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Fifteen Minutes

This is a written version of a talk I gave last night, where I had fifteen minutes to summarise my thoughts on the overall topic of policing and mental health.  It’s a while since I had such a short period in which to condense my thoughts and it was a useful exercise in rooting out the extraneous junk from my mind!

Michael./

If you look around the world at adverse incidents that cause us to discuss the police roll in mental health issues, you see a range of problems:

  • The extent to which the police are relied upon as first- responders
  • Problems in the use of force:
  • Restraint related deaths
  • Fatal police shootings
  • Controversial use of things like Taser
  • Normalisation of the police as a de facto crisis service
  • Criminalisation of vulnerable people:
  • Prosecution almost entirely for the purposes of accessing clinical services
  • Incarceration in prison where upstream interventions would have prevented the need.

From that lot and much more besides, you can start to form your own view about whatever it is that you think the fundamental problem might be. Whatever conclusion you come up with, you will find that there are only ever two real kinds of response to that problem, if people have bothered to define it all –

  1. The police need more training: mental health awareness, de-escalation and legal education.
  2. The police need to work in closer collaboration, preferably in real-time, with experts from mental health services.

Do you spot the problem with this? – there is a fundamental difficulty at the heart of how we understand the problem and how we design solutions in response to it.  The police are not all of the problem here – so they cannot be all of the solution.

REPORTS AND MORE REPORTS

Look at the Adebowale Report (2013), the Crisis Care Concordat (2014), the Home Affairs Committee report (2015) on policing and mental health – they ALL began as conversations and pieces of work to examine what is going wrong in policing and mental health and they ALL ended up concluding that this is not just about policing. In fact, it’s not even mostly about policing! Lord Adebowale was asked by the (then) Metropolitan Police Commissioner to report on what the Met needed to do to improve: twenty-eight separate recommendations, fewer than half of which were exclusively about policing. Many of the recommendations were aimed directly and solely at non-police organisations and Lord Adebowale made it crystal clear in the report that the police could not be expected to sort the problems on their own.

The Crisis Care Concordat is a national structure by which to promote cooperation between police and non-police agencies on all issues affecting 24/7 crisis care. In a national action plan containing sixty separate actions about what we must do to make the world a better place, the police are named on five of them. You could also look at the amendments to the Mental Health Act 1983 which are on hold whilst we have a General Election and will be introduced later in the year: all of the amendments bar one is legislating to push for what some areas have been able to do for many years now, with the pressure falling mainly on non-police agencies to improve access to services, provide alternatives to detention, undertake both assessment and admission much faster than we currently see. The Home Affairs Committe report made very few police-specific recommendations in the twenty-nine observations made: they were mostly concerned with the lack of commissioning and provision which made police responses necessary.

These reports are more besides make it clear that we have problems in NHS commissioning, provision and education, this is not just about poor, untrained and ignorant police officers making poor decisions because, bless them, they don’t really understand these matters. Actually, there are plenty of mental health professionals around who argue without being prompted by me or anyone else, that officers are usually not bad at all at spotting that “something’s not quite right here.” Of course there are issues with mental health presentations that are sometimes less obvious or where mental health problems co-represent with other issues from substance abuse to comorbid physical illness, but then that’s also a problem on occasion for Doctors so what standard are we holding the police to here?

FIX THE PROBLEM

Many will and do make the political (small p) point that the expanding role of the police is inevitable around mental health: they argue that cuts and politicals (large p) mean that all that can be done is being done and if that’s not enough it’s because of under-investment in mental health. No-one anywhere, is arguing that politics (small or large P) is irrelevant: but the narrative that it’s all about the politics of things just doesn’t fit the history we’ve seen or the facts available to us now.

