Exceptional Circumstances

You will remember, last December, that a review was published into the Operation of ss135/6 of the Mental Health Act 1983 after an extensive period of seeking the views of those who have been affected by the Act or involved in its implementation.

I admit to reading it and thinking a few things – this post is about just one of them. I reached only the second legislative recommendation in the review and took a sharp intake of breath on the subject of whether or not to ban the use of police cells as a Place of Safety. It stated, “Ensuring that police cells can only be used as a Place of Safety for adults if the person’s behaviour is so extreme they can not otherwise be safely managed.” We’ve heard this sort of thing before, in various forms. The reason it struck such a chord with me was because almost all the major untoward incidents we’ve seen in the last few decades or so involved issues around restraint and the use of force. So where the police detain someone whose ‘behaviour is so extreme’ we can reasonably expect the officers to be using some level of force, to protect the person from themselves in most cases. So where police officers decide they must act, how much force is enough force or too much and for how long can it continue before it becomes excessive or dangerous?

NEW GUIDELINES, NEW JUDGMENTS

In just the last few weeks we have seen yet more reasons to wonder about this. Last week the National Institute for Health and Clinical Excellence published revised guidelines on Violence and Aggression (2015), replacing those we saw in 2005. If anything, this new document strengthens the point that could previously have been made if I’d written this post even a month ago: some behavioural presentations are clinically significant and can only be safely managed with appropriate clinical intervention. This is not breaking news, the dangers of restraint have been known for years – the Rocky BENNETT inquiry heard evidence that the restraint of a mental health patient needs to be treated as a medical emergency and that Doctors should be available for such patients within 20 minutes and nurses should be on hand with drug trollies, defibrillators and so on. Well your police service encounters people like Rocky BENNETT in non-clinical settings – how do we give effect to that kind of care?

Talking about acutely disturbed behaviour or so-called excited delirium is difficult because of a lack of clinical consensus. I’ve personally heard a psychiatrist telling me that excited delirium is ‘not a thing’ because it’s not in the medical manuals. Yet it’s been given in the United Kingdom as an explanation (or a partial explanation) for sudden death and some of those examples do not involve the police. Whether acutely disturbed behaviour is a euphemism for excited delirium or not, it has been cited along with restraint and other factors as part of the explanation for the death of Kingsley BURRELL in Birmingham in 2011. The Coroner’s narrative verdict outlined neglect and excessive force was involved in the multi-agency response to a disturbance on a mental health ward that ‘more than minimally contributed’ to his death. We have seen discussions like this before (Sean RIGG, Michael POWELL, James HERBERT) and we will see them again in Coroners’ Courts (Olaseni LEWIS, Leon BRIGGS) in the months and years to come.

PEDANTRY

So we see the stakes here are high: which is why I do worry whether I’m just being pedantic. Most officers have got stories in their careers of the disturbed patients they’ve restrained for far longer than any guidelines would suggest is wise and where they’ve done so whilst medical staff feel absolutely unwilling or unable to take any other course action. I’ve asked countless times whether NHS staff have even heard of the Violence and Aggression guidelines (2005) and usually been met with a blank look – these were the guidelines that were in place on 30th March 2011, of course. Along with the Code of Practice to the Mental Health Act that appears to have been disregarded (based on factors made known during Kingsley’s BURRELL’s inquest), it does beg the question about how officers are expected to stop another human being from hurting themselves or from hurting others when they have just ten minutes at the absolute maximum in which to use any level of force and after that it will become either legally excessive or medically dangerous.

What if we find those thresholds are reached during the initial management of an incident where section 136 of the Mental Health Act is invoked and we now have to make a decision? – whether to go to the NHS mental health unit Place of Safety (which will probably exclude resistant patients, regardless of what it says on p8 of the multi-agency 136 guidelines we all signed) or whether we go to A&E (who will probably still insist, as the Royal College of Emergency Medicine did in their 2014 mental health toolkit, that they are not a place of safety and that they cannot accommodate violent patients) or whether we have to resort to custody because everyone except the police is able to point to new legislation or statutory guidance and say, “This is now an exceptional circumstance, as defined.” We can imagine the potential pressure on police officers to do what the Rocky BENNETT inquiry, recently revised NICE guidelines and various Coroner’s have implicitly or explicitly cautioned against because it is couched in new legislation or statutory guidelines.

So how does this all get squared away, because I really am trying hard not to be pedantic? – I admit I don’t understand and it doesn’t seem we’re not easily able to explain what we’re actually asking the police to do. This should worry us all because I’ve got to oversee how we write new guidelines for the police in the next six months and currently, I’m going to have to explain how to eat your cake and have it too.


