135/6: Authorising Officers

Short post mainly for those ranking officers who have statutory roles to play under the revised Mental Health Act 1983 (MHA) provisions which focus on those rare occasions where custody is still used as a Place of Safety under the Act. This is just bringing together a few of the issues which have emerged during the few months since December. It might be worth the custody officers in particular saving this link to your desktops in custody: it is the Mental Health Act (Place of Safety) Regulations 2017, issued under the MHA.

The big thing to be wary of before we even get to ongoing supervision and care in custody which is something for both the duty inspector and the custody sergeant to think about: whether the presentation the detaining officers are describing has been sufficiently triaged by NHS staff to rule out the need for A&E assessment or treatment shortly after detention. It’s all very well those criteria in Regulation 2 being satisfied to allow the use of a police station, but what if that presentation is also consistent with a medical emergency that is somehow being slightly forgotten about whilst we think through whether or not the law allows us to do something and whilst we’re focussed on managing a more difficult restraint incident:

My general rule of thumb since the new law was set out for us has been and this is what I’d do if I were operational again tomorrow:

No-one goes to custody unless they’ve been seen by a member of NHS staff who is putting their professional registration to the decision that the person does not need A&E care. We know that ‘imminent risk of serious injury or death’ presentations will probably mean restraint of at least some kind has been applied not least because we’re also saying that ‘no place of safety in the force area’ can manage that presentation … well, history shows that could be ABD, meningitis, post-ictal psychosis, Addison’s disease, brain tumours, diabetes, etc.. No triage: no custody, in my opinion. No police officer in this country could confidently use their first-aid certificate to state there is not something potentially life-altering or life-threatening going on there. The emergency NHS is wheels have roles to play here and if not, I’d be removing people to A&E and then explaining why I wouldn’t have done so if only an ambulance had turned up.

Please don’t think that such debates and deliberations are hypothetical: these things have been key features in determining police officers’ liabilities during death in custody inquiries. I can think of three examples without trying hard.

USING CUSTODY

So, let’s now assume that custody has been authorised after the inspector is satisfied of suitable triage. The person has been booked in by the custody officer and risk assessed and we’re now settled in to the rhythm of supervision until the s136 assessment is arranged or the person transferred elsewhere.

Three main things under the Regulations:

  1. Half-hour healthcare checks by a healthcare professional – this is in Regulation 4.
  2. Hourly reviews by the custody officer – this is in Regulation 5.
  3. Remove anyone from the police station if the original grounds under Regulation 2 for holding them there no longer to apply – this is in Regulation 5.
  • First big issue: there MUST be half-hour healthcare checks by a healthcare professional whilst someone is detained in police custody and if this is not possible, or ceases to be possible, the person must be removed from there and taken elsewhere. Again, it is a legal obligation.
  • Second big issue: police custody, even where it is properly authorised against the criteria can only be used for as long as those criteria remain valid. If someone’s presentation alters to a point where the inspector could not have authorised custody to be used, the person must be removed from there and taken elsewhere. This is not an option: it is a legal obligation.
  • Third big issue: no extension to the 24hrs of detention may be given in a police station unless the superintendent gives it in addition to the doctor who forms part of the assessment. The superintendent is not obliged to agree with the doctor and must form their own view that the criteria under s136B are met and this means there has been a delay in convening the assessment because of the condition of the person. A lack of doctors, AMHPs or beds is no basis for an extension.

CHECKLIST

So, this is your handy checklist, if you like —

  • Get the healthcare of the person checked (as you will have done every half-hour since their arrival in custody) and discuss the matter with the nurse or doctor concerned.
  • Ask the healthcare professional: “is this person medically fit to remain in police custody, having given due consideration to Code C of the PACE Codes of Practice, particularly to paragraph 9.5 and Annex of that Code?”
  • Ask the healthcare professional: “Does this person require assessment or treatment in A&E for any medical reason?” – you’ll need a confident “No” to that to go any further!
  • Conduct your own review of them – this is required hourly and you’re reviewing the inspector’s original grounds for authorising a police station under Regulation 2. Note: the custody officer reviews this, not the duty inspector and this is not a PACE duty, so the custody officer’s decision is final and not subject to review under s39 PACE.
  • Ask yourself: are the original reasons for requiring the use of police custody still valid? – if so, continue; if not, you must transfer the person to another Place of Safety.

