CarePlan: Call the Police!

We are hearing stories on social media at the moment, of patients who claim they were told to ‘call the police’ when they have contacted their community or crisis team for support as they recognise they are becoming unwell or at a difficult point. We also know, on some occasions, a patient’s formal CarePlan for crisis is to ‘call the police’ as the first resort. I fully understand, as pointed out by a mental health nurse on Twitter last night, that we have no way of knowing whether patients who claim to have called the police were, in fact, told to do so; and we don’t necessarily have evidence that all the CarePlans which purport to list this, actually do so.

What we do know is this: at least some of these examples are verified and we do know that some of the time that ‘call the police’ is put in to practice, it has involved a CrisisTeam or CommunityTeam themselves making that call on 999, not the patient. In other words, the ‘call the police’ phenomenon is real, even if some maintain it may be exaggerated on occasion. I don’t really want to get too far in to the obvious point raised by the nurse’s skepticism; that an early thought after hearing the anecdote was to assume the patient was lying – that won’t really get very far without getting quite shouty, will it?!

I particularly enjoyed hearing a recording recently of a call to a CrisisTeam by a patient who chose to record their own call ‘for training and monitoring purposes’ and it involved a person asking for someone to talk to as they recognised their own relapse and having tried various distraction techniques of their own, before ringing. To say my gast was entirely flabbered as the nurse sought to quickly get rid of the call and ring 999 is to dramatically understate things: there was just NOTHING there to justify ringing the police. A person wanted to talk: it was bluntly (and rudely) refused and the actual words used by the patient seemingly ignored, the phone went down and the local police received a 999 call.

So this stuff happens – doubt your patients and accuse them of exaggerating if you wish, I have stuff to say about when it does occur –

SELF-HARM & SUICIDE

Firstly, a quick point about ‘suicidal patients’ – if a nurse who is unable to deal with a patient thought to be harming themselves or threatening to do so is in urgent need of a policing or wider 999 response: don’t tell THEM to make the call and assume it will happen. There are lots of things that shouldn’t need explaining about why that could go badly awry – some people don’t want the police to come in and coerce them to ‘safety’, they want to die or hurt themselves and if you’re taking that risk seriously, leaving the reporting of it to the patient is not enough: put the 999 call in and the help the controller by sharing information relevant to the case and be prepared to advise and take things further. Remember your probably sending the cops to something they can’t deal with so don’t just hang up and get on with the next thing on your list having ticked this one off because the police are en route.

This ongoing help is needed for (at least) three reasons –

  • Most of these kinds of calls received by the police are in private homes where they have no powers – officers may need to engage you about how to safeguard the person if they turn up and find themselves powerless.
  • Officers cannot tell you whether or not your patient is ‘safe and well’ and it is not their job to do so – they may merely confirm whether the patient is dead or alive and offer the obvious helps if the person is alive but injured or obvious ill.
  • Safety in mental health is not something that is visible to the police and the officers attending will have a first-aid certificate only so they will need back up from mental health professionals to fully resolve the situation.

Secondly – a point I’ve made before: if a visual assessment by the police and support for that from the CrisisTeam or CommunityTeam is not enough, the police will need support to access or navigate the AMHP process. Because we know some AMHP services are inaccessible to the police, they will need your help and are quite entitled to ask for help, given they were put in the position by the NHS. So if the officers were to say something like, “I’d be using s136 on this person if they were not in their own home, but because they are I can’t do that – you either need to come out or arrange an AMHP / DR because it strikes me that s13 MHA is engaged here.”

What’s your response plan?

PARTNERSHIP WORKING

If we are serious about partnership working and we are going to write in to someone’s CarePlan ‘call the police’, we should be giving serious consideration to the proactive, advanced disclosure of relevant information to the police service concerned. CarePlans of this kind should be drawn up with patients themselves, obviously at a time when they are well enough to make decisions about their care. If agreement is reached that it may be necessary and appropriate to ring the police, then the patient should be asked to consent to disclosure of information to the local force which will help them get it right.

You could imagine any number of things could be relevant from, “Don’t send male officers, if possible” to “patient has spare key at neighbour’s (no 11) should entry need to be gained and consents to the key being sought and used by the police”. It could also include more safety information, “Patient uses blades to self-harm” or “patient asks that officers be patient and afford him time and space – don’t rush decisions” or “Would be helpful if officers called patient’s cousin Sue to help as patient likes her help when unwell – her number is 07770 770770, etc..”. I’m sure we can all think of even more useful nuggets to have on the system.

