Acute Intoxication is a Mental Disorder

The longer I work on policing and mental health, the less frequently I experience certain things which used to hit me square in the face every time I went near the topic as a PC: a new piece of knowledge that leaves you entirely confused and thoroughly re-examining the paradigm you’re trying to get your head around. Having done a fair few talks over the years to professionals in policing and in mental health, I thought I had it fairly squared away in my head how to answer the questions that arise when discussing intoxication by drugs or alcohol, relative to police decisions about things like section 136 of the Mental Health Act. And then, Wiltshire Police rang for an opinion on a psychiatric report they’d received ahead of an inquest.  I’m still thinking this through, several weeks later, because it’s almost entirely beyond comprehension this hasn’t come up before.

In February 2017, the police were called to an incident in Salisbury where they found a very drunk individual who had involuntarily expelled urine and could seemingly not stand or talk. Officers spent considerable time with him, calling an ambulance and whilst the paramedics did undertake some level of assessment, no records exist to show exactly what that entailed. Having made a decision the man did not require conveyance to or treatment in an Emergency Department, they left decisions about his safeguarding to the police. For reasons I’m still unclear about, the officers left him in situ on a winter’s evening and he died of acute alcohol intoxication and hypothermia. The Coroner’s verdict ruled this was an accidental death contributed to by the neglect of both paramedics and police officers. You might be wondering on the basis of that summary what this has to do with mental health?

The Coroner in this case commissioned an independent psychiatric opinion, seeking answers to certain questions. The pertinent ones for this post are –

  1. At the time of police and paramedics contact, was this man suffering from a mental disorder?
  2. If so, could section 136 of the Mental Health Act have been used.
  3. And if so, should s136 MHA have been used?!

I’ll let you have the punchline before making the points I want to make: the answer to all three questions was ‘Yes’ – he was mentally disordered (acute alcohol intoxication); ‘Yes’, section 136 can be applied to any mental disorder that is not a disorder related to dependence upon alcohol (abuse / misuse being different to dependence and addiction); and ‘Yes’, in preference to leaving the man in a public toilet, the officers should have used section 136 to safeguard him, notwithstanding the paramedics’ opinion.

WHERE DO I START?!

I decided I would write a post on this inquest when I had time, but I’ve been motivated to make the time, based upon a conversation on social media only this morning: the AMHP forum on Facebook are currently discussing whether there has been a real and steep rise in the use of s136 MHA since the legal changes last December. Several contributors to that discussion are lamenting perceived over-use of the power by police officers when people are ‘not mentally ill, they are just drunk and disorderly’. Haven’t we always been told that drunkenness is not a mental illness and that the Mental Health Act can’t be used on someone who is intoxicated?

I have spent fifteen years doing policy related work and I will be honest: I’ve had psychiatrists, mental health nurses and others shout at me(!) when discussing issues around s136 and Places of Safety because of their no-doubt genuine belief that drunkenness should be dealt with in a different way. I’ve heard argument that where s136 is used on drunk people where there is no known background of mental health problems and no context on first contact that showed any evidence of self-harm or suicide, that most people are assessed as having no extant medical needs. They might need a bacon sandwich and a cup of tea to sort their hangover, but no referral to a GP or community mental health team.

And let’s not forget this: the much-lauded concept of street triage started in the Cleveland Police are in 2012 and that began after frustration in mental health services that their local officers were using s136 too frequently on drunk people who had no ongoing care needs at all once they’d sobered up. Having approached local senior officers to offer training, they found themselves rebuffed and street triage, to quote an AMHP from Middlesbrough, “is all about stopping the police from getting it wrong.” They found that over 95% of drunk people just sobered up and went home; the other 5% were those drunk people known to have a background of serious mental illness or who were found hurting themselves or in a precariously suicidal position. So, we’re now spending millions of pounds of public money on triage schemes which, amongst other things, aims to stop an over-medicalised response to the social issue of alcohol abuse.