This is all subject to one caveat in terms of an obligation to remove because of inability to comply with Regulation 4 or because a review under Regulation 5 determines the original grounds are no longer met: the removal to the other location should not occur if arrangements to have them assessed under the MHA have already been made and transfer would unnecessarily delay this or cause the person significant distress. This is Regulation 7.

Other Notes of Potential Interest –

  • The Code of Practice to the MHA (Chapter 16 in England, 2015; and Wales, 2016) states that transfer to another place of safety must be authorised by a doctor or an AMHP; however, a statutory Regulation outranks a Code of Practice so where no authorisation is possible, officers should proceed to remove the person in accordance with this framework.
  • The Code of Practice also states that officers should ensure that a subsequent Place of Safety has confirmed they will be able to receive the person before they are moved; again, Regulations ordering removal outrank the Code and if no confirmation can be secured, it may be necessary to remove the person to A&E or to “any other suitable place” as defined by s136(7).

For more detail on the 2017 amendments to the MHA, including on the topics covered in this post, see a series of posts on the various changes.


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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Making the Same Mistakes

I woke up this morning to a tag on Twitter from Australia drawing my attention to questions being asked following an encounter between Victoria Police in Melbourne and a mentally vulnerable man referred to as ‘John’. Police officers had been requested to undertake a ‘welfare check’ by a psychologist who was concerned about John’s mental health. In the link that follows, there are various short video clips and extended footage from security cameras at the front of John’s property which show a use of force incident. It involves some footage that may prove difficult to watch, so please consider whether or not you open the link. The debate obviously focusses on the use of force by the officers, as well as the fact they have hosed down a handcuffed man whilst filming it. Accepting that there appears to have been an investigation launched, that no CCTV footage of any incident shows all that one would want to know to form a judgement about how things were handled, it does seem fair to say, even at this early stage, that it would be difficult to conceive of additional factors, currently unknown to the journalist or the public which would allow the footage to be seen in a light where concerns were completely negated. It is reported John has sought legal advice over the matter.

I’m becoming more familiar with the debates on policing and mental health in Australia in recent times: several years ago, I became aware of work done in Queensland and New South Wales to improve police responses and training to policing and mental health incidents and looked at them from afar via the internet, some Skype discussions and I met a few Australian officers at conferences I was attending or when they visited the UK on fellowships. More recently, this has expanded further: a week or so ago, I gave evidence (via a live-link) to an inquest in Sydney where a Coroner’s Court is examining the police response to incident which ended with the fatal shooting of a young woman called Courtney Topic in 2015. It was the kind of incident to which the UK police would be very unlikely to send armed officers and therefore the court was considering whether different tactics and considerations may legitimately have been expected to prevent a fatal outcome. Difficult stuff indeed and the outcome of that inquest is still awaited. In August of this year, I’ve been invited to attend a conference in Adelaide to talk about policing and mental health issues and as I’ve learned more and more, it’s obvious that we have far more in common than the issues which distinguish us from each as countries or police services –

  • We’re making the same mistakes – and this is not a specific point about Australia and the UK: to the extent that I’ve understood problems in other countries, they are largely the same everywhere with a few distinctions about local issues which alter the order you’d prioritise the problems.
  • We’re seeking the same solutions – no matter the differences, we see everywhere reaching for co-responder models where mental health nurses are deployed with the police; and we hear much talk about the need for more and better training for officers: this begs as many questions as it answers, in my experience.

Let me tell you why this is simply “doing the wrong thing righter” and that we need to remember what we say we ask our police service to do.

