We Need To Talk …

I suspect forces and their mental health partners are going to need to have some properly serious discussions later in the year about the role of police services on psychiatric wards: it’s one of those discussion I alluded to in a previous post that we often dance around or try not to have but incidents connected to it keep coming quick and fast. You’ll remember that the Policing and Crime Bill is making its way through Parliament at the moment and obviously, MPs from all parties are entitled to suggest amendments to the Bill during it’s passage. Yesterday, the those amendments so far received were published on the Parliamentary website and two MPs – Charles WALKER and Norman LAMB – have tabled proposals which mean this discussion really needs to happen. What is the extent and the role of police officers on inpatient mental health wards, should ever Taser be used and if so, what degree of scrutiny should it receive – these are all questions that arise for discussion within the amendments. And let’s not forget, this is the most serious, sensitive business: people have died in police and NHS contact on wards; NHS staff have died during disorder and disruption on wards – all of it is affected by staffing levels, approaches to Health & Safety risk assessment.

The College of Policing has been working on this for over eighteen months with professionals from other organisations, professional bodies and Government departments. I find it exceptionally interesting, so we need to start discussing what we’ve found out, accepting that data – as ever – is not adequate to allow a proper understanding.

Mr Charles WALKER MP has proposed that the Home Office should mandate the collection of data about every instance of police being deployed to wards; he further proposes that every use of Taser should be reported to the Chief Officer of police and reviewed after the fact for the appropriateness of the deployment and the use of Taser.  Mr Norman LAMB MP goes further: he has proposed that no police officer should ever be allowed to use a Taser on a psychiatric ward.  So there are two issues here –

  1. The deployment of officers to wards in the first place
  2. How officers who are deployed to wards then undertake tasks in connection with that 999 call.

WHAT WE’VE LEARNED

I’m going to simplify what I think I’ve learned in this process in to four key sentences, summarising

  1. Mental health wards are often not able to draw upon sufficient staff to undertake the restrictive practices that most people would imagine fall under the purview of NHS responsibilities to administer the Mental Health Act – the police are called to NHS wards hundreds of times a month across the country in connection with what I will call ‘disorder or disruption’ linked to ‘therapeutic security’.  In other words, situations which have become difficult or impossible for NHS staff to manage but which are not obviously incidents of offending that require arrest or even investigation.
  2. In most of the situations where the NHS call upon the police, they are not calling in connection with what they are regarding as criminal activity because in the majority of incidents where a crime has occured, the NHS’s own data shows they take the view that the patient’s actions were caused by or contributed to by their condition. That’s a whole other debate in itself, which I’ve covered elsewhere.
  3. Therefore what the NHS are usually asking for, is police ‘muscle’ to help them attend to legal responsibilities that most of us would understand to be theirs: the restraint, seclusion or medication of patients under the MHA – obviously, if you are in the business of providing mental health care that involves detaining other humans against their will and preventing them from leaving your building and taking medication you think is necessary whether or not they want it, there will be few people who would suggest this will be without.
  4. No-one is saying here, that there aren’t situations in which police support for this ‘MHA stuff’ won’t b necessary – if a patient becomes agitated because they are told medication will be given to them despite their objection and they damage furniture and fashion and improvised weapon from a chair leg or broken piece of glass, then the risks are such that the police will be required. No problem.
  5. But the police legal responsibility is to mitigate that unforeseen risk NHS organisations would not be expected to manage – and where officers attend and contain a situation, then remove a weapon or barricade in whatever way, the situation should revert as soon as possible to being one for the NHS; to make decisions about restraint, seclusion or medication, as they see fit and both health & safety law and human rights law would potentially have things to say about their inability to do so.

THIS WEEK AT WORK

Only this week, I have had five different queries from police forces about this topic of the police on MH wards and it’s only Thursday morning. Both of my meetings when I get to London this morning are about this topic – I’m not sure whether it feels like the issue is getting more frequent because I’m doing particular work on it at the moment, or because forces are experiencing more requests and queries.  Anyway, North Wales Police, South Yorkshire Police, West Midlands Police and the Metropolitan Police have all raised queries this week alone – asking “what are our legal duties; our legal powers and those of the NHS?”

In one case, officers were called to a psychiatric intensive care unit in the afternoon, at shift change over time. NHS wards often plan to undertake restrictive practices at change over time because they have more staff available to do it. On the particular occasion, twelve members of staff were reported to be tasked with giving medication to one patient, albeit someone with a significant risk history. The police were asked to be on standby on the ward, but out of sight, in case their efforts to administer medication went awry – it was agreed that they would and seven officers attended.  Nineteen professionals to give medication to one person. When the man was told he would have to receive medication, he stormed off to his room making verbal threats and all twelve staff were reported by the sergeant in charge to back off and refuse to act because of the risks involved. The police were asked to restrain the man for medication and then transfer him to a seclusion room.