If each Community MH team manager contacted their local neighbourhood policing sergeant or inspector (details available on force internet websites), they could easily agree a way to share this agreed disclosure with consent and the police then use it to improve the quality of their response if they are called. This, in turn, makes it feel like much less of a ‘bat’ from MH services who are, often, sending officers in to situations where they have no background, no context, no powers, no training, no abilities to achieve the task implicitly set by their despatch.

I’m sure it can be understood how difficult a position this creates for them and it has been the stuff of deaths following contact in our history.

MY EXPERIENCE

In case of doubt, I end with my own tale: the last time I went out to such a call –

The CrisisTeam rang 999 to say, “Patient has rung up saying unwell, asking for voluntary admission to hospital and we’ve had to say no as we’ve got no beds. She’s then threatened to kill herself and put the phone down. Can you send officers to do a safe and well check.” This was a Friday evening, just before handover to the night shift, so I was just sitting at my desk to start writing up all the stuff for the nights inspector and all the constables and sergeants were committed with 999 jobs on a busy shift. So I slugged my coffee and went to it on my own, not least because the call was just around the back of the police station.

When I arrived and knocked on the lady’s door, she did open it, but kept the door on the small chain lock so the door could only open about 2inches. She seems surprised to see me, not just a little bit anxious and I explained why I’d attended asking if she was OK? I couldn’t see all of her so it was not possible to tell if she was physically injured in any way, but I could tell that she was Alive, Breathing and Conscious. It also seemed likely she wasn’t Ill, Injured or Intoxicated, but I couldn’t be certain of that, given how little of her I could see. In this situation, I had absolutely no legal powers at all, because she’d answered the door and remained in her own house and the conversation would not have given me cause to think she met the criteria for use of s136 even if she had been outside her house.

SAFE AND WELL

So I rang the CrisisTeam –

“We’re here – she’s alive, breathing and conscious and although I can’t really see her properly though the gap in the door, I don’t have grounds to force my way in. What do you want to do now?”

“Well, as long as you’re saying she’s are and well, that’s OK.”

“Well I’m not saying that – that’s not my job. I’m saying she’s alive, breathing and conscious and that I have no powers to act. That’s all I’m saying. For all I know, she could be actively plotting to hurt herself as soon as she shuts the door because you’re the people to whom she made the suicide remark.”

“But she is safe and well, isn’t she?”

“I’ve got no idea! Is she? – how do you know?!”

Suffice to say this ended by me saying, “I’ve got a horrible feeling you’re going to write in your notes that Inspector Brown said this lady was safe and well, so let me just make clear, I’m about to write this up to say that I specifically did not and that all I’m assuring you of is that right now, she’s alive, breathing and conscious. If you need to satisfy yourself of more than that, you’ll need to come out. If you choose not to do so, you may not say I didn’t alert you to the fact that your apparently suicidal patient could still be at risk. Can I have your name please?”

All of this stuff is way more complicated that ‘call the police’ – and calling the police can make things worse. Unless we think this stuff through, share information and work in a genuine partnership, it’s often little more than trying to deflect demand to cover someone’s backside. Officers should remember the limits of their legal powers and clinical assessment skills – they CANNOT assure anyone that a mental health patient is ‘safe and well’, even if they’re trying to help. Confirm alive or dead and whether there are any immediate emergency medical needs, then refer back to whoever sent you and tell them to now deal in slower time. Escalate to supervisors and if no satisfactory response from whoever sent you, ask for the AMHP / DR response suggested by the judge in the Sessay case. Document everyone’s names in the record – history shows they may be relevant to cite in a Coroner’s Court or IOPC investigation.


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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20 thoughts on “CarePlan: Call the Police!

  1. Good article and I’d like to comment on some points if that is OK? A local police inspector has started a forum to look at the partnership working issue and you raise some points that really ring some bells with me. As an experienced psychiatric nurse I see our practices often in your mirror and I raise them time and time again, frustratingly so.

    Firstly, care plans and risk management plans rarely have police or 999 as first line of resolution to patient crisis. They are, however and unfortunately, often second, third or fourth line of a list of “do this, do that” (I would disagree with this practice in most cases).

    Care plans are rarely truly collaborative and patient focused and, ultimately, can a plan on a pc screen really provide good understanding of the actual situation and replace actual person contact?

    Crisis teams often hear “RISK” in a call. When this happens I have any number of cases where 999 has been the next step. I’ve not heard of a crisis call with “I’m worried about ‘x’, I’m going out to do a safe and well, can you assist?” Most likely outcome is a call to Police to perform the safe and well with no back up from mental health teams other than availability by phone.

    Remote decision making often occurs. Even when I’m calling my colleagues from different mental health services with my own opinion of an individual’s needs after having been with them face to face.