OVER-RELIANCE

The incident of John in Melbourne could have happened in Manchester – in the sense that UK and Australian police are asked by mental health professionals to check on the mental health of vulnerable people for reasons that I still don’t always understand. I’ve written before about this: how on earth would a police officer be expected to do this? It’s just not possible to achieve, if we actually THINK about it! No police officer can assure anyone else as they walk away that someone is OK and this is about much more than whether or not officers are trained –

  • Where the police turn up at someone’s home, even two of the friendliest officers on the planet with the best training going, it could still be problematic – we know that some patients have an intuitive fear of the police because of their clinical condition, we know some automatically think the police means they’re being criminalised or stigmatised as violent;
  • We also know that the power dynamics between officers and the public are not equal and some people may fear the encounter will end in coercion of one kind or another – and coercion doesn’t always mean being physically coerced.
  • Police officers have all the accoutrements and authority of the state to coerce people and in Australia their reach does extend to your private home and front garden, unlike in the UK. (What happened to John, assuming it was a detention under mental health law, could not lawfully have happened in the UK because he was in his own house and then his own garden.)
  • So where officers turn up and say, “John, your psychologist has asked us to check on your mental health – how are you? Do you need our help?!” … what do we think this may mean for John himself?
  • If John says or does anything that implies his mental health is difficult for him, or that he may be at risk from himself, what do we think the officers will then be contemplating? – can they ring back the psychologist and say, “Look, he says he’s not at all well and we can sense that, too – you’d best get yourself or a colleague ’round here sharpish to help him?” Invariably, we can’t.
  • And if John says he’s fine and doesn’t need police help, should we believe him where there is no obvious reason to disbelieve him? – we know there are reasons why some people lie to the police about their mental health: because the public tell us this when we ask about how we can improve our responses. Telling the police the truth is to risk being coerced, one way or another.
  • We are then cops on someone’s threshold carrying a professional responsibility for ensuring someone’s immediate safety, so what will we do if someone is unwilling or unable to seek help on their own or via their support services, where they have some? It’s got ‘detention under the Mental Health Act’ written all over it.

So before we get anywhere close to the questions that emerge about how these officers on this day decided to discharge their responsibilities – and I have loads! – we need to be asking the question most forgotten: why do we rely upon the police to the extent that we do and task them with things they couldn’t possibly do, even if they wanted to help? Remember, officers can’t be expected to reliably rate likelihood of self-harm; advise on anything to do with medication; they can’t always force a person to another location for an assessment by qualified staff and what many co-responder models demonstrate is that the person probably just needed access to healthcare services anyway. Did John actually need something from the police? – there could be more to know about this incident, but as things stand it seems unlikely.

MAKING MISTAKES

This the original mistake: to assume that demand faced by the police is unavoidable, unpredictable and unpreventable demand and that the task is merely to ensure that the police are trained and equipped via partnerships to handle it better. Frankly, this is complete rubbish. Of course, there are incidents coming to police attention which were completely unavoidable, unpredictable and unpreventable but many (or most?) of them are not; and where they are not unavoidable, unpredictable and unpreventable, that doesn’t mean it requires a police officer to respond. Whether we examine some particularly high-profile untoward events like deaths in police custody, or whether we take a broader view over population level data, like s136 detentions or ‘triage’ encounters in UK police forces: we come to learn that much of this demand involved people needing and often wanting a healthcare service and being unable to access it or for whatever other reason not receiving it. Thereby, we create conditions in which police (and for that matter ambulance services and emergency departments) become more likely to be relied upon as a blunt tool to provide some kind of ‘care’. Remember, two things ‘more than minimally contributed’ to the death of Sean Rigg in London 2008 and the first of them was neglect by mental health services. Had that not occurred, it’s quite doubtful the Metropolitan Police would ever have met him. In Sydney earlier this year, a a young man called Jack Kokaua walked out of an emergency department where he had been detained under mental health law and when re-detained by New South Wales police, died following restraint. Of course, we may yet learn that officers could have handled that situation better, but it will still leave a question unaddressed: why was a detained mental health patient, previous sedated by the ambulance service and removed to an emergency department, able to walk out more-or-less unchallenged?

