Honor’d In The Breach

I’m a bit bored this evening – sitting in a London hotel as I’ve had to stay over because of successive days of meetings in the capital.  I’ve been to the National Crisis Care Concordat Meeting and discussed policing and mental health with the national policing lead, Commander Christine JONES at New Scotland Yard, amongst other things.  The week has got me wondering about ‘policing’, by which I don’t mean the uniformed people you see dashing about the place answering 999 calls and arresting suspected criminals – I mean policing in a much broader sense, relating to the governance of our whole ‘system’ of mental health care, to which policing, the profession, all too often connects.

  • We have a Mental Health Act for example.  Last time I checked, thirty-six CCGs in England were breaching s140 of the Mental Health Act.  Who’s policing that, then?  I can’t arrest anyone for this – it’s not that kind of legal breach.  It’s not an offence for CCGs to ignore s140, so if the police can’t police it, who’s policing it?
  • We have a Mental Health Act Code of Practice.  In fact, we’ll have a new one next week when the 2015 edition takes effect at the start of April.  There are various parts of this document that get routinely ignored because services are not set up to give effect to it.  Patients who are absent without leave from hospital whose location is known should be collected and returned to hospital by the relevant health services, not by the police.  (Paragraph 22.13 in the old Code / 28.14 in the new.)  I’ve never known it happen.  Who’s policing that, then?
  • We have Royal College of Psychiatry Standards on Section 136 of the Mental Health Act – I’ve jested previously that it must have been these to which Hamlet referred when he remarked “more honor’d in the breach than the observance”.  Although published by the Royal College of Psychiatrists, they are, in fact, multi-agency agreed guidelines for the whole 136 system – including right across the police, health and social care systems.  This includes all parts of the NHS – ambulance, A&E, mental health providers and relevant specialist providers like learning disabilities and CAMHS providers, if different.

Anyone know anywhere in the United Kingdom where we can see these standards in operation?  Me neither.

I do sometimes wonder whether we should leave these agreements out there as the aspirational standard we are striving towards or whether we’d be better off ripping them up and accepting that no-one does it and no-one’s policing those that don’t do it.  Why deceive vulnerable people that they can expect such treatment?  Is it not morally quite unfair to raise expectations to that degree?!

MOVING TARGETS

Of course, the modern narrative about section 136 is that we need to reduce its use and we have seen all manner of initiatives to reduce the use of police cells as a place of safety and to reduce the use of the power itself.  Meanwhile, in the real world, use of section 136 is rising – by 18% this year in London alone – and this is materialising before our eyes notwithstanding the impact of initiatives like street triage.  And that’s another reason why smokescreens like triage hide the real problems, deep underneath: why are the police service having ever more contact with the mental health system, why is s136 rising so much and what are we doing to react to that?

One further problem here, is that we’re doing a binary comparison when we examine street triage – comparing this year’s figures with last year’s figures when last year was just another year over a decade or more where the general trend in section 136 is upwards.  Correlation is not causation, of course, but as we’re all busy policing and working in the real world, I’ll just point out how much 136 has gone up (%) since the NHS Mental Health framework in 1999 where community mental health services and in particular, crisis services, were seriously eroded.   

There is an argument that s136 may yet (need) to rise yet further, because if you look at how many people are arrested in public places for minor crimes who then receive a Mental Health Act assessment in police custody because of concerns that they may well be acutely unwell, the figure is HUGE compared to the numbers being detained under s136.  I accept I’m not an academic – as you know – but in the absence of any academics I know looking at this (weren’t we all meant to be getting evidence based?!), I will just have to extrapolate from what we do know – that around 5% of detainees in one force area who were arrested for crimes were then assessed under the MHA.  If that were even vaguely true nationally, it would mean around 50,000 people a year, which is more than double the number detained under s136, and 10,000 of those people were ‘sectionable’ which accounts for about one-fifth of all the MHA applications in England alone.  Can that be right?!