    Mental health services are not responsive enough. This last point is the key point and I apologise for taking so long to get to it… All agencies need to take ownership as the agency receiving the call. The owning agency must ensure they accept accountability for getting the correct resource to the front line. If the correct resource is a mental health professional and they cannot or will not respond in a timely fashion nothing will change.

  2. Spot on. I would add that cops have the added pressure of having to sometimes “wing it”, acting outside of their powers to find a resolution, knowing full well that an adverse outcome has serious professional misconduct connotations.

    To be fair though, we have contributed to this situation as a service, by not being resilient enough to say “no” and challenging the use of the police as medical crisis responders. Its just too easy to make that phone call and say the magic words that force a police response. Control rooms have to be more resilient in declining these requests and they in turn have to be supported by robust policies with a senior officer willing to front up and support that decision making.

    The groups that suffer as a result of this culture are threefold. Those individuals struggling at rock bottom with MH issues. The numerous young and inexperienced street cops desperately trying to keep all the holes in the dam plugged, whilst massively stretched with their own workloads. Finally, the members of the public waiting for a police patrol to come and deal with them as a victim of crime, also probably at a very low personal ebb. We might get to you in several hours or a few days……

    I’m going to be controversial and suggest partnership working as a concept, across so many arenas, has lost its way. It is no longer an equal and equitable partnership. Response cops are becoming increasingly agitated and despondent as the current state of affairs.

  3. Hi Inspector Brown, thought provoking post as always!

    I’m a full time AMHP….the only time I think I have seen/used ‘contact Police’ in a Care Plan is usually a last resort step and usually more of a step for concerned carers in relation to managing aggression or violent behavior that may be placing others at risk. Have never seen it used as a coping strategy for suicidal persons but clearly this must happen as you’ve given the example in your post! Am also a bit baffled by this welfare check scenario- why are the Police being asked to do this alone? Clearly the most appropriate people to do a welfare check are the person’s mental health/crisis team who will have the best knowledge and skills about how to potentially de-escalate the situation/assess risk or the local out of hours emergency duty team??Again I wouldn’t think that Police would be asked to attend unless there was clear evidence of immediate risk that couldn’t be dealt with safely by mental health services alone. I’m often amazed at how often we get a request for a MHA assessment to find out that the person hasn’t been seen by their Care Coordinator for a few weeks/referred to the Crisis Team first to explore what less restrictive options there could be – before we jump to the drastic step of removing someones liberty in hospital! What happened to the good old fashioned go around and knock on the door and find out how they are!!? At times I will request Police presence during a MHA if there are known risks to others to help ensure the safety of the assessing team and there is no breach of the peace. I have to say the Police I’ve worked alongside have been brilliant.

  4. Good blog
    As ever these complex issues have different perspectives . I’ll try and give mine though fear it won’t be well received by many here as doesn’t fit w general ‘MH services are terrible’ narratives.

    Ok, a person who repeatedly calls MH services/999 with suicidal thoughts and is met with a speedy response may well, in turn, present more frequently and with escalating risk. How?Why? I hear you cry. The reality is that some of us who struggle with managing emotions and associated suicidal ideation ‘learn ‘ that a rapid health response makes ‘me’ feel temporarily better. It can give a sense of being cared for and that someone else is responsible and can ‘fix’ the problem. Over time this can lessen the persons own coping skills and belief in their own intrinsic wellbeing resulting in these ever frequent presentations and risks.
    A legitimate response to this may be to encourage the person to be responsible for their own safety rather than outsource this to someone else. This can result over time in fewer crisis presentations and decreased risks though of course risks often remain and may even increase in the short term. A typical care plan may outline a number of agreed responses the person can undertake when suicidal (including phone contact w MH services)but ultimately should the person not manage to contain themselves then they are responsible for going to A+E and seeking help.
    A person responsible for their own safety.
    Typically the person is not ill (psychotic, manic) but emotionally dysregulated. It’s so important for the longer term wellbeing of the person that they do not see themselves as ill (which implies a kindly nurse can fix you up with meds or key words) but rather that an individual is ultimately responsible for his/her own emotions and responses and safety. And crucially that they are capable. This is clearly often in contrast with the idea of urgent and emergency responses to “mental health crises” and the need to do something

    We will not get away from all agencies increasingly meeting people who are distressed ,and sometimes suicidal , as the social stigma around this has decreased over time (for good and bad). It seems to me this will likely continue at pace w social media and a younger generation who often seeing their human struggles through a psychological prism. Understanding that pathologing their responses, which can undoubtedly be very uncomfortable to be around, and expecting mental health professionals to be on hand to deal with it is understandable but will often be v unhelpful to the individual and society in the long run. There can obviously never be a blanket approach to this thorny topic but let’s understand the limitations of mental health care, the very real risks of pathologising human emotion and strive to empower folk to cope.
    PS. MH services are often very useful for people with serious mental illness

    1. Hayley Bee talked about the crisis team to ‘de-escalate’ or ‘assess risk’ but in my own personal experience it has been the crisis team that have ESCALATED the situation and CAUSED more risk.
      As to ‘the local out of hours emergency duty team’ – they don’t even respond to people who present themselves physically in A&E (where they are) but allow them to be sent back out the door with no support at all.

