I haven’t blogged for almost two months! Various reasons – busy, on holiday, bored of saying the same thing over and over again … there are a few in the pipeline but I decided to put them all to one side to write this one, because the story animated me. It concerns the concept of Acute Behavioural Disturbance, or ABD – it’s sometimes referred to as ‘acute behavioural disorder’, but the ‘disorder’ word tends to send certain doctors in to an intractable debate because of the lack of research around the concept and the fact that ABD is not recognised in the main medical manuals as a ‘disorder’, implying a greater level of medical certainty about cause and effect. All this has led the ambulance service to be in a bit of a state about it where some refuse to recognise the term and others are all over this issue like a rash.
The wider debate around ABD has been going on for years, albeit conducted under another name. Some of you may be more familiar with the term ‘excited delirium’ and any distinction between these phrases only further complicates things – whether ABD is a generic term for a range of things and excited delirium is only one form of ABD; or whether ABD is the new name for what we used to call excited delirium … who the hell knows. But there are a few things I know about this ABD / excited delirium discussion which are more about the law and our legal system than they are about medicine and science. And it’s really quite simple –
- Coroner’s cite these things as a cause of death in inquests – so until medicine and science sort the issues out more clearly, that’s the end of the debate as far as I’m concerned.
- This is (at least a part of) the explanation for why some people died in the most controversial deaths in custody in the last 20yrs – we can’t keep hanging out the police to dry when we know it’s about more.
This blog is prompted by a Coroner but not after a difficult and sensitive inquest: rather a Coroner is raising this debate before a full inquest in to a death and suggesting that she may take the very rare, if not unprecedented decision to issue a ‘Preventing Future Deaths’ report over ABD, prior to the full inquest in to the death in 2017 of Douglas Oak, in Dorset.
In April of 2017, Mr Oak was reported to be acting erratically in Branksome, Poole – he was said to be walking in and out of traffic and the police were called. Upon arrival, officers located him and formed the view that he was exhibiting signs of ABD – in accordance with national guidelines in policing which have existed for at least eight years now, they called for medical help. Since at least 2010, national guidelines for the police service state that excited delirium (now known as ABD) should be treated as a medical emergency until otherwise declared by more qualified professionals. This means an ambulance should always be called where these concerns exist and someone will probably need to be removed to an Emergency Department. In fairness to this police position and the healthcare issues that I’m about to outline, there are various documents in existence to support this approach. Indeed, it was consultants in emergency medicine in Birmingham and senior paramedics in West Midlands Ambulance Service who, to their eternal credit, helped me and West Midlands Police understand the risks and threats around this stuff as we were trying to improve our responses to such incidents following the death of Michael Powell in Birmingham in 2003.
The National Institute for Health and Care Excellence (NICE) published a Guideline in 2004 (no longer available on the internet) on the short-term management of violence in psychiatric settings and emergency departments. Within, there is clear contemplation of a necessity whereby we look at ‘disturbed’ or ‘violent’ behaviour and recognise that there could be various medical explanations behind such presentations. This document has since been updated and the original replaced: NICE published Guideline NG10 in 2015 which takes these arguments further. It helps us in the police and elsewhere understand various long words which are difficult to spell: all medical conditions that may need assessment and treatment in ED as an emergency. The obvious implication here is: don’t take these people to custody and restrain them, because that could end very badly indeed and everyone will wonder afterwards why you did that.
But isn’t this a story we’re familiar with? – police removing vulnerable people to custody after restraint, sometimes whilst continuing restraint and people collapse and die?! Sean Rigg, James Herbert, Seni Lewis, Toni Speck, Rafael Delezeuch, Kingsley Burrell, and many others. We know that investigations in to the deaths of Leon Briggs, and Kevin Clarke are ongoing, in addition to the death of Douglas Oak and in the earlier of those cases the precise problem was that the police absorbed responsibility for the whole incident, without attempting to call on medical help and without thinking clinically, and people died. More recently, we’re seeing this trend change: the police ARE thinking medically and clinically but when they call upon or work alongside healthcare staff, those professionals either don’t respond in a timely way, are themselves unsighted upon ABD as a problem. Obviously in the case of Mr Oak, as with the case of Kevin Clarke, it is known from press coverage or press releases that police officers called an ambulance.
