What is the role of the police when it comes to disturbances or disorder on inpatient mental health units? – when is it reasonable and responsible to call police officers into a therapeutic environment?!
We’ll see these questions asked a lot in coming months, not least because of the Kingsley BURRELL (in Birmingham) and Olaseni LEWIS (in London) inquests. The Coroner in Birmingham found last month that restraint and neglect on the part of police, ambulance and mental health services contributed to the death of Kingsley BURRELL and three police officers are facing hearings for alleged gross misconduct, during June 2015. It emerged last week that the IPCC has also recommended disciplinary action against Metropolitan Police officers who responded in south London to the unit where Olaseni LEWIS was detained, although we are yet to hear the Metropolitan Police Commissioner’s response to those recommendations and that inquest is yet to occur.
You may recall, I entered into this debate some years ago, in a post called ‘Barricades, Weapons and Hostages‘ and the title of that post still forms the basis of where my views sit. I don’t think we can say, as some have suggested, that there are no circumstances in which police officers should be required. We know, tragically, that homicides and incidents of serious violence do occur from time to time and when things are beyond the control of staff who are present, the safety of everybody should be the first concern. So for me, it’s about defining what should trigger a police response, how does that response fit into the ongoing medical care for which a mental health trust will remain responsible and what is the exit strategy to get the police out as quickly as possible and responsibility handed back fully to the professional staff concerned?
HEALTH & SAFETY AND HUMAN RIGHTS
All organisations have legal responsibilities under Health & Safety as well as under Human RIghts laws regarding detained patients as well as others who enter buildings that are owned are run by them. We know that organisations like mental health trusts as well as police forces have duties to risk assess, both generically and specifically, the activities they undertake and to ensure systemic mitigation of obvious, predictable risks. To give a simple example, there is always a transient fire risk in any building so its standard health & safety policy to have fire extinguishers, to have fire marshalls and to hold fire drills. We see evidence of these mitigations every time someone on a Sunday morning burns the toast! So what is an obvious and predictable risk if you’re in the business of running inpatient mental health units?
There are two issues to keep distinct here – and this post is only about the first of these two matters because I’ve written about the second elsewhere —
- The role of the police in responding to ongoing disorder which has compromised the safety of staff and other patients.
- The investigation and / or prosecution of any alleged offences arising from disturbance or disorder.
I also want to sound a perverse kind of warning about calling the police, too – the officers are not, when called, ‘on the side’ of any staff who have reached for 999. I’ve professional experience of being called to an inpatient ward to ongoing disorder where the only conclusion I could draw was that the patient was acting quite lawfully, that I couldn’t rule out that if I were them I wouldn’t have done likewise and that the only legal problems were those being caused by staff. So this is why the issues can be very difficult and why police officers need sufficient knowledge, training and confidence to understand what they’re walking in to – which means knowing the right questions to ask and understanding the Mental Health act and all its vagaries.
REALITY AND IDEALITY
It seems obvious to me that if you are in the professional business of detaining people against their will and inflicting psychiatric treatments by force that are known to have serious side-effects, then you should predict and prepare for the fact that not all patients will be happy with those decisions and that some may exhibit challenging or resistant behaviours as a result. Not everyone is going to want to stay where you’re making them be. It gives rise to questions about risk assessments; about the impact of those decisions; about the training that staff may need in that environment; and about the physical infrastructure required. So therefore there are three types of considerations –
- What role should the police play in ideality – where police support may become necessary despite everyone’s best efforts? This is where my starting point is ‘weapons, barricades and hostages.’ – anything else is a predictable part of being a mental health provider and implies systemic mitigation of risks.
- What role do the police play in reality – where units may not necessarily have sufficient staff or staff with sufficient training? This is where there may be no weapons, barricades or hostages and where there may be a need to fully review how incidents came to get out of control if the police were called.
- Irrespective of points 1 or 2 – does proper follow-up occur to understand why officers were called in and was it was appropriate, whether things worked properly and is there any learning for those involved or for local protocols?
