Many years ago, there used to be a lot of discussion around the issue of patients being ‘medically cleared’ before they would be accepted in to a health-based Place of Safety, following their detention under s135/136 MHA. ‘Medically cleared’ for the purposes of this post, is the idea that all those detained under s135/136 should be seen either by a paramedic or by Accident & Emergency department before the PoS unit will accept them in for assessment. It comes up in other kinds of NHS discussion as well, but this post focusses on s135/136 MHA after police involvement.
This approach is really problematic for reasons we’ll get in to, but in my experience it diminished as a problem during the second decade of the century and I hadn’t heard of it returning as a problem until this year or two. I’ve had emails from officers in a number of forces asking about this, so it struck me a blog post is justified not least because some Accident & Emergency departments in England are again attempting to push the argument that they are not a Place of Safety under the MHA — or perhaps they are not resisting the legal point, but simply refusing to act in that capacity for anyone who doesn’t actually need their service and this becomes one of the reasons why someone being ‘medically cleared’ is problematic if the MH system is bouncing people towards A&E who A&E think do not need to be there at all.
So! —
- The ambulance service is struggling: strikes are pending, demand is sky high and there are stories about ambulance service delays contributing to patient deaths.
- You may not always see an ambulance turning up when officers call for one, after use of s136 MHA.
- Accident and Emergency is struggling: we often hear of ambulances stacked at the door, unable to enter for many hours because the department is full for a variety of reasons.
- I’ve known of someone detained under s136 be ‘stacked’ for +8hrs, despite only being near A&E because the MH unit PoS was full – the person didn’t need A&E treatment per se.
In the middle of this, we have officers trying to manage the initial part of s136 processes amidst various parts of the NHS being unable to respond, struggling with demand and pointing towards other parts of the NHS as being required or better placed to deal.
INITIAL ACTIONS
You detain someone under the power and call an ambulance —
Whether or not one turns up, there needs to be consideration of whether the person needs A&E treatment, specifically – in fairness, this should be one of the first questions asked after detention. It’s not because A&E is the preferred place or because most people will require it, but the question should ensure early attention to urgent medical risks which put the patient at even higher risk. For example, do they have cuts, broken bones, a head injury, chest pains, etc.? Are they suspected to have taken an overdose or appear to be exhibiting signs of Acute Behavioural Disturbance – or do they have other medical complications which necessitate it? Some areas called these thing ‘RED FLAGS’ and it harks back to a list of medical issues put together by Dr Tony BLEETMAN around 2009 for the s136 process in the West Midlands – those things on the list are most of the reasons to take people to A&E (it’s not intended to be an exhaustive medical list – just a guided for first responders).
If there’s nothing from the list and nothing else obvious causing alarm to the officers, the person should be taken to the MH unit Place of Safety (or to a police station, if the legal grounds for doing so are satisfied). Taking someone to A&E who does not clinically require it is wasteful and unfair, both on the patient detained and on the A&E staff who are already struggling with (winter) demand as I type.
So, the person detained is not exhibiting a RED FLAG in the officers judgement and it’s then learned the ambulance service can only offer a 5hr response time, due to other emergency demand. What should the officers do? – they should remove the person to the MH unit Place of Safety and liaise with staff there. The nurses on duty are trained in basic physical assessment of patients – as any experienced mental health nurse will tell you, the first thing you do in any mental health assessment is a basic visual or physical assessment. I did once hear a psychiatrist lament that too many mental health nurses felt this was not part of their role and / or that they were adequately trained, but he insisted on the point, as some mental health nurse friends have done many times.
The nurse at the PoS can be reasonably expected to do a sufficient basic assessment to determine whether they think there are RED FLAGS in play and if they really do think that, despite the police officer not having reached the same judgement, then A&E it is – and fair enough because it’s a clinical assessment that this is necessary.
NOT FOOL PROOF
Now of course, this is not fool proof, especially if a relative junior mental health nurse is not confident in this area and they are worried they may miss something.
But here’s the rub: the ‘medically cleared’ idea of all patients being seen by a paramedics or A&E isn’t fool proof either! Several years ago, a friend of mine who is a very experience mental health nurse gave the example of a person detained under s136 who had been seen by a paramedic and a mental health nurse from a multi-agency triage car, then conveyed to the Place of Safety where my friend worked. After half an hour of observation and engagement, he said “Something’s not quite right” and referred the person to A&E who did an examination and declared the patient ‘medically cleared’. Having returned the PoS and been there a further hour or so, my friend again bounced the patient back to A&E because “something’s still not right here!” an A&E consultant became involved, only to end up concluding the patient had a serious medical condition and they ended up admitted to ICU.
The mental health nurse sensed something that a paramedic and another mental health nurse had not and which wasn’t picked up by a junior doctor in A&E – and in full fairness to the debate, his non-specific concern that something was “not quite right” did not amount to a judgement that there was a RED FLAG, either!
Against that background, it’s then worth asking the question: how fair is it to bounce someone to a busy A&E department to be ‘medically cleared’, where the police officers detaining have no sense that ‘RED FLAGS’ are in play and where a mental health nurse has not done a basic assessment that they can be expected to do? This is a question being asked by staff in A&E whose departments are considering whether to refuse patients who don’t require that service – it’s also asked by some psychiatrists who have made known their views on social media that ‘medically cleared’ is a nonsense.
DOCTOR KNOWS BEST
Because he has tweeted publicly on this, I will cite a liaison psychiatrist from London who I know well and trust completely on these matters, Dr Alex Thomson – his trust even had badges made imploring colleagues not to say ‘Medically cleared’ because it is “ambiguous, unhelpful, confusing.” His twitter feed shows a screenshot of an email header after someone emailed “Saying medically cleared is BANNED!” It’s obviously a significant frustration for them as well.
His tweets are worth seeing if you use that platform – in others he writes:
“Today I am mostly trying to explain that it’s possible to be #MedicallyCleared AND have blood abnormalities AT THE SAME TIME! #LiaisonPsych”
“Medically cleared
What does it mean?
Nobody knows
Why don’t we stop?
Because what if something happens?
Medically cleared.”
– Dr Alex Thomson, FRCPsych.
This man, a Fellow of the Royal College of Psychiatrists who spends much of his professional life working in A&E at the interface of acute medicine and acute mental health crisis care and he’s clearly losing his rag with this and has been frustratedly tweeting about it for FIVE YEARS! It’s a nonsense not only because it can be dangerous for patients, but also because it is bouncing them unnecessarily across parts of the NHS which increases the length of their detention and because it’s worsening problems in areas already struggling with high levels of demand.
Most of all though: it doesn’t mean anything. Appearance of serious mental illness can be due to other medical factors, yes – it’s also true that known mental illness can overshadow other medical conditions and mental health patients often have poorer physical health and lower life-expectancy than those who do not live with mental illness. But none of this means that you can easily disentangle ‘physical’ from ‘mental’ health – remember the NHS strapline some years ago, “There’s no health without mental health”? Therein lies the clue: there’s no boundary between these things and if you are so ill that you need detention for your own safety and potential admission to a mental health unit on a compulsory basis, in what possible sense are you ‘medically clear’?!
It needs to stop before something goes badly awry or grinds to a halt.
NB: if you want to access my Quick Reference guides which touch on how to address all of the above (and much else besides) correctly, they are available here.
Winner of the President’s Medal, the Royal College of Psychiatrists.
Winner of the Mind Digital Media Award
All opinions expressed are my own – they do not represent the views of any organisation. (c) Michael Brown, 2022
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Government legislation website – www.legislation.gov.uk
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