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Need an Appropriate Adult?

Several discussions and questions recently about Appropriate Adults (AA) in police custody for vulnerable people that I want to quickly cover. In case you’re not aware, an Appropriate Adult is someone who, according to the Codes of Practice to the Police and Criminal Evidence Act 1984 must be called to police custody for anyone under the age of 18yrs or anyone who is ‘mentally disordered or otherwise mentally vulnerable’. They must be present for legal rights being administered, police interviews about the allegations and various other things. Al sounds straight-forward enough, doesn’t it?!  You can just imagine the booking in procedure where the custody sergeant tells the arresting officer, “He’s only 17yrs old, get an appropriate adult on the phone and ask them to come down here.”  Usually this will be the person’s parent or guardian and if there is no-one available, you can ring children’s social services as there is a statutory duty to act as an AA for someone who cannot otherwise be supported.

There are two major problems when we turn this conversation to the circumstances of a vulnerable adult – 1) what does ‘mentally disordered or otherwise mentally vulnerable’ mean? … and 2) how do we handle things if we, the police, can’t secure a volunteer? Absolutely no-one, anywhere has any comparable statutory duty to support that person whilst under arrest! Neither social services as a whole, nor any health or mental health service to which that person may be connected is obliged to fulfill this role in the absence of a relative, friend or neighbour.  Recently, I was at a meeting with Chris Bath from the National Appropriate Adult Network who I’ve heard more than once saying, “If you can’t even find someone from the banana aisle at Waitrose” given that most adults could fulfil this role … it’s merely the case that no-one employed by the police can undertake it.

WOULD YOU CALL?

Would you call an Appropriate Adult for [name a famous, intelligent celebrity with a mental health condition here]? Imagine that person was arrested for something at a point when their mental health is pretty good. Imagine that they are in regular contact with the services who are supporting them; potentially taking medication and / or undergoing other forms of treatment and that to all intents and purposes they appear ‘well’. Would you still ask for an appropriate adult to support them during the process of investigation and interview by the police?

Well first of all, anyone in police custody under arrest would be examined by an approved healthcare professional – usually a doctor or nurse from a contracted organisation who advise on police custody healthcare issues.  Ultimately, the decision about whether ot call an appropriate adult is one for the custody officer, but given that the need for an AA rests on confirming one way or the other whether or not someone is ‘mentally disordered or otherwise mentally vulnerable’ you can see why a medical or nursing opinion comes in handy on these matters. They have the skills and are more likely to have access to information to help make this decision – but it remains with the custody sergeant to resolve any doubts and disagreements.

There have been examples of custody healthcare staff assessing someone and establishing that they have, for example, a diagnosis of depression. Because the person is receiving care from the NHS, taking medication and to all intents ‘well’, the advice to the custody sergeant is that they don’t ‘need’ an AA .. and this is where things start to get difficult.  PACE (Codes) don’t talk about whether someone is thought to need the support of an AA or not – merely that the person either is or isn’t ‘mentally disordered or otherwise mentally vulnerable’.  So are they? … or not?!

LEGAL NOT MEDICAL

The question of whether someone should have an AA is a legal one, not a medical one. Of course, we are going to defer to professional opinion about healthcare issues – but it is a legal assessment that follows and it remains the decision of the police. If someone with depression who takes anti-depressants is arrested they may well be thrown in to one hell of a situation – because actually, anybody who is arrested is thrown in to one hell of a situation! This could be all the more pronounced if the particular investigation has more far-reaching consequences for that person, be that loss of employment, public reputation or any number of other things including marital or key-relationship breakdown. The fact that until arrest that person was working for living, raising their kids and living a life doesn’t alter what arrest can mean and can it do to some people. The safeguard was designed, it would seem, to ensure that people more likely to be vulnerable are supported whehter that is because of a long-term health problem like schizophrenia or situationally specific circumstances.

