Something’s Not Quite Right

You may remember that in July the IPCC launched an inquiry into the death of a man in Sussex following an incident in Hayward’s Heath.  The family of the man who died following restraint have suggested he was tasered and subject to the use of pepper spray as officers appeared to disregard information that he suffered from epilepsy and a seizure was mistaken for violent behaviour.  Initial reports suggest he may also have suffered a heart attack either during restraint or once in the police vehicle.  Another tragedy for all involved, regardless of what the IPCC findings may be and I can only imagine what his family have been through.

Of course epilepsy is not traditionally viewed in medicine as a mental illness, despite the fact that for the purposes of nineteenth-century laws on insanity, it could be viewed as such.  So could diabetes, for that matter.  However, this incident links to concerns I have written about before for various reasons:  we know that epilepsy is one of those medical conditions flagged up, along with diabetes, Addison’s disease and others, as examples of non-mental health conditions where presentation could be interpreted by many people as indicators of a mental health problem.  We also know that some people who suffer seizures because of epilepsy occasionally exhibit quite marked, sometimes violent behaviours and it’s crucial officers know enough to stand the maximum chance of recognising this where it happens.

I’ve written many times on this blog about different opinions, incidents and anecdotes which show the difficulty in deconstructing behaviour at incidents into those inherently artificial categories of disease, distress or dissent.  And of course, nothing prevents those three things overlapping just to make the decision a harder one – about how those issues should be prioritised.  The story circulated on Twitter and amidst the expressions of regret at the human tragedy, commentators started to second-guess what the IPCC will discover during their inquiry – I would advise against such attempts given that no-one yet knows the full facts and already there are disputes about what occured.

Let the IPCC do their job, first!

So what remains of this blog is nothing whatsoever to do with the specific case, about which I know nothing beyond that reported in the media.  I want to address two broader issues –

• The issue of particular awareness or training for particular medical conditions.
• The issue of deconstructing behaviour into clear decisions about whether to this ‘this’, ‘that’ or ‘the other’.

AWARENESS TRAINING

We hear requests for more police awareness training on mental health and following this incident and others like it there have been calls for more epilepsy awareness training.  A couple of comments also emerged in the discussion about autism training.  Here is a list of the various conditions I’ve heard mentioned during my career amidst suggestions that police officers should have raised awareness of that particular issues, above others.  Not all of them are mental health conditions but the others are conditions that officers may often mistake for indications of mental distress —

• Schizophrenia
• Bipolar
• Alzheimer’s
• Dementia
• Depression
• Post-natal depression
• Autism
• Apserger’s
• Learning Disabilities
• Personality Disorder
• Anxiety Disorder
• Acquired Brain Injury
• Epilepsy
• Diabetes
• Stroke
• …… plus awareness of how drugs and alcohol can confuse and conflate all of the above.

Quite a syllabus isn’t it?  When one asks the charities who represent those in our society who are affected by the above problems how much training would be required, you tend to get answers of between two and four hours.   There are fourteen conditions listed above – even at 2hrs per input that amounts to a week of training and at the end of such a course we would still need inputs about mental health and mental capacity law as well as the operational implications for the police of all of it.

You can’t do that in just one day! … so we’d already be looking at a course lasting a week and a half, if not two.

I have a more controversial question, however – to what extent do the above conditions make a difference to the way something should be policed?  If there is an answer to that then I see the relevance of training it – I’ve argued before that I see the point of specific autism awareness training for police officers because we know that where officers deal with incidents involving someone with autism there could be considerations that wouldn’t necessarily apply to other situations, if they can be accommodated.  I’m not sure if that could be said of all of the above conditions, however.  Would it matter to the policing of an emergency mental health incident whether someone who appeared to be in distress was psychotic because of schizophrenia or because of bipolar or because of Addison’s disease?  Probably not.

If police officers are going about things properly, they would be calling upon paramedics to support their decision-making about what needed to happen next where they have concerns about someone’s medical welfare.  But even this is a difficult balance to strike because police officers are not going to call an ambulance for everyone who is violent or resistant just to rule out encephalopathy or anything else.  But there is a point where no police officer with a first-aid certificate and any amount of enhanced mental health training is going to be the right person to be making certain clinical calls.

