Telephone Triage

A curious thing appeared on the internet recently: a preventing future deaths report from the Warwickshire Coroner, which has been sent to the Chief Executive of Birmingham and Solihull’s Mental Health Trust (BSMHfT). It follows the death of a man by suicide, thirteen days after the BSMHfT street triage (ST) scheme had contacted with a man who ended his own life in a hotel. No details were given about why the contact with ST occured in the first place, but we know from the PFD report that it was contact by telephone. Amongst other concerns the Coroner had about record keeping by ST (there was none), point 5 on the PFD leapt off the page at me when I first read this.

  • 5) The purpose of the telephone triage was unclear – it was described as not being a mental health assessment … so what was it, then?!

And if it wasn’t a mental health assessment, what does it mean, if anything, for police officers who have ST schemes across the country where they become involved in police incidents because they believe the person needs MH assessment, often as an alternative to the use of s136 MHA? If I believe someone may be unsafe because of mental health problems and requires a level of assessment beyond my capability, are we saying that no telephone discussion can ever be a mental health assessment or that this telephone exchange wasn’t? … it’s not clear, is it?!

This fits in to the narrative unfolded by Her Majesty’s Inspectorate of Constabulary earlier in the year: that ‘street triage’ schemes needed clearer strategic objectives; as well as evidence of evaluations being ‘poor’ or ‘very poor’, according to the NICE Guidelines on the Mental Health of Adults in the Criminal Justice System (2017). We still don’t understand these things as well as we need to – I remain of the view they were set up too casually and some of the problems we’re seeing emerge were predictable and forewarned by some of us!

THE FIRST RULE

Over many years, I’ve heard a number of clinical mental health professionals say that the first thing you do when you undertake a mental health (Act) assessment is a physical health check, if for no other reason than to ensure there aren’t obvious concerns about other medical issues or alcohol or drug intoxication. I’ve seen the importance of this myself: how many times have paramedics turned up at s136 detentions made in good faith by officers, only for the good people in green to say, “Err … A&E: this is not a mental health matter.” Diabetes, brain tumours, encephalitis, meningitis, etc., etc., – all because a decent physical of basic observations was done by an experienced healthcare professional.

There was also that job when I was shadowing a street triage team … we walked in to a man’s house one evening after a GP, who had not attended his patient’s house to examine him prior to ringing 999 for the ambulance to serve to ‘send triage and section him’; and it was obvious to me and all my clinical qualifications (expired first-aid certificate) that the only thing needed was for this bloke was for him to be taken as soon as possible to A&E by ambulance. His head, stomach and foot were heavily swollen and largely purple: something the GP and his medical degree would have noticed himself if he’d bothered to turn up and examine the man before reaching for the 999 bat-phone In fairness to him, though, it was end of office hours on the Friday before Christmas and he probably had a family or a party to get to.

So as we’ve seen the expansion telephone based approaches to mental health, it’s important to understand what these phone calls are, starting as they do at a massive disadvantage that the clinician can’t see the patient. Is it really possible to fully,and properly assess someone’s mental health? There seem to be varying views on this; but it’s importance because of one simple fact: in most areas where ST operates, the nurses do not actually see the majority of patients face to face. There are some exceptions and ironically enough: West Midlands Police’s triage scheme with Birmingham and Solihull Mental Health Trust claims to see a small majority of all the people at the centre of calls, but they are the exception. In some areas, ST actually sees 15%-25% of people and the rest are supported by the provision of telephone discussion and information sharing. So it’s unfortunate that this PFD from the Warwickshire Coroner ironically relates to a job in the area who perhaps see most. And of course, in other areas, all of the ‘triage scheme’ is telephone based, with the nurse in the police control, acting in remote support and sometimes speaking to patients by phone.

