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The Restraint Document

Since September 2014, when I started at the College of Policing, we have been working on the development of a document about those situations where the police are called to a mental health or learning disability unit and asked to do something coercive. I’ve been on mental health wards many times, as an operational police officer: calls to investigate and potentially prosecute patients for alleged assaults or damage; requests to assist in restraining patients so nursing staff can administer medication; requests to assist in moving a person from one part of a mental health unit to another … or even to move them to an entirely different unit. As a probationary PC, my colleagues and I were regularly called in to the old All Saints’ Hospital in Winson Green in Birmingham to a range of things where disorder and distress were manifest and the police were being asked to help.

These issues are as important as they are sensitive: we know that we don’t want to over-police anyone, least of all vulnerable people already detained in hospital at a difficult time in their lives, nor do we want those places to be dangerous and beyond the reach or scope of the law, where that is necessary. We know that care in clinical settings is primarily a matter for healthcare professionals and it’s for their organisations to ensure they address their own health and safety obligations; however, we also know that some things happen on mental health wards that may need the police.  For a start, around 67% of the 70,000 assaults on NHS staff take place in the mental health sector and whilst most of that is not reported as crime, some of those matters are very serious.  Recently, a murder inquiry was launched after a patient was killed on a mental health ward; in 2016 a mental health nurse was killed on a ward in Croydon and in 2014, a healthcare assistant in Gloucestershire.  No-one can seriously argue that where such incidents breakout, that the police don’t have a role to get in there and try to stop things from becoming any worse to prevent these kinds of outcomes. But it needs to be carefully considered and controlled, not least to mitigate against extremely untoward outcomes that raise difficult questions.

There are two problems this document aims to address –

  1. Police being over-relied upon to enter clinical settings and undertake restrictive practices which fall within the scope of what we would all agree are predictable risks associated with being a mental healthcare provider.
  2. Police not recognising the need to support healthcare professionals in addressing unexpected risks that are beyond their ability to cope, where control is lost and safety is compromised.

SO WHAT DOES IT SAY?

This is the three-point summary of this document –

  • The provision of healthcare and the undertaking of restrictive practices associated with healthcare is the legal responsibility of the healthcare provider who must ensure compliance with health & safety legislation as well as human rights laws in the way they undertake this difficult work. Specifically, this includes the requirement to mitigate foreseeable risks.
  • It is the role of the police to investigate allegations of crime; and to assist in restoring safety where unpredictable risks have seriously compromised the safety of staff and patients. The officers’ role is to restore the circumstances of safety that allow staff to retake control at the earliest point and to then determine whether a criminal inquiry is required.
  • Where it is alleged that safety is seriously compromised, for whatever reason, the restoration of safety is the key priority – if there are any discussions to be had about whether the call for the police is appropriate OR whether the police response was appropriate, these are discussions for after the safety of all has been ensured.

The Restraint Document, as we kept calling it, is a multi-agency Memorandum of Understanding.  The College of Policing has coordinated its production and it is agreed between the National Police Chiefs’ Council, mental health charity Mind, the Royal College of Nursing, the Royal College of Psychiatrists and the Faculty of Forensic and Legal Medicine.  In the course of its production, independent legal advice was secured from a QC and junior counsel with experience in the legal matters around police powers and mental health law. In addition, it has been supported and welcomed by Amber Rudd, the Home Secretary; by Lord Adebwoale, the chair of the 2013 Commission in to Mental Health and Policing in London; the charity Inquest and several others. I’ll let you find details of what they’ve said, if you’re interested, by going to their social media feeds or to the College of Policing website.