The real problem here is: we haven’t defined the actual problem … we’re still in the “Do Something!” phase of developing our police responses and as long as we keep thinking it’s just about police training or police partnerships, we’ll keep missing that 2/3rds of stuff from those reports which tell us it’s much more complicated and that actually, on occasion, it’s the health service taking its own decisions about the services it provides which is important. No amount of training for front line officers or those like me who work around policies and partnerships is going to ensure that a CCG complies with s140 of the Mental Health Act – it wouldn’t cost CCGs anything to start doing so, but they’d need to be aware of the provision first!  I can’t ensure before every 999 is made to the police about difficulties on mental health wards that they are adequately staffed so that response police don’t walk in to ‘Seni Lewis‘ style vacuum against which backdrop they are then being asked to undertake various tasks they are inappropriate for police officers. No Chief Constable can make an NHS provider have a Crisis Team that is equipped to operate beyond the telephone or to stop them from reducing the size of that crisis or community team because of the apparent ‘success’ of their street triage scheme. All of these things (and much more besides) are, ultimately, a matter for the NHS to determine.

So one of the problems in policing is how to prepare officers so they don’t become too far involved in things after inappropriate requests to plug gaps. In a recent example, “Inspector, can you transport this distressed and agitated patient who requires a psychiatric intensive care unit 300 miles away, in a police van without us being able to administer sedation that they require for the journey because of other medical reasons.” Oddly enough, the answer to that will be “No!” – it’s just far too bloody dangerous for a start, but it would be an entirely undefendable course of conduct if it came under scrutiny from those who hold the police to account! And, actually, the patient themselves has certain legal rights that are not protected by the police agreeing to do this … so the answer is “No!”. To think any officer would agree to that is quite worrying but whether the officers know how to say “No!” constructively … who knows?! The answer to that situation is not ‘better partnership working’, it’s clear and effective commissioning by the NHS of methods of conveyance and the patient will have to remain where they are, with static police support if there’s a risk, until you sort it. And if you don’t sort it soon, we’ll have to start speaking to lawyers to start extricating officers from a situation that is rapidly becoming illegal, if it isn’t already. Sometimes the most necessary partnership is the one between the police and the public.

THE ROLE OF THE POLICE

I personally think the real problem IS the over-reliance upon the police and our inability so far to define the role of the police in our wider mental health system. Not all of that is about politics and / or  resources: it is, as often, about the choices we make whereby legal knowledge and a greater understanding of individuals’ rights are absent from our assessment of what must be done, what may be done and what might be done. That world wide experience does show, if you don’t provide alternatives, the police and the criminal justice system will end up using blunt tools to fix complex health and social problems crudely.  The role of the police should be –

  • To remain as uninvolved in our crisis mental health system as possible, consistent with safety – this is not arguing there is no role; it is arguing against the ‘normalisation’ of policing in crisis mental health care. Quite frankly, many patients simply don’t want the police involved in their healthcare, and it always comes at a cost of one kind or another.
  • To throughly investigate all allegations of crime received where someone involved is vulnerable because of a mental health problem or learning disability – and to bring to justice those offenders who may have unmet health needs, but where the public interest is served by doing so, for the individuals own benefit in long-term as well as that of the public.
  • To work in partnership with health, mental health and social care services, mainly in the sharing of information and joint problem solving and prevention, rather than ever-improved ways of responding to crisis that is all too often an example of merely ‘doing the wrong thing righter’ and the very opposite of early intervention.

We can have as many or as few alternative to policing and criminal justice as we like: we’ll either pay for them directly, or through increases in the need for secure mental health care after the police inevitably find themselves having to prosecute some people for more serious offences, something which is a phenomenally expensive in each and every case where it happens and our secure mental health system is currently more than full.

That’s the choice to be made here.

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

Winner of the Mind Digital Media Award.