So what does ‘otherwise mentally vulnerable’ mean?! – could this not also extend to someone who has no history of mental health problems whatsoever but who has been arrested for an alleged offence that could be, literally, life-destroying?  Imagine a school teacher arrested for possessing indecent images of children – I’ve arrested a man for exactly that and you could see the utter panic and terror behind his eyes. He was ultimately proved guilty of it all and rightly jailed, but you have to consider that whilst he’s in custody, not entirely sure of the evidence against him, not sure of where this is all going, as he sat in the cell whilst we searched his house and seized a LOT of his possessions as part of the inquiry, that he must have been contemplating just how much his life was going to fall apart? I’m not suggesting everyone accused of a serious crime needs an appropriate adult, but some might, notwithstanding an absence of mental health problems. This is just one example of what ‘otherwise mentally vulnerable’ may mean.

And remember this: the PACE Codes make it clear that if there is doubt about whether someone is ‘mentally disordered or otherwise mentally vulnerable’ then you treat them in custody as if they are.  So as you think through your examples of high-functioning people who you know has bipolar disorder or depression, keep in mind someone with any other kind of condition. If someone was receiving treatment now for cancer, you would regard them as having cancer notwithstanding how well they may be at the time. However, a decade later after receiving the all-clear and ceased treatment, you would no longer refer to them having cancer or being a cancer patient.

WHAT ABOUT HISTORY

So what about recovery? Many people recovery from mental illness – they lead meaningful lives, often free from medication or further support from secondary care mental health services.  If someone is arrested who lived with a mental health condition years ago but has since recovered, would you regard them as requiring an AA?  This is perhaps where there is more of a judgement call. Keep in the mind the cancer patient analogy: if the person regards themselves as recovered, they are no longer receiving treatment and there are no current indications that the fact of the arrest has caused any particular problems, especially if they’ve been medically screened in police custody by custody healthcare staff or by Liaison and Diversion services, then a history of something would not automatically mean you fail to acknowledge their recovery in the decision-taking.

I’m aware that some custody sergeants are debating this actively and that one force in the south of England has reinforced a policy that has the effect of increasing the need for AAs in custody. I am not without sympathy about the operational implications this sometimes have because I’ve been that duty inspector on a number of occasions where all efforts to secure a human being of any description to act as AA has been tried and failed – a number of times!

In particular, I recall one investigation of a poor bloke who had been arrested for reckless arson, endangering life in what had probably been a suicide attempt. he had been fully assessed in custody under the MHA because of his mental state and his long history of mental health problems.  The investigating officers had spent over 22hrs of the PACE ‘clock’ dealing with the initial enquiries to be made, the MHA assessment and the repeated efforts to find a relative, friend, neighbour or any professional from any organisation anywhere who would be prepared to support him in custody. Nothing. We even left it a couple of hours and then tried them all again. Still nothing. So we interviewed him without an appropriate adult knowing full well this might end up meaning any evidence obtained would be excluded but we had to rely upon the fact that the requirements for an AA is in the Codes to PACE, not in PACE itself. Therefore, according to the relevant court ruling, it is something with which we should comply unless there are ‘cogent reasons for departure’. The cogent reason being: no-one on planet earth except the police and his solicitor we’re willing to try to help the guy and we’re all banned from being his appropriate adult.

Would I seek an appropriate adult for [intelligent, famous celebrity receiving MH treatment]? — there is absolutely no doubt whatsoever in my mind. I would.


IMG_0053IMG_0052Winner of the President’s Medal from
the Royal College of Psychiatrists.

Winner of the Mind Digital Media Award.


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The Restraint Document

Since September 2014, when I started at the College of Policing, we have been working on the development of a document about those situations where the police are called to a mental health or learning disability unit and asked to do something coercive. I’ve been on mental health wards many times, as an operational police officer: calls to investigate and potentially prosecute patients for alleged assaults or damage; requests to assist in restraining patients so nursing staff can administer medication; requests to assist in moving a person from one part of a mental health unit to another … or even to move them to an entirely different unit. As a probationary PC, my colleagues and I were regularly called in to the old All Saints’ Hospital in Winson Green in Birmingham to a range of things where disorder and distress were manifest and the police were being asked to help.

