Learning From History

Here are two ways of saying exactly the same thing —

  • “Most people who are violent need a policeman, not a doctor!”
  • “Some people who are violent need a doctor, not a policeman!”

I raise this because the first quote comes from a medical handbook I once picked up in a book shop – probably one of those Oxford University Press handbooks with very thin paper pages that you see junior doctors carrying around the place and stuffed into the lower pockets of white clinical jackets.  It was part of a section on responding to violent or disturbed patients in A&E and I’ve left uncorrected the author’s gendered stereotyping of my profession!

IN TWO MINDS

I’ve now told the story A LOT of the poor guy who was extremely resistant (and probably quite frightened) having been detained under the Mental Health Act by some police officers who were then told to remove him from A&E because his violent attempts to self-harm.  Ongoing restraint by the police had been the only way to stop him hitting his head (which was already cut) and they were all too aware of the dangers of prolonged restraint.  In terms of the effect on other people in A&E, there was certainly audible disruption but little else because the officers were ensuring that his behaviour did not physically compromise the safety of others.  Nevertheless, A&E staff asked the officers to leave without any clinical examination occurring as to what could have been causing or underlying his presentation.

Three days later, the same police response team took a drug dealer into the same A&E after he’d been hit about the head with a metal bar during a dispute about money that ended badly for him.  He took a serious knock to the head and had to be manhandled (under the Mental Capacity Act) to A&E because paramedics were very fearful of what may have occured internally.  His violent resistance was significantly greater than the first man’s and although still largely contained by the police, it was impacting beyond the audible and he had managed to kick an A&E nurse whilst thrashing out.  No request for him to leave – each could have been suffering from a life threatening condition and / or could have suffered from the impact of restraint.  The NHS have guidelines on these issues – showing that it is something that needs more than a visual inspection of how resistant someone is.

That’s why I juxtapose my own, second bullet point and ask this: where there is doubt about whether a person who is violent needs a “doctor or a policeman [sic]”, is it the job of the officer to determine which category someone is in, or that of the doctor?  In easy in the straight-forward cases: it will be the officer – we often make judgements that someone is just angry and there are few medical risks from restraint beyond handcuffed marks to the wrists.  But where restraint feels qualitiatively different – mainly where the need for it is ongoing – it starts to suggest that other things could be in play and that’s where the NHS needs to kick in with paramedics and from time to time, an A&E doctor.

AN EMERGING NARRATIVE

This post is not going to be much longer, because I’ve said all this before but in the last twelve months we see an emerging narrative that is pushing more and more for police stations to used to contain violent detainees with considerable ambiguity about how that decision has been reached.  We saw in 2013 a joint inspection report from Her Majesty’s Inspectorate of Constabulary, the Care Quality Commission and the Health Inspectorate for Wales, A Criminal Use of Police Cells which stated (p 18) “A police station should only be used where it is absolutely necessary to provide containment for someone whose violent behaviour would pose an unmanageably high risk to others.” (My bold emphasis.)  Last week we saw the CQC Report A Safer Place To Be which states (p29) “Police stations should only be used in exceptional cases of seriously disturbed and aggressive behaviour.”

Of course, we can argue about what “violent behaviour” actually means and what “seriously disturbed and aggressive behaviour” is – the fact is that none of these phrases is used in the Mental Health Act itself, or the Code of Practice – and on what basis are we going to identify these (fairly obvious) presentations but distinguish them in accordance with the two bullet points at the top of this piece?  My point is, that neither HMIC, the CQC or anyone else tries to do so – not at all.  As such, we don’t have a public discourse about these difficult issues and the reason why they are difficult, is because we know that such presentations have been the stuff of death in custody inquiries for decades.  There are currently several UK police officers being criminally investigated by the Independent Police Complaints Commission for alleged manslaughter and wilful neglect arising from incidents where it turns out that they basically did what our UK inspectorates think they should be doing.

