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?


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

Winner of the Mind Digital Media Award.


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10 thoughts on “Something’s Not Quite Right

  1. I think a big problem police have is they ge such a surge of adrenaline, possibly brought on by fear that they are quick to use “weapons” at their disposal before using conversation. Its difficult for them but they dont seem to want to try talking and just go for subduing.sometimes it will be possible to ask why someones behaving the way they are.some have also got the wrong idea that if someones violent towards themselves they will be violent towards other. I dont know why with all the training the police have when faced with incidents they cant think of all the medical conditions that can alter people’s behaviour. Im probabky being too simplistic!

  2. A very dificult decision to makefor a train officer or not. Sometimes the situation calls for a quick respose. Other times a talking approach may be possible. There may be family or friends close at hand tht could assist with the right response. That is in a perfect world, which we do not live in. We hear of officers laying their lives on the line for the public but we also have to understand that they too want to go home safe to their families. I hope that we can start thinking outside the box and come to a safer environment for all.

  3. There are lots of things that are not quite right. In difficult & complex situations people can only seek to do there best & behave reasonably & seek to base decision making on what they do know. We are often faced with lots of unknowns & still expected to manage risk & get it right. Experience & training help get it right more often than not. But it’s not a perfect world.

  4. I thought diabetes was an excess of sugar in the blood? Isn’t hypoglycaemia caused by taking insulin without eating?? Either he was hyperglycaemic or witheld his insulin dependency. Any doctors/nurses know the answer?

    1. Can also involve very low blood sugar and there is more than one form of diabetes. My father has diabetes and his problem is blood sugar dropping far too low, too often – hence emergency stash of sugary drinks / chocolate in home and car and frequent analysis of various readings alongside levels of insulin used.

      1. Article states person reports being undiagnosed (with diabetes). Only treatment, present/past results in diabetic hypo’s.??? Suspect person not told truth, maybe embarrased? Even suicide attempt? Or have a different untreated disorder which causes low blood sugar, eg addison’s, renal failure..)???? Untreated diabetes results in excess blood sugar doesn’t it???

      2. I’ve got no idea, mate – I’m not a doctor! What I do know from this third-hand anecdote, narrated by a sergeant with a first aid certificate – is that he wasn’t very well at all, was undiagnosed as a diabetic and that this caused him to collapse in the ambulance, in the initial assessment of the consultant in A&E who spoke to the sergeant. Maybe the DR was wrong?

  5. I do despair at comments like those posted by blanche69 and wonder where this perception comes from in 14 years as a response officer i would say we spend far to much time trying to talk to people resolve situations in terms of the resources available and amount of work we have but again each force is different, it is impossible to consider every potential medical condition when dealing with incident if i could do that i would be working as a doctor in my policing area 18 months ago a local authority survey revealed 53 different languages /dialects spoken just to add to the confusion the truth hard pushed under resourced officers are used to cover all of societies problems and no matter what a minority think we use force or as blanche69 claims weapons as an absolute last resort, sometimes we get things wrong and lessons must be learned to prevent a repeat the problem is what lesson are learnt in say one force do not get passed others to prevent or reduce the risk of a repeat issue Im all for training and awareness to help officer recognise mental or physical health issue but at the end of the days we are police officers not medics, mental health workers, social workers or doctors with te best will in hte world we can only do so much

  6. When I first started as a police officer, mental health was one of the issues with which I found difficulty coping. That changed dramatically when I personally experienced the challenges first hand, when Mum was diagnosed with dementia. I was no longer ‘frightened’ to face these situations and dealt with them in a different manner to that beforehand – that is, with more understanding of the issues and challenges faced by the person with the mental health condition, their family/friends and by police officers.

    As outlined in Michael’s article, there are so many conditions, that it is unfair to expect a police officer to be au-fait with each and every one of them other than to have an overriding briefing about the state in general. Michael gave a presentation to the team a while ago, and even though I was then more aware of factors due to the experiences with Mum, I felt that my knowledge was scant. The police officer is generally the first port of call when things go wrong. However, should that be the case? Are they the right organisation to take on responsibility for mental health matters when they could do, or say, something which might totally change the status quo.

    In times of cut-backs and rationalisation, I cannot foresee the opportunity, or desire, to spend the amount of time on mental health training for police officers when there are the relevant trained professionals within the health service. However, that said, I believe that police officers SHOULD have regular mental health training/briefings to educate and refresh, so they are aware of signs and symptoms, more than is currently the case. The training should also include the call takers and despatchers, so they can evaluate who will be the right person for the task in hand, be it the police officer, the mental health worker, or both. There is no right or wrong answer to this, and even with training, that will still be the case. However, the professionals and decision makers should be the ones taking the lead on this on the basis of ‘horses for courses’ so that each situation is dealt with promptly, efficiently, effectively and with the ‘sufferer’s’ welfare foremost. The officer on the ground does the best they can, with the knowledge to hand, so they should be helped and not scapegoated.

  7. It makes a difference whether someone has a mental health problem because if they are arrested on suspicion of a crime there are legal proceedures such as access to a doctor, appropriate adult, medication, different interview procedures…
    What about risk of self harm in custody and after release?
    What about the use of intimidation, ruses or the way questions are worded?
    Reliabity of confessions?
    Use of strip searches?

    The duty solicitor probably won’t understand mental health problems, and neither will the appropriate adult who is sometimes selected by the police, for reasons I don’t need to elaborate on. Even magistrates at court have very little idea.

    So I think it is quite important to know whether someone is suspected of suffering a mental health problem. Also, the crime of Perverting the course of justice recognizes that mentally unwell people are easy targets………..hence a stiffer sentence.

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