img_2938

Police Crisis Care Responses – part 1

Following various discussions on Twitter about crisis care responses and policing, @DrEm_79 has undertaken a short study to gauge the views of the most important people of all: those who rely on public services when things become very difficult. This is the first of two posts resulting from that research survey and I hope you will agree it demonstrates much that should give us pause and thought. I’m therefore delighted to host Em’s write-up of her findings about which you will hear more if you’re attending the above conference in Warwickshire on 24th May —


If you or a loved one were unwell at home or in a public place, who could you call for help?

For people with mental ill health, the reality is that often police are involved in responses to health crisis. Services talk about keeping people safe in crisis, and the police are seen to have a role in this in a variety of mental health situations, but this only usually encompasses physical safety. Few studies have looked at the psychological impact of police involvement on people who are unwell.There’s ongoing debate about police involvement in mental health, much of it framed in economic terms, or measured by numbers of detentions under section 136 of the Mental Health Act (Heslin et al., 2016, Irvine et al., 2016). As someone personally impacted by mental ill health, and with much more experience of police response to crisis than I’d like, those outcomes aren’t the ones that matter to me. Yet reading the various reports and papers about policing and mental health crisis, service user voices seem to be almost unheard, some evaluations consulting only with professionals not service users, and where there is service user feedback, it being collected and filtered by those delivering services.

Two million pounds has been spent on pilot studies looking at Street Triage schemes (Reveruzzi and Pilling, 2016) – where police and health services respond together to mental health crisis incidents – they have received media attention, claim wide ranging successes, and there have been recommendations to extend the pilots (Reveruzzi and Pilling, 2016). There is an assumption that attempts to reduce detentions in cells and reduce the use of s136 will decrease harm to service users, but no studies have examined in depth potential harm to services users from police involvement in first line responses to mental health crisis, and no Street Triage studies have looked at who service users want to respond to them in crisis

To better understand the experiences people with lived experience of mental ill health have had with police response to crisis, I conducted an online pilot survey. The study was not funded, and independent of services. It was a short survey, just five questions long to enable people in lots of different situations, including people who might be unwell currently and find it difficult to concentrate, to be able to take part. The survey can be found here – http://www.surveymonkey.co.uk/r/VDPNSLJ

What did the study look at?

The aim of the study was to explore experiences of police responses to mental health crisis from the perspective of those with lived experience of mental ill health, either themselves or as a carer.

The study questions looked to answer three research questions:

1. Do police responses to mental health crisis have a helpful or harmful impact on people who are unwell? Are these impacts different in the short and longer term after the event?

2. What are people’s experiences of police responses to mental ill health?

3. Which services do people with lived experience of mental ill health want to respond to them when they are in crisis?

 How was the study conducted?

The survey was online only and cross sectional in design. No incentives were offered for participation. A small pilot was conducted to ensure the questions did not cause distress.

Study recruitment was completed by sharing the link to the online survey on Twitter and Facebook. Within two days of the survey link being shared, 100 people had responded.

The five questions in the survey looked at whether people had experienced a police response to themselves, or to someone they cared about; whether people had experienced helpful or harmful short and long term effects from police responses to crisis; and who people wanted to respond to them in crisis. There was also a question where people could talk about what had happened to them and the impact of police responses in more detail.

So what can 100 people tell us about police responses to crisis?

Who took part?

94 of 100 people who completed the study said that they had experienced a mental health crisis which had involved a police response, either themselves or to someone they care about. Four people said they had not experienced this, and two people did not answer this question.

Of the 94, 70% had experienced the crisis themselves and 30% as a carer.

What impact did police involvement in crisis have? – Short term impacts of police response to mental ill health:

When asked what impact police involvement in the crisis had in the short term, 95 people answered the question.

  • Of these 95, 5 people (5%) said the police involvement had no impact.
  • 44 people (46%) said the police involvement had either been helpful or very helpful.
  • 46 people (48%) said police involvement had been either harmful or very harmful.

