually anti-logical – here’s the evidence why we should not do such things anything like so casually —

  • Faisal AL-ANI
  • Leon BRIGGS
  • Kinglsey BURRELL-BROWN
  • Rafal DELEZUCH
  • James HERBERT
  • Colin HOLT
  • Matthew LOVELL
  • Andrew JOHNSON
  • Olaseni LEWIS
  • Thomas ORCHARD
  • Toni Emma SPECK
  • Michael POWELL
  • Terry SMITH

…… and this is just in the last five years and is not an exhaustive list during that time: I could keep going and going to really ram home the point. In case you are unaware: each of these people died in contact with the police or in custody, whilst thought to be experiencing mental health problems. That is thirteen families who have been to hell and back wondering what on earth happened to their nearest and dearest and many of these families still don’t know, years after the original tragedy.

MEDICAL OPINION

I remembering reading in a reputable handbook for emergency medicine the following phrase: “Most violent people need a policeman, not a doctor.” Remember, this is a medical textbook – written by people who studied science and the scientific method to postgraduate levels over decades and are the cream of the cream of our country’s academic attainers. This quotation is in a handbook for the ease of junior doctors’ reference, written for them by more senior doctors, including consultants in psychiatry and emergency medicine.

So here’s a different way of saying exactly the same thing – “Some violent people need a doctor, not a police officer.” Or perhaps they need both? Either way, it’s exactly the same thing, isn’t it?! … although I managed to avoid the gender stereotyping from the original version!

Of all the things sitting behind violent behaviour, most people will need a police officer and some will need a doctor. Most will be drunk and / or angry and / or hateful and others will be injured and / or ill and / or intoxicated. This therefore gives rise to the following quandary: how do we tell the difference between the people who come into contact with our 999 services who are so violent they need a policeman and those who are so agitated they need a doctor? And when you set about answering this question, bear in mind that the causes of agitation in some people are invisible, unknowable and sometimes beyond the wit of paramedics with bags of kit to tell.

How does a police officer approach this question, replete with a basic first-aid certificate?

Does this mean that everyone who is violent should go to A&E? – of course it doesn’t! But it does mean we need to train police officers to a certain level of understanding about agitated behaviour and health risks. If someone is drunk and angry with a visible head injury, we know that the injury needs checking by paramedics and / or A&E and medically clearing before we start decanting them to the cells. If we know that someone is suffering a serious mental health problem and they are exceptionally resistant to being detained to keep them safe from other risks that can’t be ignored, we also know that various expert opinions (see the Rocky BENNETT Inquiry, for details) argue that the ongoing restraint of those of us with mental health problems is a medical emergency. We know that such views have been expressed in Coroners’ Courts by medical experts and also such views have been offered by families who would expect a serious mental health crisis to lead to medical assessment, probably via ambulance.

The quandary about how to distinguish the one group from the other, is essentially a clincial judgement. It can be taken by police officers in the most obvious of cases, but when subtleties and complexities become involved, it becomes more important for paramedics and doctors to become involved. What role mental health nurses play in this, I don’t know – and listening to debates between mental health nurses and emergency nurses about pre-hospital clincial screening doesn’t reveal a clear and settled view, either.

SUBLIMINAL MESSAGING

So why, despite repeated mentions in Coroners’ Courts, untoward incident inquiries and other authoratitive documents do we still keep seeing non-police professionals arguing that the police should keep doing what the police have done before. I refer to the kind of incidents which Lord ADEBOWALE spent six months of his life reviewing in order to conclude that we all need to do better all ’round – health and social services services included? Ironically, he concluded these things after an advisory committee included some who can now be spotted saying these sorts of things! It was with some dismay last year that an influential figure in the whole s136 / mental health debate told me quite casually in a lunch queue “of course, violent patients need to be taken to custody – that remains right”. WHY?!! Haven’t you read this stuff? Haven’t you at least followed the news?! It’s highly disingenuous at best, to issue such blanket statements in defiance of all that has gone above.

Far more importantly – such views are not binding on any UK police officer as we’re not obliged to do as we’re told where it conflicts with our legal responsibilities – we all took an oath of office to discharge our “duties faithfully according to law” ensuring “dignity, fairness and fundamental human rights.” << I’ll be busy doing that, if it’s OK with you.

