The discussion about street triage continues and I’ve deliberately stayed clear of much of it, acutely conscious as I am that my views on the whole thing usually go down like a lead balloon just after they’ve been misunderstood or even misrepresented. This BLOG is my evidence that I’ve always been a massive fan of police and mental health services having closer, more integrated relationships and I’m especially keen that they learn to talk to each other in real time. I’m also keen that we should ensure this happens in full and open acknowledgement that the police and mental health services are not here to achieve the same thing: and that what the police exist to do is often contrary to what mental health services are trying to do. We are overlapping, correlated but unidentical public services and the police quite often must do things that are not in the interests of some individual’s health and welfare – that’s where the most interesting discussion about this interface occurs. More about that on another occasion.
What I admit I don’t get, at all, is the double (or triple) agency vehicle idea – I’ve never really understood it and have gone out of my way to learn more and to see it for myself whilst actually hoping for something of an Augustinian conversion about my concerns and questions. I had hoped that seeing it would allow me to learn things that can’t be known from outside and I know myself well enough to know for a fact that had I found myself ‘skooled’, as my ten year old would say, I would gladly write a BLOG saying so and ‘fess up. Learning more about triage has managed to increase the number of questions and concerns I have – mainly because of the cost to police resources in (just some of) the approaches I’ve seen but I also have some concerns about civil liberties and human rights which I want to raise in the context of a deliberately hypothetical example. I will admit, however, that this kind of example came to mind whilst spending time shadowing street triage in several nights around various police forces in England.
The police are called to the area of a young woman’s home address. Paramedics were originally called by the woman’s family whilst she was in crisis and after seeing the ambulance pull up, she ran from the premises – such were the concerns of family that they then rang 999 for the police and the paramedics were able to say, even after a brief interaction, they thought the young woman was experiecncing a serious epsiode of psychosis. Various police officers flood the area which contains railways tracks and a station as well as main roads, parkland and various canals. Within approximately 20 minutes, she is located by one patrol car on the basis of her description and officers attempt to engage her. She is in serious distress.
Street triage schemes normally ask officers to consider involvement of the triage car so that information may be shared to influence any decision taken and, where possible, to avoid the use of section 136 MHA. After engaging the young woman, they shout up for the control room to inform triage and have the triage officer contact them via police radio.
My question already: is this young woman legally detained? The officers have not told her she’s detained and they have not explained what s136 is or that they may take her to a mental health unit Place of Safety for assessment … in that particular sense, she’s not detained. But is she free to walk away from those officers? … does she even have the capacity to make that decision about whether to remain with them if she’s experiencing a deeply distressing psychotic episode?! … would it be fully informed consent? Remember: the law presumes that she does have capacity to take her own decisions unless an impairment or disturbance of the mind or brain is accompanied by an inability to communicate, understand, retain and employ information relevant to that decision. There seems little doubt in my hypothetical example she may fail a capacity assessment about this interaction with the police.
So street triage are engaged in the incident, the nurse is busy looking up patient details on the mental health trust system – how immediate is this any about the use of s136 of the Mental Health Act? The nurse is only going to come back with two responses: either the MH trust don’t know the person at all; or they do – and if they do there could be information or advice attached which is helpful in formulating another response. But what if the person is not known at all? If the advice is “there’s nothing we can offer that presents a less restrictive alternative” with the implication or even an overt suggestion that s136 be used to facilitate an assessment? – how immediate was the need of the person if we’ve waited from the point of encounter for all that to happen? … how long would it take to complete all of that?!
IN IMMEDIATE NEED
Where triage is called to become involved in incidents, there are sometimes delays. This is very understandable – one triage car could be covering a population of a between half a million and a million people and I know they’re often juggling more than one incident at a time. Delays can be around half an hour for remote advice and I’ve seen it take 45mins to an hour for face-to-face attendance. What is the legal condition around the vulnerable person during that time? It is a requirement of the use of section 136 that the officer must judge their actions to be immediately necessary – I fully accept that officers don’t turn up to incidents and make instant decisions without attempting to find out more relevant information or attempting to influence a situation to avoid the use of police powers but stretching initial attendance to a forty-five minute delay and then arguing that you took action that was immediately necessary is stretching things, just a touch.
There is this period of legal limbo to further consider: if the young woman who was engaged by the officers wanted to leave the place where they’d found her, she would have to be allowed to do so unless legally detained; which means if you’re not prepared to let her leave at that moment, she is legally detained – only without being told as much. This means her rights once detained are not afforded; it also means that whilst in this limbo state of being unable to leave and being denied the rights that attend detention, any decision not to formally implement section 136 is also a decision to unlawfully end what is, in reality, a de facto s136 detention. Only doctors and Approved Mental Health Professionals can lawfully conclude a section 136 detention, once it has been implemented – fudge the implementation of it in this way and you can then argue that because it was never instigated, the MH nurse info can negate the need.
Does that any make sense at all?!
Of course the correct legal approach would be to formally instigate the power as soon as you have taken a decision that the person is not free to leave because of any obvious risks to that individual or others you cannot allow to be realised. If this doesn’t fit in with the timescales preferred by street triage to offer alternatives, then that’s what happens when individual’s rights and organisational preferences come up against each other. Article 5 of the European Convention is engaged when considering section 136 of the Mental Health Act and individuals should be detained otherwise than in a process prescribed by law and both the police and NHS mental health services have a positive duty to give effect to this.
All hypothetical, obviously.
Winner of the Mind Digital Media Award.