Serotonin Syndrome

If you are a police officer who has ever used s136 of the Mental Health Act 1983, have you ever heard of serotonin syndrome and would you know how to recognise this potentially fatal condition which can have a rapid onset? No, me neither. I read this week about the inquest into the death in York in 2011 of Toni SPECK who died in police cells having been taken there as a Place of Safety. At that time, there were no other options for the North Yorkshire Police officers who encountered her at that time and she died after the arresting officers, the custody sergeant and the custody nurse failed to identify that she needed urgent hospital treatment for serotonin toxicity.

In a narrative verdict, the inquest jury decided that it was not reasonable to expect any of the police officers involved to have spotted indications of this condition, precisely because of the nature of its presentation relative to their skill base and training. However, the jury did decide that the custody nurse should have recognised the signs in police cells when she examined Toni. Of course, my first reaction was like that of the North Yorkshire Police Deputy Chief Constable Tim MADGWICK: Toni SPECK should never have been in police custody as a Place of Safety in the first place and because North Yorkshire now benefits from various Places of Safety in NHS settings (apart from the one that the the CQC closed down because of safety standards at that hospital!) if this particular kind of detention had occured in 2015, she would have been taken to an NHS location.

My second reaction was to wonder whether this perfectly correct observation also totally misses the detailed point about many health-based Places of Safety services: they are usually unstaffed by people with clinical qualifications. People are looked after there, all too often for many hours, by police officers.

CRISIS CARE CONCORDAT AGENDA

Over the last few years, we have seen agenda driven under the banner of a Crisis Care Concordat that was initiated during the last Parliament. To an extent, it is quite right that we see the development of health-based Places of Safety celebrated: statistics suggest that the number of people taken to police custody has halved and we now see that just 25% of those detained under this power end up in the cells, rather than the 66% figure we saw from the Independent Police Complaints Commission in 2008. Of course, police stations are supposed to be used only occasionally which usually means around 2-3% of the time so there is still a long way to go!  And what could possibly go wrong?!

Well, the case of Toni SPECK shows what could go wrong and it highlights the artificial divide between ‘physical health’ and ‘medical health’. In recent discussions about s136 with the A&E profession, they were keen to stress how A&E should be used as a Place of Safety only where there are ‘physical’ or ‘medical’ concerns. But who is deciding this?! … if your answer is ‘police officers’, then we can already start to see what might go wrong. I have a first aid certificate and no-one mentioned serotonin syndrome or neuroleptic malignant syndrome to me – in fairness, no-one mentioned mental health at all but each of these conditions can occur, and only rarely, in patients who have used SSRI antidepressants or anti-psychotic medications. But the rarity makes things more complicated if you are a police officer bearing in mind that each officer will use s136, on average, only once every few years. So we need clinical input about risks that could be fatal – not just for these conditions, but for many others. I’ve also known police related MHA detention involve cardiovascular problems (not exacerbated by restraint) as well as diabetes, encephalitis and one case of a brain tumour … all in addition to the complications from psychiatric medication as we’ve now seen in the tragic case of Toni SPECK.

So we call an ambulance to each detention, right? – maybe. We all know the pressure the ambulance service is under and whilst I would be prepared to say the ambulance service has made real progress on s136 and on mental health more generally since I first got involved in this, I fully understand when they are managing outstanding RED1 and RED2 999 calls for things that are known to be healthcare emergencies, prioritising mental health can be difficult when it’s all the more difficulty to know which mental health crisis situations are literally life-threatening from those that cease to be once a police officer has taken initial protective action. It’s also worth pointing out to police officers, that ambulance services are getting better at recording their involvement in s136 MHA calls and their data suggests that quite a lot of the time where a paramedics were not involved in s136 it’s because police officers didn’t call them! – you really need to make sure you ask every single time; and you then do the best you can in whatever circumstances you find yourself.

MEDICAL SCREENING

So if an ambulance is not available, what level of medical screening can be expected? Where a person is removed to a health-based Place of Safety because it is not obvious that they require A&E treatment, surely the nurses at the PoS assume that responsibility? Well this comes back to my point about assuming NHS Places of Safety are staffed – I haven’t paused in writing this BLOG for very long to think of three PoS services not far from where I live where no nurse meets and greets the patient on their arrival; the police just let themselves in to a room using a keycode. There, the patient – who is now in an NHS building for improved healthcare purposes – waits, on average for several hours, until the AMHP and DR arrives. Had that patient gone to police custody, they would have been seen by someone within 90 minutes.