Dear #RCN17

Earlier today, the Royal College Nursing voted at their National Congress in Liverpool “to lobby to ensure that Emergency Departments are no longer designated places of safety for the purposes of mental health legislation”. So, I’ll cut straight to the chase: that’s not a really thing – in the sense that the word ‘designated’ does not appear in the Mental Health Act, and only appears four times in the whole Code of Practice to the MHA, never in relation to sections 135 and 136 which relate to police powers and places of safety. It’s just not a thing around which to have a meaningful debate because, as a police officer, I simply don’t need to care whether somewhere is designated or not. Those who urgently need ED care because of the nature of their medical needs are going to go there under s135/6 regardless of designation; and those who are detained and don’t require ED in the strict medical sense but where no alternatives exist, may also end up there, especially after the Policing and Crime Act amends the Mental Health Act later in the year. If nurses, doctors or the NHS wants it otherwise, they are at liberty to commission sufficient capacity elsewhere to give real options in the real world and work with their police services to ensure use of section 136 is appropriate.

So, for the record: none of what I’ve written here means there isn’t still work to do by police forces on how individual officers take their decisions about what is the ‘right’ thing do, where more than one option exists.

Whether or not a place is ‘designated’ or ‘identified’ in a local protocol relating to section 135/6 doesn’t prevent decisions being taken about attempting to rely on a particular location, because at the time, in the particular circumstances, it appears the best way to proceed. Indeed, the whole point behind the 2017 amendments to the MHA, which will come in to effect soon, is to get beyond rigid determinations by managers in offices via protocols about which location or kind of location should be used and on which occasion. In my career, I’ve frequently exercised my legal right as a police officer to determine the place we will seek help for someone who is detained by officers because they are thought to be unwell – and this does include asking ED departments to support someone where the only alternative was police custody. If someone actually needs a MH unit place of safety that doesn’t exist or is unavailable / unwilling to offer support, should that person be in ED or custody? They don’t need ED, strictly speaking, but is ED the least worst option of the two? Who knows! – it probably depends whether you’re asking a police custody sergeant or a ED nurse or doctor, or the person who needs help. What I know is, I’m quite happy to take time to see if we can keep octogenarian dementia patients out of the cells by improvising and I see no legal barrier to ED choosing to help. Indeed, history shows they probably will. Less likely that they will if the person detained is a 26yr old bipolar patient, but that may just be my experience.

CASE STUDY

About a decade ago, one interesting case involved my officers being asked to locate a lady who had run from a maternity unit whilst mentally unwell, very shortly after giving birth. Officers found her and shared the concerns for her welfare expressed by nursing staff at the hospital but she refused all attempts to help her to be safe. They ended up detaining her under s136 and removing her back to the maternity unit. Was this ‘designated’? … should the RCN have a discussion about the appropriateness of using maternity units, because on of the face of such an idea, it sounds quite ridiculous? Of course, the action taken was to use that hospital as a Place of Safety and arrange assessment there because it represented the best decision in those circumstances – designation didn’t come in to it because it is lawful for a police officer to remove a person to the location that they think is the appropriate choice in the circumstances and ask that location to provide help and care. Whether that location chooses to agree to that request, is absolutely a matter for them but that decision will subsequently be seen in its context: if the officer at that time, for that patient, in that place had no other alternative or if they or anything else supporting or advising them thinks it is the ‘right’ thing to do, ED or whoever sought out remain accountable for any decision to help or turn the person away. Sometimes, it may be quite right to turn people away – just remember, the custody officer at the police station retains that right, too!

Difficulties ED’s and / or the RCN have with the implications of NHS commissioning are things that could and should be raised with NHS commissioning managers, some of whose have been decommissioning MH unit Places of Safety over the last year or two. What #RCN17 seem to be trying to raise, is the lack of alternative options for police officers to support someone outside the ED setting. Their debate, reflected on social media, seemed to broaden out to other issues that were not about the operation of these powers under the MHA. This points are important to bear in mind –

  • Most people who are legally detained by the police are not detained under s136, but arrested following crisis incidents which mostly occur in private premises.
  • The whole ‘place of safety’ and ‘designation’ debate is irrelevant to them, given that they are being detained under the MHA.
  • Most people who attend Emergency Departments are not taken there by the police: they either self-present at ED or are taken there by family, friends or other agencies like the ambulance service.
  • This debate will not touch that cohort of people because the ED’s status as a ‘Place of Safety’ or otherwise is irrelevant to anyone who is not detained under the Mental Health Act by the police.
  • You cannot get away from the fact that ED is a part of a hospital and hospitals are Places of Safety, designated or otherwise, under the Mental Health Act.

