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Police Liaison

I woke upon one day last week and whilst boiling the kettle checked Twitter to find an article entitled ‘police liaison’ in the British Journal of Psychiatry (no less) about street triage.  Consumed with interest, I opened the PDF to find it granted free-access (I don’t subscribe) and I started reading.  In paragraph one, I admit to putting the phone down on the kitchen surface and breathing deeply whilst I got the milk out of the fridge. I read on, caffeinated!

The article sets an evaluation of street triage against the background of section 136 usage – more on that premise, later – and tells us that “it requires [my emphasis] the input of an Approved Mental Health Profession (AMHP) and two doctors for the assessment.”  Except that it doesn’t! …. it requires just one registered medical practitioner, which is made clear by subsection 2 of the section itself, which states, “A person removed to a place of safety under this section may be detained there for a period not exceeding 72 hours for the purpose of enabling him to be examined by a registered medical practitioner (RMP) and to be interviewed by an AMHP and of making any necessary arrangements for his treatment or care.” It doesn’t even demand that the RMP is ‘section 12 approved’, although this is highly recommended by the Mental Health Act Code of Practice.

So what occured to me after reading it –

  • The whole article about police liaison is about usage of s136 – yet we know most street triage encounters occur in places where s136 can’t be used.  There is therefore no analysis of the majority of its work!
  • We also know that s136 is only a very small, and in some areas a relatively unimportant, part of ‘police liaison’.
  • It is predicated on not fully understanding what s136 requires – although many MH trusts and AMHPs prefer to have two doctors for assessment, this does not arise from the law, but from local policy. It makes me wonder how we justify any greater, longer restriction whilst we look for that second, no doubt helpful but legally unnecessary doctor?
  • It fails to ask some really obvious questions about the approach of triage to encounters, where reductions in s136 have been observed – how do you delay the instigation of powers that are, by their drafting and definition, immediately necessary whilst officers ‘phone a friend’?
  • It starts from the premise that s136 is over-used, when we don’t know that it is – there are some commentators, including the Deputy President of the Supreme Court, who argue it’s probably under-used. In reality, forces use the thing so differently that it’s probably a bit of both and depends which area you’re looking at.
  • None of the problems associated with non-use of s136 following triage contact are mentioned, at all – we know there are some issues with it, not least because there have been Coroner’s inquiries following contact with these schemes. Have these things happened in that area?

TWITTER REACTION

I want deal with the reaction on Twitter from a few nurses and AMHPs, that two doctors for assessment is ‘good practice’ and standard procedure in many areas.  Fine: the law can set a minimum standard and areas can choose to exceed it, but we know that this will also not be without difficulties and consequences.  As s136 is currently framed, detention can last for up to 72hrs. This does not mean that all of 72hrs can be taken just because it’s convenient – surely if the principle of ‘least restriction’ (which I remember reading about once upon a time) is to mean anything, it means we don’t detain people for longer than is necessary.

If the law demands one doctor and there is no particular and obvious reason to include a second doctor from the outset, any delay in their attendance would need to be justified as proportionate to the delay it caused. If an AMHP had one (s12) Doctor available 3hrs after somebody’s detention under s136 but a second doctor wasn’t available until 9hrs after that, how do we justify the extra 9hrs of detention when the law could have been complied with at 3hrs? Indeed, during this morning’s Twitter exchanges, more than one police officer was explaining that they’ve known cases of long delay to secure that second doctor so this is not hypothetical. I’ve also known it as recently as yesterday where a Mental Health Act assessment is requested for someone in custody (which would require two doctors) and the AMHP has turned up with just one, because they apparently pre-determined that the man’s history would preclude him being sectioned under section 2 of the Act because admission to an acute admission ward would be inappropriate; he would require prosecution for the alleged offence to be admitted to a medium secure unit.  Fair enough: but these decisions were made without anyone knowing or asking whether there actually was sufficient evidence to charge the person!

And this ‘two doctors’ approach for section 136 doesn’t play the odds – most people detained are not subsequently admitted to hospital.  Accepting some cases will be borderline, I’m not suggesting that none of those cases will always just need one doctor because an AMHP and the first doctor may know enough upon receipt of the referral to know a full MHA assessment is necessary; and the 72hrs is there to be used. I’m just imagining a situation where one of my family members is jailed in police custody as a Place of Safety for 3hrs when the first Doctor becomes available, but is then kept there for a further 9hrs for a second-opinion without any sense that it’s necessary and everyone pitches up at 12hrs to do what could have been done earlier and my relative is sent home. Indeed, if a common complaint about police decision-making, also voiced this morning, is that it’s “obvious” some people – or even many people – detained under s136 shouldn’t have been detained at all and that police officers are too risk averse in their approach. It makes a bit of a mockery of that feedback that we’re always using two doctors to do what one doctor could do in the vast majority (83%) of all cases and this approach has been normalised to such an extent that we’re publishing articles on the false premise of what the provision involves.

