Entering Mental Health Units

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 —

  1. The role of the police in responding to ongoing disorder which has compromised the safety of staff and other patients.
  2. 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 –

  1. 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.
  2. 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.
  3. 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!


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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9 thoughts on “Entering Mental Health Units

  1. Once again great article, as a Specialist Adviser in aggression management within a large trust we see staff at times calling on the police far to quickly,unfortunately with recent government decisions around physical interventions training this is only going to become a more frequent occurrence, when staff can no longer be trained in, or use such things as wrist flexion or prone decent to the floor, large violent individuals will only be able to be managed by the police who retain more tactical options. Nobody i work with or liaise with feels this is a good idea, the police are not clinicians and criminalizing people with mental health problems is not desirable, and of course officers time could be better spent doing policing rather then attending a Unit because someone is shouting and threatening due to a recognized illness.
    Many staff feel at risk with the training they receive in the past but statements from the government that restraint shouldn’t be an option in the 21st century and subsequent training changes forced on training departments make them feel at risk to the extent many have stated they will no longer try to intervene in cases that they feel they are no longer trained appropriately to deal with and they will call the police.

      1. Logic would say that but unfortunately logic didn’t seem to be a factor in the Positive and Proactive document published by the DH last year. At almost the same time that the Ministry of Justice published a comprehensive assessment of the risks of using flexion, extension, prone and supine positions (concluding that in the absence of effective alternatives, they were the safest options in extreme situations) the DH guidance stated that healthcare workers should not use any intervention that MAY cause pain except in an “immediately life threatening situation”. That seemed to set the bar way higher than any legal requirement for the use of reasonable force. MHC- have a read of the responses to the latest NICE guidance as it makes interesting reading (there was some different views from a couple of police forces). The updated NICE guidance has not supported the banning of prone but has stated that restraint should not be used routinely for more than 10 mins and made it clear that mechanical restraint should only be used in high secure services (this last recommendation will prove to be problematic I believe).

        I really enjoyed reading this blog MHC- thank you for raising awareness. We are trying to arrange a training swop in my area (police attending our training and vice versa) so that we can learn from each other and better understand each other’s roles and responsibilities- hopefully this will be a step towards closer safer working

    1. Andy
      As a patient would like your comments on Mersey Care’s approach to de-escalation and attempts to limit prone restraint.Appears initially that violent incidents have fallen dramatically.

      Healthcare staff who rely on restraint should not be working with vulnerable people.Any MH staff who automatically defaults to the position that restraint is a therapeutic tool = flag to poor practice.It is seen as violent abuse by most patients – many of whom have already suffered abuse.Suspect wont come to light until undercover filming reveals true extent but if this happened in the street then it would be assault.In particular with women: 4-6 very burly aggressive men pinning smaller distressed unarmed women to the floor = not OK.Yet common practice.

      One of the points in de-escalation is that you do not create an environment where threat and coercion is perceived by most patients as the preferred treatment options

      Our local Trust (poss one you are familiar with) has a very poor documented record of following even it’s own policy regarding interventions and debriefing/supporting pts after events.Until that is in place staff wont ever change attitudes, violence will escalate and patients on wards will be at as much risk as the staff who feel threatened but have the safety of being behind an office door.

      Massive culture change in NHS MH services needed so that majority of these situations never reached.Then police can focus on how to deal with the real threats without a ‘catch all’ approach assuming all MH pts have capacity for violence and harm

  2. MHA codes of practice don’t differentiate between who may or may not use pain compliance and nor did the Joint Committee on Human Rights. It may only be used (by ANYONE) in life threatening situations or where there is risk of serious injury. If a tactic is not safe if used by health professionals then it is not safe if used by Police officers and we locally ensure that we follow all DoH, CQC etc guidance as well as ACPO / NPIA etc.
    Any use of force must be a clinically led decision.
    To be fair that has the full support of trust management.