FREQUENTLY ASKED QUESTIONS

Already, some questions have emerged a few times, so let me address them –

  • Have all forces agreed to this? – no, they haven’t.  It is not something they were asked to agree or disagree because it is an expression of standards by professional bodies and by Mind, on behalf of the public. Many police forces, healthcare organisations in the NHS, including CCGs, MH trusts and others were involved in and consulted as part of this work; but to get formal agreement of the five major signatories was hard enough!
  • What changes from before? – absolutely nothing, strictly speaking. This document doesn’t oblige us to do anything that wasn’t already possible or desirable; it doesn’t ban or discourage us from doing anything in the future that wasn’t already banned or discouraged.  This document merely summarises the law and the relevant medical and other professional standards and guidelines, for organisations and individual professionals.
  • Can I disseminate this? – yes, that’s why it was published on the internet. There may well be partnership implications here, but only if areas or organisations have drifted in their understanding of what the law demands of us all. Even frontline professionals reading this and improving their understanding of the legal, medical and practical implications will improve the experience of patients.
  • So can officers restrain for medication or not?! – there has been a rumour for many years that officers have ‘no power to restrain for medication’. This is true, to the extent that the Mental Health Act (or Mental Capacity Act) does not expressly authorise any specific professional. Obviously, it is primarily a matter for healthcare professionals and police involvement should be extremely rare where thought unavoidable. There is a detailed example below, as to when / why.
  • So what happens now? – the document needs to be taken by forces and healthcare providers, through their local Crisis Care Concordat action plans and local procedures developed around the principles outlined. This may mean forces need to consider how their control rooms handle calls to MH units, it may mean mental health and learning disabilities units need to think about staffing, contingency plans for events and how we interface and cooperate.

REAL EXAMPLES

Remember the two problems we’re trying to fix, above?  Here are some real examples which emerged in discussions of the working group. They came from professionals in policing, nursing and psychiatry.

  • Over-policing? – an adult man, a s3 patient on an acute admission ward has had a difficult morning on the ward, has seemed unusually agitated and there are some raised concerns about whether he may hurt himself. Nurses have tried closer nursing support, but this has left concerns. They have decided, and it has been appropriately authorised, that he will be secluded for a short period with more intensive nursing around him. At the point where he is told this, he is sat on the floor of the ward corridor and refuses to move. He is not actively harming himself or others and there is nothing about his background that suggests it is anything other than a nursing responsibility to move him to seclusion. The police were called to assist, however a senior nurse who learned this had occured, over-ruled the decision, cancelled the police and directed the incident. The use of the police here was not necessary or relevant.
  • Under-policing? – an adult man, s3 patient on a low-secure ward is reported to be “smashing the place up” and the police are urgently requested on 999. Upon arrival, there is some damage to posters from the notice boards but there is little more and the police are told that one nurse in the office, has been assaulted. The man is agitated, pacing around the ward whilst shouting about his delusions and making non-specific threats. The police contain him, without restraint, by having a few officers standing on either side, giving him freedom to move in that limited area without anyone in his personal space. This continues until a nurse explains what has happened and what they are asking for. An officer uses humour to de-escalate everything and it leads to the patient become less distressed. Nurses want to seclude him and provide medication so the police escort him 10m down the corridor, without restraint, and in the room he agrees to receive an injection. The police then speak to the victim and record an assault which is investigated later.
  • Too casual? – a s3 patient on a ward grabs a nurse unexpectedly and starts attacking her. It quickly emerges that he has improvised a weapon out of something plastic and later, it is found to be a plastic biro-style pen. Having grabbed the nurse from behind, he uses the weapon to inflict several puncture wounds to the nurse’s torso and colleagues immediately ring 999 for help. Without officers attending the ward, the police control room feel entitled to say that this is something the hospital should be able to handle and refuse to attend. A further 999 call is handled similarly. Thankfully, staff on the ward do manage to contain the patient, but not before another of them is assaulted. The injures nurse requires A&E treatment to her injuries, which amount to grievous bodily harm, for the purposes of crime recording standards.
  • Inappropriate? – officers were called on 999 to a female patient assaulting staff and causing damage. Upon arrival, the staff have forced the patient in to some kind of side-room, off the main ward. There is damage to doors and a door frame, but those staff who were assaulted are uninsured and still involved in leaning on the door of the side room to contain the patient in there. Three male officers arrive and the doctor, after some vague discussion that had to get precise using closed questions(!), requests the officers to restrain the patient on floor so that nurses can give her an injection. What do we think about three male police officers being involved in the restraint of a young woman, so her trousers can be partially pulled down against her will? I think, if police officers did that in anything other than a life-threatening situation, they could expect to be disciplined and sacked. So as the young woman was at immediate risk, despite ongoing agitation and distress, the decision was to ask the doctor to summon whatever he thought were the appropriate resources to do this. Police merely monitored the situation until that had occured and withdrew from the area, remaining nearby.
  • In extremis – five nurses on a ward have come together to administer medication to a patient after all efforts to persuade him to receive it have failed. They are appropriately trained to do this and have done it before, including with this patient. As the nurses take hold of the man’s arm, he begins to struggle. Attempts to secure him are not successful and as he pulls his arms away from control, he manages to completely pull away from the grip of that nurse on that arm. As his arm suddenly breaks free, the back of his hand hits the face of another nurse with such force that is causes a serious injury, fracturing his jaw. He disengages in agony, a second nurse intuitively disengages to check on him and then to summon help, leaving the other three attempting to contain the man whose agitation is escalating. 999 is called for an ambulance and police and officers arrive within 9 minutes of the call. By this time, the remaining three nurses are struggling on the floor with this man, obviously exhausted and screaming for help. Two of them have been further assaulted, albeit without significant injury. The officers take control of the man to help and the nurses move away, obviously ‘spent’. The nurse who rang 999 is the only one left who is neither exhausted nor serious injured and she asks the officers to keep the man restrained whilst they administer medication. There are no other nurses available. After this, one of the three nurses gets re-involved and the four of them – two nurses, two officers – move the man to a seclusion room on the ward.