Many mental health trusts and police forces have various kinds of agreements or policies which govern how things occur. I’ve been reading many of them in recent months and think we have some way to go. The College of Policing has brought together a multi-agency expert reference group to look at this area of business, under the independent chairmanship of Lord CARLILE QC to try to achieve a consensus across organisations about what the role of the police is. In a preliminary conversation I recall an NHS professional saying that a mental health nurse working in a mental health ward is entitled to the same protection whilst at work as they are when they are out shopping. This, of course, is nonsense – they aren’t.
Mental health nurses are entitled to far more protection because whilst at work, they are under the legal umbrella of their employer’s Health & Safety responsibilities. So, for that matter, are any police officers who attend the unit.
BARRICADES, WEAPONS AND HOSTAGES
Mental health inpatient facilities differ enormously, not just in terms of their size. Acute admissions wards, Psychiatric Intensive Care Units, medium secure services, rehabilitation wards – then repeat all of that over again for children, or for patients with learning disabilities. Different facilities will give rise to varying staffing and training requirements; geographical proximity to other services might influence how individual wards or units think about contingency planning for predictable, but unscheduled crisis incidents. It is therefore not a level playing field for police officers to unilaterally declare that their role is X, Y or Z and that the NHS must simply get on with the rest. That being the case, how do police officers avoid being drawn further into things than instinct tells them is consistent with their role? Various legal commentators have suggested, for example, that it is not the role of the police to restrain patients to allow staff to forcibly medicate them – quite right too.
So where are the boundaries?!
In another version of this discussion, I wondered whether it might be the role of the police to contain a situation to prevent it getting worse, rather than actively restraint patients unless it is necessary to stop violence towards others? We know from the CPS press release following their confirmation that officers in the case of Olaseni LEWIS will not face criminal prosecution, that police officers who are entitled to use force are ‘not required to run the risk of being assaulted’. In other words, they are entitled to use sufficient force to keep themselves safe whilst undertaking their job. We can infer from the same press release, that some (but not all) mental health professionals were not satisfied with the use of force decisions that the officers made, which included baton strikes. So there is another really sensitive dynamic: the view of mental health professionals about the use police use of force techniques that no mental health professional could justify using. But isn’t the point that the techniques that nurses undertake were the very things thought inadequate for the task and which contributed to the 999 call to the police in the first place?! It’s not the first time I’ve known mental health professionals protest about police decision-making that was within the law and it does rather beg the question, if you don’t want something done our way when we are acting within our training, our guidelines and the law, then perhaps we are not the solution to your difficulty?
And finally, there is the issue of transport or movement – in both the Kingsley BURRELL case and the Olaseni LEWIS case we now know that the police were being requested not only to intervene by restraint to end disorder, but to then take that intervention forward into a physical transfer to another location – something which inevitably extends any period of time that restraint would remain applied, thus raising the dangers involved. Kinsgley BURRELL was moved via an A&E department to another mental health unit several smiles away from the original incident – Olaseni LEWIS was moved within the same mental health unit to a different part of the facility and in both cases it was to allow for each patient to be placed in seclusion. We know in each case that mental health professionals had administered drugs to those patients prior to asking the police to physically move them. How do we assess and manage those dangers, especially given that the Code of Practice to the Mental Health Act old and new) imposes certain clinical obligations on mental health trusts? Who is in charge?!
ENTRANCE AND EXIT STRATEGIES
It is obvious that bringing the police into a psychiatric unit means we are inviting professionals who are unknowledgable about particular patients’ backgrounds and needs into an unfamiliar environment to take action that can have direct medical consequences. Let us not forget here, the expert testimony offered to the inquiry into the death of David (known as Rocky) BENNETT – the restraint of a psychiatric patient is a medical emergency. This must mean that whatever the police are doing or being asked to do should be overseen by the senior doctor or senior nurse present at that time who should not disengage from the incident at any stage, even where a transfer is required for whatever reason. The objective has to be avoiding the use of restraint in the first place and ending it as soon as possible after it has begun if it has been unavoidable.
So here are the challenges and I’d welcome views below as to how we meet them and I’ll take them to the group chaired by Lord CARLILE QC. We obviously can’t say “there’s never a role for the police” – so how do we define the terms and how do we describe the safeguards? Most crucially, how do you disengage if you decide you must get involved?!
Answers on a postcard below, please!
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