THE REAL PROBLEM

I can agree with what (I think) RCN are getting at here: they seem to be wanting sufficient health-based Places of Safety that are not in ED settings, but which are either adjacent to them, run by the mental health trust, OR which are located in mental health trust premises. Fine – why not just say so?! Focussing the debate on the legally illiterate point about designation (which, I can only remind you, isn’t a legal thing but a proxy term for internal NHS arguments about inadequate commissioning!) is a way of indirectly focussing frustration on perhaps the most vulnerable group of all: those of us who are so unwell that an uniformed police officer has taken our liberty away because we seem to lack agency to make safe decisions for ourselves.

So, the RCN weren’t discussing mental health in ED, or even mental health more broadly: any attempt to debate or change issues around designation is purely an attempt to discriminate between those who are in police custody under the MHA, and those who are detained for other legal reasons, and those who are not detained at all. Bearing in mind the point above: most people with mental health issues detained by the police are not detained under the MHA; most people with MH problems in ED are not detained by the police. This debate is targeting a very narrow group of people who are already stigmatised by virtue of their legal circumstances.

For the record: no-one is saying ED is a good option for those of us who are mentally ill or in distress, or therefore saying that those of us with mentally health issues who are detained by the police under s136. But whether you’re ‘designated’ or ‘not designated’ locally will make not the slightly bit of difference to whether or not the CCG or LHB commissioners are going to ensure adequate alternatives for those patients who do not, per se, require what we traditionally think of as ED care – the broken bones, lacerations, head injuries, chest pains, breathing problems, overdose attempts, etc. Under the laws coming through in just a matter of months, if I detain a 17yr old under the MHA and there is no locally identified pathway, I’ll be heading your way to ED – designated or not, and not withstanding whether there is a ‘need’ for ED care. Likewise if I detain an 86yr old dementia patient when the local PoS facility is full. To do so may be the only lawful option I have available to me – to a location which is recognised by law as Place of Safety under the MHA, which is defined in s135(6) without reference to the use of the word ‘designated’ or to what a local protocol may say.

There is absolutely no legal obligation on any organisation to provide a Place of Safety – let’s just have a think about that. And whilst we do, remember that debates caused by component parts of ‘the system’ pushing against each other cause those of us with mental health problems to think they’re just not welcome in ED – something reflected in the CQC inspection on crisis care pathways last year – and I’m worried that nursing has reinforced this perception by supporting this motion without proprely defining the problem they are actually trying to fix. Many service users have contacted me on social media today to say this is precisely what they’ve been made to feel – and perception is reality for people.

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

Winner of the Mind Digital Media Award.

Seni Lewis

The Metropolitan Police and the South London and Maudsley NHS Foundation Trust were subject to a damning verdict in the south London Coroner’s court earlier today – each of them facing criticism for contributing to the death of a vulnerable man. The death of Olaseni Lewis in September 2010 is one the most sensitive, controversial and difficult of all the death in police custody cases I’ve known connected to mental health issues. I had the opportunity to hear Mrs Lewis speaking in Brixton last year about her family’s ongoing ordeal: it was nothing short of absolutely heartbreaking to listen to the experience of someone who’d already waited six years to learn how her son died, and to hear first hand how the post-incident system had exacerbated the distress of what must have already been a devastating incident.

