Today the College of Paramedics produced their position statement on Acute Behavioural Disturbance and it adds weigh to those tomes I’ve previously pushed as authorities or resources on the subject. ABD continues to be a subject of debate, arising recently in another post I did during a pre-inquest hearing in Bournemouth in to the death of Mr Douglas Oak who was 35yrs old. In that matter, Dorset Police called for support from South West Ambulance Service after believing Mr Oak was suffering from ABD and the subsequent issues with ambulance attendance have led to a comparatively rare direction from the Coroner who is inquiring in to Mr Oak’s death at a young age.
Bearing in mind a full inquest is yet to occur and not scheduled to take place until 2019, the Coroner gave the ambulance service two weeks to produce more material on ABD and their policy or response to it, and suggested that unless she was satisfied she may issue a preventing future deaths report prior to the full inquest occurring. I’m not sure I’ve ever known that happen before, so it’s not insignificant. I don’t know whether we’ll hear more about that publicly prior to the inquest, but it’s one to watch.
And meanwhile, following the inquest in to the death of Terry Smith, which was listed as partly attributable to ABD but where a private ambulance crew acting on behalf of South Coast Ambulance Service called for police support and then remained uninvolved in taking clinical decisions about his welfare; and following the death of Leon Briggs which is subject to ongoing proceedings but where it is known the ambulance service called for police support and where the police ended up conveying him to police custody without paramedic support, there are ongoing questions all around the country about ABD.
COLLEGE OF PARAMEDICS
So today, I think it’s welcome the College of Paramedics has weighed in to this with a very brief position statement, just two pages long and it will be worth police officers and paramedics reading this. It will now be added by me to my standard list of resources I mention when having to give reasons to push past some of the junk we hear about ABD from all manner of healthcare sources, including some MH trusts, some acute trusts as well as some Ambulance trusts.
Anyone who has read up on this topic or followed this BLOG will know that ABD is not officially listed in medical manuals like the DSM5 or the ICD-11. We are all fully aware that the ‘pathophysiology’ (try spelling that after a few drinks) is not settled amongst clinicians or scientists and we know that the position various NHS trusts adopt on this issue can often be influence by one or two people with opinions which are nor more or less credible than the opinions of their peers in other similar organisations which are the polar opposite of theirs. We all get that this is difficult because we don’t want to over-medicalise things, but concern that we may do that doesn’t automatically trump the concern under that we might have been under-medicalising things.
So this is a fact: in the absence of certainty or a more clearly agreed position on the aetiology and epidemiology of ABD (we’ve all got dictionaries), the police service are the ones in charge of refereeing this argument and we will resolve it for you. This may seem like a controversial, indeed a very arrogant opinion to offer, but it’s predicated one simple reality: we are the ones left dealing with people if the NHS can’t decide what to do.
So in the absence of an agreed position across the UK, and in light of the these difficult cases being rare events that could happen anywhere in the country and where simple instructions are needed for officers who will deal with this kind of incident maybe once or twice a career, at most – the police service will be letting its most junior people and it’s junior leaders sort out which consultant psychiatrist or emergency consultant gets ignored and which ones get listened to. You may ask yourself what could possibly go wrong with that approach?! – they do have first-aid at work certificates, after all so are not entirely unqualified to arbitrate on such lofty clinical matters involving multi-syllable words!
WHY NEW GUIDANCE?
The College of Paramedics made it clear in their social media coverage why they’ve produced a statement and you can see it in their tweet, in the header image, above –
This is a direct response to problems which have bearing on the ambulance service from deaths in police custody which have been aired in Coroner’s Courts. So it’s in the interests of ALL operational officers to know the College of Policing guidance on this, which reflects the documents I normally cite when ABD comes up –
- The RCEM guidelines (2016)
- Nice Guidelines on Violence (2015)
- NHS England Patient Safety Alert (2015)
The College of Policing, like NPIA before it, have guidance which says:
- ABD is a medical emergency until otherwise declared by a clinician in direct contact with the patient.
- So consider the need for an ambulance every time for urgent assessment and transfer to hospital.
- There may be rare cases where it would be faster to get someone to A&E by police vehicle than it would to get an ambulance to the person: this may amount to a ‘cogent reason’ for not calling an ambulance, but that should be a deliberate decision.
- Where ABD is suspected and any detention is under s136 MHA, by definition of the medical emergency there will be no time to consult with a professional who is not on scene and it should be borne in mind that a ‘paramedic’ is suitable professional for the purposes of s136B consultation.
- Where someone has been removed to an healthcare environment whilst exhibiting challenging behaviour, officers should support NHS staff to ensure the safety of all.
Today’s publication isn’t saying anything new: it just adds weight to what the police service have been saying for years, but please bear in mind if you are an officer: not all ambulance services have agreed positions, procedures or pathways so in order to give weight to the above, you may need to assert your position and take control of a clinical situation in the face of clinical staff who are not necessarily working with you. Having had to give evidence in Coroner’s Courts in the last year or so, it’s important you demonstrate you have discharged your responsibilities under the police services’ national guidelines, notwithstanding what your local paramedics or ambulance service thinks. History shows the spotlight will be on you, not them, if things go wrong so you need to know your position and be ready to assert yourself for a safe outcome.
For other links to resources on ABD, including a three part series written by a Consultant in Emergency Medicine, see my most recent post on ‘ABD and the Ambulance Service‘.
Winner of the President’s Medal,
the Royal College of Psychiatrists.
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All views expressed are my own – they do not represent the views of any organisation.
(c) Michael Brown, 2019
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