Plenty of scope, then – for better training, information and risk assessment to divert boatloads of vulnerable to relevant assessment first.  I can imagine CCGs haven’t considered this – data about people arrested for crimes is held by the police and I’m not aware of any areas developing their local Crisis Care Concordat plans who are asking for it, to lift the stone in an unfamiliar area of crisis care to see what is lurking underneath.  Are MHAA data assessed at the population level in each local authority area to look for trends, repeats and particular problems?  If not, why not?!

As I conclude this brief blog, one of Surrey’s most senior police officers is stood in an A&E department with someone who ran off from there a few hours ago and who was found on a roof threatening to jump.  Chief Superintendent Matt TWIST is, ironically enough, the lead Surrey officer on all things mental health and he’s chosen to spend his Tuesday evening working a busy late shift with his front line officers.  It is absolutely a core police function to protect life and this includes vulnerable people in crisis and using s136 where necessary.  However, before 9pm he had already concluded on Twitter that officers may well still be there until the morning and all the while an already agitated, suicidal person is becoming increasingly distressed as psychiatric services stand-off, pending certain medical results becoming available.

I’m sure I read somewhere that there should be three-hour turn-around for assessments, once someone is medically fit to be assessed under the Act?

So who’s policing that, then?!


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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17 thoughts on “Honor’d In The Breach

  1. Me often wonders about sec 129 & who is obstructing who & who we might call !?

    Btw given what I think I know about privately contracted FME services I wouldn’t be so confident about the figures in relation to custody & peeps arrested for offences. Tho I suspect we will see 136 on the increase as we see MH services constrict further.

    Enjoy the big smoke 😀

  2. sadly the ipcc seems to be the only body that examines whether the mha codes are followed. Impossible to follow as NHS doesn’t support them!

  3. Great post. As a relative you read all the docs and then wonder why it is OK for services to ignore it. Slightly separate comment on the A&E scenario – certainly in our area no assessment will be done until someone is declared physically fit, which leaves the police responsible until then. Also you can’t be assessed at A&E so have to be at A&E for hours – then back to Custody and then the clock starts ticking…..AMHPS can’t even be called until the person is either at Custody or 136 POS

      1. SD try MHA CoP 16.44 for starters 😄

        But before u get too excited remember even if u get to speak to a helpful AMHP they will still have to find themselves a Sec 12 Approved Medic & that is becoming increasingly less straight forward. Also depending on where u r with ur 136 person another medic or HtT/Crisis Team will need to be present. In the A&E example maybe that version of liaison will/should have a medic able to assess & provide a med rec if required. But then we will all be stuck waiting until the person is declared “medically fit” (what ever that means). But in a police station it is likely that the FME will be unable to a med rec & again a team of peeps will be need to be gathered. Plus people tend to forget that the whole thing is a legal process. BTW I have even known a PoS not to have the medical cover u or I or my mum think that it should have & is presumably commissioned to have.

        Unfortunately there appears to be very little compliance or respect for the CoP & ultimately the law currently allows for up to 72 hrs for assessment.

        But I would suggest talk nicely to an AMHP & support them to get done what needs to be done. But the AMHP can’t order other professionals or indeed the ambo to convey to hurry!

  4. Interesting to hear someone reflect on the impact that the misrepresentation of reality has on the individual in crisis. The number of times I’ve been told ‘you won’t get arrested, you’ve not done anything wrong, we’ll just take you to hospital for an assessment’, only for that assessment to not occur/not result in an outcome that was deemed to match/mitigate the risk to myself, and to find myself arrested for a breach in A&E/outside the doors of A&E as soon as I left. I’m not criticising the individuals, many have apologised to me, sometimes while arresting me, I got the impression they weren’t happy with the situation either, but eventually you feel you’ve been lied to so many times you don’t believe anything people say to you in a crisis. I don’t think that makes the next time easier for anyone.

    1. “Not calling the AMHP until the person is at the PoS or custody is a breach of the MHA CoP – as a coroner recently pointed out in Reading.”

      Is this in the new code and where could I find the corroners repport.

      I ask because I believe my organisation is working on a policy to change our response times around this issue.