NATIONAL POLICY

For all of these reasons, national guidelines in policing advise officers away from using s136 on drunk people unless there is that known background or context, because it plays the percentages in a realistic way if people are either conveyed to A&E for potentially toxic levels of alcohol consumption and, if people need legally detaining, arresting someone for being drunk in a public place or drunk and incapable does not preclude a MHA assessment for anyone who sobers up and who is still thought to be exhibiting unusual behavioural signs that may mean an underlying disorder. Remember the story of the bloke in Walsall who bought over-the-counter products to help him stop smoking and then drank a load of red wine? – he ended up sectioned under the MHA in hospital because after sobering up, there was a lingering effect of the alcohol and the medication that took three days to wear off.

But, it turns out it really is true that acute intoxication (by either drugs or by alcohol) is listed in the International Classification of Disease, 10th edition, published by the World Health Organisation as a mental disorder. The MHA can be applied to any mental disorder that is not a disorder related to dependence; therefore s136 is ‘in play’ for drunk people or those experiencing a drug-induced psychosis. I should imagine any mental health professionals reading this are starting to panic at the potential their local police officers may start scooping up nighttime economy punters and pouring them in to Places of Safety and Emergency Departments! …

Well, in his oral evidence to the Coroner’s Court, the expert psychiatrist did say that he was not arguing the police should be detaining all very drunk people under s136. What I left the Courtroom without, however, was a clear understanding from him of how a police officer could or should tell the difference between the very drunk person who should be detained under s136, from the very drunk person who should not. Maybe that detail will follow later. But what did become clear is that the reason for suggesting the use of s136 was merely as an alternative to leaving someone where they were. In reality, of course, those were not the only two options available – the officers could have removed the person to A&E under the Mental Capacity Act, they could have arrested for at least two criminal offences and in other incidents involving very drunk people there may be other offences committed or friends / family on hand to help that person without the police needing to act.

DECISIONS, DECISIONS

My final point is to ask what standard we are holding the police to in these matters? Having seen a copy of the psychiatrist’s report, I rang a few mental health professionals. “Did you know that acute intoxication (drugs or alcohol) is a mental disorder in ICD-10?” I also asked this on Twitter: literally no-one knew! I must have canvassed over a century’s worth of experience and none of them knew this. When that was explored in the Coroner’s Court, the psychiatrist also admitted that he’d shown his expert report to a Professor of Psychiatry who had apparently exclaimed, “Ooooh, I didn’t know that!” The expert went on, after that admission, to say he thought the fact Wiltshire Police officers didn’t know this as a ‘serious concern’.

I’m just going to say that one more time: two frontline police officers not knowing something was a mental disorder when a Professor of Psychiatry and a raft of mental health professionals with over a century of experience between them also did not know this is, apparently, a ‘serious concern’ … seriously?! What standard are we holding the police to here?! It is – quite frankly – completely ridiculous!

But let’s imagine these officers did know something that a whole mental health system (almost) full of professionals with postgraduate degrees appears to not know: how does that change any real-world decision-making?! What do we think a place of safety nurse or AMHP may say when we ring them up and explain, “We’ve detained this guy whose name we don’t yet know: he was lying drunk in a puddle of his own urine, unable to walk or talk and there was no background known or context of self-harm or suicide and we’ve brought him in under s136.” One professional admitted, perhaps because they know me well they felt they could speak freely, that they’d probably just say, “Michael, you’re taking the p*ss mate, you can f*ck off with that!”  Seems fair enough, to me.

MEANWHILE IN THE REAL WORLD

I just can’t my head around any of this – it’s simply too weird for words. But if you are a police reader, you can have some fun with this: next time someone mentions the police should not be using s136 MHA on drunk people just say, “The ICD-10 lists acute intoxication as a mental disorder and as abuse of alcohol is not the same thing as dependence, the MHA can apply to it.” And then just watch their face – you’re welcome.

My opinion remains the same: we should stay well clear of s136 with drunk people unless we know from their background or the context we’re responding to that we need to have concerns about their mental health. This means (amongst other things) where someone is known to mental health services, currently or recently; where parties connected to the incident are telling you they have a history of mental health problems or where you find them hurting themselves or in suicidal state. Otherwise, safeguard that person in a different way that does not involve leaving them in a public place to freeze overnight.