Most crucially though, this is not an argument against better training and leadership in policing; or against efforts to cooperate with mental health services – those things are very necessary for those occasions where we are responding to unavoidable, unpredictable and unpreventable demands. But like all the best medicine, prevention is better than cure. If we can ensure that those who simply need timely access to relevant services get it, we might reasonably expect to see the police responding less often to people in crisis and where they do, making a more positive difference because they’re better trained and supported – the real partnership issues to be address between policing and mental health services is not the day to day efforts between frontline cops and front line nurses; but the strategic relationship, the population data sharing, the proactive addressing of repeated and more difficult problems which is best done in meetings by knowledgable senior managers and analysts. We do this for domestic abuse and child sexual exploitation – we’ll start doing it more systematically on mental health eventually.

Other mistakes –

  • We give the police tasks they can’t actually do – like making suicide or self-harm risks assessments of vulnerable people during welfare checks. I can tell you whether someone is alive or dead, whether they’re conscious and breathing, but whether they’re likely to hurt themselves in the next 6hrs is something my psychiatric training didn’t touch, I’m afraid. You want to know that someone’s OK – you’ll have to come and check that yourself.
  • We give them tasks they can’t legally do – police services don’t always have legal powers to ensure a contact occurs between a vulnerable person and a mental health professional: the UK limits its police powers under mental health law and prevents their use inside private dwellings but even in countries like Australia where this is not the case, there is a threshold for using police powers. By definition, thresholds are not always met.
  • We give them tasks they can’t morally do – calling officers to psychiatric units to undertake tasks normally expected of mental health professionals gives rise to ethical questions: I can’t be the only police officer asked to undertake tasks in a hospital where gender of staff wouldn’t matter but where analogous tasks in police stations, gender of officers would be controlled by law. I’m not forcibly removing a woman’s clothing for medication unless her life is quite literally at risk (and it wasn’t)!

THE ROLE OF THE POLICE

I’m not going to defend for one moment what I saw watching footage of a man wearing the word ‘POLICE’ on his back hosing down a beaten, mentally ill pensioner kneeling in handcuffs in his own front garden whilst one of his colleagues smiled and filmed it. Feel free to try and convince us, gentlemen, that this was reasonable, proportionate and necessary, but you’re going to have work damned hard and show me a detailed argument that negates suggestions this amounts to torture or inhumane and degrading treatment. But I do insist that whatever investigation gets going in to this, it should also ask the forgotten question: what the hell were the police doing there in the first place; and if it were thought unavoidable necessary because of urgent circumstances, where was the back up for the officers to address the questions that will necessarily arise for the psychologist after the officers have said, “Yes, he’s here: alive, breathing and conscious. What do you want to do next given we cannot assure you of anything else?”

Police uniforms, power dynamics and implied threats and coercion from even deploying the police can be a game changer: it is not benign and this is all too conveniently forgotten by those who over-rely upon the police to ensure adequate coverage of crisis ‘care’. If you doubt these subtle implications, ask yourself whether a police car suddenly pulling behind you at speed with lights activated makes you instantly check your speed? – whether an officer knocking your door unexpectedly makes you worry what they’re about to tell you that you might really not want to hear? Now imagine that whilst you’re struggling with your mental health, whilst you’re frightened or where you worry about being touched or coerced by people you know have limited training on mental health, even if they are attempting to communicate effectively and compassionately. Policing in mental health ‘care’ is, by default, an implied use of force – because it carries the implied ‘or else’ of the entire state right behind everything it does and that can be frightening to any of us. Some have looked at this footage and said it was all a police reaction to the officer being assaulted: all I saw was a vulnerable man pull away from being grabbed, which we can probably agree, is just human instinct.

We’re not going to see the elimination of adverse incidents until we stop tasking the police inappropriate with stuff they cannot do: so whilst no-one is defending anything on the footage relating to John or any other incident where police actions are rightly questioned, society needs to ask itself more keenly how it wants its police service to spend its time and then train officers properly for the tasks that are legitimately within their competence and capacity. ANything else is doing the wrong thing righter and making the mistakes history has already told us not to make.

