Immediate Need

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.

HYPOTHETICAL EXAMPLE

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.


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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16 thoughts on “Immediate Need

  1. It also doesn’t help when officers take someone “voluntarily” to hospital and know, in their minds, if that person then tries to walk out they will be detained under 136. Or even worse, sit with them in hospital to ensure they get seen!

    Best of intentions, coupled with lack of support from other locations, often leads to bad decisions.

  2. Good post. Just been implemented in our area , would love to have details on how it works, what longer term outcomes have been and what alternatives mental health professionals have ben able to offer in the middle of the night.In our area there is no out of hours service, so presumablyall that can be offered is go home and ring in the morning…. As you say if police are worried enough to stop someone leaving then they are detaining them, and I am so worried about the idea of a nurse then saying, oh they’re fine, or sending peopel off to A&E unaccompanied. Lookibg at outcomes for a neghbouring area it was very unclear how many of the calls could have ever resulted in a s136, it seemed very few. There was also no info o how many peopel ended up being arrested for an offence instead,.Anyone known to services shouldn’t be allowed to get to the point where police are getting involved…….

  3. It makes complete sense. As a previous psychiatric inpatient that was once detained by the police I can fully confirm that you could have read me my rights, or not. You could have even said you were a pink chicken from the planet zumbalaga ruled by the emperor blurb and that you are taking me back so that I can stand trial for war crimes against chickenanity. It wouldn’t have made any difference. I wouldn’t have taken it in. I was in full psychotic episode, seriously distressed and I needed to be detained. Who knows what I would have gotten up to if I wasn’t. You see when in full flow there is a story you believe in your mind, and every detail, every event, every story, every discussion plays towards that story. Your mind convinces you that everyone part of it.

    I think the main thing is that you do your best to keep the detainee comfortable, keep them watched at all times and make sure they have food and water in their belly. That’s all that can be asked. However, I can understand massive funding cuts and sparse officers available for this sort of treatment. Good post!

  4. 29 September 2015
    Dear Mentalhealthcop
    My hat is taken off to you once again.
    In effect it seems to me this is like another “Bournewood Gap” appearing but this time on the outside rather than inside.
    And then add the Mental Capacity Act 2005 and there is a real humdinger of a problem.
    I really feel that the Care Act 2014 has increased the problems rather than resolved them.
    Thank you so much for all your sterling work.
    Best wishes
    Rosemary

  5. You miss a fundamental point about capacity. Even though they express psychotic ideas or have a diagnosis the MCA forces us to assume they have capacity unless they demonstrate capacity about a specific decision.
    They may labour under a range of bizarre and psychotic ideas and still be able to make an informed decision that if they cooperate and remain they are less like to be detained for assessment. The new Code of Practice actively encourages officers to seek advice before applying s136. There will be circumstances of urgency which a s136 is immediately necessary but not always.

      1. A situation moves from not being necessary to being immediately necessary. I think you know what I meant.
        Taking your position a gentleman who was threatening to jump from a bridge and had a section of road closed for hours, s136 couldn’t be used as he had demonstrated by remaining there so long there was no immediacy.

      2. I would take the view that the situations is manifestly different: if the police were able to take him into custody safely, they would probably do so, to prevent him jumping – I know on just one occasion in my career, two of us grabbed a guy who was on the adverse side to stop him jumping because he looked imminently likely to do so and the danger acting suddenly outweighed the danger in acting.

        Where the danger of grabbing someone is greater than the danger of not yet grabbing them, there is little point in verbalising a detention, because it means nothing in reality and risks aggravating the situation adversely. But if there was a tried a tested tactic for getting someone back over by force, then many officers would do the verbal ‘tactical comms’ required before a use of force, resort to force and secure the s136.

        I see the situations as fundamentally extremely different.

  6. I’m surprised to read that you don’t get the idea of a 2- or 3-agency triage car. So much has been written and experienced about organisational and professional barriers to finding the appropriate response to urgent need – the triage car idea was an attempt to address this by offsetting these barriers by close joint working. My experience of a triage service was that the staff felt they could understand and accommodate the organisational/professional demands upon their colleagues often for the first time and come up with creative solutions to crises because they worked so closely together while retaining their own professional perspective.

  7. I think you’re looking a bit too deeply into the argument of when a decision to not allowing people leave is formed and when you legally detain them. Just a few quick examples along the same lines which are never an issue. When an officers stops a vehicle for a minor traffic offence the chances are the officer will not be letting them leave before everything is dealt with. The driver however would only be arrested if they tried to leave before details etc had been establish. Or how about an voluntary interview. In some case a decision is made prior to the interview that should the interviewee try to leave they will be arrested. It may be semantics but in my opinion its an important difference. It’s a bit like stop searches, you can speak to person prior to a SS to negate the search even if the grounds are there to carry out the search. The concept is very different to the ‘guided bird cage’ argument.

    On the point of ‘immediate’ though, why does it seam that the police the ONLY people able to detain people instantly? Everyone else needs a signature etc. It makes some of the sections rather pointless at times such as Section 5 MHA and in patients on wards. By the time the paper works completed they’re off the ward and police are asked to use 136.

  8. I’m just wondering here – but officers would make a capacity assessment and the person could be held under the MCA, surely? And then, people still talk of the Common Law of Necessity. How does that apply here? (if it applies at all)

    But in this instance, I can’t see anything to be gained by not using s136 – street triage here seems only to build in delays where someone is clearly in mental distress and their health and safety are at risk.

  9. I understand your concerns and agree there are definitely circumstances whereby preventing someone leaving the officers could be seen as dodgy under strict legal terms. Sectiondetection’s comments are interesting and I consider that when I attend officers who have requested our Triage team for assistance they have (on most occasions) kept a person with them respectfully, ethically and with their consent to wait for me.

    Our team is named ‘Community Triage Team’ recognising that the majority of contacts do not actually take place on the ‘Street’ but in peoples home addresses. Most of our contacts are made prior to officers even arriving on scene, within minutes of the call being taken. Advice being provided directly to Police control, often with contact details for current care teams, last attendances for appointments or alternative telephone numbers in the case of high risk missing persons, advice on not attending and preventing a Police response at all in certain cases where we have a very comprehensive understanding of the person (there are many, many more examples).

    In the case of those not known to us, we are very responsive and have a very good reputation among officers for providing a timely, effective, economical service which frees up responding officers much quicker than prior to our onset.

    We too have needed to grab a guy on the adverse side. Very frightening to consider the potential outcome. Interestingly enough he was a very clear example of how peoples’ emotional state is not static in time. He went through a tidal wave of emotions but, after an hour, was re-assessed and went home with input from our Home Treatment Team. From actively suicidal to gratefully accepting support within an hour.

    One of the areas we have worked very hard on from the outset is helping our trust to understand the pressures the Police are under Out of Hours and helping to reconfigure our Mental Health services so that the ‘Front Door’ is always open 24/7. That doesn’t mean admitting people to hospital but, helping them to remain safely in the community using approaches that are transparent enough for Police to witness and feel confident their Duty of Care has been handed over appropriately. s.136 is always an option when there is not the time to stand and ponder our options. If we do have time to ponder then we have to question 136. Triage is reliant on support services as, if there are none, I can’t Triage. We are lucky in our area.

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