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New ABD Guidelines

The Royal College Of Emergency Medicine and the Faculty of Forensic and Legal Medicine have today published a new best practice guideline on the topic of Acute Behavioural Disturbance.

All 999 response officers, first-responders and street triage police officers need to know about them bearing in mind the number of deaths following police custody or contact that are still linked by Coroners to ‘restraint related’ or ‘cocaine related’ excited delirium, now more often termed acute behavioural disturbance.

The whole classification and conceptualisation of these ideas remains subject to debate within the medical professions, and the document alludes to this by stopping short of regarding these phenomena as a ‘disorder’. My point has always been: regardless of medical taxonomy, Courts and organisations like Inquest tell the police service that people die from whatever it is that’s going on and that alternative approaches are needed to learn lessons from history because we can control or reactions and responses, even if we cannot control the background or underlying issues.

It’s only sixteen pages long and when you strip out references, intros and covers, it’s perfectly consumable and the medical language is not impenetrable to those of us with a first-aid certificate as our highest clinical qualification!  It essentially says –

  • Suspected ED / ABD is a medical emergency until otherwise proved.
  • Restraint and restrictive interventions need to be seen as a last resort, although they may be unavoidable.
  • Urgent action to end restraint as soon as possible will be necessary.
  • Emergency Departments have a role to play – by definition then, so do the ambulance service!
  • It highlights the police as the inevitable first-responders because clincial presentation is associated with highly unusual, bizarre and often aggressive behaviours.
  • There is NO minimum safe period of restraint.
  • Treatment with benzodiazapenes, antipsychotics or ketamine may be required.
  • It could be safer to consider the application of Taser to allow for medication, rather than manual restraint, becuase the impact upon the person concerned may well be less, given the risks of acidosis in ED / ABD cases.

LEGAL ISSUES

What the document doesn’t massively touch on but which will be relevant for any police or paramedics who become connected to such incidents, is the legal basis for acting – that will also be relevant for EDs. The detention of a person by the police may have already occured before the involvement of healthcare professionals and it could either be for a suspected criminal offence or under the Mental Health Act 1983.  Neither of those things matter massively, because neither of them allows for the treatment of the person in the way suggested by this guideline. The Mental Capacity Act will be of relevance to those considering treatment options and where a case of ED / ABD is honestly assessed, there will be few limits to what is urgently justifiable under ss 5/6/4B of the MCA because these situations will be regarded as life-threatening until otherwise assessed and that may well take an ED consultant to do so.
But this revisits that old debate about violence and aggression. Only this week, as part of #MHAW16, I’ve seen police forces proudly telling their public how much they’ve reduced the use of cells for those detained under s136 MHA and that the examples which remain are only those where detainees are ‘unmanageably violent’. Always makes me wonder whose skill base has been able to say, “This is not clinically significant”.  The RCEM / FFLM document tells us that fatal outcomes can be expected in 10% of cases, so the odds are difficult ones to ignore if we are talking about potentially fatal outcomes. In reality, it seems we still have officers taking unmanageably violent detainees to cells and detaining them there, without that person having been seen by paramedics, without them having been seen by a DR in ED and with knowledge that the FME may be 90minutes or more away from the police station.

One of the Oxford University Press handbooks for Emergency Medicine says, “Most people who are violent need a policeman [sic] not a doctor.” Exactly the same intellectual proposition can be said in different way, “Some people who are violent need a doctor, not a police officer.” In reality, some situations are going to need both: because I’m fairly confident you don’t really want me taking decisions about your medical welfare when you lack capacity to do so for yourself and when 10% of the time, the outcome could be fatal for you.


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

Winner of the Mind Digital Media Award


Human Rights

Bullying and Intimidation

Did you see the recent piece by an anonymous NHS bed manager in the Guardian about being scapegoated on behalf of the NHS for the ‘beds crisis’? – if not, it’s worth pausing already to read the link before going any further. It really did set me thinking because of the various references to the police bullying and intimidating the writer, in the context of various difficulties ensuring the efficient admission of a patient to hospital. Then I had that horrible period of reflection, wondering whether I’ve bullied and intimidated NHS professionals, too? – I couldn’t help but conclude that I probably had been perceived in that way; and that I had once received direct feedback to that effect from an NHS CrisisTeam nurse who said they felt pressurised.

My job is, at the end of the day, about conflict management and conflict resolution, set against the backdrop of having various legal responsibilities. Police officers use a range of tactics to go about their business and it can look and feel unpleasant: we use coercive force, we threaten the use of it; we arrest and prosecute people – sometimes we threaten such a course of action to promote compliance with less restrictive outcomes such as drunk people going home quietly and so on. I can’t truthfully say that in the course of my work I have never raised my voice to a member of the public as a tactic in making my communication understood and impactive. Within the arena of mental health, I can’t say I’ve never done this either.

Maybe this makes me an intimidating bully in the minds of some?