There is a subliminal message hidden within this narrative – the police should just do as they’re told. It’s when the (untrained or poorly trained, quite frankly uneducated) police ignore the advice of the experts in these issues that we see all manner of problems, according to some.

Actually, I’d argue it’s because the police have followed such implicit advice in the past, that we have seen some of the tragedies we have. The officers in the case of Michael POWELL in Birmingham in 2003 did exactly what the structures of the NHS expected and wanted them to do at that time. Having done so, they were suspended for three years and criminally prosecuted in the Crown Court. The officers in the case of Colin HOLT in Kent did exactly what the NHS expected and wanted them to do at that time. Having done so, they were suspended for two years and criminally prosecuted in the Crown Court. We could keep going along this line, but I think you see my point.

Meanwhile, it seems the wholesale breaches of large tracts of the Mental Health Act Code of Practice that gave rise to these contexts were not sufficiently important to be challenged by anyone. (For the legal significance and importance of a Code of Practice, read the Munjaz case.)

How many of these incidents do we need to see before we realise three vital things? –

  • Mental health awareness training for cops is not good enough
  • the legal knowledge of health professionals is not good enough
  • the intergration of health and police services to delivery lawful, safe outcomes is not good enough.

Absolutely none of this is going to get any better as long as we keep hearing reputed professionals casually offering opinion that flies in the face of history, law and the NHS’s own guidance on these things. Read the Royal College Standards (2011) – read the NICE Guidelines on the Management of Acutely Disturbed Behaviour. It’s all there. It’s not just ‘hearsay’ or my opinion. Read the legal judgments in the case MS v UK (2011), Webley v St George’s (2014) as well as the Coroner’s verdicts from the death in custody cases above, which have progressed to that stage. I will admit that I find it truly startling: the notion that you could read and absorb all of this material and yet still form a view that “violent people should go to the cells” is an acceptable blanket statement.

Perhaps it is just rhetoric? An almost political device to keep the police absorbing risk and liability. To claim that “Most violent people need a policeman, not a doctor” is about as anti-scientific as things can get and the public and our police officers deserve far better, quite frankly.


IMG_0053IMG_0052Winner of the President’s Medal from
the Royal College of Psychiatrists.

Winner of the Mind Digital Media Award.


Advertisements

18 thoughts on “Somewhat Exasperating

  1. Having now heard about good deescalation on an inpatient ward, it is really good, but does need medication to make space for talking, and of course a s136 does not mandate medication without consent. And a 136 suite in a mental health unit is typically just a holding cell, so a less secure custody cell……So it’s back to the issue of how long it typically takes to get an assessment doen, and if the professionals won’t do it as long as the person is agitataed, then they can’t be given any medication either….. a geat Catch 22

  2. A v strong, pointed & annoyed piece me thinks & having read your twitter stuff over the weekend I think I spot the “reputed professionals” – plus I hope that you are ok.

    It is a v imperfect world & there are v few real experts in all this & not nearly enough £s being invested. Sometimes people & their families & the community at large needs all of us.

    Today a colleague & I found ourselves between a rock & a potentially high profile hard place. BTW we had a warrant, but as the person was not at home it was of little use to us.

    Without going into the detail I assure you that we all needed to be there together.

    By working together & filling the gaps we managed a safe outcome in v difficult circumstances. Luckily for us we had a bed so we could do the legal stuff & your colleagues were excellent. However Despite us & plod using 999 for the ambulance the person ended up in the back of a police car – the ambo could not be dispatched! I will take it up with the ambo trust. The person was not taken to a cell but admitted to an appropriate health facility = PICU. This was possible because we had the bed & the officers accepted that neither a warrant nor 136 was appropriate, but they accepted that they still had a role because of the level of risk & because an offence or two had probably been committed.

    We were able to manage this because we had a bed & two medics & because we all sought to resolve the issues together & did not retreat into silos or seek to pass responsibility. It’s got to be together that we move forward & support each other & challenge the accepted views that your highlight above.

    Anyone who thinks that the Code of Practice is being adhered to his very far from the frontline & perhaps needs to return to the floor to understand the real impact of that.

    Take care mr MHC

    1. Cheers, thanks – you too. What gets me about the obvious risks of retreating into silos is that some “reputed professionals” are just not prepared to even discuss the views of others on these important matters. I know that meetings are being held without relevant parties present, views are being put forward presented as fact and evidence when actually it’s based on poor methodology and flawed data sets. It’s no way forward on complex issues that are ever harder to manage because of the situation we all know we’re in!