These issues are as important as they are sensitive: we know that we don’t want to over-police anyone, least of all vulnerable people already detained in hospital at a difficult time in their lives, nor do we want those places to be dangerous and beyond the reach or scope of the law, where that is necessary. We know that care in clinical settings is primarily a matter for healthcare professionals and it’s for their organisations to ensure they address their own health and safety obligations; however, we also know that some things happen on mental health wards that may need the police.  For a start, around 67% of the 70,000 assaults on NHS staff take place in the mental health sector and whilst most of that is not reported as crime, some of those matters are very serious.  Recently, a murder inquiry was launched after a patient was killed on a mental health ward; in 2016 a mental health nurse was killed on a ward in Croydon and in 2014, a healthcare assistant in Gloucestershire.  No-one can seriously argue that where such incidents breakout, that the police don’t have a role to get in there and try to stop things from becoming any worse to prevent these kinds of outcomes. But it needs to be carefully considered and controlled, not least to mitigate against extremely untoward outcomes that raise difficult questions.

There are two problems this document aims to address –

  1. Police being over-relied upon to enter clinical settings and undertake restrictive practices which fall within the scope of what we would all agree are predictable risks associated with being a mental healthcare provider.
  2. Police not recognising the need to support healthcare professionals in addressing unexpected risks that are beyond their ability to cope, where control is lost and safety is compromised.

SO WHAT DOES IT SAY?

This is the three-point summary of this document –

  • The provision of healthcare and the undertaking of restrictive practices associated with healthcare is the legal responsibility of the healthcare provider who must ensure compliance with health & safety legislation as well as human rights laws in the way they undertake this difficult work. Specifically, this includes the requirement to mitigate foreseeable risks.
  • It is the role of the police to investigate allegations of crime; and to assist in restoring safety where unpredictable risks have seriously compromised the safety of staff and patients. The officers’ role is to restore the circumstances of safety that allow staff to retake control at the earliest point and to then determine whether a criminal inquiry is required.
  • Where it is alleged that safety is seriously compromised, for whatever reason, the restoration of safety is the key priority – if there are any discussions to be had about whether the call for the police is appropriate OR whether the police response was appropriate, these are discussions for after the safety of all has been ensured.

The Restraint Document, as we kept calling it, is a multi-agency Memorandum of Understanding.  The College of Policing has coordinated its production and it is agreed between the National Police Chiefs’ Council, mental health charity Mind, the Royal College of Nursing, the Royal College of Psychiatrists and the Faculty of Forensic and Legal Medicine.  In the course of its production, independent legal advice was secured from a QC and junior counsel with experience in the legal matters around police powers and mental health law. In addition, it has been supported and welcomed by Amber Rudd, the Home Secretary; by Lord Adebwoale, the chair of the 2013 Commission in to Mental Health and Policing in London; the charity Inquest and several others. I’ll let you find details of what they’ve said, if you’re interested, by going to their social media feeds or to the College of Policing website.

FREQUENTLY ASKED QUESTIONS

Already, some questions have emerged a few times, so let me address them –

  • Have all forces agreed to this? – no, they haven’t.  It is not something they were asked to agree or disagree because it is an expression of standards by professional bodies and by Mind, on behalf of the public. Many police forces, healthcare organisations in the NHS, including CCGs, MH trusts and others were involved in and consulted as part of this work; but to get formal agreement of the five major signatories was hard enough!
  • What changes from before? – absolutely nothing, strictly speaking. This document doesn’t oblige us to do anything that wasn’t already possible or desirable; it doesn’t ban or discourage us from doing anything in the future that wasn’t already banned or discouraged.  This document merely summarises the law and the relevant medical and other professional standards and guidelines, for organisations and individual professionals.
  • Can I disseminate this? – yes, that’s why it was published on the internet. There may well be partnership implications here, but only if areas or organisations have drifted in their understanding of what the law demands of us all. Even frontline professionals reading this and improving their understanding of the legal, medical and practical implications will improve the experience of patients.
  • So can officers restrain for medication or not?! – there has been a rumour for many years that officers have ‘no power to restrain for medication’. This is true, to the extent that the Mental Health Act (or Mental Capacity Act) does not expressly authorise any specific professional. Obviously, it is primarily a matter for healthcare professionals and police involvement should be extremely rare where thought unavoidable. There is a detailed example below, as to when / why.
  • So what happens now? – the document needs to be taken by forces and healthcare providers, through their local Crisis Care Concordat action plans and local procedures developed around the principles outlined. This may mean forces need to consider how their control rooms handle calls to MH units, it may mean mental health and learning disabilities units need to think about staffing, contingency plans for events and how we interface and cooperate.