ANONYMOUS HIT AND RUN

I can almost understand why a bed manager wishing to write such a piece as this would do so anonymously.  Those castigated within it have no ability to reply and the piece itself raises questions about legal compliance of individual professionals, mental health trusts, CCGs and local authorities. Whilst it doesn’t tell us anything we don’t already know, it re-emphasises the pressure in the acute mental health system, which is something we know is also far worse in the CAMHS and LD systems. But I got to the end of this piece and wondered whether or not the author had escalated these concerns via the appropriate channels to the Trust management, the CCG and the CQC.  Maybe they did – writing this piece under the cover of anonymity did make me wonder whether this was their preferred way of doing so.

I want to start by focussing on that nugget of misunderstanding in the third paragraph of the piece which makes me think they author doesn’t understand the implications of the points they raise and why their protest is mis-directed.

“I’m often faced with harried community mental health professionals, struggling to manage a newly-detained unwell individual while surrounded by exasperated police and ambulance workers, collectively waiting for the private sector to decide whether they’ll provide a bed halfway up the M1.”

So here’s the major problem that might let us see this bullying and intimidation in a new light: if the harried professionals in the community haven’t yet been supplied with a bed by our scapegoated author, then the person is not ‘newly-detained’! AMHPs never cease to remind us all that you cannot make an MHA application without knowing where the bed is and will most likely refuse to do so until the bed manager has identified it on behalf of the first-assessing DR. It’s far from unusual that AMHPs who are struggling in that context would have requested police support, otherwise I’ve known scenarios where they remain unharried at the premises until the bed is found.

MURDER

In my favourite example of this kind of problem, I had been contacted at home by a Detective Inspector who was the Senior Investigating Officer for a murder inquiry. His suspect had been in custody for 27hrs after a superintendent’s extension of detention and it was now 5pm. A recent assessment of evidence had revealed that they did not have sufficient evidence to charge a young man with any offence and he had been assessed by professionals as requiring admission to hospital under s2 of the MHA. One of those discussions began where the medium secure unit refused to admit him unless the police charged him with a crime and the psychiatric intensive care unit refused because he was too risky, having probably killed someone.

That impasse had run it’s course for a few hours at the point where I was called. The DRs involved had told the custody officer at 5pm that they would be back the following morning at 9am to re-start their search for a bed and looked fairly blank about what the sergeant should do at 2am when his ‘PACE clock’ ran out! I remember getting out my laptop at home and writing a letter for the DI. I advised him to whack it on a job letter-head and give a copy to the DR and the AMHP going through all the standard explanations and requests for this kind of situation and meanwhile, I took advantage of knowing a senior person in the MH trust who helped resolve the impasse. Bed found within an hour – murder inquiry derailment resolved.

I’ve absolutely no doubt that those involved in the MHA assessment felt pressured – that was absolutely the intention of it. I suspect that ACC Paul NETHERTON also intended that when he took to Twitter and made national headlines in November 2015 in respect of the 16yr old girl from Devon who had been languishing in police custody for two days. Making views firmly known, issuing threats of non-passive reaction to unlawful situations and warning of consequences is absolutely a part of making headway in some situations and I’d want the police doing all of this if it were my relative whose rights were being denied to them, whilst holed up in some police custody area.

TACTICAL COMMUNICATIONS

In the case where I was firmly informed that I was pressurising and intimidating, I had been caught out by a CrisisTeam nurse ‘interfering’ in the processes of admission for a patient who had been in police custody after arrest for a minor offence in excess of 30hrs. I had decided I should probably start ‘interfering’ and ‘initimidating’ people having commenced work at 2200hrs that day as the duty inspector and found an undoubtedly illegal detention in my cell block. An AMHP was unable to comply with s13 MHA because of there being no bed from the trust and so they had become an unwitting party, along with the CCG and the NHS trust concerned, to an Article 5 ECHR violation – they were insisting that the police do not release the patient despite having been told by the custody sergeant that he had run out of lawful grounds on which to detain them.

The conversation was an awkward one: I re-hashed that old stuff about the Mental Health Act Commission’s guidance about section 140 MHA and applications in circumstances where there is no bed available; I pointed out that I would be recommending to the early shift that they asked police legal services to consider High Court action to expedite the onward discharge from police custody; I asked for a mental health nurse to be deployed to police custody overnight, to ensure the wellbeing of the patient, bearing in mind the distress they were in and our concerns for their welfare after more than a day in dark concrete cell. I will be honest: I didn’t expect any of this to go down terribly well! That wasn’t the point – but it did appear to result in progress and a bed found within two hours.