  3. Forgive me, but I’ve not had the time or energy to follow your links, so perhaps this is a simple-minded question, but is part of the problem to do with what is perceived to constitute violent behaviour? It seems from your opening paragraphs that some medical staff are perhaps wont to elide ‘highly resistant, aggressive behaviour’ — which is already rather slippery and apt to be determined by them — into ‘violent’. Accepting the thrust of your blog entry, is there here an unspoken need for medics to receive better (or more) training in handling such challenging behaviour without resorting to the use of coercive methods that they implicitly expect someone else (i.e., police) to implement?

  4. Please look at Mental Health with regards to ethnic minorities and immigrants, if it is not serving White British people well, then those who need special cultural sensitivity are worse. It is harder coz we come from a culture that is fearful of authority and suspicious of mental health services

  5. Last night I arrived at the local A&E escorting a patient who had voluntarily attended the hospital in an ambulance with what was believed to be a MH crisis. Upon arrival at the A&E I explained the situation to the A&E supervisors. I was asked if the patient had been detained by me under S136. I explained that this was unable to be done as the patient was found in their home. The nursing supervisor insisted that I should have taken the patient outside their home & conducted the S136 detention and insisted to the point of argument that this was the correct and agreed procedure to be undertaken. The supervisor eventually acquiesced to my insistence that such actions were unlawful and were not going to be undertaken, however remained resolute that the patient was not going to be triaged and admitted into A&E. To cut a long story by working with the local duty AHMP and the attending ambulance staff we were able to get the patient assessed and admitted for MH treatment in the local MH centre that night.

    1. Ian well done & thank u 🙂

      There are lots of things I might say about A&E & the supervisor – but I will keep it simple & repeat that it really is by working together that we will achieve safe outcomes.

    2. Good effort – it is obviously worth raising with that person’s supervisor that they were inches away from inciting false imprisonment, which in itself is a criminal offence. Tends to focus the mind. 🙂

  6. whilst I agree that in an ideal world all mentally individuals should be cared for in a mental health facility your blog misses a stark reality- i have worked on PICUs for many years- mental health nurses are an ageing population most of us are small females without the luxury of anti stab vests, handcuffs, batons tasers etc – we are left only with an ability to communicate and persuade- sadly that does not always work and we cannot always manage the level of violence we are expected to deal with. I believe that the police / mechanical restraint will be used more and more in the wake of the recent DH guidance on restraint as nurses are forced into adopting restraint systems that are ineffective for the highly aggressive / violent service users.

    1. I submit that the post absolutely does not miss the stark reality you describe – it is precisely BECAUSE I see and understand the stark reality you describe that I’m spending my time off arguing on social media against the utterly disgraceful, not to mention unlawful, situation to which we’re both referring. The reason we will disagree about this very profoundly is that you’re describing the world as it is and saying the police will just have to like it because that’s the way it is and I’m describing the world as our joint guidance and laws say it should be and saying that we all need work towards delivering that reality – because anything else would be negligent, literally.

      There are mental health nurses in this country right now being criminally investigated for their part in decisions to deflect the clinical management of resistant mental health patients to the police, whilst breaching the Code of Practice to the Mental Health Act and in situations where service users have subsequently died. There are also three dozen police officers being investigated for homicide and other indictable offences because they, acting on the assumption that mental health systems are properly set up to give sound clinical advice to officers at the policy and operational levels, did what they were expected to do by the NHS only to find that when people died as a result, the legal system took a dim view of their acquiescence. It is very interesting indeed to watch professionals when they’re trying to pressure police officers into doing the wrong thing and you push back against their preferences to violate legal frameworks for expedience. It is my personal experience that a significant minority of the mental health professionals I’ve met have significantly under-developed legal knowledge within which to situate their clincial decisions, especially in emergencies.