POLICE VOICE

During discussion about potential research on things like s136 and street triage, it was mentioned this week on Twitter that ‘clinical’ people should be doing it. Conscious that this tends to mean doctors and nurses, I was most curious because a) look at the above; and b) there is an obvious role played by non-clinical professionals in a mental health crisis care: police officers, paramedics (who someone recently insisted to me are ‘healthcare’ not clinical staff!?) and – of course – AMHPs (usually mental health social workers). I do try really hard not to be too picky with this kind of stuff (believe it or not!) – but one reason I keep banging away via a BLOG is: if we’re happy to exclude the police from and others from research and discussion about a process that flows from a police decision and which requires ongoing police involvement then what else is being missed by professionals who often have too little legal training around the issues they purport to evaluate?! This is just one example: there is no ambiguity at all in s136(2) about what is required – it’s written in everyday English language and is hardly the most technical or complicated of our laws.

But that gets me to a wider point: I worry about the exclusion of the police from various discussions that are going on in this country about the police role in our wider mental health system. In the same way that many patients have rightly demanded, “Nothing about me, without me”, the same should be true across organisations and their partnerships.  The College of Policing has worked for two years on Guidelines for situations where calls are received asking the police to undertake restrictive practices (ie, restraint) in mental health or learning disabilities settings. It took this long purely because of the large number of health, NHS, third sector and other organisations who needed to be involved and consulted. Collating that feedback was a mind-consuming nightmare which I will never full tell you about because of the volume of it, the considerable contradiction within it and so on. But imagine if we hadn’t consulted and the College produced guidelines on matters affecting inpatient wards without speaking to staff who work there or more importantly with the patients who are detained there without liberty or autonomy?!

Yet in that time, I can think of at least three of four programmes of work or guidelines in health that directly affect the police where it seems highly likely that no effort was made whatsoever to consult with the police. I won’t embarrass those involved, but I could back this up, if required to do so. I suspect there are plenty of conversations going on in rooms to which the police are not invited about how responsibility, risk and liability can be transferred to the criminal justice system and we see this in police-mental health processes. New data on the use of section 136 MHA has been celebrated as progress because the number of people being removed to police custody as a Place of Safety has halved over the last year, whilst the use of the power is still rising over time. On how many of those massively increased number of cases are two officers now being required (despite national guidelines to the contrary) to remain at the PoS for assessment? “Most of them, in many areas”, is the answer and in some cases this means even more resource being expended by Chief Constables than was the case when cells were being heavily relied upon as Places of Safety under the MHA. Do the Chiefs realise this? – why would they unless they turned over the stone themselves. No data is being gathered on it and it gets buried beneath the argument, “We agree that cells are the wrong place and we don’t have enough staff.”

LOOKING WIDER

Any premise that section 136 tells us very much at all is fairly flaky. We saw the 2015/16 data published last week and immediate comparisons were being made with the previous year’s. Yet we know that the 2014/15 data was incomplete and that the data to is, at best, partial. I still can’t tell you how many patients were admitted to hospital on a voluntary basis following assessment under s136. But there is so much more to triage and to police liaison as a whole –

  • What about criminal suspects who are mentally ill – the whole liaison and diversion debate? When and at what point do we prosecute someone for an offence and when do we divert them from justice? – this group is about four or five times the size of the cohort detained by the police under s136 but we hear far less and know far less about them. What is the re-offending rate of individuals arrested for offences who are ‘diverted’ from justice at the point of arrest? We don’t know.
  • What about those in contact with the police who are not detained under s136 and don’t need to be – whether that is street triage encounters; welfare checks on vulnerable people, etc.. Police forces around the country are asked to undertake tens of thousands of welfare checks every month, most of the time where the person is not ‘missing’  and where there is no other urgent issue that justifies risking the psychological wellbeing of someone by ‘calling the police’ on them.
  • What about matters pertaining to the administration and application of the MHA – things like AWOL patients and those who have otherwise absconded; calls for the police to attend wards to undertake restrictive practices on behalf of ward staff, etc.?  We know that there is still too much reliance upon the police to undertake these functions where they have no legal duty to do so and, again; where it risks having a very negative impact on the public.
  • What about allegations of crime on mental health wards – whether those allegations are made by patients or staff?  We know that there is dissatisfaction with the consistency of the police in their investigations and that improvement in this area could bring many benefits to all. However, the NHS needs to understand how much damage their own approach around the recording of ‘medical factors‘ could do in this arena.

So I worry that we really are still making this stuff up as we go along; and that without a greater effort to gather data, we always will be. But first, we have to open our eyes to the questions and problems and an informed police view point is vital to that.