Choose from letting family or friends help them; let another agency help them, if willing; use the MCA to remove them to A&E, or you could even arrest them for being drunk and incapable in a public place – just don’t leave them where you found them face down in a puddle of their own waste in the middle of winter. It’s a real shame that needs saying, isn’t it? – whether that’s to the police or to paramedics.


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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22 thoughts on “Acute Intoxication is a Mental Disorder

  1. I knew intoxication was a mental disorder. It falls within ‘impairment or disturbance of brain or mind’ so is within the scope of the Act. So though technically a mental disorder, it is not of the same kind as say schizophrenia, depression or head injury, in that it is temporary and when the alcohol is processed the person will very often not have a mental disorder (unlike schizophrenia, etc) so that might point to a different disposal for the drunken person than MH services which are specialised for the treatment of persistent disturbances of mind.

    That being said, this guy who died of hypothermia (and consequences of intoxication?) had health needs that could have been met at the Emergency Department.

  2. What a bloody mess
    Suspect in time we’re heading to a point where everyone has a mental disorder till proved otherwise

    Makes a mockery of everything and the idea of treatability and personal responsibility a thing of the past.

  3. There seems to be one cherished constant. The lower ranks will be the recipients of blame for any and all mistakes and deficiencies made by those in elevated positions – some would claim the chief purpose of the lower ranks is that very reason.
    It also seems that we are obliged to create as many conditions, mental and social, as we can. Of course, these conditions require experts to explain and address them, naturally without judgment. Inevitably, those with these conditions will be effectively monetized in order to pay for the salaries and status of those experts.
    Being normal is of no financial or political interest.
    Thanks for this sobering post.

  4. I could of done with this a few weeks ago! Male in custody, suffering the effects of taking spice! To the extent he was not deemed fit of interview but fit to detain and fit for transfer. He was hallucinating, had history of mental illness, and was not making much sense at all. His pace clock had stopped, but was kept in ‘for his own welfare’. I took him over in the morning and immediately requested be detain s.136 and taken to a PoS, as he was ultimately unlawfully in police custody. The arguments that subsequently followed, with response sgts, and mental health workers was biblical!! If I had this article to hand then…..maybe the arguments would not have been quite so biblical!!

  5. I worry about all these “professionals” who were contacted and were unaware of the definition of mental disorder. The 2007 ammendments are quite clear in stating ” any disorder or disability of the mind” and being however temporary or permanent. As with the exclusions for alcohol or drug dependency, acute intoxification is not in or of itself a mental disorder. However the effects of intoxification from whatever source may well lead to a temporary impairment of the mind and/or brain and may then be considered a mental disorder. Trying to label this as a stand alone diagnosis does not help any one in as much as how much intoxification is needed to meet the tag?
    As for s136 being overused for those considered drunk and fine when sobering up the inference is wrong.
    If a police constable believes someone is experiencing a mental disorder (no diagnosis necessary) and in need of immediate care and control he may be taken to a ace of safety for a mental health assessment to include whether P need detention in hospital or for consideration of other care and support needs which may in the above scenarios include referral to drug or alcohol services.

  6. Very odd that a coroner has decided it’s a MHA issue.
    The paramedics and police had a duty of care and other options available. They failed chap in this case, but S136 is not the answer to everything.

  7. Wow it’s almost like the expert witness and the coroner left reality and couldn’t touch base with it when they wrote the PFD report.

    I just read the circumstances and think life threatening / life altering, use MCA and take to A&E. PFD report should probably have something to the ambulance service to train paramedics that acute intoxication can be life threatening and therefore use MCA if no capacity and jobs a good one.

    To ask officers to comprehend somehow what is a drunken person who will sleep it off and what is a mental disorder that requires s.136 is nothing more than silly and fanciful. Haven’t worked in this arena for some time I couldn’t come close to understanding what the dividing line is and I know our local NHS provider would be in shock at this PFD.

    I also wonder about the level of foresight by those who right these reports. They risk creating far more scenarios that could lead to deaths than this very scenario (imaging officers taking extremely drunk people to places of safety under restraint on mass and the number of challenging scenarios this could create).

    Headache!