NOT AN ASSESSMENT

So this question of whether telephone discussion is or can ever be mental health assessment is actually important to the vast majority of ST schemes and I would urge those involved in them, whether police or NHS, to have the discussion for the record: is telephone discussion never, ever or always or a mental health assessment? … and if not never or always, when is it ever?! Whatever actually was going on in the phone discussion to which the Coroner refers it was definitely thought to relate to someone thought by the police (or ambulance service) to be at risk because of mental health problems. But all we really know at this stage is that when after hearing the evidence in the inquest, it has caused the Coroner to be concerned enough to raise the question about what the purpose of it was, if it was ‘not a mental health assessment’ and the trust definitely stated it wasn’t.

Did the police or paramedics know this? … or did they think it was and therefore feel able to walk away reassured on the basis that an assessment had occurred?! Communication was and is always vital to joint agency working and police officers need to be careful to understand what has actually happened in an incident. There have been a few other Coroner’s incidents recently where officers have made assumptions about the nature and quality of healthcare assessments and then felt reassured to walk away, only to learn the very hard way (gross misconduct investigation) that healthcare professional hadn’t clearly communicated and in some instances, including this one, hadn’t made any professional notes about what happened.

The original point of ST, as outlined by the Prime Minister when she was Home Secretary and by various senior officers since, is to ensure more appropriate assessment of vulnerable people and this should lead, it was hoped, to a reduction in the use of s136 MHA and in the use of police cells as a Place of Safety under the MHA. It was further hoped this would, in turn safe police time and resources and I’ve written elsewhere about why I think in some cases, the opposite has occurred – I won’t repeat that hear, but Chiefs should think about it more!

PRACTICAL PURPOSES

Where my brain is completely seizing up is this – so all comments from mental health nurses welcome: is non-face-to-face discussion of someone ever a MH assessment? – or not?!

One-word, closed question.

Whilst I’m at it, I’m going to outline a related concern raised to my attention recently by an AMHP. In that AMHP’s area where he regular conducted a number of s136 assessments each month before the invention of triage, he would personally expect ‘at least a handful’ of people detained under s136 whilst so intoxicated by drugs or alcohol that they would be allowed 4-6hrs by him to sober up before his assessment – his colleagues would see other people each month and allow sobriety periods, also. He wasn’t complaining about the use of s136 on intoxicated people, except in the odd case here and there because the individuals were often found at risk on bridges, on high buildings or in positions where suicide was imminently accessible, if the choice were made. He also accepted a large proportion were found to be known to mental health services currently, or previously. His point was this, after discussion with his colleagues: they, as AMHPs, were *never* seeing people in such circumstances any more, or maybe 1 or 2 per month across the whole AMHP rota. Street triage were seeing them instead and his question was this –

Are mental health nurses in his local triage scheme assessing drunk / drugged on their own, whilst still intoxicated, in positions where they were previously being detained under s136 in order to allow them to sober up and be assessed? A section 136 is always at least two-professionals undertaking assessment in controlled conditions – sometimes three professional. Street triage is one MH nurse, usually operating alone (clinically speaking).

We still haven’t fully discussed all that we need to, in order to understand the new dynamics of these processes and on the day that publication is made of the IOPC deaths in and after police custody and contact report where, yet again, no specific mention is made of street triage despite the fact that s136 related deaths in or after custody have risen as have deaths after contact without custody, I think we need to start talking just to make sure we understand what’s going on here.


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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8 thoughts on “Telephone Triage

  1. 1. Yes telephone triage definitely can be an assessment
    2. It’s intrinsically difficult for the reasons you describe and others
    3. This will often result in face to face assessments occurring subsequently as a precaution
    4. Mental Health care is a messy business either way and we make it all up as we go along. We’re human beings after all, how could anyone possibly predict with great accuracy if another human will actually kill themself,others etc and intervening usually comes with disbenefits and drawbacks anyway.