  5. If every police force and ambulance service in Britain published their figures on how many of the calls they deal with are mental health related and how many of those people are already in the mental health system, we may just begin to get somewhere. Not only do poor mental health services impact on the service user, the police, the ambulance service, A & E, GP’s, the public etc. the sheer volume of avoidable suicides seem to be swept under the carpet.
    I have a 6 year complaint against my local Mental Health Service for their appalling treatment of someone who lives in my community. To put it into perspective in economic terms – she had a care plan that worked which cost the Trust 1 week’s respite care in an Acute Care Hospital every 8 weeks. In the 3 years I knew her when she was in receipt of this she had 6 ambulance call outs, 3 of which resulted in hospitalisation. In the subsequent 3 years after her Care Plan was changed she had 26 ambulance call outs, the majority of which ended in hospitalisation, numerous emergency and welfare checks by the Police, increased reliance on GP’s, A & E and, and, and. In human terms she has suffered appallingly and her health and wellbeing is now seriously diminished.
    The Trust leave her when she is in crisis to “gain insight and autonomy into her own illness”, which is a bit like Russian Roulette in my opinion and has on every occasion resulted in police/ambulance attendance. Local politicians then jump on the bandwagon of criticising the ambulance response times, knowing full well about the pressure they are under from inadequate mental health care and of course the police are criticised endlessly full stop.
    Meanwhile our local trust made 6.4 million pounds efficiency savings in 2013/2014. I can’t imagine how!!!!
    The most worrying aspect of all this is that I would expect our Mental Health Service to want to save her life, treat her with dignity and do their utmost to ensure that her life is bearable/improved but it just isn’t the case.
    I have done absolutely everything I can think of to get changes for her (CQC, Monitor, Healthwatch, MP, PAL’s, Solicitors, Charities, etc.) and with the exception of SEAP (Complaints’ Advocacy Service) I have had little success. My complaint is now with the Ombudsman, but it is a slow process – meanwhile service users are left at great risk and everyone else is being left to pick up the pieces.
    In my case the police and ambulance service have been absolutely fantastic, but so much of what they do would be avoided by effective mental health care. So let’s get all the statistics out into the open – not only will it save lives ultimately, it will prove that as the system stands at the moment there aren’t any winners apart from the very services who are paid/supposed to care for people with mental health problems.
    Ultimately mental health services cry lack of funding, but my experiences shows just how much money they are prepared to waste protracting/defending a complaint and the sheer volume of money wasted on picking up the pieces of not providing decent care in first place.

    If it weren’t for the fact that people are dying unnecessarily it would be laughable.

  6. Seems that services sometimes see self harm and suicide or parasuicide attempts as attention seeking and something you have to learn to manage……but without help………and put everything down to personality disorders / poor coping skills. Would love to see figures on where suicide has been preceded by care from services……..

    1. In the case I cite the services were involved with her care throughout and quite simply left her to her own devices, despite knowing she was suicidal. On every occasion she was looked after by me, the Police and Ambulance Service. Opportunities to Section her prior to it becoming a very high risk major incident were missed/not taken. On the one occasion a member of the Crisis Team was present she was told that they “had other priorities” and a Psychiatrist was told later on that evening that he was to “pull out and leave her with (me) until she collapsed and couldn’t refuse to hospitalised”, despite the fact she was critically ill.

      On another occasion she was allowed to walk 22 miles home from hospital in the middle of the night wearing her nightclothes. She got 8 miles on unlit rural roads before phoning me reverse charge from a telephone box. The crisis team were involved with her care that evening, but yet again I had to call the police to look after her until I got there.

      On another occasion she tried to hang herself and very nearly succeeded. Mental Health Services had ample warning of it, but again it was left to me, Police and Ambulance to deal with. The Police just managed to save her life and she taken to hospital, only to be released a few hours later and sent home to an empty house in the middle of the night – where the noose she hung herself from would still have been hanging had I not asked the police to take it down. On a previous occasion I didn’t remove the noose for a few days as I couldn’t face it, so there was a very real possibility of it still being there on her return! On the first occasion the Crisis Team told the police she was attention seeking, after they had just cut her down and saved her life. When I complained about this the Trust said it couldn’t be verified, but of course it could be verified by the police officer himself.