LESSONS LEARNED

So what is going on here, in terms of the thinking?  Whatever was behind the nurse in the first example calling the police, we can probably agree it’s not appropriate – no current disturbance or violence, nothing that links to crime or serious risks to staff. Even if there were certain risks, as long as he’s sat on the floor in the corridor, there should be contingency for bring staff together to undertake this task. In the second example, we can see that it is necessary for the police to attend to assess things, but upon arrival, they haven’t done a huge amount because it’s not quite as serious as first reported. We can debate all day long whether it was ‘right’ to call the police, but that’s the judgement staff made – why not attend and assess things? Doesn’t mean the police automatically will do anything or will do very much, but at least we can say we’ve assisted in assessing what’s required and that any decision not to act is taken after a proper understanding of the circumstances.

We obviously can’t do that in the third situation because the police didn’t go! … it doesn’t need much explanation, does it?! – if nurses are being stabbed, we should be going! It’s a real shame that even needs saying and thankfully, such examples were very rare but in those sorts of things, if there is anything to discuss about it, that’s for later, not for now.

In the final example, it gets most controversial: the assessment the officers made at the time was that it was more dangerous to disengage and argue a point, than to help. One nurse and already suffered GBH injuries, two others were assaulted and three were, put frankly, completely knackered. There was one nurse left to actually administer the medication and no others available from nearby wards (for whatever reason – right here, right now, there were none available). If the police had not continued to assist, there could have been further serious assaults. Remember, when medication is authorised by nurses or doctors under Part IV of the MHA, nothing expressly prevents the police assisting – but we should obviously only be doing so in circumstances like this where there is no other option, at all.  We should also remember s139 MHA, which provides that –

“No person shall be liable, whether on the ground of want of jurisdiction or on any other ground, to any civil or criminal proceedings to which he would have been liable apart from this section in respect of any act purporting to be done in pursuance of this Act or any regulations or rules made under this Act, unless the act was done in bad faith or without reasonable care.”

I hope the document helps you out!


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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6 thoughts on “The Restraint Document

  1. Great blog Michael! Thanks. Any chance you could explain what you mean by ‘uninsured’ where, under the heading ‘Inappropriate’, you say “…but those staff who were assaulted are uninsured and still involved in leaning on the door of the side room to contain the patient in there.” Thanks again.

    1. A few points a) it’s not advice: it’s a summary of existing laws and guidelines from professional bodies; b) when APP is next updated, whole sections of his document will be pasted in to it! c) the document is either right or it’s not!

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