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

Winner of the Mind Digital Media Award


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New Section 136 Data

Anyone fancy doing a PhD?! – we’re badly in need of some proper research to be done on section 136 data so we stand a chance of knowing what on earth is going on! Friday saw publication by the National Police Chiefs Council of the latest data on the use of this power and we can see various ways of looking at this stuff if we wanted to provide a tabloid-style headline. So depending on whether your glass is half full or half empty –

“Use of police cells as a Place of Safety reduces by over 50%!”

“Police use the Mental Health Act more than ever before!”

In then bears much further scrutiny and begs many more questions –

  1. Why are some police forces of similar size using s136 very differently?
  2. Why are some forces using this power to a very similar extent when they are so obviously different from each?
  3. Why have some forces with street triage schemes reduced their use of s136 and sustained that, whilst others reduced it but it has returned to normal levels?
  4. Why have other forces not reduced it at all, despite street triage?
  5. Why are some forces still relying upon police custody for almost half of their Place of Safety provision, but some haven’t used the cells at all?!
  6. Where s136 has been used in the street, how long does it take to sort out where someone will be removed to and how long are officers sitting in queues for hours until they can even get in to those locations?

Here is the Press Release from the National Police Chief’s Council (containing links to the last two year’s worth of detailed data).  The image below, broken down by force area, is for 2015/16 and at the bottom, in yellow, are the total figures for the last three years.  During reaction to the release of this data, I raised caution about the accuracy of the numbers involved: not only are simple year or year comparisons sometimes unhelpful, but we know there are still problems with this data despite the effort of NPCC to collate it.

Comparing this year with last year, use of s136 is up by almost 5,000 to 28,271. However, we know there was an incomplete data last year! To point out one big example of that, in 2014/15, the Metropolitan Police reported incomplete data (for whatever reason) which put their annual numbers at 829. This year it was 3,693 – up by almost 3,000 and back to where you’d roughly expect it to be (albeit rising). Factoring that in along with other data omissions, we can see the 2014/15 data needs a lot of salt! –

  • 28,271 (15/16) – inc 2,100 to custody.
  • 23,602 (14/15) – inc 4,537 to custody.
  • 26,137 (13/14) – inc 6,667 to custody.

Here is the detailed breakdown, across England and Wales.  The header image of this post, above, is the (inaccurately!) recorded use of s136 going back over a decade.


WHAT’S GOING ON?!

Who knows what’s really happening?!  In reality and based on what we know there are a large number of significant factors influencing all of this and understanding the relevance of them to different areas is fairly important. It is quite beyond me to understand it all without a great deal of work in each area that I don’t have the time to do!  So I would encourage people reading this in various areas to try to ensure the conversation starts and perhaps engage some decent academics to look at it?

I still receive enquiries at the College of Policing about mental health street triage with people asking, “What’s the best model to operate?!” and I always reply, it depends what your problems are and what you’re trying to achieve.  And of course, none of this even begins to discuss the issue of the ‘conversion’ rate, which is a major piece of information used by some professionals to argue the police are over-using this power. Previously, just 17% of people detained under s136 would be admitted to hospital under the MHA but we know two things that put this figure in context –

  1. The threshold for admission is not a constant factor – many MH professionals have been arguing it has risen over time as the number of available inpatient beds has significantly reduced. Is it any wonder that with fewer beds, fewer patients become inpatients?!
  2. How many ‘successful’ outcomes do not involve admission under the MHA – how many patients were admitted informally, referred or re-referred to a community mental health or other health service? If a cop spots a vulnerable person who is subsequently cared for by a community MH team who transforms their life, isn’t that a success?!

I would argue, for a few reasons, there are forces in represented in the above data who are under-using this power and need to think about how to use it more. I argue this because section 136 is just one legal power from a a whole range of legal authorities that can be applied by the police in various situations. To fully understand section 136 usage, you also need to understand how it fits in to those overall options. How many people arrested for criminal offences or to prevent a Breach of the Peace were subsequently and rightly assessed in police custody under the MHA because of concerns for their health? How are interactions between the police and people with potential mental health problems handled and what factors influence an officer’s decision to a) detain; and b) chose the framework for detention?

In other words: are some forces more likely than others to find their officers are using public order laws, drunkenness laws or other provisions where a further moment’s pause and interaction may make it clear that detention under the Mental Health Act is a more appropriate route – and how do forces encourage officers to make decisions where substantive offences are involved like possession of a knife or an assault?  Only this week, we saw concern raised by a judge about a prosecution being dropped where a man was waving a knife around in a public place whilst mentally ill; this comes just a few months after a coroner raised concern that the police arrested someone with mental health problems for possession of a knife and didn’t detain her under the Mental Health Act.

