Inherent Contradiction

A Coroner’s Inquest in London ruled earlier this week that Darren NEVILLE died from the effects of prolonged restraint after an ‘acute behavioural disturbance’.  This is the second verdict in a month that mentions ABD – you will remember it featured as one aspect of the multi-factorial death of Kingsley BURRELL who died in Birmingham in 2011 amidst a broader ruling of neglect by the police, ambulance and mental health services.  There are other ongoing inquiries and pending inquests into deaths in state care whilst patients were under restraint, including after the use of s136 of the Mental Health Act 1983 where the concepts of ABD or excited delirium (ED) are raised so we are going to hear more about this later in the year and in to the future.

This remains controversial stuff and is at the heart of an inherent contradiction.

There is a pile of printed reports on my shelf at home (I will soon need a new shelf) that includes a range of materials which tell us that ABD (or ED) is a rare, but potentially dangerous medical complexities that we still don’t fully understand.  These materials include –

  1. The Royal College of Psychiatry Standards on s136 of the Mental Health Act 1983 (2011)
  2. The NICE Guidelines on Violence and Aggression (2015)
  3. The Inquiry into the death of Rocky BENNETT (2000).

The BURRELL and NEVILLE coroners were not the first to to return verdicts that mention ABD or ED.  Others have included –

  1. Jacob MICHAEL in Cheshire in 2011.
  2. Jason PEARCE in Shropshire in 2011.
  3. Dale BURNS in Cumbria in 2013

Such is the concern across the police, emergency medical and mental health services that in the South London and Maudsley Mental Health Trust, they have worked with the Metropolitan Police and the London Ambulance Service to produce a training DVD for involved professionals that briefly covers the identification, risk issues and effective responses to situations that could involved ABD (or ED).

MEDICAL TEXTBOOKS

No point avoiding that fact: these concepts or conditions are not universally accepted as disease entities or illnesses, notwithstanding what some Coroner’s have ruled.  In the article above about Jacob MICHAEL it is pointed out these terms have been cited in 17 deaths in custody and yet ABD / ED do not appear in the medical textbooks.  Neither the Diagnostic and Statistics Manual (5th edition, 2012) or the International Classification of Disease (10th edition, 2015) list these conditions and it is not recognised by the Department of Health.  In 2012, a File on Four investigation by the Bureau of Investigative journalism looked at this and a documentary was broadcast in which Home Office pathologists were interviewed.  It was interesting to note the Home Office pathologists within that documentary who stopped just a touch short of saying, “This is not a thing!” and did suggest that responses to the kinds of behaviour that was described in various so-called ED / ABD cases is behaviour that should give cause for medical or psychiatric concern.  Police officers and paramedics should be especially careful about applying restraint to such patients because they are likely to resist detention and very unlikely to stop resisting.

Of course, whether or not these conditions are in the DSM-5 or ICD-10, they are conditions mentioned in various other kinds of medical literature: an academic paper was written in the 1990s following the death from excited delirium in an Edinburgh mental health unit.  I just want to be extra clear here, that this death did not involve the police in any way, at any stage.  There are other academic papers from the mental health nursing profession that make mention of these kinds of conditions – and again: not in connection with policing or police-led restraint.  It is clear from any attempt to survey these issues of ABD or ED that this is not and cannot just be a discussion about police restraint.  That said, there are various reasons I’ve written about elsewhere as to why the police are more and more seen by mental health professionals as the agents of physical coercion and various reasons to think the number of individual encounters by the police with people who are acutely mentally ill has gone up over the last decade or two.

CONTAIN OR RESTRAIN

So is it just a question of police officers making sure that where they think they are dealing with a situation involving ABD or ED that they ‘contain rather than restrain’? This is something I’ve argued about for some while and something which I’ve successfully put into practice when working operationally. I’ve often told the story of the young woman in residential care for patients with learning disabilities who had started smashing up the kitchen and the police were called. Seeing that there wasn’t much more damage she could cause by the time we arrived, we left her to chuck the broken furniture around a bit more until she came out of her own volition. At all times, she was kept under observation of a female police officer – because she was naked whilst doing this – but a while later she came out.  I don’t think she was suffering ABD but I do know that avoiding restraint was desirable because her body weight would have increased risks of positional asphyxia – something else to worry about in these situations.

Not all police activity takes place in situations where containment can be applied.  In the case of Darren NEVILLE, it was reported by various witnesses at the inquest that he was ‘covered in blood’.  I realise that can mean a number of things and clearly, I wasn’t there.  But I’m wondering about how practicable it is to contain someone, potentially for a long while, if they are also bleeding to such an extent.  There is the other problem that whilst police interventions in the cases of Olaseni LEWIS and Kingsley BURRELL have involved inpatient mental health units, more police interventions occur in public places where officers would also have to consider other members of the public, traffic and who knows what other situational factors in deciding whether they can contain someone, rather than restraint them.

And what happens next?!

Imagine that officers, perhaps with riot shields, could create a sterile area within which a person in acute distress is not restrained or even touched, but is effectively held within a safe area.  For how long does that position get maintained before something else has to happen?  I always recall a case from London of so-called excited delirium involving Paul COKER.  From (admittedly limited) information online, I was caused to have the impression that Mr COKER was restrained at the point of arrest and taken to a police station, but that once in the cell, he was not actively restrained in the two hours that followed.  It was then he was found to have died in the cell.  So it’s also not just about the active application of restraint, but the observation of people who should have been identified as exhibiting indicators of ABD where restraint has ceased.  Again, in the inquest which followed, the Coroner was dissatisfied with the application of training and concerned that further deaths could occur.  He was right, in fairness to him.