Now, let’s descontruct this: a man on a PICU (for patients who require intensive support because of their condition and the way in which it manifests) required medication and made verbal threats. Even if they amounted to an offence of threatening behaviour under s4 of the Public Order Act 1986 of Threats to Kill under the Offences Against the Person Act 1861, those offences weren’t the main point behind police support being requested: it was about police ‘muscle’. And final point about deploying the police to that incident from a legal point of view: the hospital’s legal duty of care under Health & Safety law is owed as equally to the police officers who attend as it is to the NHS staff who work there. Nothing in law particular prevents the police from doing this. However, it should be recognised that nothing obliges them to do so either, especially where they have contained a situation that only they can manage and / or where no offences are being committed or threats to life being made out.

This creates the potential of a stand-off and it is that, right there, which we need to discuss – properly.

WHAT AM I NOT SAYING?

Is this a point about mental health staff? – no! It’s a point about how organisations approach the management of this kind of risk. Actually, a man in his room verbalising threats in circumstances where we are never going to consider immediate arrest and removal to police custody for the offence, is never going to be a legal responsibility of the police service. It remains an NHS legal responsibility to administer the MHA and until the situation becomes so serious because of raised risks, the response to these kinds of operational problems needs to be reflected in mental health trusts’ risk assessments and contingency plans.

Is this to say there is never a role for the police? – no! It’s about everyone understanding that the police do not have legal responsibilities to patients on wards, or staff, until situations are sufficiently serious to trigger what we expect the police to do in society as a whole. I’m often told that mental health staff have the same right to protection in law as members of the public who are shopping in Waitrose and if someone thought they were about to be assaulted whilst picking up their quinoa and pomegranates, they would be able to call the police. Unfortunately, this is not as simple a comparison as you might think: Waitrose also have to risk-assess the situations in their shops which are forseeable: their staff and customers are owed a duty of care in that same regard. But somewhat obviously, Waitrose are not obliged to consider how to coerce a vulnerable individual as part of their forseeable business – it’s just not what they do.

Now, as a society we could all take a view, that we don’t want mental health professionals undertaking this – we could, as a country, legislate to make coercive practices in hospitals the responsibility of the police, when directed to do so by the NHS. If an MP wishes, they could table such an amendment to the Policing and Crime Bill and it could be considered. It strikes me, based on their amendments, that neither Charles WALKER nor Norman LAMB think that is the way to go forward and their views could yet, be reflected in law depending on the debate that emerges around the Bill in the House of Commons next month.

IN THE REAL WORLD

Some final points: some times these debates lead to the discussion about cuts, funding and resources. Well, I’ve never believed that this argument is the right one to have, but if you insist: between 2001-2011 the NHS’s own data shows a real-terms increase in funding of 59%; over the same period, the police received 31% increase. Since 2011, the NHS have cut mental health services by 8%, whilst the police have been cut by around 20% – some would say it’s nearer 25%. So if you do want to have the discussion based on resources and cuts – the police are having to rationalise far harder. This is probably why in one of the other incidents I’ve discussed with a force this week, part of it involved an NHS manager reacting with incredulity that ‘only’ two officers were provided after a request for assistance. Again, a request that didn’t trigger any legal duty on the police, incidentally. When the manager protested to the duty inspector asking specifically for another ‘three or four officers, the duty inspector said, “How Many officers do you think I have at the moment?!” Pressed for an answer the manager said, “Twenty?!”

“No – nine, you’ve got two; another two are at A&E with a s136 detention we’ve been told you can’t assess until morning and of the other five, two have prisoners and there are three officers left dealing with all the 999 calls – crack on!”

We need to talk … and more importantly still, we need to talk to patients themselves, which is exactly what I’m spending this afternoon doing.


IMG_0053IMG_0052Awarded the President’s Medal by 
the Royal College of Psychiatrists.

Winner of the Mind Digital Media Award.