Eight people added comments to the question. One of these said the question was not applicable to them, and another contained factual information about the outcome. One response was very positive about the impact the police response had:

 “They couldn’t have done more to find my friend (they had gone missing with fears for their safety) and they couldn’t have been more caring & helpful when they found them.”

 The other six comments described negative impacts from police involvement. These included feelings of criminalisation, increased mental health stigma, loss of trust in police, worsening of distress, and worsening of suicidal thoughts. One comment described a 14 year old being kept in a police cell for 26 hours.

“They made sure I was physically “safe” and alive but they made my suicidal feelings and distress worse. After they left I went from feeling suicidal to determined and making plans to end my life.”

“Scary. Felt criminalised afterwards lost all trust in police and stigma from people who’d seen me out in the van.”

Longer term impacts of police responses to mental ill health:

Participants were also asked what impact police having been involved had in the longer term, 97 people answered this question.

  • Of these 97, 27 people (28%) said the police having been involved had no impact in the longer term.
  • 17 people (18%) said the police having been involved was helpful or very helpful.
  • 47 people (48%) said the police having been involved was harmful or very harmful.

The question also had an option for people to not answer harmful or helpful but add their own comment instead. 6 people (6%) did this. Of these one person felt the question didn’t apply, one was positive about the involvement of the police:

“[…] the brilliant way they dealt with the incident gives us great confidence.”

Four of these comments from people who had not completed the scale of helpful to harmful indicated the response had been harmful:

“Very detrimental”

“Long term trauma from being locked up”

“An increase in medication. leading to excessive amounts of prescribed drugs. suicidal thoughts. fear and anxiety. PTSD.”

“Scared of police. Don’t tell anyone and try to hide when am in crisis, scared it will happen with police again”

 Which services do people with lived experience of mental ill health want to respond to them when they are in crisis?

This question asked: If you or someone you care about were mentally unwell in a public place or in your home and needed help because of your/their mental health, which of the following services would you most like to come to help?

100 people answered this question, cross referencing this with the first question this means that four of those responding did not have lived experience of police responses to crisis either themselves or as a carer, and a further two people may not have.

The question asked people to pick the service they would most like to respond. The options were: mental health services, general health services, social work, police, a combination of police AND health or social work (similar to a Street Triage team), a combination of health and social work but NOT police (similar to high fidelity models of some mental health crisis teams), or other.

Participants indicated the following preferences for response:

  • Mental health services, e.g. mental health nurses or doctors – 31%
  • General health services, e.g. ambulance or GP – 7%
  • Social work, e.g. AMHP or MHO – 4%
  • Police – 6%
  • Combination of police AND health/social work – 16%
  • Combination of health/social work, but NOT police – 27%
  • Other – 9%

Of the nine people who wanted a response other than those services listed:

  • One person said they were now reluctant to engage with any service.
  • One person suggested an Independent Mental Health Advocate.
  • Four people suggested family, along with Samaritans (two people), staff already paid to look after the person (one person), and the early intervention mental health team (one person).
  • One person differentiated between locations, saying police should respond in public places and mental health professionals should respond to incidents at home.
  • One person said police and ambulance.
  • One person said health professionals only, and suggested a mental health paramedic service made up of mental health nurses and social workers, and a mental health A&E equivalent,

 What are people’s experiences of police responses to mental ill health?

Participants were asked if they would like to say more about the impact of police involvement. 61 people answered this question using free text with no word limit. These answers have been analysed thematically. Themes emerging included: loss of trust in police or in health services, impact on health behaviours – disinclination to seek help again in future and trying to conceal symptoms to avoid a further police response, feeling let down or betrayed by health services, criminalisation including impacts on work and volunteering, worsening of symptoms, associations with trauma both with the police response as a source of trauma, and as a trigger to previous trauma, detention in cells, stigma, physical restraint and containment and physical injury, short and long term distress, and shame. These will be discussed in a follow up blog looking at the qualitative analysis in more detail.

What do these results mean?