We all understand that MH trusts say they are struggling: I know from colleagues and friends in those professions that budgets have been cut in some trusts by 20% despite the overall protection of the NHS budget in the last paraliament and I’ve seen for myself how both NHS England and individual CCGs have cut providers’ budgets. I’m not unsympathetic to that. But when a police officer is aware that laws are being violated in respect of a vulnerable person in custody or at risk in the community and especially where the police service are being expected to suck up the consequences of that in vacuum of legal powers to ensure safety, it’s not unreasonable that concerns are raised, that threats are made about counter-reaction to those unacceptable circumstances. It’s less then a handful of times I’ve ever told an NHS professional that I was going to contact a solicitor with a view to considering legal action to protect a vulnerable person and the custody staff caring for them and on each occasion, it has brought a solution to the impasse.

UNPROFESSIONALISM

Policing is about conflict management and conflict resolution: various tactics are deployed to manage and resolve the various conflicts in which we become engaged and whilst no-one is going to defend bad manners, aggression or unprofessionalism, it has to be accepted that assertiveness, exhibiting frustration and declining to accept that which should not be tolerated are quite different things.

It was the US police chief Charles RAMSEY who recently said that when you stop viewing police work as law enforcement and start viewing it as the maintenance of constitutional and human rights, that you start to understand how the police can be on the same side of the community in the various struggles that it faces. Sometimes, public service organisations will find themselves in conflict with each other and I’m aware of situations which reverse this principle, where the police get things wrong. However – and without wanting to to over-egg the pudding here – our scapegoated author is referring to various situations that can and have been found to amount to human rights violations.

I’m not quite sure why they thought the police would keep quiet about that or do nothing?


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

Winner of the Mind Digital Media Award


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Crime Recording Rules

It is a criminal offence in the United Kingdom to abscond or escape from lawful custody – two separate ways of phrasing the same common law offence. Most typically, we think of this where someone has been arrested by the police and after arrest, they have found a way to escape; or perhaps someone who has absconded from a prison or a prison service vehicle. When you stand as a criminal defendant in a courtroom, you are also considered to be in the lawful custody of the court and if you leap the dock and then run, you are also liable for the offence. I remember about fifteen years ago a defendant did that at Birmingham Crown Court, which is a modern three-story building of courtrooms: to make good his escape from the building, he jumped all three floors of the atrium in one go, smashing his ankles upon landing and still trying to get away … security had little problem taking a leisurely stroll down the road to catch up with him as he attempted to hobble!  Jailed, obviously.

But how does this all relate to the Mental Health Act (MHA) detention, which we don’t traditionally think of as ‘absconding lawful custody’ – we don’t usually think of it as ‘custody’ at all and as Dr Lesley STEVENS of Southern Health reminded us, “We don’t lock people up!”.  As with all crimes, the Home Office issues guidance to when offences should be officially recorded in the crime statistics and the rules were updated in April 2016 – the overall guidelines are known as the Home Office Crime Recording Rules. I emailed all force mental health leads about this a few months ago, ahead of the change, but it didn’t occur to me to write a post about it until a recent case in London.

REECE DAVIS

Mr DAVIS is a 23yr old man who was a patient at the Bethlem Hospital in Beckenham, south London. He was detained there under s37/41 MHA, which means he has already had contact with the criminal justice system after an alleged offence whilst mentally ill. The court obviously found it necessary to authorise a hospital order under s37 MHA because of mental health problems but they also imposed a restriction order under s41 having been satisfied that Mr DAVIS posed “a significant risk of harm to the public”.  He was recently taken from the Bethlem Hospital to Croydon University Hospital from where it is alleged he escaped through a window. He was later arrested for attempted murder after a man claimed to have been stabbed whilst jogging.

From a criminal offence point of view, the question then arises, do we record an offence of escaping from lawful custody?  These are the new and current rules –

  1. If someone is detained in hospital under Part II of the Mental Health Act 1983, no offence is recorded if that person absconds from hospital – this will cover sections 2, 3, 4, 5, 6, and 7.
  2. If someone who was detained under Part II has already absconded and then been re-detained by the police, an offence is recorded if that person escapes from police custody whilst being taken back to hospital – this would include patients who are AWOL under s18 and those who are re-detained under s138 MHA.
  3. Where someone has been detained under s37/41 of the MHA, the offence is recorded as soon as possible after they escape from hospital or from escorted leave, as in Mr DAVIS’s case – I’m having to infer that this would also cover patients who are transferred to hospital from prison under sections 47 or 48 and are then also ‘restricted’ under s49. The MHA requires such patients to be treated ‘as if’ they were restricted under s41.

What the Home Office were not clear upon, is those who abscond from sections 35, 36, 37 (without restriction), 38 or 45A – these are all Part III detention provisions and it seems sensible to me to record them for the same reasons but take advice from your crime recording registrar because this is not what the HOCR say, but neither do they say what should be done!

This gives the effect of meaning that absconding from civil detention under the MHA, where admission was not connected to criminal offending that was taken to court, should not lead to patients being criminalised if they absenting themselves from hospital or fail to return. However, where hospital admission is at the direction of the criminal justice system, the offence of escaping is recorded and in need of investigation straight away. Makes sense, if we think about it.


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

Winner of the Mind Digital Media Award