  8. I think that this has got far too complicated and pedantic. An incapacitated person who has any impairment or disturbance of the mind is clearly to be dealt with under the MCA, as it is the least restrictive option. Why would anyone consider use of the MHA until an individual is in a position to have a Mental Health assessment? The Police nor the Paramedics have such training or ability and the individual would not be in a mental position to undertake that assessment. This is absolutely about professional neglect in relation to an individual who, for whatever reason, is not in a position to protect themselves.

    Yes! – We all didn’t know that Acute Intoxication = Mental Health, but so what as it should always be seen a Mental Capacity position? This is not about someone being ‘in drink’, it is about someone being incapacitated by drink.

    F1x.0 Acute intoxication
    A transient condition following the administration of alcohol or other psychoactive
    substance, resulting in disturbances in level of consciousness, cognition,
    perception, affect or behaviour, or other psychophysiological functions and
    responses.

    1. Yes, pedantic is *exactly* what I’m being. I’m not having a position where the police ate blamed and criticised for using s136 on drunk people AND a positioned where they’re blamed for not doing so! None of us joined the police wanting to become quasi-MH professionals so just decide what the rules are and let us know – we can then do our bit. But if you object to the above, you’ll need to take it up with the Coroner and his expert.

  9. I agree with your conclusions both that expecting the police to have this granular level of knowledge of the MHA is unrealistic but that in any event they could and should have intervened. I think the problem here is that the coroner asked the wrong questions and then reached a misleading verdict based on the expert evidence. If Q.3 was ‘Should the police and ambulance service have exercised any or of the powers available to them including s.136 MHA to assist this man?’ the answer is clearly yes. But as you say depending on what else is known it might have been far more appropriate to remove him to a police station or ED under the provisions you suggest. The question as worded implies their powers were limited to s.136 and they were negligent not to use it which is inaccurate. I cannot think of any precedents concerning police duties to protect life which suggest their duties are this circumscribed – although i am happy to be corrected on this. The difficulty is, of course, the actions of the paramedics and police probably did contribute to the death albeit not for the reason suggested which would make challenging the verdict fairly pointless.

  10. How could paramedics leave someone who was so obviously dangerously intoxicated , who could not walk and talk lying in his own urine? If he had been taken to custody unable to walk/talk the clinician ( I’m an FME) would have sent him to ED as he would be unfit to detain. This is truly shocking, maybe the Paramedics had been told not to bring drunks in, but someone who is as drunk as that is at risk of death from alcohol intoxication , inhaling vomit or as left by dying from hypothermia. Disgraceful, the paramedics should have been hauled over the coals for leaving him. MH assessments can’t be done until the person is over all stages of the drug or alcohol , that includes withdrawal or major hangover.

    1. In all fairness, though, neither their organisation or the Coroner found that was a reasonable professional judgement: the ambulance trust inferred there had been disciplinary action and the Coroner clearly declared this was a professional neglect that contributed to the man’s death.

  11. I found this post very interesting. There is a small point I’d like to add.

    The ICD-10 is the International statistical classification of diseases and *related health problems*. Not every disorder classified by ICD-10 is a disease, which means that not everybody suffering from a disorder classified by it has a disease.

    A person suffering from acute alcohol intoxication is indeed suffering from a mental disorder classified by ICD-10 (F10.0 Mental and behavioural disorders due to use of alcohol: acute intoxication) but they are not necessarily suffering from a *mental disease* (or mental illness, if you prefer).

    Could a person suffering from acute alcohol intoxication be detained under s136 and taken to a place of safety where they can receive medical attention? Yes.

    Should a person suffering from acute alcohol intoxication be detained under s136 and taken to a place of safety where they can receive medical attention? I think that depends on the judgment of the officer(s) attending as to whether the person is ill based on the information they have available to them at the time.

    1. Well said. I’ve always found it difficult to see why the Police use s136 on some people and not others. It is incredibly difficult for Police officers to make that decision and I’ve always supported them in their decision when working in Custody

  12. I’d like to make a few points. Ignorance of the law is no excuse for any of us. The Code of Practice makes it perfectly clear that acute intoxication is a mental disorder. Is it not the case that we should all know that? It’s there in the text, not in some obscure appendix. The reason we don’t may be related to moral judgements about alcohol use. Our moral judgements should be put aside when it comes to our duty to protect vulnerable people. Finally, the expert psychiatrist wasn’t asked to make policy for all cases of alcohol intoxication. He was asked about one specific case. Let’s remember that the man died. And in fact, the man DID have a mental health marker on the Police National Computer. That has been left out of the account.

