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For The Want of a Nail

Guest BLOG from Chief Constable Simon COLE, former lead on mental health for the National Police Chiefs’ Council.

NB: I will format this properly just as soon as I’m not doing it from an iPhone in a Cornish field! 👍🏼

Michael./

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For the want of a nail the shoe was lost

For the want of a shoe the horse was lost

For the want of a horse the rider was lost

For the want of of a rider the battle was lost

For the want of a battle the kingdom was lost

And all for the want of a horseshoe nail

I must confess that I had always thought (and still do think) that this was about Richard III’s defeat at Bosworth Field, Leicestershire, but then, as the chief constable of the city in which he is laid to rest, for me Richard is the most alive and omnipresent of medieval monarchs in day to day life! However, my researcher (well Wikipedia) tells me that this quote is attributed to Benjamin Franklin, Founding Father of the United States of America.

I am always interested in how such basics impact on policing. For every positive impact of grand strategies or complex delivery plans it does seem that commonsense, compassion and attention to detail have a place too. They are the nails that hold things in place.

There are often stories in the national press about bed shortages in the world of health, and about logjams of patients waiting to move out into social care. What does that have to do with policing? Because policing is part of a huge, complicated, system that supports people we are absolutely at the heart of these issues. The lack of beds for mental health patients, accompanied often by problems accessing appropriate transport, sees police officers and staff spending time hunting for those crucial nails. A cursory look across social media quickly reveals officers and staff having to transport people who are ill in police vehicles, often after lengthy waits. This is not what is described in the Mental Health Crisis Care Concordat.

The concordat focuses on four areas;

  • Access to support before crisis point
  • Urgent and emergency access to crisis care
  • Quality of treatment and care when in crisis
  • Recovery and staying well

That should be supported by local agreements, and overseen by a partnership group that includes a combination of police, PCCs, partnership trusts, ambulance trusts, health commissioners, and local authorities amongst others. They are the people who decide how many ‘nails’ there are: how many bed spaces, how many vehicles for transportation, how many actual places in the Place of Safety. If there aren’t enough of those nails, or there are too many, then they need to know that is the case. It is also the place where some dynamic, innovative partnership based systems thinking can take place to drive progress.

Escalation of what is going well, and what isn’t going well, is really important. That is both as things are happening through control rooms and duty teams, and then slower time through the provision of data and information. That will enable those who are doing the commissioning of health services to see that they have got enough nails, enough horses and enough riders. Because of course the kingdom that we are fighting for is one where people who are ill receive timely, compassionate and appropriate support. For want of a nail that Kingdom can be lost….if you doubt that then please just pop to Leicester and ask Richard III.

Simon Cole QPM is Chief Constable of Leicestershire Police.


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

Winner of the Mind Digital Media Award


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Tasers on Psychiatric Wards

If you have been following the progress of the Policing and Crime Bill 2015, you will have seen it has recently started its journey through the House of Lords. Accordingly, noble peers have had an opportunity to table amendments to the original Bill, for consideration and debate during the committee stage and on the floor of the House.   

The main aspects which affect mental health are –

  • A proposal to remove the words ‘police station’ from the definition of a Place of Safety under s135(6) MHA – this would mean police stations could never, ever be used.
  • A proposal to ensure the right to an appropriate adult for anyone detained in a PoS under s135 or s136 MHA – the amendment fails to specify who would have to provide this adult or who funds it.
  • Finally, it is re-suggested that Tasers or ‘electro-conductive devices’ should be banned from use on psychiatric wards – this is a second attempt by the Liberal Democrats to introduce such a ban. It was previously introduced by Norman LAMB MP and defeated in the House of Commons.

DEFINITIONS

There is a great BLOG on this topic by @NathanConstable from Twitter which gets in to the whole debate about tactical options and asks the obvious questions about what will be expected by those who are proposing and supporting this ban?  Will they, ultimately, back police officers who shoot an armed patient if a Taser would have sufficed were it not banned by them?  Remember, the ‘use’ of Taser in around 78% of incidents simply means it was drawn from a holster and threatened: no-one was touched, at all. Yet we are having a second argument to suggest that police officers should, instead, hit people with metal poles or fire baton rounds or bullets at them.  (Assuming in all instances that attempts to de-escalate without resort to force have been tried and failed.)

