Fog

Tasers on Psychiatric Wards

If you have been following the progress of the Policing and Crime Bill 2015, you will have seen it has recently started its journey through the House of Lords. Accordingly, noble peers have had an opportunity to table amendments to the original Bill, for consideration and debate during the committee stage and on the floor of the House.   

The main aspects which affect mental health are –

  • A proposal to remove the words ‘police station’ from the definition of a Place of Safety under s135(6) MHA – this would mean police stations could never, ever be used.
  • A proposal to ensure the right to an appropriate adult for anyone detained in a PoS under s135 or s136 MHA – the amendment fails to specify who would have to provide this adult or who funds it.
  • Finally, it is re-suggested that Tasers or ‘electro-conductive devices’ should be banned from use on psychiatric wards – this is a second attempt by the Liberal Democrats to introduce such a ban. It was previously introduced by Norman LAMB MP and defeated in the House of Commons.

DEFINITIONS

There is a great BLOG on this topic by @NathanConstable from Twitter which gets in to the whole debate about tactical options and asks the obvious questions about what will be expected by those who are proposing and supporting this ban?  Will they, ultimately, back police officers who shoot an armed patient if a Taser would have sufficed were it not banned by them?  Remember, the ‘use’ of Taser in around 78% of incidents simply means it was drawn from a holster and threatened: no-one was touched, at all. Yet we are having a second argument to suggest that police officers should, instead, hit people with metal poles or fire baton rounds or bullets at them.  (Assuming in all instances that attempts to de-escalate without resort to force have been tried and failed.)

I want to address another question and it causes me to ask “So what is a ‘psychiatric ward’?!” There are many kinds of environment in which patients may be detained under the Mental Health Act 1983 that I would never describe with those two words. What about the patient who is living in semi-supervised accommodation as a ‘step-down’ from low secure forensic care, prior to being conditionally discharged? – if there were an incident a that location and officers attended, Taser would be permissible because it’s definitely NOT a psychiatric ward. It’s not a ward of any kind! What about a dementia patient, living in a nursing or residential care home, detained under the MHA? – the same argument applies. But surely someone’s vulnerability is their vulnerability; the risk of these devices (all equipment carries risks; as. Does doing nothing) is still the risk whether the Taser is discharged on a ward or not. Are we also going to ban Tasers during the execution of warrants under the MHA – if not, why not?! I’ve directed Taser officers to undertake such tasks and would happily do so again, unless legally prohibited from doing so.

What happens where a person who is detained in a psychiatric ward under the MHA is transferred to another kind of location – that could be to A&E for urgent medical treatment or to an acute inpatient setting for whatever purpose. We know that some patients are detained under the MHA to general hospital wards because they require surgery or other treatment for conditions that are associated to their mental disorder. If there were a serious incident – and can think of several, I’ve known – then would the officer be able to use a Taser?  What about a learning disabilities hospital or unit – they’re not traditionally referred to or thought of as ‘psychiatric wards’. What about a health-based Place of Safety – I once knew a patient pull a knife an officers in an NHS PoS. They drew a Taser and threatened to use it – gaining compliance without touching the person and causing no injury whatsoever. Thankfully, that seems unaffected by this proposal but if that had been patient who returned to a ‘psychiatric ward’ after a period of s17 leave, Taser wouldn’t be an option.

I can’t help but think: we either issue this kit, accepting it’s risks; or we don’t. Restricting it’s use in such an arbitary way really just tells us that those proposing the amendment don’t trust officers to make the appropriate judgement about its suitability.

THE OTHER MATTERS

The reason I’m looking forward to the debate occurring, is that the proposal around police stations will mean there must be discussion about the kinds of circumstance in which opponents to the proposal think stations should be used. Here’s a predication: we’ll hear about people whose behaviour is ‘so extreme it cannot otherwise be safely managed’ – we’ll hear about the capacity and capability deficit that prevents safe management of vulnerable people who exhibit challenging behaviours – as if that somehow obliges the police to put people at risk by incarceration and ongoing restraint – and we won’t hear how the deliberate decision to remove people to custody indifferent as to whether or not their resistant behaviour could be indicative of underlying medical problems or something that puts them at raised risk because of the need to engage in restraint

I doubt whether it will be acknowledge by those who oppose a ban that most of the circumstances in which it is still argued police stations are acceptable places to gaol the vulnerable are actually just deaths-in-custody waiting to happen. We’d know that if we just listened to families whose relatives have died. I obviously hope that police stations are removed from the list of Place of Safety locations, but I genuinely fear that the amendment won’t succeed, not least because the Government could have chosen this reform to begin with and someone will probably point out the impact on NHS services, including A&E which would have to act as the overspill if mental health trust PoS were full and police stations unable to be relied upon. I fear that will be prioritised over more important things.

