I’ve been a police inspector for most of my service – about fifteen of my twenty years so far. Regardless of what happens to me in the future, I will retire from the service having spent more time at this rank than any other. And what a position it is! – it’s an operational enough rank to mean you can still do real police work and see the raw humanity in to which policing offers the most amazing and privileged insight. And it is the most Romantic rank of all – most of the policing heroes we idolise from television and literature, like Frost, Rebus, Gently and Morse were inspectors. Actually Morse was a Chief Inspector, but you’ll notice he didn’t always tell people about that. He knew …
The Inspectors’ Central Committee (as it was then called) of the Police Federation of England and Wales were kind enough in 2014 to recognise efforts I’ve made over the years to try to help around policing and mental health: of the various recognitions I’ve had for banging on, that one’s just a bit special because it’s from those I’ve served alongside and who do what I’ve done night after night, weekend after weekend and Christmas after Christmas. We’re usually the sole operational police leader for large areas, sometimes overseeing hundreds of officers and likely to take many of the early big decisions for the largest or most sensitive events in all operational policing. And so this post is written specifically for the inspectors and the inspectors alone – to help you navigate what will soon become one of the gravest responsibilities carried by our rank and on which much political attention has been focussed.
We’ve been invested with sole responsibility for what I consider to be the single most contentious decision of all, in the Mental Health Act amendments: we will be the sole guardians of the decision about whether police stations should be used as a Place of Safety under the Act and only for those most in need and potentially at the gravest risk. This is the stuff of seminal reports for years gone by: the Equality and Human Rights Commission, the Angiolini Report, the Adebowale Report, the Bradley Review, the Home Affairs Committee report, multiple CQC, HMIC and IPCC reports as well as Coroner’s Inquests and Regulation 28 ‘Preventing Future Deaths’ reports … ALL have touched on this point and it has been the stuff of debate at the very highest levels for the last five years or more. We – the Police Inspectors of England and Wales – are the safeguard against human rights abuses under the MHA and deaths in police custody in the most time critical circumstances. This could appear a somewhat daunting responsibility(!) but it’s also an immense privilege which I know we can discharge with common sense and compassion to lead police officers and the public. This post doesn’t highlight much that’s new: it just brings existing guidelines together in the context of this new legal authority for our rank and I admit I don’t see this as needing a four-hour training package: we already know most of what will follow in this post.
Once the Act is amended on 11th December, any decision to use a police station as a Place of Safety requires an inspector’s authority and I think it will be fair to predict that when this call is required, there could well be objections and concerns no matter what we do or why. The decision itself will only be the beginning of our involvement in an incident that may absorb us in to subsequent discussions, concerns or even complaints. I suspect our partner organisations are going to want to speak to us to challenge some of our decisions not to authorise removal to a police station; we may also find custody sergeants fancy a ‘quick word’ with the boss where authority has been given, but where the custody sergeant disagree with it. I suspect a few of us will also find a statement to resolve, where we are not content to authorise the use of a police station but where mental health partners are also struggling to agree to allow an NHS facility to be used.
There is a lot invested in this decision: the IPCC will be very interested, I suspect, in the rationale for a police station being used or not used, in the event of an adverse incident; partners will question the insight the inspector has to the consequences of their decision where they have declined to authorise it and want to persuade some of us to change our minds. And if we don’t, it may well beg immediate questions for how much we are going to ensure the safety of the patient, the NHS staff and the detaining officers by ensuring sufficient resources are made available for the consequences of the decision.
Firstly, a quick reminder about the decision we have to take: under the Mental Health Act (Place of Safety) Regulations 2017, a police station may only be used as a Place of Safety in exceptional circumstances. This means –
- The detaining officer reasonably considers that the person’s behaviour poses an imminent risk of serious injury or death, to themselves or another
- No NHS place of safety in the force area could reasonable handle the risk posed by the detainee
- YOU have authorised the use of custody, against those criteria.