      And those incidents are just the tip of a very large iceberg.

      In relation to what you said about the number of suicides being preceded by care from the services I have been trying to find out the same thing. Unfortunately when you look at Coroner’s verdicts they are not particularly helpful. Out of the total number of people who hung themselves in the county I live in in 2013/2014 one third of them have been recorded as ‘open’/’other’ or narrative verdicts. Having spoken to the Office of National Statistics it seems this happens across the UK. As the Coroner’s Office is in the perfect position to identify failings in care services, I find it really strange. I, therefore, wrote to them at the beginning of March, but haven’t heard anything back yet.

      As I said before I am now 6 years in and I have never witnessed anything so disgusting in all my life. I am determined to get answers/resolution/changes and would like to see the statistics you mention and statistics from the police and ambulance service too. Although it’s the lack of humanity that concerns me the most, if the politicians are faced with the facts and figures they won’t be able to keep on ignoring what is going on.

  7. I would guess that she has a diagnosis of personailty disorder…but are they really happy to let her carry on until she succeeds either accidentally or deliberately? The theory seems to be that if you are bpd then you just have to learn to manage it – but there are no services to help you – guess you have been down the route of only therapy will help – but they are too risky to undertake therapy! No one will ever get better if they are dead…..Equally what good is autonomy if it means that your life is s**t. I don’t know what you can do……….. assume you have tried MIND etc

    1. You have hit the nail on the head Judy. Everything you say is absolutely spot on. I was even told that “she may choose to take her own life” and I said I wholeheartedly believe in her right to die if that’s what she really wants, but not just because she has a crap Care Plan.

      In answer to your question I have tried absolutely everybody. The Advocacy Service SEAP were fantastic at helping me to progress my complaint and for support. Had it not been for them I would have given up, as dealing with the Trust and putting up with the lies, misrepresentations, etc. made me ill, in addition to looking after this woman. The Trust didn’t care about the effect it was having on me either, so I am now signed off work. Ironic that a Mental Health Trust can give you serious mental health issues isn’t it!

      Unfortunately MIND weren’t of any help at all, but I have recently been on to Rethink regarding campaigning, etc. and they have been really helpful. Truthfully on a day to day basis I have been left to get on with it and am shocked that the organisations set up to help people like this woman have done absolutely nothing to help and therein lies a whole other story. The Department of Health did put their heads about the parapet last year and contacted the Trust due to the “very serious nature of my concerns”, but of course they can’t intervene, nor can they take on the case of the individual – which of course is a common theme.

      My complaint is now with the PHSO and I am waiting for them to appoint a “complex case investigator”. Meanwhile I thought the Coroner’s Office would be the next positive step to take, but that has just opened up another can full of worms. In the darkest hours, of which there were many, I thought I would only be able to get justice for her if she died – now having seen how suicides are being reported I’m not so sure.

      My local MP doesn’t want to know, but a Lib Dem Councillor from another ward did help me which kind of supports all that Norman Lamb MP has been doing so well. I am considering just going public on the whole thing, but then I worry how it will impact on other local service users with BPD/complex mental health problems. If they read such negativity about the services who are supposed to care, it may be the very detrimental to them. So all in all it is a bit of a no win situation. On the upside this is the first time I have really written about it openly so the gloves are beginning to come off, largely thanks to Michael Brown who I have followed avidly for years and thanks to you for responding to what I am writing.

      Finally (for now) I do support the Crisis Care Concordat, but who is going to monitor the services that sign up to it. The Trust I am up against seem to wear this and the Francis Report like a badge, but don’t adhere to the principles. And so we go round in circles again.

  8. Is there any way we can get in touch privately – I’ve got some more to say but don’t want to say it in public…….

    1. I was going to say exactly the same thing. Send me a friend request on Facebook if you’re on it and I can then private message you with my contact details. My surname is Doran and yes Keyna really is my name. Look forward to connecting with you. If you’re not on Facebook don’t worry I will just give you my number.

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