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7 thoughts on “We Need To Talk …

  1. As someone who worked in a central London MH hospital several years ago and was involved in calling the police on 2 occasions I have some experience of this. Once, a patient was using a drip stand as a weapon while the other concerned a person with a significant risk history who was thought to be in possession of a gun -he wasn’t – and the ward was visited by armed police! The ward was very volatile,given its location,and didn’t have a PICU on site so managed significant levels of violence and aggression. The ward was staffed by, generally, young fit enthusiastic staff. Here in lies the rub. MH nurses do not have fitness/strength tests before training as the possibility of dealing with significant levels of violence is not usually contemplated by prospective students or university lecturers despite the high likelihood this will be encountered. Most MH wards are staffed by middle Aged ,and older, relatively unfit ppl who are not ‘up’ for managing violence though may be good therapeutic nurses. Realistically, if it is thought necessary to have basic fitness tests for police officers it is probably also necessary for similar tests for nurses if expected to manage significant levels of aggression safety without police assistance. This, I feel, is the realistic question we need to address if wanting nurses to only call police if weapons or unusually high levels of violence are present. Of course this is likely to lead to other questions including about therapeutic environments, culling prospective nurses -who may be fab in other ways- and the role of MH nurses etc.
    Interesting debate

  2. We have a memorandum of understanding in place with the police, health and cps which has been really helpful in defining roles and where the boundaries are. I’m a Matron of a busy acute inpatient and PICU and we only call on colleagues in the police when activity on the wards meets the criminal justice threshold.

    1. Really interested in waht ‘the criminal treshold’ actually is – in my experience and in the dip-samples of data I’ve seen or produced, the calls upon the police to wards are usually nothing to do with requests for criminal justice activity (and for the record, I’ve argued for years that the police need to be better at the criminal investigation of offences that are alleged to have occurred on inpatient wards) – moreover, the requests are usually in connection with disorder or disruption which has taken place which the NHS is ill-equipped to manage. This is not a complete criticism: some of the requests are in connection with risks or threats that are so serious, we wouldn’t reasonably expect the NHS to manage alone – but in my experience, these are the exception to the rule. My experience and the data I’ve seen is mostly in connection with requests for police to restraint, seclude or transfer patients who are not exhibiting risks associated with weapons, barricades or hostages, but are unwell. It’s not just my view that indicates this wouldn’t survive contact with health & safety law, or human rights law, if tested.

  3. Michael as ever a really thought provoking discussion, but it also goes further, hospital security are called to assist give patients medication when the patients are not complient, NICE guidelines should be firmly embedded around a restraint but is it appropriate, I know every case is different but we need to avoid the Police and security being the go to solution, if this can ever be achieved by staff training alone, I’m not sure,

  4. There’s something in the Waitrose analogy that’s worries me, it kind of spins the point that I’d suggest staff and others are making to the Police when they use it. It’s not the fault of a member of hospital staff, if the staffing levels are insufficient to meet the risk profile of the patients for whom they care. I’d suggest that isn’t an uncommon occurrence! But surely it is the responsibility of the Police to protect citizens from harm and danger, and so doesn’t it follow that in all situations where a member of staff is in fear of violence, or where there is a loss of control of a service user(s), that the Police have a duty to respond to protect the citizen, wherever and whenever the citizen deems it necessary to make that call for help?

    1. No-one here is suggesting that the police won’t respond to prevent harm, assault or damage where staff are saying they are at risk – quite the opposite. What is being said, is that one the police have arrived and stopped any ongoing danger by contain the person or the broader situation, that is the end of their legal obligations. If staff then wish to restrain a patient in order to seclude, medicate or transfer them, the legal powers available to do so are principally those enjoyed by mental health professionals under the MHA.

      To give an example from my own career: a patient becomes distressed and disruptive whilst psychotic on a ward as a s2 patient and staff managed to separate her from other patients by pushing her in to the nearby Place of Safety room minimise the risk of harm. They are struggling so call the police and I attend with two PCs and when I ask what they are asking us to do, no-one is reporting assault or damage with a view to an investigation, they want help to restraint the patient for medication. They want the three male police officers to be a party to forcing a young woman to the ground so her trousers and underwear can be pulled down and medication forced upon her.

      I took the view that I’m neither obliged to do this and that if anything similar occured in police custody with a young female detainee (even if they were there under the MHA), I’d probably be sacked, so I declined. What I did do, was offer to remain in the PoS to help contain the situation until the staff could gather sufficient nurses to do this for themselves. They protested that we “must” help and were obliged to do so, I continued to decline. They protested they didn’t have the staff, I told them to direct that problem to the appropriate person: the on-call manager because it wasn’t a police matter.

      All I’m saying here, is that the legal advice received supports this approach. I realise it is difficult stuff.

  5. An approach,which shall I’m sure generate debate amongst MH nurses would be the use (in prescribed circumstances) of mechanical restraint by nursing staff. Not ideal but neither is having 4 staff sat on top of some one for however long perhaps we need to be more pragmatic in our approaches in managing violence?

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