So you need to be satisfied that the detaining officer is giving you information that says the person poses such a risk. You must then ask yourself what that risk could signify – it will not just be risk of assault to the officers or the wider public, it may also be a presentation that is because of an underlying medical issue or a presentation which gives rise for the need for restraint, which in itself can prove fatal.
- Your first considerations must be – have we called an ambulance to this. If not, why not? – do it.
- Does the detaining officers have enough support from colleagues to manage that scene? If not, can we get more officers up there?
- I’d be directing a sergeant get involved very closely, if there isn’t one already – this incident could go to anywhere yet, I want a first-line supervisor all over it like a rash whilst focusing on nothing else, if at all possible.
- What is the ‘clinical assessment’ of RED FLAGS – best done by the paramedic, of course; but if they’re not coming or will take too long, it will have to be the cops present to make that call on the basis of their first-aid certificate and personal safety training.
If we have someone whose behaviour is giving rise to the need for a high-intensity or protracted restraint and de-escalation has failed before restraint and following it, we need to think about whether this is a medical emergency. Some highly resistant, agitated presentations can be attributable to underlying medical problems, to the use or abuse of drugs or alcohol and in some cases latent risks can be exacerbated by the use of restrictive practices like restraint. This stuff is documented in many of the inquiry reports mentioned above. This has been repeated most recently in the Angiolini Report and there are medical guidelines and documents which pertain to this, also.
For what it’s worth, this is what I’d be thinking: no-one goes to police custody unless someone in the NHS has confirmed to me or my officers that the person concerned does NOT require medical assessment in an ED. If they want to put their professional registration to that decision based on watching the police detain someone at a scene or outside an ED, then fair enough. Then – and only then! – will I begin to think about it.
RESOURCES YOU NEED
I’d recommend saving this post on a device you carry with you at work, just in case you get in to real difficulties with discussions and you need to pull out the references for why you’re arguing what you’re arguing —
- NICE Guidelines (2015) – Violence and Aggression: Short-Term Management
- Royal College of Emergency Medicine – Guidelines on Acute Behavioural Disturbance
- Faculty of Forensic and Legal Medicine – ABD: guidelines on management in Police Custody.
- NHS England PSA (Dec ‘15) – vital signs during and after restrictive interventions / manual restraint.
There are some big words and complicated ideas in that lot – probably best that cops aren’t trying to disentangle this stuff and sort it out, until we know people are going to be safe. My thinking is unable to take me very much further than this: high intensity or protracted restraint = Emergency department unless some paramedic is putting their name to a decision that this course of action isn’t necessary. They should batting in accordance with all of the above guidance so if they’re trying to argue it: ask them. “The NICE Guidelines on Violence, the NHS England stuff on post-restraint obs: you’re saying this person doesn’t need attention in an Emergency Department and are safe without clinical supervision from now on?!”
And remember this: your decision to authorise the use of a police station is not the same thing as the custody sergeant’s decision to authorise detention in custody. All that stuff in PACE Code C stuff that we remember from when we were custody sergeants and which we consider when acting as Review Officer then kicks in: does this person require clinical attention? – if so, can they receive it from the custody healthcare staff and if not, call an ambulance or transfer them to hospital. We are trying to ensure the person may be removed to the police station, both legal and medical grounds; the custody sergeant must ensure the person may remain there, on both legal and medical grounds. These two things are quite different, because people can deteriorate in custody, especially after restraint – see the NHS England PSA, above.
So, ask yourself this – how can we tell in the street that someone who is busy resisting or even fighting the police whilst in an acute mental health crisis is not suffering from ABD or any of the various underlying medical problems we’ve known in the past, like serotonin syndrome? Answer honestly: do you even know what that is? – and if you’d heard of it, did you know it’s a rapid on-set potentially fatal condition that requires urgent treatment in ED?! I didn’t until a couple of years ago – and had to look it all up after reading the outcome of a death-in-police custody inquest. And obviously: brief your officers on all of this, so they know what your reaction is likely to be – share the resources with them, if that helps.
Thanks to @NathanConstable for reading this one and ensuring what I’m trying to say lands cleanly!
Winner of the Mind Digital Media Award.