Various resources relevant to this post –

BACKGROUND

Seni, as he was known, was detained by the Metropolitan Police under s136 of the MHA and removed to a Place of Safety for assessment. After absconding from the unit, he was located and returned before being admitted on a voluntary basis to the Bethlam Hospital in south London, part of the South London and Maudsley trust. Following a disturbance on the ward which involved him trying to leave and damaging a door in the unit, the police were called.  As officers were seeking a briefing about what was going on and what they were being asked to do, a nurse beckoned them on the ward itself because things were becoming very difficult. Seni was restrained in handcuffs by the police and staff asked the officers to remove him to a seclusion room within the same hospital. The officers engaged in a 10 minute restraint as they placed him in to the room. After failing to close the door properly, it was thought necessary to re-take control of him using restraint and attempt against to place him within the seclusion facility, this time involving a 20 minute restraint which involved officers striking him using a police baton and other mechanical restraints. He collapsed under the strain of all of this and a DR examined him, finding a very slow heart rate. Little was done at that stage and when Seni fully collapsed, there was an inadequate response with failures in first-aid and CPR.

This is all reflected in the narrative verdict published today.

THE VERDICT

The jury stated that five things had a cumulative effect in creating conditions in which police restraint of a patient on a mental health ward would be thought necessary:

  1. The admission process was substandard: lacking a full Doctor’s assessment, adequate risk assessment and the influence of family members to help.
  2. Ineffective use of medication to treat escalating agitation.
  3. The NHS trust failed to meet their own target for trained mental health staff to adequately ensure care.
  4. A lack of communication throughout between the police and the medical staff contributed to inadequate responses to Seni’s medical needs.
  5. A lack of trained and physically able staff to move Seni from the ward to a seclusion room, which led to them asking the police to do this, having already used hancuffs.

“These five cumulative factors led directly to the police restraints within the seclusion room.”   

Five issues: all of them omissions, conscious or otherwise, on the part of an NHS Trust, indirectly creating conditions within which calls for police support / restraint become more likely than they would otherwise have been. This is exactly what the 2017 Memorandum of Understanding (MoU) on police restraint in mental heatlh settings was designed to address. If you are an operational police officer, please read this document from cover to cover, twice.

The narrative verdict lists three things which, on the balance of probabilities, contributed to Seni’s death at the hospital.

  1. The two periods of restraint were each described as ‘prolonged’, the first being ‘unnecessary and unreasonable due to the length of time Mr Lewis was in a prone position. The second restraint involved ‘excessive force, pain compliance techniques and multiple mechanical restraints’ which were ‘disproportionate and unreasonable’.
  2. During the second period of restraint, a doctor examined Seni after he became unresponsive and recorded a pulse of 45-50 beats per minute but failed to respond to this medical emergency.
  3. The police failed to follow their training, which requires them to place an unresponsive person into the recovery position and, if necessary, administered basic life support.

WHAT DOES THIS ALL MEAN?

This means, that police officers can be drawn in to situations in NHS trusts where factors way beyond the officers’ control, influenced by decisions taken hours and even days before by healthcare managers, may create conditions in which nursing and / or medical staff want the police to do things they should be extremely careful about doing, if they agree at all. I’m afraid to say this, but in the real world I police and given what we know about the accountability mechanisms and how they work, officers need to realise they are NOT there just to do as they’re told or to agree to everything that’s asked of them. It could be OK – in fact, it could be critically necessary – to say ‘No!’ and do something else, whilst escalating to the duty inspector to take control of the wider issues. I also accept this can create conflict with mental health staff on wards and I regret that, but only to a degree: conflict is not always a bad thing – it forces greater consideration of intuitive ideas and a counter-intuitive truth is a truth nonetheless.

The verdict tells us, in this case as in others, a failure to communicate throughout the incident created the problems which contributed to a death. The 2017 MoU tells us, the police should remain as uninvolved as possible until we’re clear what’s being asked or attempted. In Seni’s case, agitated behaviour led to him damage a door on the unit. We can all agree, I’m sure: that’s nothing worth risking his life over because we can always repair or replace a door. What prevents officers containing a situation, preventing a patient from approaching others or damaging things further but leaving them more-or-less untouched? This could involve something like a small, moving cordon on the ward whilst we think about how best to achieve the objective. Of course, professionals make the point that no-one thought life was being placed at risk: but no period of high-intensity or proloned restraint is inherently safe. 

Any period of prone restraint is inherently unsafe – and it’s less safe the longer it goes on. This is all the more precarious when we refer to those of us with mental health issues.