Finally, I’ll be intrigued to see whether the Appropriate Adult proposal succeeds. This one slightly surprised me, because the role of the Appropriate Adult role is currently one for police custody, for those taken there against their will. That is usually because they have been arrested for an offence and may well need to be interviewed after having their rights explained. The AA role is to ensure people understand the process, assist with communication, see that the person’s rights are being respected and challenge or advocate, as necessary. Where someone has been detained under s136, Code C to PACE makes it clear (para 3.16) that the AA has no role during the formal interview by the AMHP and Doctor, presumably meaning their role is restricted to just the booking in procedure for the administration of rights and to ensure a general understanding of things.

Some people argue that this is broadly the role of the AMHP when they are undertaking an assessment under s136 so this just duplicates things. It also would create the highly unusual situation in which  the right to an Appropriate ADult is a statutory right for those detained under ss135/6 whereas it stops short of being a right for those under arrest at police stations, detained under PACE. And it does raise that question – who is going to do it and pay for it, given that the amendment doesn’t specify?

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Leytonstone Sentencing

Muhiddin MIRE was today sentenced by a criminal court following the attack at Leytonstone Underground station last December that made prominent national headlines.  I admit, I had a bit of a job initially piecing together what exactly the court had done, following vague media reports that appeared somewhat to contradict themselves! One simply claimed the man had been sentenced to ‘life in jail’ whilst another that he would ‘begin his sentence at Broadmoor’. This made me wonder whether, in fact, the court had sentenced him to what’s known as a hybrid order – this turns out to be exactly what they’d done; so I thought I’d quickly explain it, in case of any doubt as to what this means!

Before I do, I’d observe that somewhere between being charged with attempted murder by the police and his sentencing today, he has been transferred between the criminal justice and mental health systems. When he first appeared at court, there would be no power for Magistrates to remand the defendant to hospital under the Mental Health Act. At or after his first appearance at the Crown Court, he could be transferred and that has obviously occured and facilitated a period of assessment by the psychiatrists who have given professional opinion to the sentencing judge. The defendant has pleaded guilty to the offence, notwithstanding that his mental illness is serious enough to mean he reaches the threshold for admission to hospital under the MHA.

So this is yet another example to prove the point that serious mental illness does not always equate to a lack of criminal responsibility for serious crimes. Indeed, as previously pointed out, attempted murder is the most difficult kind of assault to prove – because a charge of murder succeeds if it can be proved that the defendant intended to kill or seriously injure the victim; attempted murder requires proof of intent to kill. A notably higher threshold to satisfy.

HYBRID ORDERS

A hybrid order means that the court can issue a ‘normal’ criminal sentence of imprisonment to any defendant over the age of twenty-one, but they will first be admitted to hospital under the Mental Health Act for treatment. It then depends how long the patient’s treatment lasts as to whether they are discharged from hospital or transferred to prison to complete that original sentence.  All of this is done under s45A of the Mental Health Act 1983.

So in Muhiddin MIRE’s case, he was sentenced to ‘life imprisonment with a recommendation that he serve a minimum of 8.5yrs in jail’, commencing with the treatment aspect of the hybrid order.  Let’s imagine he remains in hospital for 6yrs receiving treatment, he will then be transferred to prison for a minimum period of 2.5yrs before the Parole Board would be able to take any decision about his release from prison.  Were his hospital treatment to last 9yrs, then release would be considered – but not necessarily granted! – as soon as the clinician in charge of his care recommended discharge from hospital. If the Parole Board did not grant immediate discharge, he would be transferred to prison to serve further time in jail until his case for release is reconsidered.

Finally, anyone made subject to a hybrid order after conviction for any offence specified in Schedule 1 of the Criminal Justice Act 2003, will be subject to the provisions of Multi-Agency Public Protection Arrangements, or MAPPA.  These are arrangements which aim to ensure, amongst other things, post-release mechanisms through which public authorities cooperate to share information, to ensure risks are properly managed in the community, if or when a patient is discharged or prisoner released.

So this is the only form of sentence which combines two periods of detention: first in hospital and then in prison. These orders seem to becoming more popular amongst judges, the point being that they prevent people with serious mental illnesses who are convicted by the courts of being subject to a far shorter period of detention under a (restricted) hospital order than they would have done if they had been sentenced only to a period in prison.

And we could debate the ethics that sit behind that approach, all day long … on another day!


IMG_0053IMG_0052Winner of the President’sMedal from the Royal College of Psychiatrists.

Winner of the Mind Digital Media Award


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A Comedy of Errors?

Imagine a patient taken to A&E by ambulance after taking an overdose who is then admitted to the poison’s unit of the acute, general hospital. A mental health assessment is requested as routine, because of the overdose, but is scheduled to take place tomorrow once the patient is anticipated to be medically well enough to undergo that assessment.  Later on the day of admission, he becomes distressed on the ward and attempts to leave but the junior doctor on-call places him under a s5(2) Mental Health Act order.  Still distressed, he patient lashes out at staff and verbally threatens them, so they desist in attempts to prevent them from leaving and call security to stop him getting out of the hospital. For whatever reason, security cannot locate the patient and he is presumed to have absconded.

