Amongst the Preventing Future Death reports which have been published after update to the website of the Chief Coroner, is the report relating to the death of Mr Khalid Yousef. The victim was killed by Hassan Mustafa in January 2018 and following a criminal trial for murder, he was found not guilty of murder by reason of insanity.
He was given a restricted hospital order, under s37/41 of the Mental Health Act 1983.
HM Coroner for Birmingham and Solihull oversaw an inquest in to Mr Yousef’s death earlier in the year and we can now see the detailed PFD notice which has been sent to NHS England and Birmingham and Solihull Mental Health Trust as well as West Midlands Police and the Home Secretary. It details various matters of concern regarding the commissioning and delivery of Liaison and Diversion schemes as well as highlighting what I might call some cultural attitudes about L&D schemes, including amongst the police.
LIAISON AND DIVERSION
The Coroner’s points in this particular case are around the lack of psychiatrists in the NHS England model for L&D and how assumptions and culture evolve about the role of L&D —
Such L&D schemes are largely band 6 nurses working in custody, screening those who are flagged by the police to the mental health (or learning disability) nurses who undertake the scheme’s work. This scheme is commissioned by NHS England as part of NHS provision in the criminal justice system and it is distinct, for example, from the custody healthcare provision which is commissioned by a Chief Constable. As the PFD makes clear, it is a parallel system to custody healthcare and this gives rise to questions and concerns about their difference or distinction between the two roles and responsibilities.
Where police / custody healthcare staff have identified an arrested person as having potential mental health problems and unmet needs, they can refer to L&D and a nurse-led assessment takes place. In Mr Mustafa’s case, he was seen by an L&D nurse for 45mins in his cell after being arrested for less serious matters and there was no discussion with a psychiatrist or referral for a Mental Health Act assessment. HM Coroner was very clear about his opinion on this in the PFD notice itself —
“Had he been referred he would have received the treatment or been detained and the death would not have occurred.”
He goes on to state the detective dealing with Mr Yousef had admitted to concerns about his release, specifically having concerns about further offending but these concerns were not raised with L&D. The Coroner then highlighted some confusion amongst police officers about the role of Liaison and Diversion and in particular, the assumption that those working in such schemes are ‘experts’. We‘ve often heard the claim that nurses working alongside the police are experts, not just in L&D.
ROLES AND RESPONSIBILITIES
Any confusion about roles and responsibilities between these parallel schemes is also highlighted in the PFD notice itself. For example, the Coroner highlights expert witness evidence which remarks on reduction in the number of Force Medical Examiners (FMEs) – these are the doctors who work in the police-commissioned custody healthcare process; but he also flags the reduction in the number of those FMEs who are “section 12 approved”. A section 12 doctor is one who has particular qualifications and experience in treating patients with mental disorder – they become ‘approved’ to take particular decisions under the Mental Health Act 1983, for example around ‘sectioning’ patients who require compulsory admission to hospital.
This is curious, in a way because no Chief Constable needs to ensure the ability to administer the Mental Health Act 1983 – such responsibility sits entirely with NHS England and local authority AMHP services. It’s always been an historical legacy that some FMEs were section 12-approved, often because they are so approved for other roles they have or still do perform and they can therefore ‘double hat’ when a person in custody is seen by an FME acting in that capacity and where they determine the person requires assessment under the MHA, coordinated by an AMHP. Strictly speaking, they stop being an FME when they start taking part in the MHA assessment because that is not a police responsibility – and statutory fees payable to doctors who undertake MHA assessments for example, are paid by the NHS, not the police.
But doctors have no formal, commissioned role in L&D services and the conduct of Mental HEalth Act assessments is a distinct statutory function, not a part of L&D itself. Confusing, isn’t it?!
This was all contrasted by the Coroner with similar services in-reach services in prison, which do have psychiatrists embedded within and which are entirely NHS run. Amongst other things, it means a police-based NHS L&D nurse who wishes to refer an arrested person for a medical review has nowhere to go, unless they are seeking a statutory MHA assessment. This would then be coordinated by an AMHP who has to organise the doctors required for that assessment and amidst this confusion, the coroner observes that the investigating officer didn’t escalate their concerns about the assessment received by Mr Mustafa, despite reservations about further offending.
We’ve seen more than once that some officers – including some more senior in rank – appear to suggest it is not for the police to be challenging “experts” in healthcare. Of course, in principle that’s quite right because we have distinct boundaries and different professional roles, backed by qualifications when it comes to doctors, nurses and AMHPs – it would beg an immediate credibility question if a police officer were to suggest a psychiatrist was wrong about medical matters, for example. But this doesn’t and shouldn’t preclude discussion about things which leave us all uncomfortable because of concerns of future risk or where it is felt that decisions have not been explained in a way which allows them to be understood. We also saw this point made in the response by a force’s deputy chief constable to a PFD reminding us it is “important to defer” and we heard a senior detective make a similar point that it’s “unreasonable to suggest police should have over-ridden” healthcare decisions prior to a different homicide in the south-west.
Away from specific incidents, I remarked more than once the media coverage of ‘street triage’ schemes often described the police as working alongside ‘expert’ mental health nurses in these new initiatives. No offence to hardworking nurses everywhere, but they were nurses – usually band 6 (experienced but not senior). The police officers were not ‘experts’, either – they were police officers. They are all hard-working and skilled front-line staff, drawn from response policing or crisis teams and who, no doubt at all, picked up some extra knowledge along the way by working with the other agency. But expertise is next level – or at least it should be.
It’s a cultural and a linguistic thing and it this case reminds us it needs checking from time to time. Where officers may have concerns about healthcare decisions and remain uncomfortable about the implications of them, nothing at all prevents that concern being appropriately and professionally escalated for review or reconsideration. To do that is not to suggest the officers are attempting to over-ride the professionals skills of others and we seem to fully understand this when other agencies ask for a sergeant or inspector to review police officer decisions. From my experience of reviewing things, you most usually agree with and back your staff because you’re happy with the decision once its explained and often things come down to the quality of the explanation given for the decision under question. But not always – people can (and do) get things wrong and nothing should prevent escalation in good faith to review things that leave us uncomfortable. Inquests like this tell us we should not assume our colleagues in other agencies have all the knowledge, training or experience we would hope they do and that in any event, nothing is inappropriate about requesting explanation or review of things which leave us uncomfortable.
There are examples known to me of where officers who were nervous about the nature or quality of healthcare decision-making in police custody have escalated concerns and on occasion, exercised powers under the Mental Health Act to force a statutory assessment which would otherwise not have occurred, leading to a outcome which would not otherwise be achieved. There are examples within those of where the police determination to force explanation or assessment of things has led to a obviously better outcome than would otherwise have been achieved.
Winner of the President’s Medal,
the Royal College of Psychiatrists.
Winner of the Mind Digital Media Award
All views expressed are my own – they do not represent the views of any organisation.
(c) Michael Brown, 2023
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