REAL EXAMPLES

Remember the two problems we’re trying to fix, above?  Here are some real examples which emerged in discussions of the working group. They came from professionals in policing, nursing and psychiatry.

  • Over-policing? – an adult man, a s3 patient on an acute admission ward has had a difficult morning on the ward, has seemed unusually agitated and there are some raised concerns about whether he may hurt himself. Nurses have tried closer nursing support, but this has left concerns. They have decided, and it has been appropriately authorised, that he will be secluded for a short period with more intensive nursing around him. At the point where he is told this, he is sat on the floor of the ward corridor and refuses to move. He is not actively harming himself or others and there is nothing about his background that suggests it is anything other than a nursing responsibility to move him to seclusion. The police were called to assist, however a senior nurse who learned this had occured, over-ruled the decision, cancelled the police and directed the incident. The use of the police here was not necessary or relevant.
  • Under-policing? – an adult man, s3 patient on a low-secure ward is reported to be “smashing the place up” and the police are urgently requested on 999. Upon arrival, there is some damage to posters from the notice boards but there is little more and the police are told that one nurse in the office, has been assaulted. The man is agitated, pacing around the ward whilst shouting about his delusions and making non-specific threats. The police contain him, without restraint, by having a few officers standing on either side, giving him freedom to move in that limited area without anyone in his personal space. This continues until a nurse explains what has happened and what they are asking for. An officer uses humour to de-escalate everything and it leads to the patient become less distressed. Nurses want to seclude him and provide medication so the police escort him 10m down the corridor, without restraint, and in the room he agrees to receive an injection. The police then speak to the victim and record an assault which is investigated later.
  • Too casual? – a s3 patient on a ward grabs a nurse unexpectedly and starts attacking her. It quickly emerges that he has improvised a weapon out of something plastic and later, it is found to be a plastic biro-style pen. Having grabbed the nurse from behind, he uses the weapon to inflict several puncture wounds to the nurse’s torso and colleagues immediately ring 999 for help. Without officers attending the ward, the police control room feel entitled to say that this is something the hospital should be able to handle and refuse to attend. A further 999 call is handled similarly. Thankfully, staff on the ward do manage to contain the patient, but not before another of them is assaulted. The injures nurse requires A&E treatment to her injuries, which amount to grievous bodily harm, for the purposes of crime recording standards.
  • Inappropriate? – officers were called on 999 to a female patient assaulting staff and causing damage. Upon arrival, the staff have forced the patient in to some kind of side-room, off the main ward. There is damage to doors and a door frame, but those staff who were assaulted are uninsured and still involved in leaning on the door of the side room to contain the patient in there. Three male officers arrive and the doctor, after some vague discussion that had to get precise using closed questions(!), requests the officers to restrain the patient on floor so that nurses can give her an injection. What do we think about three male police officers being involved in the restraint of a young woman, so her trousers can be partially pulled down against her will? I think, if police officers did that in anything other than a life-threatening situation, they could expect to be disciplined and sacked. So as the young woman was at immediate risk, despite ongoing agitation and distress, the decision was to ask the doctor to summon whatever he thought were the appropriate resources to do this. Police merely monitored the situation until that had occured and withdrew from the area, remaining nearby.
  • In extremis – five nurses on a ward have come together to administer medication to a patient after all efforts to persuade him to receive it have failed. They are appropriately trained to do this and have done it before, including with this patient. As the nurses take hold of the man’s arm, he begins to struggle. Attempts to secure him are not successful and as he pulls his arms away from control, he manages to completely pull away from the grip of that nurse on that arm. As his arm suddenly breaks free, the back of his hand hits the face of another nurse with such force that is causes a serious injury, fracturing his jaw. He disengages in agony, a second nurse intuitively disengages to check on him and then to summon help, leaving the other three attempting to contain the man whose agitation is escalating. 999 is called for an ambulance and police and officers arrive within 9 minutes of the call. By this time, the remaining three nurses are struggling on the floor with this man, obviously exhausted and screaming for help. Two of them have been further assaulted, albeit without significant injury. The officers take control of the man to help and the nurses move away, obviously ‘spent’. The nurse who rang 999 is the only one left who is neither exhausted nor serious injured and she asks the officers to keep the man restrained whilst they administer medication. There are no other nurses available. After this, one of the three nurses gets re-involved and the four of them – two nurses, two officers – move the man to a seclusion room on the ward.