POLICIES AND PROCEDURES
This is not necessarily about, or not just about, individual ambulance clinicians or their staff. No doubt, from my experience, there are some clinically qualified staff who could do with clicking on the link for NICE Guideline NG10 and reading it, or perhaps some other material I will link at the bottom of this post. However, a bigger problem is whether organisation recognise the risks an issues. For example, a number of ambulance services across the UK have told their police forces that they don’t recognise the term ‘ABD’ and that officers need to stop using it, instead providing descriptions of behaviour which work better with ambulance triage systems. Of course, just what we want and need when handling an emergency as a long and complicated discussion of descriptive features rather than the ability of police officers to just say (or shout!) “ABD!” to then allow a shared sense of what we’re referring to.
And this is not just about ambulance services: we have seen in recent years and in some of those Coroner’s proceedings problems of this type with locally agreed policies on the operation of s136 of the Mental Health Act. You might remember the case of Terry Smith in Surrey, where local policy expressly stated (and still states!) that officers who have detained someone who is ‘violent’ or ‘unmanageably disruptive’ are more likely to require removal to custody as well as those who are known to the under the influence of drugs. So where Mr Smith had contact with the ambulance service initially but where the police were called because of agitated behaviours, the use of s136 lead to his removal to the police station and local policy said nothing to even countenance that may not always be safe. It did contain a vague paragraph stating the obvious: that if someone required urgent medical attention they should be taken to an Emergency Department but the document made no attempt to reconcile the contradiction that can occur between the need for urgent medical attention and the imperative to take ‘unmanageably disruptive’ people to custody. And just to be fair to Surrey, their policy isn’t isolated: similar problems existed in the policy in place at the time of the deaths of James Herbert and of Leon Briggs – all three cases occurring in different parts of the United Kingdom, so we can infer this is about something more deeply ingrained in our health system’s approach to these matters.
And in all fairness to the point I’m making here: there are guidelines out there in the real world about ABD – some of them more recent, but others are older. The Royal College of Emergency Medicine and, separately, the Faulty of Forensic and Legal Medicine have published guidelines on these matters. The RCEM guidelines from 2016 are linked within the Guardian article covering this Coroner’s request for clarification about ABD after the death of Mr Oak. And yet the ambulance service have been known in some areas to say, “Those guidelines don’t apply to us”. Well, no they don’t – strictly speaking. But on what basis does the ambulance service reject the clinical guidance of the United Kingdom’s specialist Royal College for Emergency Medicine?! These guidelines don’t ‘apply’, strictly speaking’ to the police service either, but I’m not sure where we’d start in any rejection of them, unless that objection were a legal one, where we can claim at least some competence. But if the RCEM guidance isn’t sufficient, then we also need to know where the ambulance service stands on –
- Nice Guidelines on Violence, NG10 – published in 2015
- NHS England Patient Safety Alert on post-restraint observations – published in 2015.
ADVICE TO POLICE OFFICERS
Firstly, if any officers or paramedics wish to know more detail than I’m covering in this post, there is a three-part series on ABD elsewhere on this BLOG, written by a consultant in emergency medicine. Part One of the series contains the links to the other two.
All frontline police officers can do whilst people like me are sent in to rooms with senior health and ambulance leaders to work with them as they get their heads around this, is –
- Call an ambulance to every detention you make under the MHA or in any other arrest / detention you make where ABD is a concern.
- Remove that person to ED for assessment and treatment whilst bearing in mind that paramedics will be unlikely to be able to rule out ABD at the scene.
- If the ambulance service can’t / won’t / don’t come, then get that person to ED without further delay, once you know you’re not getting an eight minute response.
Also bear in mind the reverse imperative to support: in the deaths of Leon Briggs and Terry Smith, the 999 calls and initial incident handling were ambulance service incidents. In each case the police were called to assist and it led to detention under s136. However in neither case did the paramedics on scene travel to the chosen location with the patient – if these people are on scene when you’re busy helping them with the incident, make sure they continue to help you after you’ve helped them! It’s only fair. We don’t want people collapsing in the back of police vehicles; and if people do collapse we’d prefer that a paramedic with a grab bag was right on hand. Whether people travel in the ambulance with police support or in the police vehicle with paramedic support – I don’t mind. Make a sensible decision based on a risk assessment but whatever you do, make sure as far as you can, that both professions travel with the person. Document everything afterwards, about whether they showed up, whether they helped, whether they travelled. The Coroner may well be interested.
Our ambulance service is strapped and paramedic education around mental health and mental health law is not where the College of Paramedics would like it to be – they are currently working on that. But their service being strapped means there will continue to be cases, beyond the control of operational paramedics and front line officers, where they are unable or unwilling to attend, perhaps because the ‘ABD’ term isn’t pressing buttons for them.
You can only do your best and once you realise they’re not coming: Emergency Department as soon as you possibly can – it’s a medical emergency until otherwise declared and you have all the documents available today (linked above) to support this position.
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