In December of 2015, NHS England published a Patient Safety Alert (PSA) on the topic of medical ‘observations’ following restraint. A PSA is notification to NHS Trusts across the country of an emerging topic that requires urgent attention by healthcare providers to check that their own procedures are consistent with the latest guidance in the alert. This document reminds us that risks during restraint are quite well known before adding, “harm can also occur in the period following restraint from the effect of illicit substances, alcohol, prescribed medications (including any rapid tranquilisation) and co-existing medical conditions. People with diagnoses of severe and enduring mental illnesses are at increased risk of coronary heart disease, cerebrovascular disease, diabetes, infections, epilepsy and respiratory disease, all of which can potentially be exacerbated by the psychological and physical effects of restrictive intervention; between 2008-2012 there were 11 deaths within 24 hours of restraint in mental health settings in England.”
Against this background, the PSA was issued to the NHS. Of course, policing is also a context where those of us living with serious mental illness may be subject to restrictive interventions like restraint, during arrest or detention under the Mental Health Act. For that reason and because of the implications of a number of high-profile inquests in the last twenty years, the PSA is of relevance to the police as well. We know officers have engaged in high-intensity and / or prolonged restraint during mental health encounters and this hasn’t always ended safely, with the medical context and impact being subject of detailed scrutiny in Coroners’ Courts. Fundamentally, what is the difference between a group of police professionals restraining a person and a group of health professionals doing it? – for that matter, we also know there have been restraints by private security officers and transport staff which have ended badly, so the medical impact of restraint needs to be understood.
This PSA is worth reading and it’s only two pages of text: it advises there should be medical / physiological observations on those of us who have been restrained for at least a couple of hours after the intervention has ended. (For the avoidance of doubt, this isn’t visual observation: it is things such as heart rate, blood pressure, temperature, oxygen saturation, etc.) The effects of metabolical disturbance from restraint can continue long after the actual intervention has ceased and for that reason, monitoring is advised. There are all manner of implications for policing here, I hope you will agree? – and it goes beyond Mental Health Act interventions. Police officers having no legal powers under the MHA in private premises, may be effecting arrests under common or criminal law in private premises but the background factors may involved individuals with serious mental illness and all the potential their physical health has been affected accordingly.
Of course, most custody areas have some degree of medical cover – larger custody blocks have 24/7 nursing support; smaller areas call upon doctors or nurses as requested so there is at leas some potential in principle for healthcare professionals to ensuring physiological obs. But what about those custody blocks where the cover is not constant? Some times, the police’s medical contract with a private provider will mean the health professionals are covering three or more custody blocks, travelling between them as required – it may simply not be possible for those obs to be conducted with the required frequency.
And of course, think beyond mental health. What about the situation where police arrest someone with substance addiction for substantive offences like burglary or vehicle crime and there follows a similar restrictive intervention? Although an addiction disorder is a mental disorder for medical purposes, it is not one which can always lead to Mental Health Act intervention and we know those addicted to drugs and / or alcohol can also have poorer physical health: restrictive interventions can also have a significant impact and I have to presume from the wording of the PSA that similar degrees of caution should apply to post-restraint care.
It strikes me the PSA (which has been linked on this blog for some years after I came across it) perhaps needs wider consideration and its implications more keenly considered in criminal justice contexts. We know more generally that the social determinants of poor health and very similar to the social determinants of crime (see ‘The Health Gap’ by Professor Sir Michael Marmot, it’s really quite fascinating).
Finally, for ease of referencing or access, here are various links to other medical or professional guidelines which touch on topics related to mental health, acute behavioural disturbance and restraint in situations where criminal justice or emergency services may find themselves dealing.
- Position Statement on Acute Behavioural Disturbance (2018) – College of Paramedics.
- Memorandum of Understanding (2017) – on Restraint in MH and & LD settings (link temporarily unavailable, I have informed the College of Policing).
- Authorised Professional Practice on Mental Health (2016, updated 2017) – College of Policing guidelines.
- Guidelines on Acute Behavioural Disturbance (2016) – Royal College of Emergency Medicine.
- NICE Guidelines on Violence (2015).
- Guidelines on Management of ABD in Police Custody (2019) – Faculty of Forensic and Legal Medicine / Royal College of Emergency Medicine.
- NHS Patient Safety Alert on Restraint (2015).
Winner of the President’s Medal, the Royal College of Psychiatrists.
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All opinions expressed are my own – they do not represent the views of any organisation. (c) Michael Brown OBE, 2021
I try to keep this blog up to date, but inevitably over time, amendments to the law as well as court rulings and other findings from inquests and complaints processes mean it is difficult to ensure all the articles and pages remain current. Please ensure you check all legal issues in particular and take appropriate professional advice where necessary.
Government legislation website – www.legislation.gov.uk