    1. I’m very aware of Mersey Care’s approach to training its very similar to ours i cant speak for all training providers but over the last 20 or so years I’ve been involved in training, my colleagues and I have always ensured in all our training that using physical interventions is and should always be a last resort.
      Quite rightly all the emphasis on restraint reduction should be proactive, service user involvement within a person centered approach to care planning, ensuring that unit environments are therapeutic and non aggressive environments, ensuring staff have the skills to both recognize warning signs early and De-escalate at the earliest opportunity. all these should be part and parcel of daily nursing care. Non of these ways of working are new the Safewards initiative is a good framework to use but these things are common sense strategies that have been around decades in one form or another. But with all these in place at times staff still have to use physical intervention skills due to the fact that if an individual is placed on a section of the MHA that requires them to comply with a prescribed medication regime and the refuse conflict at times will develop,there are other times that this can become unavoidable due to the immediateness and degree of risk encountered. The University that i have input into certainly does cover M.H law and Capacity Act. Human rights Act as well as Common and Criminal law in relation to physical interventions in nurse training. I agree that staff can at times make wrong decision and i am certain that there are some staff who due to lack of interpersonal skills shouldn’t have chosen to work in mental health but that should be dealt with by management. in relation to debriefs i agree that following any incident a full and frank debrief should always be undertaken including the service user this is the only way lessons can be learned, mistakes/miss interpretations apologized for and future plans put in place or existing plans adapted this is also currently within our training and staff are told this is a must.
      I will finish before i go on forever but try and be assured there are many trainers in the safe and therapeutic management of violence and aggression who would love to see restraint be reduced to zero and every member of staff i have come into contract with I’m sure would love this restraint is the worst part of mental health nursing it is frightening stressful and upsetting. On a final note what was secretly filmed at Winterbourne was nothing to do with any Physical interventions training i have seen it was abuse, assault and torture.

  3. From a patient point of view Mental Health Units are already terrifying places.The level of aggression including from staff creates a volatile antagoniastic situation from the get go.And the level of sexual violence is horrific.

    So before police already attend this is the prevailing culture – rarely feels therapeutic, often feels very frightening.

    I don’t want to talk about ‘riots’ or hostage situations but the more common events where staff call police

    Throw in to this staff who may have very few de-escalation skills and where face down restraint is the norm.Maybe what police are not aware of is that MH nurse training does not include MH law let alone other aspects of law.This in turn means that from what I have witnessed police are often called to a situation where staff have quite possible acted illegally – egs would be forced searches w/out grounds, removal property as ‘punishment’, assault during restraint, forced medication issues.

    As a patient I would like the police to respond to patient’s calls for help as often as they do to staff’s.With the same level of caution and circumspect applied equally.Just because I am unwell and terrified does not mean I am any threat or have any propensity for threat ( and in my case no arrests, history of aggression, criminal damage or even raised voice). I want my version of events heard – and without a staff member present because retaliation is very real as many of us have experienced.

    Before attending can police please ask when the last risk assessment was done- if a any forced event has taken place then this is required and the police will be asking risk questions on the scene.Ask staff what exactly they are doing to contain and de-escalate the situation.We all wish police would demand staff try this first. The threat of Breach of the Peace is based on what exactly? It is the term staff are told to use in Trust police guidance to get the police to attend whether real or not.And just as you can not remove someone from their home for threat of BoP unles intention to present before magistrate then presumably similar legal standard applies to ward situation?

    Probably most of all is the learning afterwards: INCLUDE THE PT IN THIS.Not only is it Trust policy and they are meant to but it opens up dialogue so police can get more balanced view and advise and support staff better.

    But as starting point would like to go back to it is a hospital, people are ill, most of us have never committed a crime in our lives yet have less rights than in the criminal justice system.And as patients we are often the victims so parity in approach would help

    Not a legal or possibly coherent post but the pt view rarely gets heard on these particular issue

  4. Thanks for a timely and interesting article.

    I can provide a recent example where an informal patient on a MH ward asked to be allowed to exit for a cigarette and became aggressive and hostile when told he would have to wait. Nursing staff attempted to physically escort the patient to a de-escalation room to calm him, but he refused to go. He then assaulted two members of staff. They had difficulties restraining the patient and Police were called. My understanding is that officers assisted in restraining the patient for the purpose of preventing him from injuring them or nursing staff; during the restraint, however, the patient was given an injection (presumably a sedative). This clearly begs many legal questions, not least re the use of force on an informal patient, administration of medication without the patient’s consent, and the consequences of the officers’ unwitting involvement don’t bear contemplation.

    There is a suspicion among officers that on occasions some MH hospitals have to deal with aggressive and potentially violent individuals who staff believe would be better placed in a secure unit with higher staff numbers. They have exhausted their representations to their own line management about having these patients transferred, and report violent or aggressive incidents to Police in order to strengthen their arguments.

    I bring these points to your attention as an operational police officer who has great sympathy for the challenges faced by front-line MH staff, but feels that Police answering assistance calls at MH hospitals are sometimes put at unnecessary risk..

    1. I think the Code of Practice is pretty clear that seclusion and restraint shouldn’t be used on informal patients, and if it is used then they should be reviewing whether a section is required. Why was an informal patient told he had to wait, according to the law I think he had a righjt to leave unless staff felt he was a danger to himself or others….all sounds very illegal, would like to hear what the police have to say?

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