Only 16% of participants, given a choice, would choose police and health/social workers to attend together to a mental health crisis, and only 6% would choose police. This means that given a choice 78% of people would not choose for the police to be involved in a response to them in a mental health crisis. Mental health services were the most popular choice to respond with 31% of participants preferring this. The second most popular option was a combination of health and social work but not police with 27%. These findings have implications for those who commission services for mental health crisis, and those involved in frontline services making decisions about how best to respond to incidents. There is a disconnect between what service users want and current trends in service provision.

Many people (46%) rated the impact of police response as helpful in the short term. This is reflected in the comments people made describing kindness and compassion of individual officers. However in the short term, more people (48%) found police involvement to be harmful than helpful. When this question was extended to the longer term impact of police involvement, the results are striking, only 18% of people finding police involvement in the crisis response to have had a helpful impact in the longer term, and 49% of people considering it to be harmful. This matters because almost half of people say they have been harmed by the police response, yet little work has been done looking at what aspects of response cause this harm. Also feedback with service users rarely looks at longer term impacts of contact with services, so these longer term harms may be missed by some service evaluations. It also raises questions about the types of harms people are experiencing, and how these can be prevented.

The qualitative analysis of the free text question provides some initial answers to these questions about the types and causes of harm, and will feature in a follow up blog. The comments left on the questions analysed here also provide insight into this, with descriptions of longer term traumatic effects of police involvement, and in the short term, worsening of suicidal thoughts. These suggest that despite an emphasis on safety in police responses to mental health crisis, paradoxically responses in some cases cause harm, and the psychological safety of people in mental health crisis needs to be better understood. Impacts on health behaviours and criminalisation of service users are also concerning, and are discussed more fully in the follow up blog.

What are the limitations of this study?

This was a small study without funding, and it has some limitations. Sharing the study on social media only will have limited the range of people who could take part and may have introduced bias, although question answers did indicate that people in a range of situations, including people currently detained in hospital under the Mental Health Act had participated.

As a service user who has my own experience of police responses to mental health I may also introduce bias into the design and analysis of the study, and positioning it as service user led research may also have limited or influenced who took part. However the responses describe a range of positive and negative experiences and some participants were keen to praise police responses. The independence of service user led research could also be seen to attract responses from people who might not take part in research conducted by services. If the study was extended and funded these biases could be addressed more fully.

How were ethical considerations addressed?

As a small service user led study this study was independently conducted and not approved by an institutional ethics committee, however ethical considerations were important to this study, and the study was conducted according to ethical good practice. No service user data were collected so participants are not identifiable. The survey was piloted with a small group of people with lived experience of mental ill health to ensure the questions did not cause distress. It was designed to be short and easy to complete and the Samaritans number was given at the start of the survey so even people who did not complete it would have a route to get help if thinking about the issues caused them distress. The introduction to the study also explained who was collecting the data (a service user) and why, and offered an opportunity to ask questions.

Following the survey being shared several service users tweeted me and said it had been interesting or easy to complete. No questions were compulsory so people could take part in the study even if they did not want to answer particular question,

 Conclusion

Despite investment in Street Triage schemes, 84% of those with lived experience of police responses to mental health crisis would prefer other services respond to them if they had a choice. The study suggests some individual police officers are having positive impacts on individuals, and 46% of people find police response to crisis helpful in the short term, however this impact changes, and only 18% of people found police responses helped in the longer term. People also described longer term traumatic effects of police involvement, and worsening of distress and suicidal thoughts in the short term. .This study points to the need for better understanding of the impact of police responses on people in mental health crisis, including both short and longer term effects. It also highlights the importance of service user involvement in service design and research.

Coming up – Qualitative analysis of participants’ experience of the impact of police involvement in mental health crisis

References

HESLIN, M., CALLAGHAN, L., PACKWOOD, M., BADU, V. & BYFORD, S. 2016. Decision analytic model exploring the cost and cost-offset implications of street triage. BMJ Open, 6.

IRVINE, A. L., ALLEN, L. & WEBBER, M. P. 2016. Evaluation of the Scarborough, Whitby and Ryedale Street Triage Service, Department for Social Policy and Social Work, University of York.

REVERUZZI, B. & PILLING, S. 2016. Street Triage – Report on the evaluation of nine pilot schemes in England. University College London.