    2. The partnership comment is spot on.years With 20 years plus in the voluntary sector, the idea of partnership is more about making money go further between at least two agencies, it isn’t necessarily about actually working in tandem spirit towards a goal or outcome. Signposting is as bad if not worse, maybe someone should commission research into this kind of offloading and see if Friday afternoons figure largely in the ‘traffic’.

    3. I am concerned reading your response. EUPD needs treatment and has an at least 10% mortality rate. Telling people to take responsibility and manage their emotions better without any other input makes about as much sense as as saying it to someone with depression or bipolar. Too often the threshold for any treatment is ridiculously high. The ’emotions’ that people suffering with EUPD experience is way outside what certainly I experience, and is so different that yalking about it as an emotional regulation issue is not really helpful. The old description of psychotic/neurotic seems much closer as a description.

      If mental health services think the only people they can help are people with psyhosis ( and to be honest it has to be the right sort of psychosis) then who is going to help everyone else – or are we as a society happy to watch them die?

      1. Yes JudyB, however a large part of that 10% isn’t death by completed suicide, it’s often misadventure because the individual continually placed themselves in risky situations that compromised their health and safety and the plan to rescue themselves failed. The research suggests that removing self-responsibility in the short term increases risk to themselves in the long term and can make their issue become more entrenched. The evidence also points to the fact that if you are working with someone to try and reduce their risk to themselves in the long term, you will likely increase said risk in the short term.

      2. Not sure how to reply to DK92, I don’t know what the answer is but from the outside I see women ( in particular) with effectively no care, unable to help themselves, likely to die before they teach themselves how to ‘manage their emotions’. Why is this OK, that families are destroyed because mental health professionals think it is better to leave people to ‘take responsibility for themselves’ than look at alternatives?. Inquests are told ‘lessons will be learnt’ but they won’t because the institutions think they are providing ‘appropriate care’.

  5. I am hit by the shocking realities of a medical services that should care and appears not to. Michael writes with a complete eloquence, which hides what must be a deep sadness, that the most vulnerable in our communities are at risk! Policing has always swept up for those services that other agencies who don’t work 24/7 or don’t have the resources to attend. We are then criticised when the wheel comes off, when we shouldn’t have been the people there in the first place.
    Having had the pleasure of speaking with many people who are living lives with Mental Health with immense dignity, I am shocked that care in the community often appears anything but that.
    Whilst reading this and as part of a process of writing training on MH, I thought of the incapacity act, in which the underlying principal is doing what is best for the patient… seems sadly lacking here?
    Steve

  6. Excellent message! I personally suggest 999 only in crisis, can’t keep themselves safe, and/or need medical. Assistance ….. BUT also on if they can’t get themselves to A&E!!

    1. Might be good to re-evaluate Mental Health week as well.

      Great words, often from the good and famous, ideas talked about and shared across the media. All warm and fluffy but how many living with MH in their daily live actually engage with the heightenned awareness. Is there anything for other 51 weeks?

    2. I would love to know what you think happens at A&E if there are no physical injuries? Several hour wait in crowded waiting room to see a psych liaison and be sent home?

      1. Why would you be suggesting A&E Kim? And calling 999 in crisis when they should be calling actual mental health crisis teams?

      2. Ever called a crisis team? “Have a bath/walk around the block/cup of tea/sex/bag of chips”
        And yes, all of the above are real examples. In one area, a crisis team member is known as chips man because that is his standard response to everything.
        The message is generally, we’ll come out and see you a week on Thursday if you haven’t topped yourself by then.

  7. i think a major part of the problem why crisis teams get criticised is the hollowing out of the services particularly at night. a crisis team may have only 3 or 4 members of staff to cover a large area, cover ED, deal with incoming inquires, answer the police phone etc. a lot of the workload will have already been prebooked and allocated leaving little space to respond to emergencies. i think the other problem is the very name crisis teams, it creates a false image of a very quick response team which crisis teams are not

  8. I’m a MH nurse and an AMHP and I’ve worked in psych liaison and crisis and it absolutely staggers me when health feels it can devolve all its responsibilities for keeping people safe to the police. We have responsibilities and powers to keep people in hospital safe. We shouldn’t rely on the police to do it for us.

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