OTHER IDEAS

This is more than hypothetical – but I want to stress ahead of the example that follows: all situations turn on their individual circumstances and involve subjective judgements. What follows doesn’t imply it could have ‘worked’ in any other situation. It’s offered only in the hope that nurses and police officers may take just a second or two, if at all possible, to think whether it offers ideas that may help.

Some years ago I attended a medium secure mental health unit to a similar report of a disturbance. We also met a large, physically strong man at 5am who had, apparently, “smashed up the ward” when they were understaffed. We were being asked to move him to a seclusion room … does this sound familiar? Of course, all circumstances are different and officers vary in their judgement of what’s needed but more than once in such cases, we’ve been able to put a few officers between the patient and the other people present and then just allow time in which he can see the officers are not going to use a high-intensity restraint. We tried to strike up a conversation, in fairness to a bloody cheeky PC on my response team, they somehow managed to get jokes going at my expense about how the boss is bald(!) … the patient laughed for the first time. He then joked at my expense and we laughed again. We spent about 20 minutes moving in a small area of the ward corridor and didn’t touch him during that period whilst nurses made various arrangements, moving other patients and so on. In fairness, I did touch the mental health nurse who entered the ‘cordon’, walking in to the patients personal space and shouting at him(!), because that really wasn’t helping. 

At the end of building a some degree rapport based on giving him time and space to be safely in distress and for the situation to defuse, he moved to a seclusion room without being touched or even ‘ordered’ to do so. Ultimately, some patient discussion by officers caused him to agree to receive medication and no-one was restrained. The only adverse outcome was for the cheeky PC had to get himself back to the nick sharpish to have coffee on my desk by the time we’d returned – but he’s one of those cops who can influence others, he knows how to influence with words. He did his job well. For the record: this doesn’t always work despite best efforts and my telling this tale is about suggesting there are other ways which are far less controversial to contain, not restrain. Worst case scenario, it doesn’t work – but by that time, the bosses should be involved. 

WHAT HAPPENS NOW?

It seems highly likely the Coroner in this case will issue a Regulation 28, Preventing Future Deaths notice which normally comes out a short while after the announcement of a verdict and is normally uploaded to the website of the Chief Coroner. We will have to wait to see what that says, but it seems it will have implications beyond London, because other forces have experience of being called in to mental health units in similar circumstances. Of course, both South London and Maudsley NHS Trust and the Metropolitan Police made referenence in their press responses to the Memorandum of Understanding between five major national bodies, which I was involved in drawing together over the last two years. It’s fair to say some officers on social media, want to know what they are expected to do if called in similar circumstances. Some officers are still of the view that there should never be a role for the police on mental health wards and that NHS organisations need to ensure staffing, training and so on which ensure the capacity, capability and training to handle incidents.

There will be more to say on this case in due course, once we see the PFD report but in the meanwhile, I encourage all operational police officers to read the MoU mentioned above, twice. Your role on mental health wards is finite and limited – and it does NOT extend to doing everything you’re asked to do by others, just because they are struggling. Doing ‘something’ might be the worst thing you could do; doing ‘nothing’ can often be best, containing a situation from getting worse, whilst pausing to escalate to some very senior people, getting them out of bed, if we need to do so. And if operational police officers do have concerns about the background conditions in any healthcare facilities creating conditions around this sort of thing, the MoU makes it absolutely explicit that things should be escalated and reviewed.

The worst news for Mrs Lewis and her family, is that this is far from over. They have called for the CPS to review the decision not to bring criminal charges against the officers involved, the IPCC have directed Gross Misconduct and Misconduct hearings against the officers involved, there is an outstanding Health and Safety Executive investigation in to the South London and Maudsley NHS Trust and the potential for civil or human rights challenges to be brought, if thought necessary. Based on history, it could be several years yet before those processes conclude and when you remember that we’re almost seven years beyond Seni’s death, you can’t help but wonder why things have to take this long.

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

Winner of the Mind Digital Media Award