BBH218 twenty pounds note twenty pound notes money sterling currency bundle stack

What Cost Progress?

One of the main reasons the Home Secretary emphasised that we need to make progress on policing and mental health is to free up police time to concentrate on other issues – mainly around the broader crime prevention agenda. I don’t think she is trying to imply that police time so the most important thing in the world or that there is no overlap at all between mental health issues and core police functions. She just seems to be making the point that the police time committed to this overlap is considerable and could very obviously be reduced. So various things have been happening to deliver progress on this under the overall banner of the Crisis Care Concordat agenda. It certainly can lay a highly intuitive claim to some impressive results –

  • reliance upon police stations as a Place of Safety massively down since 2010, from over 11,000 to the cells down to about 4,000;
  • the overall use of s136 MHA in street triage areas massively down, typically by 25-33%; and
  • overall satisfaction of those professionals and members of the public who have experience of this stuff seems to be up.

What’s not to like?!

One of the main problems is that we need to fully analyse this to understand whether or not the ‘progress’ we claim is actually just making this problem worse, from the point of view of police time. If it is, it raises some interesting public policy questions for us all.

Before I get in to details, I want to make one thing clear: progress at the interface of mental health and policing is not and should not just be about saving police time. The service benefit to the public is obviously more important and nothing is free of cost or unintended consequences. Improving the experience of vulnerable people who come in to contact with the police is about far more than the amount of time the police will expend and I will highlight some examples where it will quite rightly involve greater time and effort. But what follows are mainly examples of where, in an effort to save time and resources, we’ve managed instead to spend time and resources. It begs the question: if we have also improved the experience of those vulnerable people for whom the police have had to provide a response, to what extent should a Chief Constable be paying – quite literally – to improve that crisis pathway to assessment and care for vulnerable people? My final caveat on this post, is that we still don’t have proper data on this stuff – people saw fit not to collect it, notwithstanding that they were advised, so I’ll try to bear that in mind as I am inevitably forced to generalise and over-simplify!

PLACE OF SAFETY

In an ideal world, your local police officers will use s136 responsibly and correctly, leading to the removal of vulnerable people to a Place of Safety only where necessary and that person will be handed over to the NHS within half an hour for assessment and the police will leave. Such a process doesn’t happen anywhere in the United Kingdom, to my knowledge, but it’s what we all agreed to in the Royal College of Psychiatry standards on s136 which were published in 2011 and were slightly updated in a guide to NHS commissioners in 2013.  Always amazes me that our NHS can transplant human organs and knows what will happen tomorrow if there is an Ebola patient, but we don’t know how to staff a building to accommodate a vulnerable person in crisis for an assessment of their needs and we certainly don’t know where they will go tomorrow afternoon if they’ve also consumed half a bottle of vodka to quieten the voices in their head.

Less than a decade ago, 66% of the 18,500 people detained under this power were taken to police custody; and none of the 33% who were spared this indignity benefited from a service that worked according to the national standards, referred to above.  Since then, ‘progress’ means we now see only 20% of 24,500 people taken to custody – we can agree this is a good from the point of view of more timely, dignified assessment for the person concerned (albeit someone should be examining why the use of the power has gone up by around a third in a decade).

  • The average assessment time in police custody is still around 10hrs, where the cells are still used.
  • The average assessment time in an NHS PoS is around five hours.

If the police remove someone to custody, they don’t always have to leave an officer there to undertake one-to-one or camera observations of someone. Custody staff can often do it, and if camera observation is required, one member of staff or police officer can watch multiple cameras at the same time. Where someone is taken to an NHS PoS, it is still usually necessary for two officers to remain there until the assessment is completed; and if an inpatient bed is required after admission, it will take longer again.  Do the maths on this at your leisure, but you’ll find it means more police time is invested in staffing unstaffed NHS Places of Safety than if we used the cells as often as we did a decade ago. Many NHS areas will simply say they don’t have the funds to properly staff their Place of Safety in such a way as to ensure it complies with those RCPsych standards so the police will have to remain.