I want to address another question and it causes me to ask “So what is a ‘psychiatric ward’?!” There are many kinds of environment in which patients may be detained under the Mental Health Act 1983 that I would never describe with those two words. What about the patient who is living in semi-supervised accommodation as a ‘step-down’ from low secure forensic care, prior to being conditionally discharged? – if there were an incident at the location and officers attended, Taser would be permissible because it’s definitely NOT a psychiatric ward … it’s not a ward of any kind! What about a dementia patient, living in a nursing or residential care home, detained under the MHA? – the same argument applies. But surely someone’s vulnerability is their vulnerability; the risk of these devices (all equipment carries risks; as. Does doing nothing) is still the risk whether the Taser is discharged on a ward or not. Are we also going to ban Tasers during the execution of warrants under the MHA – if not, why not?! Such events are often the immediately preceding step in admission to a psychiatric ward so the sensitivity and / or medical risks will be broadly similar. I’ve directed Taser officers to undertake such tasks and would happily do so again, unless legally prohibited from doing so.

What happens where a person who is detained in a psychiatric ward under the MHA is transferred to another kind of location – that could be to A&E for urgent medical treatment or to an acute inpatient setting for whatever purpose. We know that some patients are detained under the MHA to general hospital wards because they require surgery or other treatment for conditions that are associated to their mental disorder. If there were a serious incident – and can think of several, I’ve known – then would the officer be able to use a Taser? What about a learning disabilities hospital or unit – they’re not traditionally referred to or thought of as ‘psychiatric wards’. What about a health-based Place of Safety – I once knew a patient pull a knife an officers in an NHS PoS. They drew a Taser and threatened to use it – gaining compliance without touching the person and causing no injury whatsoever. Thankfully, that seems unaffected by this proposal but if that had been patient who returned to a ‘psychiatric ward’ after a period of s17 leave, Taser wouldn’t be an option.

I can’t help but think: we either issue this kit, accepting its risks; or we don’t. Restricting its use in such an arbitary way really just tells us that those proposing the amendment don’t trust officers to make the appropriate judgement about its suitability.

THE OTHER MATTERS

The reason I’m looking forward to the debate occurring, is that the proposal around police stations will mean there must be discussion about the kinds of circumstance in which opponents to the proposal think stations should be used. Here’s a predication: we’ll hear about people whose behaviour is ‘so extreme it cannot otherwise be safely managed’ – we’ll hear about the capacity and capability deficit that prevents safe management of vulnerable people who exhibit challenging behaviours – as if that somehow obliges the police to put people at risk by incarceration and ongoing restraint – and we won’t hear how the deliberate decision to remove people to custody is indifferent to whether or not resistant behaviour could be indicative of underlying medical problems or something that puts them at raised risk because of the need for restraint.

I doubt whether it will be acknowledge by those who oppose a ban that most of the circumstances in which it is still argued police stations are acceptable places to gaol the vulnerable are actually just deaths-in-custody waiting to happen. We’d know that if we just listened to families whose relatives have died. I obviously hope that police stations are removed from the list of Place of Safety locations, but I genuinely fear that the amendment won’t succeed, not least because the Government could have chosen this reform to begin with and someone will probably point out the impact on NHS services, including A&E which would have to act as the overspill if mental health trust PoS were full and police stations unable to be relied upon. I fear that will be prioritised over more important things.

Finally, I’ll be intrigued to see whether the Appropriate Adult proposal succeeds. This one slightly surprised me, because the role of the Appropriate Adult role is currently one for police custody, for those taken there against their will. That is usually because they have been arrested for an offence and may well need to be interviewed after having their rights explained. The AA role is to ensure people understand the process, assist with communication, see that the person’s rights are being respected and challenge or advocate, as necessary. Where someone has been detained under s136, Code C to PACE makes it clear (para 3.16) that the AA has no role during the formal interview by the AMHP and Doctor, presumably meaning their role is restricted to just the booking in procedure for the administration of rights and to ensure a general understanding of things.