So where is that line?

DECONSTRUCTING BEHAVIOUR

The reality is that not every police officer in the United Kingdom is going to get a two-week mental health training course – and I would ask the question whether every one of them actually needed such a course.  I would argue a few need whatever we eventually decide is the most comprehensive training on offer and that most need a diluted version of that.

For many policing incidents, of course, an approach which starts with understanding particular conditions looks at things the wrong way ’round – officers are only occasionally asked to attend an incident where a family member is giving full information about medical or psychiatric history.  More frequently, we meet people and have to figure it all out for ourselves from scratch.  We often don’t know the person’s name when we first meet them and paramedics are rarely better off.  We simply don’t attend vast numbers of jobs where we know in advance which medical box someone fits into and even where we do things become more complicated when you introduce issues like drugs, alcohol and obviously, restraint.

And perhaps less obviously, some police incidents are going to be policed in exactly the same way irrespective of a mental health issue because it sometimes makes no difference to a police response whether someone is mentally unwell or not, at least to very initial handling of an incident.  All cases on their merits – everyone is an individual in those particular circumstances, whatever they may be.

I would argue that the police can be expected to make the obvious calls; but the more subtle things become the less reason there is to think the police are the right people to be deconstructing behaviour into clinical or non-clinical paradigms.  Clinical support is important and it isn’t always there, frankly.  That’s why I argue for greater involvement with our colleagues in the ambulance service and I suspect more integrated ways of working across those 999 agencies could bring enormous benefits, not just in the arena of mental health, but also domestic violence, night-time economy policing and so on.  It’s fair enough for police officers to see someone with a gaping, bleeding head injury and allow them to make the judgement about whether someone needs to go to A&E or not.  I say this because we would all hope an officer in that situation would agree that they should!  But it is far less reasonable when a knock to the head didn’t lead to any visible injury or any other sign of distress.  Does that mean everyone with a knock to the head goes to A&E? – no.  It means we need a combination of paramedics, healthcare support in custody and A&E as suite of options with good training on how far things should be escalated.

UNREALISTIC EXPECTATIONS

The same principle holds true with diabetes or epilepsy: if a person has collapsed to the floor and appears to have slipped into a coma, we would expect officers to spot that and react, irrespective of whether they knew it was caused by diabetes or whether they were quite unsure.  But where someone is disoriented but conscious, slightly incoherent and confused, would we immediately say “suspect diabetes” when a similar presentation could arise from other conditions?  Probably not, unless given information from someone at the scene.  Some years ago, just after West Midlands Police started routinely calling ambulances to all detentions made under s136 of the Mental Health Act, there was an incident that showed how precarious this all gets –

A gentleman outside a pub brought to police attention because of concerns by a member of the public about him being in the “confused, disoriented” category.  He didn’t appear to be drunk and enquiries confirmed he hadn’t been in the pub and officers formed the view he may be suffering a mental health problem.  They detained him under s136 and called an ambulance – he promptly collapsed in the back of it and was rushed to A&E has his blood sugar levels had fallen through the floor.  He was entirely undiagnosed – he had absolutely no knowledge at all that he had diabetes and after not eating properly that day he found himself in some medical difficulty.

Of course, it must be said that the police have got a bit of form in some high-profile incidents for not making use of information and people available to them who could better help them to understand certain situations.  This was true in the so-called ‘ZH’ autism case in London.  In certain other cases, family and professionals have claimed to have given the police information that should have been seen as relevant and it was ignored or disregarded.  If true, this is quite damming and officers must bear in mind how useful information and advice is from people who know those were are interacting with.

However, on the main issue here of officers’ recognition of medical issues cutting across mental health and other conditions I have to wonder whether the best we might be able to hope for, is not something which approaches diagnosis or specialist awareness of particular conditions, but an ability to have a general sense that ‘something’s not quite right here’ with a set of standard approaches to keep people safe and engaging with clinical professionals of whatever kind, as soon as possible?

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

Winner of the Mind Digital Media Award.

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