Live-Tweeting

All of us who use Twitter are probably guilty on occasion of wanting to shout up about a job to highlight something we see as important – a success story where someone was helped, a criminal caught, officers who’ve acted bravely, etc.. We want to highlight our work, the pressures on us, the successes we have and help explain to the public the reality of our work and what we’re contending with as we wrestle with it – sometimes literally. In that context I want to write here about something I’ve done as much as anyone and to caution against it: therefore to the extent that this might look like a telling off – and I really hope it doesn’t – it’s one that applies to me at least as much as anyone else. It’s something (I think) I’ve stopped doing after listening to others on Twitter who live with mental health problems: live-tweeting mental health or suicide related jobs. And I mean this both in the sense of an organised live-tweetathon, for example of a kind that was once set-up and then cancelled at the last moment by a police force street-triage team; as well as the occasional live-tweet by an officer in a shift, but which is put out in real time as just one job of many they’re dealing with that day.

What harm could this cause, you may ask? We normally anonymise tweets about all the things we deal with and mental health issues are, we keep insisting, a part of our “core business”, so why shouldn’t the public learn of someone’s life we’ve saved or the hours we do spend sitting about in mental health units when all the laws and guidelines say we shouldn’t? After all, we could be at the next 999 call helping other people by then, couldn’t we?! It all comes back to the identifiability of individuals within the tweets – not that the public at large will identify the person being referred to, but the person themselves may recognise the person being referred to and we quite simply don’t know what impact that will have. Would you want one of your most desperate moments of all, broadcast without your express permission, even if the officers did take steps to minimise how likely it would be for a third-party to read it and identify you? Potentially not.

But we also know that third-party identification has occurred, despite those attempts to ‘anonymise’ things so this is not just a hypothetical risk.

DIFFICULTIES LIVE-TWEETING

It’s remarkably straight-forward: even if you tweet something without using someone’s name or age, by simply stating their gender after they have been detained, located or arrested, we’re also telling 50% of people reading, “this is not about you”. If my local police did that in my home town (Bromsgrove, Worcestershire – population c29,500), then we’re certainly narrowing down on just over 14,000 people if we’re trying to think who it may be. Although that’s still a lot of people and whilst there is the possibility Bromsgrove police have detained someone in Bromsgrove who is not from Bromsgrove, that only narrows it down further because the police do mostly detain people in their own home area, when using s136 MHA or criminal powers of arrest.

We also find other clues that narrow things down –

  • General indicators of age – elderly man, young woman or teenager. We’re narrowing this number down even further:
  • Of the c14,000 men in my home town, how many of those will be teenagers or pensioners – well, at any given time, most will be neither; so that excludes most men and we’ve now narrowed things down to a few thousand.
  • How many times would my local force use s136 in a given day? – well, they used it 786 times in the whole of the previous year, that’s twice a day, force wide and I live in a small town in one of the three counties they cover.

If a tweet goes out about detaining an adult male in Bromsgrove under s136 and I know that I was detained on that day, it’s almost certainly me, without further information. And because I’m an individual in a tweet, not a police officer conducting a criminal inquiry, I only need to believe the tweet could be about me, for potential damage to be done.

If you scan social media on this point, you can meet people who now know that they were at the centre of a police-tweet some hours or days earlier. This has included examples of police helicopters tweeting pictures from heat-seeking equipment of their search for someone in a wooded area – the picture including that human being, just located. It has included a tweet from a small town by a twitter account connected to that town and making reference to enough vague identifiers to narrow things down quite considerably whilst telling the person just how many officers and resourced were expended on finding them – just in case they didn’t feel bad enough! << of course, we all know that wouldn’t be the intention of the officers. Police officers join and go to work every day to help people, even where there may be a view that someone has fallen between the cracks or could have been helped earlier by others. But it always risks looking like we may be describing the burdens we carry.

SUBLIMINAL IDENTIFICATION

Other inherent qualities of a tweet narrow things down even further: if we know the timing or rough timing, the identity of the officer who responded and tweeted or anything specific about the incident. Officers may withhold all information about the patient they think is identifiable, but they themselves may be identifiable – if I’ve been helped by PC Smith at 9pm and remembered his name because of how supportive they were; and then by 10pm PC Smith is tweeting about an incident as they book off-duty, that may make me realise it’s about me, even though there’s nothing identifiable in the tweet. If police were searching for me whilst I’m missing and they find my in a difficult or unusual place and refer to it, even non-precisely, that may make me realise the tweet was about me.