LESSONS LEARNED

So what is going on here, in terms of the thinking?  Whatever was behind the nurse in the first example calling the police, we can probably agree it’s not appropriate – no current disturbance or violence, nothing that links to crime or serious risks to staff. Even if there were certain risks, as long as he’s sat on the floor in the corridor, there should be contingency for bring staff together to undertake this task. In the second example, we can see that it is necessary for the police to attend to assess things, but upon arrival, they haven’t done a huge amount because it’s not quite as serious as first reported. We can debate all day long whether it was ‘right’ to call the police, but that’s the judgement staff made – why not attend and assess things? Doesn’t mean the police automatically will do anything or will do very much, but at least we can say we’ve assisted in assessing what’s required and that any decision not to act is taken after a proper understanding of the circumstances.

We obviously can’t do that in the third situation because the police didn’t go! … it doesn’t need much explanation, does it?! – if nurses are being stabbed, we should be going! It’s a real shame that even needs saying and thankfully, such examples were very rare but in those sorts of things, if there is anything to discuss about it, that’s for later, not for now.

In the final example, it gets most controversial: the assessment the officers made at the time was that it was more dangerous to disengage and argue a point, than to help. One nurse and already suffered GBH injuries, two others were assaulted and three were, put frankly, completely knackered. There was one nurse left to actually administer the medication and no others available from nearby wards (for whatever reason – right here, right now, there were none available). If the police had not continued to assist, there could have been further serious assaults. Remember, when medication is authorised by nurses or doctors under Part IV of the MHA, nothing expressly prevents the police assisting – but we should obviously only be doing so in circumstances like this where there is no other option, at all.  We should also remember s139 MHA, which provides that –

“No person shall be liable, whether on the ground of want of jurisdiction or on any other ground, to any civil or criminal proceedings to which he would have been liable apart from this section in respect of any act purporting to be done in pursuance of this Act or any regulations or rules made under this Act, unless the act was done in bad faith or without reasonable care.”

I hope the document helps you out!


IMG_0053IMG_0052Winner of the President’s Medal from
the Royal College of Psychiatrists.

Winner of the Mind Digital Media Award.


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Training and Collaboration

If we look around the world at policing and mental health issues, it doesn’t matter whether we are looking at the incident-specific tragedies we read about or the wider issues raised by taking a broader overview: we only ever hear of two solutions in response to whatever we think problem is —

  • Training – the idea that if only police officers were better trained, outcomes and encounters would be very different. They need more ‘awareness’ training about various mental health conditions, de-escalation techniques and alternatives to detention that may be available locally.
  • Collaboration – the idea that if only the police and mental health services only work more closely together. And in real time, then we would also see improved outcomes and encounters because more appropriate people are then dealing with people in crisis, with police support to their decision-making.

I’m unconvinced, quite honestly. There is some obvious, intuitive merit to these ideas – my point is not to dismiss how important they are – but I wonder if you can also see the obvious problems here?! … there are several.

Even where there is evidence that these two solutions improve things – and there is some evidence they may help – it is all predicated on improving encounters people have with the police. It doesn’t even begin to touch on why people have encounters with the police in the first place; and what we could do to avoid that. I suspect there is much more than we can and should do.

POLITICS AND HISTORY

Look back over the last fifty to sixty years and you can see a series of political decisions (big ‘P’ and small ‘p’) about how we deliver mental health services which have significantly increased the likelihood of contact with the police. This, in turn, increases the likelihood that some people, following that contact, will experience detention, the use of force or criminal proceedings. This remains true notwithstanding efforts we may make to ‘divert’ people from the justice system. We regularly hear complaints about the prevalance of individuals suffering from a mental disorders in death-in-custody reports, fatal shootings and prisons statistics all over the world: this is what happens regardless of national Politics (big P), governments or wealth … although the extent varies, obviously.