In other words, the ‘progress’ we’ve made is now costing the police more than it was before, because NHS trusts often don’t staff their Places of Safety.

STREET TRIAGE

Meanwhile, of course, in an effort to reduce the use of s136 and avoid the use of custody, we have seen street triage schemes emerge.  I won’t repeat here what I’ve already covered but we know that from the point of view of s136 reduction, many ST schemes now mean the police have tripled their resource committment to managing the workload.  And we know that the very existence of triage schemes is resulting in existing NHS structures like out of hours GPs, crisis teams and community teams, asking street triage to pick up work that the police would not have previously been involved in, because nothing in the referrals is anything that you might recognise as a core police responsibility? (Yes, I’m aware of the other, non-s136 related workload in private premises but someone in the street triage world forgot to record that, never mind analyse it.)

It must be right that I acknowledge the impact of particular triage schemes varies depending on the model operated by the force you look at; and depending upon the number of days and hours that are covered. The resulting mathematics therefore varies and I’m more than satisfied that some models of triage are saving police time, but for me this only reinforces the importance of understanding not only the demands we face, but also the reasons why we face them – it’s about the overall flow of patient demand right through the mental health crisis and police system. We do nowhere near enough of this mapping, currently.

So I ask –

To what extent is it appropriate that a Chief Constable pays – both literally and in resources – to improve NHS Place of Safety and other crisis care pathways when it is also involves more demand being deflected to 999 than was previously the case?

The amount of police time spent is not the most important thing in the world – but it’s not irrelevant either and it only becomes a discussion in the first place as a result of choices some areas have made about the accessibility of the unscheduled care services they offer. When I have mental health nurses and AMHPs themselves telling me that there are conversations going on in rooms to which the police are not invited which involve explicit discussion about how much more crisis care demand can be deflected to 999 (including to A&E), then it means we cannot totally ignore the impact on police resourcing where it is connected to deliberate decisions by NHS managers*.

* If anyone is tempted to point out something political about cuts – 1) I’m a policeman, so I’m not going to do anything party political; 2) police budgets increased by less than the NHS MH budget in real terms 2001-2011; and have since decreased by more since 2011.

img_3030

High Hanging Fruit

This is really difficult post – and it’s necessary because I’ve often thought in policing and mental health we spend a lot of time avoiding the really difficult conversations and picking the low hanging fruit. I would argue that much of the time spent discussing Place of Safety provision, street triage schemes and liaison and diversion services: they are all examples of the low hanging fruit. I recently watched a person in a meeting have s moment of clarity that some fruit hangs higher and brings in to view a whole host of debates – I want to highlight some of them. The one I’m not going to mention here, because I intend to cover it soon, is that all those low hanging initiatives are ways of avoiding the discussion about how the will or capacity to intervene early has been lost and that this is measured most keenly in the extent to which people are criminalised. More on that next week.

I heard recently that one area has more or less abandoned its Crisis Care Concordat (CCC) plan, just over two years after the Concordat was published and made subject to an overview process via the mental health charity, Mind.  We recently saw publication of the final evaluation report of the CCC, and I think it’s fair to describe it is ‘mixed’. I don’t think many people seriously doubt that the whole agenda has been a positive step in bringing together organisations who, in some areas, didn’t have an effective relationship. But getting together to chat about stuff and write it down, doesn’t make it happen and I think that summarises my view of the problem with it. My son has got a massive Christmas list on standby for December 2016 and we already know that no amount of careful handwriting is going to see him own those items come Christmas!

I remember asking police forces about the CCC when I first arrived at the College of Policing and received various emails saying, “They won’t talk to us – they’re not interested” and and so on. The number of those replies have dissipated over time but the police seem reassured that the lower hanging fruit is being gathered. I hear many mental health trusts and many forces highlighting what a good relationship they have and how important it is to work in partnership. Indeed, it has long since been my experience that where you start a conversation about the details of particular aspects of partnership work, in an effort to ensure that it works properly, you are often reminded of the importance of partnerships if the police part of that discussion is not willing to accept a status quo where they are committing more resources than they should be, because of NHS choices not to do what we all agreed they would.