At last week’s Summit in London, the Home Secretary spoke on these issues and the need to improve.  Not just the need for the police to improve – Lord ADEBOWALE is out front of us all pointing out that the police cannot do this alone.  We also need the NHS to improve, which is why we are now seeing various events to develop actions plans for the Crisis Care Concordat; and we also need our inspectorates to improve.  We cannot, surely, continue to push out very generalised statements like this without qualifying what we mean, by introducing extra-legal considerations to our legal framework and in effect suggesting that we keep doing what we’ve always been doing.  Various indicators suggest that mental health demands for the police are rising – suicide is rising, use of s136 MHA is rising (by 35% in the Metropolitan Police area in just the last year).  As such, the very small percentage of incidents that are as unpredictable and tragic as those we’ve seen in history are more likely to feature in our demand.

And we’re running out of excuses – if we haven’t already – for why we keep bring simplistic (policing) solutions to complex (medical) problems.


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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5 thoughts on “Learning From History

  1. This point is such an important one that you can’t make it too often, particularly when you consider that a “violent” struggle against restraint, is a kind of flight(not fight) response and indicates terror and confusion and added to an acute mental disturbance can be lethal, as many of the deaths in custody show. Police officers need to know it– talk down and use force as a last and not first resort and do anything other than restrain, but if you have to, go straight to A and E in an ambulance, Paramedics and A and E staff need to know it too and they must never refuse medical emergency treatment to a medical emergency, particularly when police officers can help keep them safe in the unlikely event it is necessary. Thanks for your compassionate good sense on this matter.

    1. Thanks, Tony – just stuns me that after everything families like yours have been through, we have formal inspectorates saying things like this. I know what they’re getting at by saying things like this – it’s a kind of intuitive thing to some. But we’ve seen how it can go wrong far more than once and we need to show we’re learning from it. If there was a chance that a detainees chest pain was a heart-attack, we wouldn’t take the risk – we’d engage NHS emergency services. Not sure why psychiatric emergency is different – or are we?

  2. You are right Michael, it is an intuitive response- violence/ serious disturbance/ aggression means” police matter and police cells”– but it is dangerously lazy thinking. Awareness that under the circumstances that you have described in many of your blog articles, restraint equals a medical emergency would save lives. That needs to be understood by police officers, paramedics and all medical staff . Even better not to restrain in the first place, wherever possible. It was this time last year that Mercian Police took the brave and compassionate decision to close the M42 for over 24 hours, as I recall, to talk down one highly disturbed, suicidal individual,. Those are the sort of values and skills that I hope you can spread in your role. I was held up in traffic for a couple of hours and when I knew why, I literally applauded your Merican Police colleagues in my car! That is what I call good police work!

  3. A well titled and well timed blog, especially post publication of recent CQC report. 1998 Rocky Bennett case talked about ongoing and prolonged restraint, equals medical emergency. ‘Violent behaviour’ and ‘seriously disturbed’ patients in police cells? I don’t get it. The reports almost direct that police cells are the right place in such circumstances. Learning from history?

    I totally agree with you Michael and Tony.

    Seriously disturbed, often perceived as violent people, suffering from a mental health crisis; ABD is sure to come to the forefront of an officers mind. Police cells, suitable? …even when you apply that word ‘exceptional’? No, of course they’re not.

    These type of situations lead to deaths and it is not right that reports from such authoritative bodies even get close to suggesting police custody is the right place.

    So there’s a problem….:

    Police shouldn’t take such patients to police cells
    A & E’s often refuse to treat, allow such a person to remain in their environment
    Places of Safety refuse to admit, as they don’t have the facilities nor staff to manage

    This is why I talk about the issue of restraint and the need for this to be tackled once and for all at Concordat launch events and other meetings. It’s just too important to brush under the carpet. So let’s tackle it and engage the people and organisations that need to change this view. A solution needs to be found and greater understanding quickly achieved.

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