The crux of this little anecdote is to get at the legal powers that are now in play. The ambulance service were requested to attend the patient’s home address and return him to hospital – an interesting decision, given that he had lashed out at hospital staff and threatened them.  What powers would a paramedic or technician have in this situation?! – the answer will be revealed towards the end!

Enquiring with the ward staff about the missing man, they are told by nursing staff that the Mental Capacity Act allows them to bring the person back – someone who has taken an overdose must be suicidal and that means they lack capacity, right?! – the answer is towards the end but the paramedics are unconvinced and given a stand-off, because the patient would not return, the ambulance service seeks the support of the police.  A section 5(2) MHA patient is refusing to return, can the officers help them out?! – answer towards the end, but the police claim to lack powers in this situation, can therefore add nothing to it and decline to attend.

ABSENT WITHOUT LEAVE

We’re still not getting very far, are we?! – an overdose patient, not yet medically fit and potentially suicidal according to ward staff and we can’t work out whether they can be returned and / or whether anyone has a legal power to do this. So far, we have various ward staff – including those who instigated the power! – two paramedics who could be elsewhere answering 999 calls and the police who have probably interrupted perfectly good coffee and doughnuts(!) to turn down the chance to help; and despite their collective training, we’re still unsure about this.

Welcome to the health and criminal justice systems of the fifth largest economy in the world! – inspiring, isn’t it?!

So far, the only people who are right in summing up the predicament they are in, are the ambulance service: they have no powers of their own to rectify this situation and yet they are the people stood near the patient’s house with the responsibility for them.  The advice they’ve had from the ward is wrong; the support they’ve not been given by the police is wrong and there is a clear and easy answer to this situation! … that does not rest with the paramedics only.

This patient is absent without leave, missing from section 5(2) MHA – he may be retaken by a constable, an AMHP or anyone else authorised by the managers of the hospital, in the 72hrs after the section was implemented.  As all of this happened in the first day of absence, there was well over two days in which to get it sorted.  As with all other powers for AWOL patients, there is no power of entry in order to return the patient, so a warrant under s135(2) MHA would be required. Of course, what I don’t know, is how the communication occured between the various parties. Did the ambulance control room tell the police it was a section 5 patient? – we know that some problems of this kind is actually just about communication.

BECOMING JADED

If this post sounds slightly cynical or jaded(!), I fully accept the rebuke! – I’ve noticed myself recently becoming quite impatient with these sorts of things. I unintentionally woke up the dog shouting at the tellybox this week when I saw #999whatsyouremergency on Channel 4 and I suspect it’s because there is a human limit to the amount of times a person can keep saying the same things, over and Over and OVER, again and Again and AGAIN … and that I’m towards that limit after another two years of working on nothing but this stuff, bringing me to a total a five full years over the last twelve and ongoing attention in between those jobs. I may need to go and be a policeman again!?

All that said, I did then immediately had a sharp word with myself: this AWOL situation is one of almost forty different scenarios where people who are not where they are meant to be under the MHA, need to be considered for return.  The law allows for people to become AWOL under the following twenty sections of the MHA –

  • 2
  • 3
  • 4
  • 5(2)
  • 5(4)
  • 7
  • 17A
  • 35
  • 36
  • 37
  • 38
  • 37/41
  • 42
  • 45A
  • 47
  • 47/49
  • 48
  • 48/49
  • 135(1)
  • 135(2)
  • 136(1)

And in addition to the above sections allowing for some people to be ‘absent’, some of them also allow for people to have absconded. These AWOL situations have various timescales that apply to the period within which people can be re-detained and returned, ranging from a few hours to indefinitely; and they don’t allow that same group of professionals from the above scenario to act. Some of these things are police-only powers.  In the police-only powers – 35(10), 36(8) and 38(7) – the person should not be returned to the hospital from which they’re missing, but to a courtroom. One of these things requires a warrant from the Ministry of Justice before the legal power can be invoked.

All clear for you?! … no wonder people less involved in this are confused! I asked a question on Twitter as part of writing this blog, seeking to understand what people thought the answers were and there are other professionals, including mental health professionals, getting this wrong. Why wouldn’t they?! – we don’t actually provide legal education of any reasonable standard for our professionals – I make an exception for the Approved Mental Health Professionals who are trained and examined on this stuff; but certainly MH nurses get next to nothing.

So for what it’s worth, here are some links to other posts I have done with reference materials and other ideas to use smartphones to access material quickly.  We can all imagine what would be said if this patient had come to harm whilst everyone was busy not knowing what they were doing, yet we didn’t really give any of these people the chance to get it right by training them properly —

Finally, if you want this stuff easily accessible, do what I’ve done and create a reference section of BLOGs on your phone’s homescreen.  Instant access to this stuff which I know various police and paramedics have resolved situations for them in seconds – at least in terms of knowing what they have to do!

I can explain most of this stuff, but I can’t understand it for you or look it up for you when you need it most! … but good luck with it.


IMG_0053IMG_0052Winner of the President’sMedal from the Royal College of Psychiatrists.

Winner of the Mind Digital Media Award