I’m sure an example would help! –

POLICE POWERS AND DUTIES

Recent work on calls for police responses to inpatient mental health wards have led to discussions about staffing levels in the NHS – you may remember that NICE have stopped work that Government originally asked for on what constitutes safe staffing levels. Some mental health inpatient wards are occasionally not staffed in such a way as to ensure they could take care of those predictable aspects of being a mental health service provider. The RCN point out it is often not unusual to find 3 nurses during the day and 2 at night for a ward of 15 patients. (I do understand that not all available staff are nurses, there may be others available, too). But given that restraint can involve five staff, how do you do it? In some areas, anything that is known to be necessary occurs at shift change when double staff are available.

Accepting that not all wards involve similar levels of ‘therapeutic security’, these restrictive functions are usually understood to be –

  • preventing people who are legally detained from leaving,
  • being able to administer medication under Part IV of the Mental Health Act;
  • secluding a patient or transferring them between wards and units.

It is an inherent risk of running an organisation that detains other people against their will and occasionally forces medication and location transfers upon them, that some patients will object and resist – I’m genuinely unable to see it any other way. I remember the occasion as a duty inspector running a 999 response team where we were contacted around 6pm to be asked if officers could attend a ward at 8pm to restrain a patient for medication because they were insufficient staff? The answer was, of course, the we couldn’t and the caller was advised to start ringing their managers to escalate any staffing problem they had. No current disorder or disturbance, no immediacy required – not something that needs to involve the police, assuming the organisation has the right plans in place around those functions listed above.

But this is really awkward isn’t it, as it starts to edge in to difficult ethical and legal territory? … in recent work, which has involved the College of Policing asking an independent QC to give legal advice on police powers and duties in these contexts, one question in particular arises about whether the NHS should be calling the police to wards to assist in preventing an assault if a patient is becoming disruptive; or is likely to be resistant and aggressive where staff must attempt to seclude, transfer or medicate a patient. It’s hard to resist the fallacious lure to answer the question that has been posed to me several times recently, “Does a nurse have to be assaulted before you’ll come, then?!” … it sounds like a relevant question, doesn’t it? If you say “Yes”, you’ll be slaughtered for appearing to countenance NHS staff being attacked during their work – which we all agree is an outrage – and if you say “No”, you open up the police to attending incidents that the NHS should be handling with sufficient staff who are trained and, if necessary, equipped. Obviously, I’m referring here to those functions that are obvious implications of the work these trusts do in circumstances where they have greater powers to handle the situation than the police (if the police have any at all).

It is slightly clearer where there has already been an unforseeable incident that involves significantly raised threats and / or an obvious criminal offence: if that patient were in possession of a weapon or something that could be used as one upon return from authorised leave, the risks are higher and it’s more obviously a police responsibility to become involved – that would be the case in any hospital or location. It is a challenge to draw any kind of distinction between what is a forseeable NHS responsibility and what could occur within a hospital that amounts to a police responsibility – but it can be done. It seems to be when we get in to the territory of attempting to define* these thing, we often hear that legend rolled out that we have to keep making sure we work in partnership, like the CCC says. I admit to feeling that this is often a euphemism for “can you please make sure you keep doing certain things that we know are not your responsibility?” I can’t help but wonder whether this is because of the cost of ensuring safe staffing levels – I admit I’d love to know why NICE stopped this work where it relates to mental health.

PERCEPTION

More than once I’ve known NHS managers describe their partnerships and relationships with the police as extremely positive: you only need to look around various social media platforms to see evidence of this. I admit to wondering on occasion, whether the closeness can create a blindness? One NHS manager recently told me that their relationship with their police force on s136 and Places of Safety was ‘perfect’ – they have meetings, they’re on first name terms, they have each other’s mobile numbers and can ring at any time to discuss problems and solutions to problems: it’s just perfect. That person looked stunned when I said that I doubted it.