Something I don’t know about mental health nurse training, is whether identifying signs of serotonin syndrome on first contact with an unknown patient is something they are trained and expected to do? I remember reading something by leading forensic psychiatrist Nigel EASTMAN some years ago which stated that the first priority in any mental health examination is a physical examination: I’ve also heard psychiatrists say they cannot undertake such examinations and request patients be transferred to A&E for ‘medical clearance’. So if it’s acceptable, or at least a part of current practice, that registered medical practitioners in psychiatry pass of concerns about ‘medical clearance’ to A&E, why can’t police officers with a lower skill base? I should point out, this is not an argument for greater use of A&E, but of better clinical support to police officers! – I can almost hear colleagues in A&E fainting from here.

If you take someone to police custody, they will see a custody nurse or doctor within ninety minutes and to that extent, removing someone to the cells is often a faster route to healthcare than taking someone to a health-based Place of Safety. Read that sentence again and tell me in the comments below why that is ever correct! It fails my common sense test, if I’m honest. So the DCC’s media reaction expressing regret to Toni SPECK’s family and trying to provide some cold comfort that this wouldn’t happen again is quite right in the sense that she would have been taken to an NHS building as long as the it was commissioned and provided to the required standard, as outlined in the RCPsych Standards on the Use of Section 136 (2011). The reality however, is that many PoS services are not operating to that standard – even where there is a ‘meet and greet’ for patients it is often from a nurse who briefly attends from the adjacent ward and returns to their main functions after the initial assessment. I don’t know whether they are briefed or trained around serotonin syndrome but the sad case of Sally MAY causes me to wonder.

IMPLICATIONS

It was especially tragic to read the comment from Toni SPECK’s sister, Dawn ATKINSON, “We have all been left devastated after hearing from the expert witness evidence that Toni’s life could have been saved, if she had been transported straight to the Accident and Emergency Department at York District Hospital.” Back to the A&E debate we go – it seems incumbent upon the NHS as a whole to make it clear how opposed they have been for decades to the use of A&E for anyone detained under s136 MHA, unless it is obvious A&E is required. It’s not clear that serotonin syndrome symptoms would be obvious, certainly not to a police officer and so it seems incumbent upon all those who oversee NHS policy to look again at what action they want police officers to take. Officers should be calling an ambulance to everyone; if that ambulance doesn’t turn up, they could be directed to take patients to A&E – perhaps that should be done in areas where they have no staffed PoS unit that would allow a mental health nurse to undertake that role; or they could just take everyone there.

I am quite satisfied that anyone from the Royal College of Emergency Medicine who has read that last idea will have fainted at the thought of an extra 25,000 complex and often challenging patients a year being taken to their already very busy departments as we head towards a busy winter in the NHS, so we need to be clear about something very specific –

If police officers have responsibly exercised legal powers to detain a vulnerable person who is now in the care and control of the state, that state owes that person a duty of care and this narrative inquest verdict makes it very clear: we cannot expect police officers to make clinical judgements about complex medical issues and that some of the clinical issues that affect people detained under s136 can be potentially fatal. Unless we are going to adopt a totally irresponsible policy position of suggesting that officer should gamble with the health of those they have detained, we need to establish a reliable method of securing clinical input. Maybe street triage is one such way, but I’ve expressed my reservations about that and I repeat my question about the nature of physical examinations done by mental health nurses – I don’t know the answer to that.

So I’ll put it this way: would I ever take a person to police custody who had not yet been seen by someone from the NHS? – quite, honestly there’s not a snowball’s chance in hell I would. If the arrangements in my local area did not allow for an ambulance or for access to an NHS mental health nurse, I’d take them to A&E. If A&E want to turn that person away, that’s up to them – and if it goes awry, they can give evidence to the Coroner just after I finish explaining my reasoning for my actions because this is really serious stuff! It doesn’t get more serious and we can all imagine the anguish of Toni SPECK’s family now that they know what they do.

