I want to highlight a case that has been covered in the media this month which shows exactly why we need to be careful about the false dichotomy of mind-body dualism and why we need to be really careful about the ridiculous things we hear some frontline staff saying and doing. It is a case which really shows how much work we all have to do if parity of esteem is to become any kind of reality in the United Kingdom healthcare system.
The case is exceptional because it has a very tragic outcome. It makes me angry precisely because it is so unexceptional for being the kind of case that could happen far more frequently than it does. Just take in how wrong this can all go from circumstances that most professionals in the police, A&E and mental health services will recognise. I doubt any of us in these professions will be surprised at the narrative that precedes the outcome and will be thankful it wasn’t us in the Coroner’s court. And when we get over ourselves, we’ll also wonder what on earth we would say in court, with a vulnerable person’s family listen and watching.
I’ve been somewhat monitoring this case since hearing of it, because when I first learned about the circumstances I just though, “That’s all kinds of wrong.” it seems Her Majesty’s Coroner agrees and if you want more background and detail, there were two pieces in the local, Berkshire press. The first was published after the arresting officer gave evidence during June, the second one emerged at the conclusion of the inquest earlier this month.
It’s just heart-breaking.
TERRIBLY SAD AND QUITE AVOIDABLE EVENTS
Stephen CHURCH woke up on the morning of the 13th May 2011 with a “sense of mission” that he should kill himself. Around 11am he took the decision that should get himself in front of an oncoming train and made onto a railway line. A young police officer took the decision to go “trackside” and pull him away from danger, detaining him under the Mental Health Act 1983.
The officers present then took decisions around his medical care, calling an ambulance (that didn’t come) and removing him to an A&E department. Amidst pressures about whether the police should stay or remain in A&E, and amidst confusion about who should do what and when, one officer left the hospital and while the detaining officer was talking to a Doctor, Mr CHURCH left the department.
He was able to throw himself from the multi-storey car park at the Royal Berkshire Hospital in Reading.
When he was detained earlier that day under section 136 of the Mental Health Act 1983 he was actively suicidal and physically injured. Not unreasonably, the police officers took him to an emergency department rather than a place of safety facility in a mental health unit. Most PoS units will not receive patients who are also physically injured: most A&E departments seem to look at people in police custody who are physically injured and mentally ill as if the only issue for them is the physical injury. Amidst these false distinctions, what happened next was referred to in the Coroner’s summing up and used as the headline of the second news article, above:
“A chain of failures contributed to death of suicidal man who was left alone.”
The circumstances of this poor man’s death just show how, when all of the long-standing frustrations of different agencies conspire together, we end up with vulnerable people who can die. What could be more important than making sure that the needs of people like Stephen CHURCH are put in front of the bureaucracy of Berkshire or the views of agencies like the Royal Berkshire Hospital or British Transport Police which fail to take full account of statutory, clinical and other relevant guidelines?
There is so much to say, I barely know where to start —
POLICIES, ATTITUDES AND GUIDELINES
British Transport Police’s policy on section 136 was written by a superintendent who gave evidence in the Inquest. He admitted during question that he did not know about the existence of the Code of Practice to the Mental Health Act. The policy stated that British Transport Police would only stay in areas to which people under s136 were removed for two hours. I’m not sure where that two-hour time period comes from, but it certainly wouldn’t satisfy the law of negligence for two cops who have detained an actively suicidal man to just walk out without further regard to what happens next. In fairness, the BTP duty inspector on duty that day actually did instruct the officers to remain there. Eventually one of those two officers left and when the remaining officer was taken aside to be spoken to by a DR, the patient absconded and ended his life.
If any police force wants to see how any alleged negligence is viewed by civil courts, look at the case of Webley v St George’s from earlier this year. It shows, that in order for the police to discharge the duty of care they owe to people in their custody, they must ensure they are handing responsibility over to willing, competent and fully briefed professionals who then assume that duty.
The Royal Berkshire Hospital stated in court that they were not a “designated” place of safety, as if that settles matters or absolves them from responsibilities. This case should be a salutary lesson for all A&Es and those who work within them. Firstly, there is no such thing as a “designated” place of safety. The word designated appears in the Mental Health Act Code of Practice only twice and neither time in relation to section 136 and places of safety. This concept of designation has been made up and this case shows what utterly dangerous nonsense it is, for its potential to pervert the process by which vulnerable people are managed. The MHA reminds us in s135(6) that a place of safety is “local social services accommodation, a hospital, a police station or anywhere else temporarily willing to receive the patient.” The RBH is a hospital – by anybody’s standards – and it is a matter of record that they allowed Mr CHURCH access to their treatment facilities. In what sense were they not a place of safety? It’s highly disingenuous to suggest they weren’t. You can’t have some highly alternative reality in which the hospital can accept him clinically (hand injury) but not legally (s136) – he is a full package: a legally detained patient with injuries and potential mental health issues who has legal rights of various kinds whilst in that environment. More importantly, this kind of approach assumes you can separate mental health from physical care problems and that mental health issues can just wait until ‘the real medicine’ is done.