    1. I’ll reply to this and the other comment in course – I’d die in the ditch before I agree with most of that, quite honestly. For now I’ll just say this:

      Yes – the psychiatrist was asked about one specific case and told the court the man ‘should’ have been detained under s136 MHA – yet that view was offered with an acknowledged lack of understanding about what the other alternatives even were. How we can suggest the question can be answered credibly when we accept the options were not fully known or understood, I have absolutely no idea at all.

  13. A few further points. What we as a society do with acutely intoxicated people is indeed complex. I don’t have the answer; I wasn’t asked and I would have declined to answer. ( I’m the simple minded psychiatrist in this case, if you haven’t guessed.) Mental Health professionals have to make judgements about individuals at a point in time. This case didn’t involve your average drunk in Manchester city centre on a night out with friends. The man in question was alone, spoke no English, had no money, was five times over the legal limit, and had previously been described as the drunkest person they had seen for a long time by the police officers. Not one to be left alone, I hope we can agree. I also made it clear that I could not comment on what else the police could have done as that wasn’t my area of expertise. I’m unapologetic about believing we should all know the Code of Practice. Apologies for being somewhat defensive in my comments.

    1. But yet again: nobody, anywhere suggested he should have been left alone! – the only point I am making today, that I make in the post and that I made in court: he should NOT have been detained under s136 MHA and in response to the Coroner’s PFD report this is what we said. In fairness to us and the view you gave which caused us to think again about what historic assumptions we may have been making based on not knowing the one fact (that your Professor of 30yrs colleague didn’t know, that every other clinician I’ve met before or since didn’t know), and what came out was: the police service, the ambulance service and the (Royal) Colleges of Psychiatrists, Nurses and Paramedics as well as other specific police-liaison clinicians of various kinds and the service itself agree that s136 was not appropriate at all, even if it were possible.

      We couldn’t find anyone else who thinks is is a s136 detention and the case was discussed in detail, including at the MHA Review meeting with Sir Simon Wessely present, etc.. He should have been removed to ED for medical supervision whilst sobering up and if that required a legal kind of framework, there were probably four other kinds to be preferred to s136 MHA. I literally cannot find any other person who argued it another way – and I *really* tried hard.

  14. You will of course remember that I told the Coroner that I wasn’t a police officer and that if they had used other options, that would have been acceptable. However, in the absence of using any other option, they should have used S136. It would have saved a life. And I’m not surprised that the Coroner’s finding leaves us with a massive task in sorting out what to do in similar situations. I will leave it there.

    1. Feel free – you chose to comment here and the Coroner’s Court were public proceedings. Whilst you may have said that in court under questioning, you’re written report didn’t allude to options, expertise or lack thereof in other options: when faced with the written question from the Coroner, “Should they have used s136?”, your answer was ‘yes’ and wasn’t subject to caveats. That’s why it was felt the view should be challenged and you moderated it in oral evidence, presumably because of that challenge, but only you know if that’s correct.

      1. You are perfectly correct that I did not, in my written statement, explicitly state that I was not a Police officer, and was not appraised of all the options available to the Police. I thought that would be self-evident and in that I was wrong. I made that clear in my oral evidence. I also moderated my stance when presented with your own evidence. I think moderating your opinion when confronted with additional information is advisable.
        The Jury, not mentioned in your account, will have had all the evidence before them, including your own detailed statement and oral evidence. They also had the benefit of seeing me cross-examined by the 3 Barristers, including the one for the Police.
        In your account you state that nobody knew Acute Intoxication was a mental disorder in ICD10. You mean in the Code of Practice. It’s an important difference as the Code, which has the authority of the law, is our guide to use of the Act. ICD10 is arguably driven by psychiatrists and subject to all sorts of objections. We’re stuck with the Code.
        I am grateful for the opportunity to comment but we aren’t going to get any further. Thanks.

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