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.
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