I’m sure the relationship is courteous, good-humoured and professional and it can’t be a bad thing that there are open channels of communication between senior operational managers, but if the Chief Constable is still staffing unstaffed NHS Places of Safety and frontline officers are moaning about being bounced around the county looking for an PoS premises that will accept them and have to remain there with low risk patients for almost 24hrs (real example), it seems we need better insight in to what is going on. Things seem far from ‘perfect’. I do wonder whether there is a CCC plan that has moved an area forward on this particular issue, or on inpatient ward staffing levels to reduce calls on the police to coerce patients? Is there a CCC plan that means police officers or paramedics attending crisis incidents in private premises that can only be realistically solved by an AMHP pitching up rather quickly with a s135(1) warrant and a DR can access those people and  those mechanisms in a timescale that isn’t edging towards the geological?

This is some of the high-hanging fruit which the CCC agenda may highlight or document, but which it often doesn’t address. If CCGs don’t commission services in a way which allows for sufficient NHS staffing to detain or restrain and medicate or transfer patients on wards, to what extent is it a role for the Chief Constable to undertake bearing in mind he or she will usually have no legal duty whatsoever to do so? The answer to the question “Do we have to wait until …” is that NHS organisations have legal responsibilities to patients, staff and anyone else who enter their premises (including to police officers and paramedics!) to ensure safety by mitigating forseeable risks. And ‘forseeable’ in this context doesn’t mean that the risks we’re talking about are only those which will be frequently occurring.

THOUGHT THINGS

So here’s the challenge, in a thought experiment

An incident occurs on a ward where an assault is threatened by a patient who is acutely unwell, unless staff allow him to leave. When this is refused during an attempt to de-escalate the situation, he attempts to force open the doors of the ward and leave. Staff manage to get him away from the door and ring 999 for the police. Upon arrival, they are not raising a criminal allegation around the man’s behaviour or conduct because it is recognised that he remains psychotic after a recent admission under the MHA. The unit is staffed by too few nurses to undertake these functions and in any event only one of them is trained in restraint to a level that is beyond their basic, ‘breakaway’ training  (to maintain their own safety).

The request of the police could be to restrain the patient for medication or to help move him to another ward or unit where there is an available seclusion room. Either way –

The police arrive and contain the situation by surrounding the man on the ward, attempting to engage him in discussion thereby preventing any Breach of the Peace or criminal offence – order restored without any ongoing need to actively restrain him. The senior nurse or doctor makes the request (to restrain and / or transfer) and the senior officer declines to do so, arguing it is an NHS responsibility to administer the Mental Health Act but they will remain to prevent control being re-lost whilst NHS arrangements are made. The lead clinician states they do not have staff available to them and the police suggest contact with their on-call senior manager to make the necessary decisions around these responsibilities.

What is that police officer doing wrong, legally speaking, bearing in mind they don’t work for the NHS?  It could be argued – and just to be clear, I am arguing it – that the police re-taking control of a situation and containing it whilst affording time for NHS arrangements to be marshalled is as far as legal duties upon the police extend. (Subject to any duty that arises to criminally investigate any alleged offence, which most usually will not necessitate an immediate arrest and which returns us to the main dilemma.) Any interruption of this principle should only be where the action is literally time-critical and cannot otherwise occur. In such situations, the police can refer the situation after the fact, including to the CQC who carry oversight responsibility for Health & Safety issues in the NHS. Happy to hear why I’m legally wrong, in the comments below.

Difficult stuff, isn’t it?! – that’s why proper partnerships need to be about the difficult discussions that I think we’re busy not really having and which are based on organisations’ legal responsibilities, not evolved custom and practice which we know has gone badly awry in the past, costing real lives.

* I was once accused by an AMHP of redefining policy on police attendance at MHA assessments with regard to situations where s135(1) warrants are required. Notwithstanding that my supposed views had been mis-represented, I made the point that this wasn’t an attempt to re-define a policy, but merely to create one in the first place. There were no national guidelines on MHA assessments and s135(1) warrants until 2010, the same is true of the topics covered in this post.

We’ve evolved our practice based on unagreed assumptions about roles and powers – enough people have been injured or worse to mean we now need to correct all conditions and that’s what I thought the CCC was all about.


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

Winner of the Mind Digital Media Award