This is not just true in the United Kingdom – look at the USA where police officers are frequently criticised for their actions: why are so few people asking the question about why US citizens have so little access to mental health services and why they are coming in to contact with the police? It’s not that it’s illegitimate to wonder about the police’s use of force OR to think that anyone is putting an argument that officers should not be held to account. This doesn’t preclude the support of ideas like Crisis Intervention Training but the idea that these things are solutions, is to assume that contact with the police was unavoidable, inevitable and the first possible point where society could intervene to support the vulnerable. We know this isn’t true – and if we could reduce the over-policing and criminalisation of people with mental illness, we have less of a policing problem to fix.

Look at some developing countries where there are often very few mental health services – the criminal justice system absorbs people where social capacity, tolerance or patience for their distress has evaporated. I saw this whilst working in Namibia just over a year ago. This doesn’t mean efforts by Namibia’s prison system to improve training for correctional officers was pointless, just that a junior prison officer can’t do that much to ensure support for someone two years before they are jailed. In Pure Madness (2003), award-winning journalist Jeremy LAURENCE reminded us that we don’t know whether or community care for mental health works, because we’ve never really tried to do it – at least not properly. We don’t resource mental health or community mental health services, anywhere, then when as a direct result of that decision, the criminal justice system becomes involved in responding to things that occur – from crisis incidents and minor crimes through to occasional high-profile incidents – we wonder about the nature or quality of the response and forget about the main problem here.

CRISIS RESPONSES

Only this month, we read of yet another inquest where the ‘crisis’ advice to someone who is already receiving care from a mental health trust is to ‘ring 999’, despite the fact that the police would inevitably be drawn in to a situation where they had no legal powers whatsoever and where no-one really knows whether fluorescent, paramilitary uniforms are going to be a positive addition to the situation or not. If you want to improve the experience of vulnerable people when they are in need of unscheduled care, they actually have to have unscheduled care options that are able to meet their needs.

There police are not always going to get it ‘right’, when it comes to mental health – look around the news and you’ll see examples of health services and professionals getting things wrong on mental health and they come pre-loaded with a three or five-year university degree plus years of post-qualification experience. There was a recent complaint on Twitter that police officers don’t have the skills of a consultants psychiatrist – it’s probably a good thing they don’t, given we don’t really want police officers prescribing meds and I’ve never seen a consultant psychiatrist rolling around the floor attempting to restrain someone. Policing and psychiatry are different jobs: we don’t want the skills to match!

There are many reasons why all of this is vital: we can’t always control the circumstances in which the police come in to contact with vulnerable people. A call may come from a person seeking support for themselves which they cannot otherwise get; or from a third-party because of concerns they have. That could be a family member, a neighbour or unknown members of the public who feel the police should be informed in order they can “do something!”. However, some incidents are what I usually call deflected demands – calls that were made to health services for a health care response to someone who is unwell, but which are then directed to the police. We need to know more about whether this is about the urgent management of risk and an inherent need for the police, or because we are demand managing.

By the time of police involvement in anything, the tools they have available to them, irrespective of their training and irrespective of their collaboration arrangements, are potentially very blunt. Whether they are appropriate to the situation in ensuring we don’t make people feel stigmatised and criminalised … who knows! By the time a police officer and mental health nurse turn up to private premises where most incidents occur, even the best trained police officer on the planet and the best mental health nurse co-pilot will still have just three options: do nothing; hope that talking achieves a different outcome; leave and hope you can persuade an Approved Mental Health Professional to obtain a warrant under the MHA.

TRAINING & COLLABORATION

So these two responses to problems may be helpful – this post is not arguing that they aren’t. If someone has come to police attention, a nurse sharing information, offering an assessment or an alternative way of dealing with a situation may well be helpful. Police officers better recognising the need for that can only support a diversionary approach is vital. It just isn’t the major problem to address here – unless we start talking about why and how those of us with mental health problems and in distress increasingly come to police attention and are less able to access established pathways of help and support when in distress, I fear we may just keep on trying to do thing wrong thing righter.


IMG_0053IMG_0052Winner of the President’s Medal from the Royal College of Psychiatrists.

Winner of the Mind Digital Media Award.