I had a recent conversation about a policing and mental health issue, relating to the role the police may play on inpatient psychiatric wards where nursing staff are seeking support for some restrictive intervention under the MHA. In passing summary of the relevant legal issues at play during such requests, I said, “It’s the responsibility of healthcare providers to plan and prepare to mitigate foreseeable risks connected with their activities; and it is the role of the officers to investigate allegations of crime and to respond to serious risks which arise from unforeseen circumstances which have gone awry to the point where safety is seriously compromised.”
This has become more or less my standard summary of the work we’ve been doing under the chairmanship of Lord CARLILE CBE QC, which should emerge early next year. I usually add one further point: “Where the police do attend because of unforeseen or more serious risks, it is their role to create safe conditions within which healthcare staff can re-take control of the restrictive intervention unless it needs to become a criminal justice intervention, for example by arresting someone.” In other words, because MH staff may want to administer medication, this does not mean it is the role of the police to assist in that process just because a ward is not able to do so. If it were a matter of life and death, then the law would probably would allow for the police to support this process, but it often isn’t quite so serious.
The recent conversation revealed disquiet at this statement. Surely if a patient needs medication and the ward cannot muster enough staff to administer it, it falls to the police to help, right? No. Let me give a real example to show why.
CAN YOU IMAGINE?
Imagine a 999 call where a patient is ‘smashing up the ward’, with demands for urgent help. The police arrive to find a group of nurses and a doctor holding a patient in a small room off the ward, physically leaning on the door to stop the person from leaving. There is shouting coming from within and through a small observation panel, it is obvious the patient is highly agitated and distressed. The first police officer to arrive is the duty sergeant – concerned he is on his own, the staff immediately shout, “You need more officers, get more officers!” and the sergeant explains that two constables are just arriving and will be here within a minute. The doctor explains that staff have attempted to persuade the patient to receive medication over a long period and it has all failed. She is a s2 MHA patient and they have taken the decision to administer medication without the patient’s consent. They ask the three male police officers to enter the room, take hold of her and place her in a prone position so her trousers and underwear can be pulled down and an injection given.
Meanwhile, the patient is pacing around room and hitting the walls, but not causing any damage. Prior to police arrival, some damage has been caused on the ward, but that cannot now be undamaged by anything the police do or don’t do and nothing more is at risk as the patient is contained in a side room.
Can you imagine the furore if three male police officers forced a vulnerable woman to the ground and pulled down her underwear in any other context? – imagine if we learned that had taken place in police custody, even at the direction of an FME for some medical reason or other?! If it didn’t make the mainstream media as an outrage, it would probably still make the Professional Standards Department and / or the IPCC as a complaint and police officers have been disciplined for less. Why such urgency to have three male officers, partially strip a female patient? – she’s now in a room, contained and not causing herself any further harm in the short-term. The damage is now history, it needs repairing and there can be a criminal investigation in to that if anyone is alleging it should be considered for a prosecution. But in terms of the immediacy of entering the room to undertake a restrictive intervention to administer medication – there is no obvious immediacy (or at least, none was being made clear) such that the dignity of the patientneeded to be compromised in this way.
THE ROLE OF THE POLICE
This is what we’re getting at when we discuss the role of the police, not just within inpatient settings, but more generally – how do we frame some broad principles which would allow officers to understand how to judge their role in any mental health related incident; how do whole police forces understand how to judge their role when framing policies and procedures? I’ve recently spent a lot of time around the country, talking to forces in order to help their learning and development staff understand the legal material within the College of Policing’s Authorised Professional Practice (APP – guidelines, to you and me) and to prepare for the reality of standing in front of a room full of operational officers to deliver the training. Of course, the complexity and difficulty of this topic is reflected in the almost-700 posts on this BLOG and in outlining how the College of Policing are asking forces to approach this topic, I have outlined what I would say is a theory of policing and mental health.
This is not an attempt to sound grandiose, but to use the word ‘theory’ in its scientific sense: the explanation we offer to what we (think we) know from the world around us. Scientists throughout history have observed the world around them and sought to explain it with reference to theories that take account of those observations and the results from their work. If you find a persistently troubling fact that disturbs your theory, you have to refine the theory by changing the explanation, not insist that the troubling information can be dismissed. So the theory used to be that the sun and moon revolved around the earth and various people including Copernicus suggested otherwise. This alternative was eventually proved, in the sense that the best explanations for what we know is that the original theory was only half right: the moon does revolve around the earth, but the earth around the sun.