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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8 thoughts on “Exceptional Circumstances

  1. Police are called to a man having a psychotic episode in a street. It’s 2am and the man is knocking on the doors of private dwellings, shouting and screaming. Many local residents a woken up by the disturbance and dial 999 and request the police. Police officers arrive in minutes and find a 30 year old man suffering a mental health crisis, it’s obvious that this man needs urgent mental health crisis care. The man is difficult to control, does not make any sense and refuses or is unable to cooperate with police demands. Officers are satisfied that all the criteria for S136 MHA are met. The two officers on scene are unable to call the for ‘advice’ from MH services as they need to act to control the man from hurting himself. They are also unable to establish his personal details which would assist services establish previous history etc. Man is detained under S136 and a call is made to nearest mental health based place of safety. Police by this time are struggling to control the man who is trying to run off. The man is thrashing about, shouting, with an obvious intent on hurting himself as he repeatedly tries to inflict self harm. Police Control tell the officers that the mental health place of safety is full and are unable to accommodate the man. The mental health facility also states that they are unable to find an alternative option as all other mental health places of safety in a wide radius are reporting to be full. Officers by this time are calling for help from colleagues as the man is struggling violently. De-escalation does not work. They also request an ambulance, but are told that there are no ambulances available, with estimated delays of at least 90 minutes. About 7-8 minutes has elapsed now from when officers first arrived.

    Another police unit arrives with two officers within. They assist the two officers already on scene, who are now struggling to hang onto the man, whom they are trying to calm. It was decided that handcuffs would enable the officers to better control the man, but actually getting them applied was easier said than done. This man was physically strong exaggerated by his mental illness and determination to break free. In order to control the man, officers work together to take the man to the floor, where after a couple of minutes of further struggling manage to apply handcuffs. The mans behaviour is such that officers recognise the very real likelihood of Acute Behavioural Disorder. Mental Health plus ongoing restraint is a medical emergency. Officers call again for an ambulance where it is clearly relayed that continued restraint is required which should prompt an emergency response from ambulance services. This doesn’t alter the fact that there were no ambulances to send.

    The four officers on scene now decide to convey the patient by police vehicle, but due to the behaviour of the man, whom even in handcuffs is still struggling violently, shouting and screaming and requiring ongoing restraint to prevent self harm, a police van is decided to be the only viable safe transport in the circumstances. It would be practically impossible to get this man into a car, and the accessibility of the van, with double opening doors is the best and safest option. It takes 10 minutes for the nearest police van to arrive. Officers have continually done their best to keep the man safe. By the time the van has arrived the man has blood coming from his mouth. Although not sure officers believe the man has a cut lip but are quite rightly concerned. What if something else was going on?

    The officers struggle to get the man into the police van, but as soon as they do, they’re off, towards the nearest accident and emergency. The man is foaming at the mouth, continues to shout and struggle and is monitored throughout the journey by two officers in the back of the van. They have to hold his head to prevent self inflicted injury.

    Upon arrival to A&E the Police summon help from medical staff. Medical staff tell the officers to bring him into hospital so they can carry out all the required health checks. The man continues to struggle and whilst trying to take him into the hospital he kicks one of the officers, badly, resulting in the officer hitting the floor and banging his head. He too is now a patient for the hospital to treat.

    Although the man continues to be violent and requires ongoing restraint, medical staff are satisfied the man has a split lip. What about ABD? Medical staff struggle to assess vital signs but manage to get what they need and tell the officers to leave. Officers explain that there are no alternative health based places of safety available and are concerned that due to the patients disturbed behaviour he will require ongoing restraint and the dangers of ABD will not stop at the exit of A&E. Medical staff tell officers that A&E is not a suitable place for the man ad get quite frustrated with officers when they continually voice their reluctance to leave. Even a leading consultant attends and has a very firm chat with the officers. All whilst the officers continue to try to keep the patient safe, who is still highly agitated and obviously ILL.

    ‘II’L’: A man acutely unwell in need of urgent care. Care which doesn’t appear to exist. Still no mental health based places of safety are available. The ‘best intersts’ of the patient doesn’t appear to count for much as the officers are told to leave A&E.

    I would like to put my case that ‘health’ need to sort this. If such MH provision is not available for whatever reason, what is the expectation of the police? A&E is a far more suitable place than a police station, when faced with such ‘exceptional circumstances’.

    Royal College of Emergency Medicine need to sit around the table with the police and mental health services, as there seems to be a forgotten element to all of this, who should remain at the centre throughout and that’s the patient. You cannot tell me that this unwell man should now in the tragic story above, be taken to a police cell? By the way, this man has an extensive history of mental illness, is a diagnosed schizophrenic and is prescribed various anti-psychotic medication and has done for years, so we haven’t even discussed the missed opportunities leading up to this crisis and the fact that we later establish this same man sought help the day before by attending a local A&E himself as repeated attempts to access MH services failed. He ended up walking out of hospital after waiting over 6 hours. How different this story could be if 24/7 access to adequate mental health services exist and who are able to respond.