INHERENT CONTRADICTION

So here is the problem:  we want police officers responding to incidents to recognise those cases where resistant, aggressive or violent individuals are potentially suffering from excited delirium and at risk of sudden death should officers apply and restraint and / or fail to summon emergency medical intervention or remove someone to an Accident & Emergency department.  At the same time, we have a Government recommendation in the review into operation of ss135/6 of the Mental Health Act which wants to codify that individuals whose behaviour is so extreme that it cannot be safely managed elsewhere, are those exceptional circumstances where police custody should be used.

This is a contradiction in the strategic context in which officers and paramedics have to make fast tactical decisions –

  • This behaviour XYZ = a medical emergency, so call an ambulance if possible, and go to A&E.
  • This behaviour XYZ = so extreme it cannot be safely managed, so go to custody.

Can do one of these things, but not both.  We must choose and make it clear to operational officers what the direction is, because some of my colleagues who have been criminally investigated and indeed, prosecuted, arising from this contradiction deserve clarity.  Even more importantly, vulnerable people and their families deserve to know that there is clarity in the policies and directions that are given, because there can’t be anything more traumatising than knowing that when a police officer did something that led – whether directly or indirectly – to the death of your most precious loved one, that they were ignoring some of the advice and opinion that exists.  If that officer then defends their actions with reference to other direction and advice that exists, it can’t help but sound like a fudge and a cover up.

We need to square this circle.


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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5 thoughts on “Inherent Contradiction

  1. Extremely important point. Thankyou. I’ve found through his of sitting with my distraught friends/family etc in ER under detention, that a familiar calm and unafraid person can do what the guard on the door and the busy nurses and staff often cannot – calm and connect. I frequently have to translate between different people and their different ways of approaching the distraught person – nurses want them back in bed when they need to pace off their intense agitation and adrenaline. The guard on the door wants then to stay in their room when they haven’t eaten or drunk anything for two days – I can walk them or get for them a drink and a sandwich. I can advocate for nicotine replacement (frequently takes 24hr or longer otherwise – totally unsuitable for someone in crisis or acute psychosis). I can coax them into cooperation with the doctors who are frequently insensitive, abrupt, and totally lacking in insight into intense states. It’s not always possible to connect with our calm someone in that state, but it should be at least offered, because sometimes it is and that saves lives as well as a lot of dollars.

  2. When you say, “Imagine that officers, perhaps with riot shields, could create a sterile area within which a person in acute distress is not restrained or even touched, but is effectively held within a safe area”, you’re clearly meaning *physically* safe. How *mentally* safe is it for someone in acute distress to be contained by police officers behind riot shields? I’m suggesting there’s more to the concept of being “safe” – in mental health terms – than mere physical containment. Physical containment can be mentally traumatising. Containment and monitoring may be better than physical restraint – but not much.

    1. I agree with you – had only hoped to convey this idea of containment as potentially and briefly preferable to either doing nothing where someone may be a risk to themselves; and restraint where dangers can escalate very rapidly. In that sense I’m wondering whether it may be temporarily the ‘least worst option’ to minimise risks, mainly to the individual. I probably didn’t spend enough time making that clear and (I hope) you know I agree completely about your substantive point, above.

  3. The “Is it a thing or not?” debate about acute behavioural disturbance / excited delirium brings to mind the valency theory I was taught in chemistry. From long-distant memory, I recall it’s a simplified theory of how atoms “hold hands” to form molecules and was perfectly adequate as a tool for teaching children – but at chemistry GCSE that’s debunked and of course no-one working as a chemist ever uses the theory.

    ABD / ED may not exist in medical textbooks but recognising the state seems a useful tool for non-medics – a shorthand to identify a medical emergency which requires an ambulance to be called or for the detainee / patient to be taken straight to A&E. In that context, why on earth is this conversation about “Is it or isn’t it a thing?” even taking place? A useful tool is a useful tool.

  4. The guidance issued in regards to a person detained under S136 who is suffering a mental crisis and that their behaviour is so violent that they should be taken to a police station as opposed to a place of safety I think is causing the various parties involved to draw dubious line of demarcation about something that should be handled as a team.
    The guidance states that if someone is so uncontrollable that they should be taken to a police cell which is a pretty indestructible and secure environment and could under certain extreme circumstances be considered to be a reasonable place to take someone. However when as I have experienced in the past when such a decision is made to divert someone to a police station for whatever reason be it alcohol or aggression any responsibility duty of care towards that person appears to dissolve in regards to the NHS leaving the police to deal with a volatile and complex patient and their symptoms. As if all drawbridges are somehow firmly sealed.
    Surely if someone is so volatile that they cannot be kept in a S136 suite and have to be kept in a police cell as the guidance states, then should not a medically trained team of specialists follow on to ensure that the person who has been detained receives the correct medical care supervision and medication that they need. Could the drawing up of these demarcation draw bridges have been a contributory factor in the deaths of many of these poor unfortunate individuals who have found themselves in such circumstances.

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