A MATTER OF SHAME
If anyone reading this thinks I’m being somewhat harsh, I just remind you of the opening lines to a 2008 document from the Academy of Medical Royal Colleges, signed up to by the Royal College of Psychiatrists, the College of Emergency Medicine, the Royal College of Nursing and the Royal College of Physicians. You really should read the document and this opening really sets the tone for what it is trying to do:
“It is a matter of shame that this document is needed, but needed it most certainly is.”
The document goes on to talk about how we need to consider mental health issues for acute trust patients more keenly, how liaison psychiatry services can reduce the health burden and improve patients’ outcomes and experience. But of course since publication, the College of Emergency Medicine has produced its ‘Mental Health Toolkit‘ which effectively pushes back against this. In the toolkit the CEM effectively tells us that they are not aware of the latest edition of the Royal College of Psychiatry Standards (by referring to the 2007 edition, obviously unaware it was updated in 2011) and it allows casual language to create confusion. It states (p12) that A&E should only be used after the instigation of section 136 where there is an “acute healthcare need”. It seems to me that running towards a train in the hope of ending your life is a fairly acute emergency. Are the CEM using ‘acute’ as a euphemism for ‘physically injured’? Most psychiatric emergencies are fairly acute, by medical standards. Anyway, how does any doctor know whether psychotic behaviour arises from a functional mental disorder or some other condition, unless they examine for it? Exactly.
And taking this further for both BTP and the RBH: the Code of Practice makes it clear that when a person arrives at a place of safety – which we are now reminded they are, the Coroner himself having given that position very short shrift – then an AMHP should be notified of the detention so that preparation can be made to assess the man. Neither the police nor the hospital contacted an AMHP and I’ll wager a bet that no-one explained to Mr CHURCH his rights whilst detained under s136, either. These rights are laid bare in s132 of the Mental Health Act and apply wherever anyone is detained in hospital. For the purposes of s132, ‘detained’ means under any provision, not just the full inpatient admission provision, as so it applies to s136. Mr CHURCH would also have rights under the Police and Criminal Evidence Act 1984, to have someone informed of his whereabouts and to legal advice. Was he made aware of this? I don’t know – maybe he was. So many patients aren’t.
PARITY OF ESTEEM
This case and hundreds more like it raise loads of issues for me –
- The extent to which some police and NHS organisations are just making stuff up to suit themselves.
- The extent to which some of this nonsense puts vulnerable people in harm’s way.
- The parlous state of legal education amongst our professionals – and I throw this one equally at the NHS and the Police.
There is no reason whatsoever why Mr CHURCH could not have had a mental health assessment in the RBH, either before or after his hand injury was addressed. I’ve known MHA assessment take place before treatment of physical injury and here’s why: you cannot force medical treatment on people unless justified by law. Mr CHURCH was not going to die from his hand injury so it wouldn’t be possible to rely upon the Mental Health or Capacity Act to do anything about his hand injury before MHA assessment. In another case I heard about a man had been detained under s136 after he jumped from a bridge and had very badly broken his leg. He was fully assessed under the MHA and sectioned to an orthopeadic ward before an operation to address his protruding fibula which had broken through the skin. Because his physical injury was deemed to be a direct result of his mental disorder, he was treated without consent in an operation where he received a general anaesthetic. Rare, but possible and shows that on some occasions, MHA assessment should be the priority – but we can’t discuss that unless AMHPs and DRs start talking to each and they can’t do that unless the AMHP is informed.
Whenever you see discussion ongoing on Twitter about physical versus mental health or ‘mind-body dualism’ you often see doctors and nurses pointing out, in reality, such a dichotomy doesn’t really exist. It’s a false distinction and many medical conditions traverse this divide: dementia is often dealt with by mental health services, but it is caused by organic conditions in the brain; psychosis can arise from conditions that are caused by physical healthcare problems like Addison’s disease. More to the point, the AMHP and the A&E Doctor could talk through the best way to deal with any individual case if they had been told. Informing the AMHP as soon as possible isn’t in the Code of Practice because anyone envisaged them running to the location as fast as they could do an assessment. But it does allow for early discussion about how and when assessments will be handled; it allows for the planning of workload and it allows for an exchange of information that might influence risk assessments – for example, about whether it might ever be safe and wise to leave a patient in NHS care without police support!
But beyond the specific case, this kind of situation also gives rise to something else. RHB evidence at the Inquest indicated that they only saw their role as being the treatment of Mr CHURCH’s hand injury. The ‘mental health’ side of things was not down to them, apparently. This attitude is common place in A&Es after police instigation of the Mental Health Act. In terms of the seriousness of the overall situation, which of the two matters was the greater emergency? It wasn’t his hand injury but his mental health problem that killed him – by any assessment, that was the medical priority. But we often see physical treatment given priority over mental health care, as shown in this case where A&E were interested in addressing the smallest aspect of this man’s broader clinical presentation and where his legal rights were not explained to him, nevermind afforded him. Add to that the confusion and pressure around a police force who want to be able to get out of there as quickly as possible and it is a recipe for the disaster that it tragically became.
How do we achieve parity of esteem if a life-threatening psychiatric emergency is not as serious as a broken hand? It was his mental ill-health that killed him, not his hand – and in the opinion of a court, the Royal Berkshire Hospital and the British Transport Police contributed to that because of what looks to me like pre-occupation with issues that were nothing to do with Stephen CHURCH.
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