So in policing and mental health, how do we explain the role of the police? Well, you take all of what we (think we) know and provide an overall explanation that fits. Things like —
- We know, legally speaking, the police have no Mental Health Act powers in patients’ homes, yet we also know that most of the crisis incidents the police attend are in exactly those locations. Many such incidents can be professionally resolved without resort to legal powers but where they do become necessary to keep people safe, this cannot be for the police alone, because we don’t have powers that others do posses. To suggest that it can always rely on the police, is to miss both the legal thing and the policy thing we know or to fail to take them in to account.
- We know mental health crisis presentations where patients are so distressed and frightened that they exhibit very resistant and aggressive behaviours, can be attributable to underlying medical emergencies. We know that any restraint thought necessary can exacerbate that situation and medical guidelines exist in relation to this: so any suggestion that people presenting in such must be taken to police custody and until they ‘calm down’ or specialist inpatient beds are available is to miss that thing we know about medical and restraint risks.
- We know that 30 cases of assault on NHS staff have been privately prosecuted in the criminal courts by NHS Protect after the police and / or CPS declined to do so – this is why officers who say, “We can’t prosecute a s3 patient who punches a nurse” is not explaining that professional issue in a way that survives contact with what we know, because NHS Protect won all thirty of their cases. To suggest that inpatients in mental health units cannot be prosecuted is to miss that thing we know, about the history of criminal allegations from inpatient mental health settings.
- We know the mere fact of police involvement in a mental health or crisis response can be criminalising and frightening for some patients involved. That may even be because caring, empathetic officers had limited options available and had to do something regrettable, like detaining someone. To think the police can always be a reassuring presence when someone is in crisis, is to miss that thing we know about human beings all being unique, sometimes frightened and with different needs; and police officers being police officers, they don’t always have the skills or the options.
A THEORY OF STUFF
So look around you: see the legal frameworks we have in this country and the international frameworks we’ve brought in to our domestic law; see the various judgments of the courts in civil, criminal and human rights cases; look at the medical, nursing and care guidelines; read the books that academics and professionals have written; look at the way the police fit in to that wider system of 999 and of emergency mental health care; but most importantly – listen to what patients say about their needs and about the role of the police; read what they say on social media about how the world revolves for them.
Then, you can start working out how to structure a wider social response to those of us with mental health problems which must involved the police to some degree – mental health is core police business. But by better understanding those things, you’ll see where the police fit in to that wider response … and where they don’t.
For what it’s worth, about twelve years in to my efforts to do so, this is where my head is: if you disagree, please do so in the comments below as I’d enjoy discussing it –
- The police should be as uninvolved as possible in providing responses to mental health crisis care incidents – this is not to argue there is no role for the police: mental health is core police business, but not all crisis events are predictable or preventable and some will require the skills and legal powers that only police officers possess. This is about wanting to minimise the potential that police officers will unwittingly criminalise people; and inadvertently provide the wrong response to the circumstances, despite their best efforts.
- The police should ensure a more consistent response to crime involving those of us with mental health problems – living with mental health problems means we are more likely to be victims of crime; we are more likely to suffer criminal justice ‘attrition’ with our cases not being taken forward; and we need much greater consistency of whether we prosecute a vulnerable suspect or divert them from the justice system, especially where the offence is alleged to have occured against healthcare staff in a clinical environment.
Whatever specifics I’ve learned over the last twelve years – legal material, medical guidelines, Coroner’s outcomes, IPCC inquiries, etc., etc.; – all of that feeds in to those two conclusions. Every time I read a new case, study a new report or think about the various lessons that we’ve been told we must learn, I re-test whether these two things stand up to what we know about how the courts and lawyers say we can act; and to how healthcare professionals say we best serve those of us in distress. Every time I hear of initiatives that go against these ideas, I wonder whether that means we end up going in to conflict with things we know about the real world: and I invariably find we do.
We need to remain open minded about how we make the world a better place; and we need to ensure we ask questions when new information arises – does this information reinforce this working theory or do we need to re-think our overall approach in light of this new information? Then, in the end, it comes down to what we’re trying to achieve. I suspect that’s where some of next year’s conversation needs to focus but we need to find the best explanation for now about what we know whilst acknowledging we always need to know more.
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