    This is tragic, it’s real, it’s happening, all too frequently and the police should not be the solution. So health/NHS, Government please keep talking but let’s act quickly on this. I find myself repeating the same challenges over and over again and I genuinely fear that I will be discussing the same in 10 years time. 135(6) Mental Health Act needs to change. Police Stations need to be removed, ‘exceptional circumstances’ is a dangerous position and goes against the learning of so many, too many tragic cases.

    Let me know the date, time, place where we can find a solution to this, but I personally feel this needs to involve Government departments, as local agreements are unable to plug this re-occurring and high risk issue.

      1. I agree. It’s also a concern that Royal College of Emergency Medicine don’t see they have a role here, not even when there are no alternatives, purely pointing at Mental Health commissioned services to absorb demand. Fact and dangerous fact it is, for whatever reason (and that’s probably it’s own blog altogether) MH services cannot cope, so again although in many situations A&E is not the best solution, it’s a far better one and preferred option than a police station. Let’s be honest, in a number of situations it comes down to exactly that: a police station or an A&E? Bearing in mind every A&E should have liaison and psychiatry services, a suitable place for mental health patients, I cannot see how it will EVER be more suitable to take someone to a police station. Even if the patient cannot be controlled easily, due to violence: mental health + ongoing restraint = medical emergency, so why would we ever take such patients in crisis to a police cell? It’s not as if we would be able to close the cell door, as we would need to monitor and probably and in a lot of cases continue to restrain to prevent self-harm.

        So let’s remove police stations from 135(6), people in mental health crisis is an issue that must secure a health response, the dangers are just too great to take these people to police stations as various reports keep pointing out to everyone.

        I honestly believe that if police stations were removed, it will provoke a number of urgent meetings between those who commission emergency medical care and those who commission urgent mental health care and solutions would be found. There would be a programme of change instigated, to secure better pathways for those who do suffer from mental health and need an urgent response to resolve a crisis. Until this happens health will always point to police stations as being an option, whilst police officers are left, often with little in the way of alternatives, to take a very unwell patient to a police cell, next to a violent offender and an aggressive man who has been arrested for public order and a screaming shoplifter! Yep, I would probably panick and need to be restrained if I were taken to a place like that whilst suffering from a mental health illness.

        I keep telling myself, but we’re in 2015. In fact over half way through now. Surely government can see that this change is needed and in my experience is required urgently. So let’s act.

      2. I’ve always maintained though, that it’s just simply not in the interests of the NHS to sort this. An ability to blame police misconduct is an extremely easy way to deflect responsibility for all the difficult medical, philosophical and economic challenges that this stuff throws at them. I’ve long since believed that this needs a stick, not a carrot – and and we know they’ve have ruled out any use of a stick.

        Strap in – the journey is still young. This is why forces and the College need to issue unilateral advice that puts officers in the position of being unable to be accused of anything, because guidance means their actions are defendable irrespective of how the NHS responded in any particular case. As long as such guidance is measured, evidenced and legal, they can think what they like about it.

  2. I think there would need to be / needs to be a major change in how Mental Health services respond to a s136. I can only speak for my area and it may have changed recently, but last year out of hours the overall wait for an assessment could easily be a minimum of 12 hours. In that time you are unlikely to be prescribed anything as a) you could refuse to take it, b) it would make it impossible to carry out an assessment a you would be asleep. Our local NHS POS is not equipped or staffed to deal with anyone who doesn’t want to be there. They certainly aren’t staffed to deal with someone who is determined to self harm. There doesn’t really seem to be nay expertise in how you look after people for such long periods of time. As you know a 136 suite is typically just a room, and there is no treatment available. The best answer would seem to me to be much swifter assessments, but I understand the practicalities around this, and I think there is also a feeling that you have to wait for people to be less agitated. If you detain someone in a seclusion room, you are effectively in the same environment as a cell, but without people who are used to keeping people safe without medication…..It has been commented to me taht in some ways custody is nicer as life goes on around you, whereas in a 136 suite it is just you and a member of staff, who quite often doesn’t even speak….To summarise after rambling on, Custody is designed to keep people safe who don’t want to be there. Your average NHS POS attached to an acute unit isn’t………

  3. When are you going to get that detention in custody is hugely traumatic?
    Of course you can physically keep someone safe, but what happens once they leave? Oh yes, they’re even more distressed and likely to self-harm/ suicide. In fact it may ruin their mental health. What is the point of keeping someone physically safe while they are breaking, when they may have flashbacks YEARS later of vicious bullying thug aggressive officers who hate them.

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