  2. Result seems to be people with possible mental health issues being assessed on the phone by a nurse who may not even speak to them. Nurses will happily tell you they can’t diagnose so people with mental illness even worse off than before the ‘reforms’ as the possibility of getting any help is brushed off with ‘known to services’ and ‘its behavioural’.

  3. Yes, discussion with the patient and other professionals on scene by telephone is an assessment.
    It’s a situational assessment of whether there’s a need to see someone face to face, and it’s fraught with limitations, which often means it can’t be described as a mental health assessment, (because that would have clinical connotations of an holistic overview of the patient’s condition including their current physical presentation).
    So if I say I’m a mental health nurse and I’ve conducted an assessment over the phone, it’s easy to interpret that as someone having undertaken a mental health assessment of that patient, and that’s not usually accurate.

  4. telephone triage/assessment/advice is inherently risky. i am a nurse and work in a single point of access. the job consists of members of the public requesting psychiatric services, GPs requesting an assessment for patients to see if they are eligible for secondary services, IAPT referring because of the risk is too high for them and a fair proportion of time is spent talking with our colleagues in green and blue. the police part consists of several parts, it may be that the officer is on scene and wanting advice on management and what services are available, or that they are considering a section 136 and want as they are required do if practicable to speak with a clinician or it may to inform services that they placed someone on a 136 and require a place of safety. the risk is often around the advice been given, some of the advice given is plain wrong (don’t get me going about the mental capacity act and the magic powers police have under it), some is unlawful and some is flaky. it seems there is a gap around nationally agreed standards and response times for telephone triage/assessment. top tip for officers i think is to get the nurses name and what their role is, you might surprised to find the advice you are receiving is not from a qualified nurse or even a member of the mental health trust (agency nursing assistant springs to mind). on a side note the level of knowledge about mh law among nurses tends to be abysmal. mick

  5. I am a police triage mental health practitioner in east Anglia. I believe we are one few forces / trusts that offer the mental health triage car. I do my assessments face to face and would never consider a telephone consultation a full mental health assessment, there is so much more than verbal communication expressed by people, 95% of all communication is non verbal.
    Sadly the mental health car is not valued by the “bigger bosses” and we are constantly fighting for an extended service.

  6. Having managed both mobile street triage (still do) and also managed a control room triage (for a year) my views are…

    1. Telephone Triage is not an adequate process to be an assessment, it’s contained to purely crisis management. In our control room pilot the nurses were very reluctant (and I agree) to give any sort of conclusive advice to officers when they hadn’t seen them. These were the same as those in the mobile car.
    2. Suicide will happen even when we do all we can, ask all the relevant questions and consider all powers. How much can and should we as a state control people and their decisions? I understand why we have PFD reports but they surely need to be realistic, achievable in the climate and surely not just another stick to beat under resources services with? Sorry frustration boiling through here but there’s no wonder we are all so risk averse and there increasingly can’t deal with all our ever complex demand.

  7. I’ve witnessed a lot of what happens to patients in Sussex, and the general pattern is this – s136 is seen by some as ‘not a police matter’, others as pointless because a patient will rarely see an amhp or undergo a formal assessment, staff lie or neglect to enter information into patient notes. There is the additional issue with incredible resistance to recognising adult patients as Adults with Care and Support Needs, leading to botched discharge and looping the system. There is also the NHS joke about withholding treatment on the grounds of a genetic disorder – e.g. a Did Not Attend abbreviated DNA, perhaps due to being in hospital, a police cell, or otherwise too much in need of assistance.

  8. The question assumes there is a shared understanding of what a mental health assessment involves. I’m not confident that there is such an understanding within mental health services let alone across and with other agencies and the public at large.

    https://www.nhs.uk/NHSEngland/AboutNHSservices/mental-health-services-explained/Pages/your-mental-health-assessment.aspx provides a starting point. Nothing there that telephone contact would exclude. How far you get with it though will vary on a case by case basis whether that’s on the phone or face to face contact. As with most things there are gradations and it’s usually better where more than one person is involved.

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