Some people argue that this is broadly the role of the AMHP when they are undertaking an assessment under s136 so this just duplicates things. It also would create the highly unusual situation in which the right to an Appropriate Adult is a statutory right for those detained under ss135/6 whereas it stops short of that for those under arrest at police stations, detained under PACE. And it does raise that question – who is going to do it and pay for it, given the amendment doesn’t specify?

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Leytonstone Sentencing

Muhiddin MIRE was today sentenced by a criminal court following the attack at Leytonstone Underground station last December that made prominent national headlines.  I admit, I had a bit of a job initially piecing together what exactly the court had done, following vague media reports that appeared somewhat to contradict themselves! One simply claimed the man had been sentenced to ‘life in jail’ whilst another that he would ‘begin his sentence at Broadmoor’. This made me wonder whether, in fact, the court had sentenced him to what’s known as a hybrid order – this turns out to be exactly what they’d done; so I thought I’d quickly explain it, in case of any doubt as to what this means!

Before I do, I’d observe that somewhere between being charged with attempted murder by the police and his sentencing today, he has been transferred between the criminal justice and mental health systems. When he first appeared at court, there would be no power for Magistrates to remand the defendant to hospital under the Mental Health Act. At or after his first appearance at the Crown Court, he could be transferred and that has obviously occured and facilitated a period of assessment by the psychiatrists who have given professional opinion to the sentencing judge. The defendant has pleaded guilty to the offence, notwithstanding that his mental illness is serious enough to mean he reaches the threshold for admission to hospital under the MHA.

So this is yet another example to prove the point that serious mental illness does not always equate to a lack of criminal responsibility for serious crimes. Indeed, as previously pointed out, attempted murder is the most difficult kind of assault to prove – because a charge of murder succeeds if it can be proved that the defendant intended to kill or seriously injure the victim; attempted murder requires proof of intent to kill. A notably higher threshold to satisfy.

HYBRID ORDERS

A hybrid order means that the court can issue a ‘normal’ criminal sentence of imprisonment to any defendant over the age of twenty-one, but they will first be admitted to hospital under the Mental Health Act for treatment. It then depends how long the patient’s treatment lasts as to whether they are discharged from hospital or transferred to prison to complete that original sentence.  All of this is done under s45A of the Mental Health Act 1983.

So in Muhiddin MIRE’s case, he was sentenced to ‘life imprisonment with a recommendation that he serve a minimum of 8.5yrs in jail’, commencing with the treatment aspect of the hybrid order.  Let’s imagine he remains in hospital for 6yrs receiving treatment, he will then be transferred to prison for a minimum period of 2.5yrs before the Parole Board would be able to take any decision about his release from prison.  Were his hospital treatment to last 9yrs, then release would be considered – but not necessarily granted! – as soon as the clinician in charge of his care recommended discharge from hospital. If the Parole Board did not grant immediate discharge, he would be transferred to prison to serve further time in jail until his case for release is reconsidered.

Finally, anyone made subject to a hybrid order after conviction for any offence specified in Schedule 1 of the Criminal Justice Act 2003, will be subject to the provisions of Multi-Agency Public Protection Arrangements, or MAPPA.  These are arrangements which aim to ensure, amongst other things, post-release mechanisms through which public authorities cooperate to share information, to ensure risks are properly managed in the community, if or when a patient is discharged or prisoner released.

So this is the only form of sentence which combines two periods of detention: first in hospital and then in prison. These orders seem to becoming more popular amongst judges, the point being that they prevent people with serious mental illnesses who are convicted by the courts of being subject to a far shorter period of detention under a (restricted) hospital order than they would have done if they had been sentenced only to a period in prison.

And we could debate the ethics that sit behind that approach, all day long … on another day!


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

Winner of the Mind Digital Media Award