Those who control policy need to look at this and I’ll be emailing this case around all English / Welsh police forces on Monday to highlight the issues it raises – not about serotonin syndrome specifically, but about clinical risk assessment and screening for all those detained under the MHA by the police.


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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14 thoughts on “Serotonin Syndrome

  1. I agree that whilst there have been many improvements in s136 arrangements nationally, so many are a half-hearted fudge about respecting the rights of individuals detained and still leaving the responsibility with the police that SHOULD be with Health & Mental Health. Absolutely agree advice to officers should include calling for an ambulance ALWAYS, but MH nursing & medical staff should also be aware of & able to check for signs of neuroleptic malignant syndrome/serotonin syndrome. My belief is that any PoS should provide that screening for any new “admission”.

    Taking folks to A & E is not a great answer – for all sorts of reasons – not least the wait times/ finances/ lack of appropriate environments/ minimal supportive attitudes of some staff. But when needs must, until policy makers and Service Commissioners take their responsibilities seriously. I have to wonder if they could be held accountable in law for their ultimate evasion of “duty of care” or find themselves named in Sunday paper headlines would they change their priorities – or if they or one of their loved ones fell foul of this misguided gate-keeping.

    Thanks for highlighting the important stuff & not letting it keep getting swept under the carpet.

    1. Taking folks to A&E was never my proposal, but it is the potential consequence of officers being left totally unsupported in their decision-making by an NHS who can’t ensure ambulance and / or PoS nurse support in a timely fashion.

  2. Hi Michael, a few questions / comments…

    What were the circumstances of her detention? Was there any suspicion of illness? Was there any mention of overdose? What was her medical history? Why was custody used as PoS?

    Regarding use of A&E as a PoS only if there are physician or medical concerns… If this wasn’t the case wouldn’t they be inundated with patients? This highlights the need for a specific mental health triage process so that paramedics and police can take appropriate patients there with confidence if they aren’t going to a s136 suite.

    I believe that when put in such positions police officers should act in the best interests of the patient, ask about medical history, physical problems and overdose and ensure plan and decision-making process is well-documented. Ambulance should be called if police reasonably assume there is a risk of physicial (or indeed serious mental) health problem.

    With regards to A&E, there is often nothing in place to ensure that a patient remains there for treatment and unfortunately some of these patients abscond and it is then the responsibility of the police and ambulance service to bring them back – why is this still happening?! A mental capacity assessment, description and contact details need to be recorded immediately.

    If mental health departments state that patients need to be cleared medically first, why can’t there be a general nurse or paramedic working in that department to facilitate this?

    Serotonin syndrome is a rare condition which I am aware of through my own self-directed learning. I think it’s seriousness needs highlighting amongst paramedics and A&E staff.

    Finally, and somewhat unfortunately, (in addition to patient care) the importance is on sound decision-making and correct documentation of this process ensuring that a handover is given and fully understood. We need more access to mental health services to improve outcomes for patients.

    1. Any suspicion of illness? – they’d detained her under the MHA, so I’d say so!

      Why police cells? – because there was literally nowhere else at that time, unless they tried A&E and part of the debate here is on whether there was a need to do so.

      Background – I don’t know what they knew.

      Circumstances – from what I’ve heard it was calls from the public to a woman in distress, behaving ‘oddly’.

  3. By illness I meant physical illness.

    Unless she had committed a crime, a women behaving “oddly” she be taken to A&E or an ambulance called in my opinion.

  4. I know that all cases need to be looked at individually, but come on folks “serotonin syndrome” may be relatively rare, but the whole process is a tragically infrequent, but not unfamiliar scenario – for the individual, family & police officers.
    There are MANY cases when all involved do the right thing at the right time & sometimes by good practice, luck, good networking the outcomes are positive. Sadly this isn’t always how it happens. BUT all involved in these challenging & difficult situations would like to know that a consistent process is followed wherever you are in the UK and whichever “role” you find yourself in AND that the resources are there to support you.
    Let’s be arguing for the right things.

  5. A & E don’t recognise it either, they prefer their first wild guess by asking the wrong questions and not listening. The problems eventually reduced and told to go away but still too ill to walk. Patient recognised it and was able to prevent worsening after several hours.