      Above, I made no reference whatsoever in the post to an assumption that all mental health patients should be cared for in a mental health facility – I made numerous references to medical emergencies which imply that A&E has a role to play and I’ve heard it argued time and again that some psychiatric emergencies involving resistant presentations are A&E style medical emergencies just like a heart attack or stroke would be. We know that this is true because of the NHS’s own published guidance on the matter of agitated behaviours and their sometime clincial causation. We know this because of Rule 43 letters from HM Coroners and it all gives rise to a challenge:

      How, precisely, do we tell the difference between the patient who needs an MH unit Place of Safety and those who need an A&E department? I’ve got only a rough idea – being just a policeman with a first-aid certificate. I also know that if you take a highly resistant mental health patient who is psychotic and let him or her bounce around a police cells for three days, we’re then into the territory of human rights violations.

      But what we should all also know – from the criminal, coronial and civil cases which have gone before – is that simply saying “violent, resistant patients to the cells” is simplistic and dangerous nonsense which is often the special kind of illegal that would get me prosecuted if I just did it blindly because I was following a 136 policy that should never have received clinical approval in governance procedures; and it would get you pulled into that investigation if you argued for that approach on the grounds that either your MH service or the wider NHS had failed to prepare for the reality that a small minority of patients present with mental health and / or substance use and / or other medical complaints which mean that they are at very raised risk of suffering an untoward outcome in police custody, if restrained.

      So regardless of your personal view about restraint or mine, I’d rather we looked at the laws that govern us all and worked out how your managers and mine could actually get themselves in the same room at the same time to sort out joint operating protocols that represent something close to the patient safety and dignity that relevant guidelines demand, whilst also being lawful, roughly speaking. It’s not too much to ask – and whilst they’re busy either sorting it out – or not, as they prefer – I am still accountable to the law of this country when people are in my care and after nearly fifteen years of work on this issue I have got the names of the consultant clinicians in psychiatry and emergency medicine as well as paramedicine that I’d call upon to help me justify the decisions I would take to disregard the kind of things we’ve seen before which led to the deaths in custody mentioned above. I’ve written about that elsewhere on this blog if you want to read it.

      We cannot just keep restraining people to death and saying, “Sorry, we didn’t set ourselves up properly to handle it in any other way.” The real stark reality is this: the duty care owed to vulnerable people in extreme crisis exists whether the infrastructure by which to deliver it exists or not.

      1. i don’t agree that my comments inferred that the police “will just have to like it” or that the current situation was acceptable- I’m just predicting that it’s going to get a whole lot worse for both groups – that doesn’t mean that I want it to

      2. Communication is a two way process – it’s not just about what you intended me to understand. You stated, “I believe that the police / mechanical restraint will be used more and more in the wake of the recent DH guidance on restraint as nurses are forced into adopting restraint systems that are ineffective.”

        What else did you hope I’d think? The police can only be used “more and more” if they agree to be. I can certainly say that the last three times I’ve been invited to enter a certain MH unit wher I work to use force on patients at the request of staff, I’ve flatly declined to do and we’ve had a robust conversation about the law.

  7. I apologise for my poor choice of words – I believe the police will be called more and more. I am interested in hearing your thoughts on the new guidance though- do you see any potential issues or is it just my incredibly cynical view that colours my judgement?

    1. No problem at all – it’s just good dialogue. Frankly, I haven’t had time to read them yet!? – will now do so in light of your comments because I’m sure you’re right: there will be implications for the police – intended, correct or otherwise.

      Also probably should as I’ve just been asked to speak at a conference on reducing restraint! I will certainly get back to you. 🙂

      1. if it’s the ‘no force first conference’ I will say hello to you there.
        in an earlier response you commented on views presented as facts and evidence based on poor data sets- this is so relevant to the DH guidance. I could go on and on about the flaws in both the circulation of the consultation document and the biased / leading questions posed BUT even more concerning to me is that the responses gained were ignored in the final document. 361 responders – “the majority did not support a ban on prone restraint” but you will only find this out if you write to the RCN. How can this be described as a consultation ?

        Norman Lamb said
        “No-one should ever come to harm in the health or care system. Although it is sometimes necessary to use restraint to stop someone hurting themselves or others, the safety of patients must always come first.”

        I would suggest staff and patient safety of equal importance and think that the issue of physical restraint should at least merit a proper consultation with the front line staff before bans are imposed.

      2. Given the pressure on all state systems, we are seeing ever more politics (small p) being introduced to the organisations. It worries the hell out of me, frankly.

  8. With passion comes frustration – in any field, but especially in police and criminal justice. Great piece though, I certainly experience plenty of these frustrations…

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s