And finally, there’s descriptive wording: recently a police force twitter account described a specific person who was detained as ‘volatile’. The force concerned is large, they use s136 a lot, but given it came from one of their local accounts, it narrowed things down massively and they also used the gender of the person concerned, thus ruling out half of the population. I wonder how many people of that gender were detained by that force, in that area of that force, under the MHA that evening? << Note: they even narrowed down the shift on which this took place, thus ruling out those shifts in the day when the detention did not occur.

And this is the big message that bears repeating: the risk isn’t mainly that a third-party may read something and think, “Oh, I bet that’s Billy from down the road”, but that Billy himself may read it and think, “Not sure I wanted my healthcare issues broadcast across twitter, even if they do think they’ve anonymised it. And I’m not sure I’m happy to be described as ‘volatile’ or for any inference to be out there that I’ve consumed resources apparently ‘better’ spent elsewhere on ‘real’ crime. I already felt worthless and I certainly do now every knows!”

WHAT I AM NOT SAYING

And let me repeat this point so it’s not un-said and so no-one accuses me of throwing stones from my greenhouse: I have actually done this, many times. I’ve done this more times than care to admit and it took a long while and some very real examples for the points that were made to me to sink in. When you’ve actually sat down at reasonable length with someone over a cuppa, someone who was the unwitting focus of a tweet and you’ve listened to them explain the reasons why they’d have preferred to have the option and, even then, may well have said “No, thanks” despite recognising virtuous motives, then you can say you’ve got an insight in to these kinds of issues. If you haven’t done that, you may struggle to get it. I certainly did now I’ve actually had the chance to do this more than a few times, it made me realise people on the opposite end of the police-person encounter have questions and concerns I hadn’t even thought about. Unless, I’m misjudging myself very badly, I would venture to suggest some of those things may well have escaped most police officers.

No-one, anywhere, is saying the police shouldn’t use Twitter to highlight the kind of work we do, including on mental health and this point includes highlighting difficulties, human stories and officers’ bravery on occasion – it’s all just about the way we go about this, and when. Using single incidents as the basis for a tweet, risks the kind of thing I’ve heard about a lot from people who’ve had police contact. As do single incidents at the centre of a BLOG and several years ago, I had that experience, too. I’ve got a blog in draft form, entirely finished and ready for publication, but I’m all too aware it relates to a particular case and even though that case has been heard in a Coroner’s Court where all details were made public, it wasn’t a high profile case covered in the media and I am not prepared to publish it without the family’s permission because it relates to the death of their loved one.

If you’re concerned about mental health, suicide prevention and offering support to people, nothing prevents you from tweeting to say so – you could do so because of news articles, new research or simply to signpost people to services by offering helplines or other sources of online information, etc.. I couldn’t help but notice one recent reaction which told us such concerns are unfounded because things are anonymised where names and precise details are withheld and that this is an important topic and it “needs talking about”. Even a cursory scan of that person’s social media feed shows us see they have not tweeted about or discussed the importance of these issues once during 2018. The topic is so important, they haven’t mentioned it. << If you are this person and you’ve ended up reading this BLOG post wondering if I meant you, ask yourself whether I’ve sufficiently anonymised this final paragraph so that you couldn’t tell this remark was about you? Your yardstick was: if no names were used, it has been anonymised. I used no names, I didn’t even raise the matter of gender or rough age, so you tell me: can you spot yourself?!

Exactly.

Post-script: just after I finished this post and whilst I was busy sorting the paragraphing, spell-checking and so on, I was tagged on Twitter in another example of people raising concerns after an official police account tweeted something, just as outlined above. The rudeness and lack of professionalism from what appear to be police officers responding to objections on private accounts was nothing short of breathtaking, to be honest. Various levels of “WOW!”


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

Winner of the Mind Digital Media Award.