  6. One of the two pathologists had put forward excited delirium as the cause of death. That would suggest that Toni’s behaviour was very disturbed/distressed. The advice you have given in your blogs, the lessons that might have been learned from restraint related deaths, including that of my son James, would have identified Toni as a medical emergency at the point of the restraint. Really getting that message to all response officers as well as custody staff must remain a priority. Excellent piece, Michael.

  7. I think that an NHS Place of Safety should be regarded as a ‘psychiatric A&E’ The patient should be seen urgently by the duty psychiatrist. Psychiatrists are medically trained and should certainly be familiar with medical conditions which can present with psychiatric symptoms, and with serious side effects of common psychiatric drugs.

    It would have been difficult at the time of detention to medically assess someone as agitated as Toni but this could have been done once she had calmed a little.Perhaps a street triage nurse could have calmed her sufficiently to allow basic medical checks.

    As regards medical checks in police custody, simple checks of pulse and blood pressure could have identified that Toni was unwell.

  8. I have been following the press reports of Toni’s inquest and it struck me that Toni was another example of a person in mental health crisis who was restrained and on the basis that one of the two pathologists gave Excited Delirium as the cause of death, Toni probably fought against restraint, at least for a time. The Rocky Bennett Enquiry findings, many deaths in custody, including that of my son, James, and your own advice given in many Blog posts over the years, suggest that the safest course of action would have been to seek emergency medical help much earlier than when Toni was in the police cell. I also had not heard of serotonin syndrome and if the suggestion is that the restraint was not even partially causal to Toni’s death, then the implication is that seeking emergency help when a highly agitated patient is struggling against restraint, could save lives, even when the restraint itself is not part of the cause of death.

    Be that as it may, this is another excellent blog post, looking square at the practical issues.

    My deepest sympathy to Toni’s family.

    1. Tony, that’s the way I’ve looked at it for years and the more I learn and the more tragic outcomes I read about the more I’m reinforced in this view: that officers are gambling with unknowable unknowns. So in the end it’s about how you make decisions amidst uncertainty and where the consequences are hurt feelings it may be acceptable to take some risks but where, as all too often appears to be the case, the risks are potentially fatal, a fundamentally different approach is required.

      This is a problem because the commissioning of all the services that are relevant to this is straddled across numerous organisations – no-one is in charge of it.

      1. Michael, if that advice you have been giving for years– Mental health patient struggling against restraint equals a medical emergency– was understood and acted on universally, this would be such a big strep forward. This is not the sort of thing that you would expect a police officer to understand intuitively but you have been saying it, it is normally part of limb restraint training material as well as articulated in restraint policies (defined as “excited delirium” or “acute behavioural disorder” ) and it figures in so many death in custody cases, it is about time it was there in every response officer and custody staff’s mind, ready to implement on the hopefully rare occasions it will be needed.

        Keep up the good and important work you are doing. From, where I sit, you are making a real difference,

  9. Many Mental Health Nurses have neuroleptic malignant syndrome drummed in to them but I think few would recognised serotonin syndrome.
    Even in the comments the cracks start to show though.
    Police officer says it’s crazy the police providing better health screening than the NHS, although some people having contact with custody medical staff would dispute that. Uses the word illness although the vast majority of s136s involve drug and alcohol use, adjustment reactions or mental disorders and often these would be better managed through the criminal justice system.
    Doctor says I’m not sure there’s value in Patients coming to A&E when they should provide physical health care in MH settings,
    Paramedics says, despite the ambulance service being commissioned to do it and (where I work it’s also firmly in policy), our stretched ambulance service shouldn’t be involved in medically screening MH patients unless there is something obviously wrong (in the eyes of officers who aren’t trained to see what’s obvious or not).
    While we are all working with tight budgets and limited resources people will not be safe. I. The best system in the world deaths won’t be totally preventable and we don’t have such a system.
    Meanwhile we can all be defensive about our services and maintain its somebody else’s’ problem.
    1 in 4 people have mental health problems.
    1 on 12 people have asthma. Compare the clear pathway and resources for treatment for one with the other.
    The Crisis Care Concordat came with no resources and is therefore just another way of ensuring the NHS fails. We need to sort that out.

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