LOOKING FORWARD

This is the last set of data to be published ahead of the law being changed in 2017 and it’s obvious that some areas have far more work to do than others to prepared for the likely implications. If police stations are banned (one amendment to be discussed in the Lords next week will seek a total ban), there are seven police forces who need to be thinking of their contingency plan for over 100 people a year – will that mean unless there is provision, each of them is taken to A&E?!  I fully accept colleagues in A&E may have a view about this but if the law literally bans the use of custody and there is no health-based Place of Safety, what are the other options?!

We are obviously still waiting to learn what ‘exceptional circumstances‘ will mean if that Lords amendment is defeated and the original proposal in the Bill is enacted.  A further problem that is not reflected in these figures is the ability to access a bed for those who are to be admitted to hospital following the police’s use of s136 MHA.  Only this week, I was called at 9:30pm by a triage car from one force who told me their duty inspector was putting pressure on them to sort a situation where someone had been in detention in a health-based PoS for around 30hrs and the MH trust were having a right old job finding a bed in either the public or private mental health sector. In eight months time, that situation will either be unlawful and a violation of European Convention Rights; or just a couple of hours away from becoming so.

Section 136 MHA and everything that flows from it and is associated with it needs to be better understood. In all fairness, there are PhDs being done as right now on the use of the power, on street triage and other aspects of policing and mental health. However, what access those research students have to some of the data, I don’t know. How many forces or MH trusts will be free with data that supports the notion that they are breaching the law or Codes of Practice to the Act because of the overall pressure on our mental health system. How much of this research will reflect operational practice where police officers are sometimes required to become involved in or responsible for highly un-desirable situations that should never have occured in the first place?

We have a lot still to do – and first of all: what is section 136 actually for?! 


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

Winner of the Mind Digital Media Award


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ABD – part 2

This is the second in a three-part series on Acute Behavioural Disturbance written by Dr RS, a UK consultant in emergency medicine. 

The first instalment of this series has been widely read and you may wish to begin there if you missed it originally.

In the previous edition, the history and clinical features of acute behavioural disturbance/disorder (ABD) were described; the triggers for the condition will be described, along with the underlying physiological changes associated with the condition below.

CAUSES/TRIGGERS FOR ABD

Delirium – one of the key diagnostic features of ABD is described as an acute confusional state; theoretically any cause of delirium can trigger an ABD, however the overwhelming precipitant of ABD is related to drug use. Most of the medical literature relates to cocaine however since Wetli’s initial case series, a variety of substances have been implicated.
The underlying pathology of delirium relates to a disturbance in the function of the brain, as opposed to anatomical changes. Brain cells (neurones) constantly signal to each other through chemical messengers (neurotransmitters) to change the processes within the cell itself; several neurotransmitters have been identified, namely serotonin, dopamine, nor-adrenaline, GABA and others. Whilst the type of neurotransmitters is relatively limited, the receptors to which they bind are numerous; for example serotonin receptors have 14 subtypes alone. For the purposes of simplicity, delirium can be characterised as an imbalance of the closely regulated processes governing the balance between excitatory, and inhibitory neurotransmitters, resulting in an ‘overstimulated’ brain, predominantly in the areas of the brain relating to perception (interpretation of sensory input), cognition (thinking), and wakefulness.

Drugs – drugs used for recreational purposes are the most frequently reported cause of ABD, especially within the domain of forensic pathology. Drugs exert their psychoactive effects acting within the brain to alter neurotransmitter release, reuptake or breakdown; some drugs act as direct receptor stimulants.   Cocaine, the first substance reported to trigger ABD continues to be responsible for such presentations; similarly, amphetamines (including met-amphetamine ‘crystal meth’ or ice), feature frequently. Within the UK, deaths secondary to ABD as a result of cannabis intoxication and various novel psychoactive substances have been reported. GHB (liquid ecstasy) intoxication may induce an ABD; acute withdrawal from GHB in users who consume the drug daily may rapidly manifest an ABD.

Mental illness – incidents relating purely to mental illness are rare, with substance use often compounding presentations; in the very first descriptions of acute behavioural disturbance in the mid 1800s, mental illness was the the sole determinant. The mechanisms by which mental health conditions may lead rise to ABD are complex and beyond the scope of this article; case reports featuring predominantly manic states, and to a less extent schizophrenia exist. Postulations as to the underlying brain chemistry responsible for such episodes again lend to alterations in neurotransmitters.

Physical health – isolated case reports relating to ABD are rare, but a physical cause for such events should be excluded. Recognised causes for delirium secondary to physical illness include head injury, brain tumours, stroke, prescribed medications, low blood sugar, and alcohol withdrawal. Such cases often present in a more advanced age group (excluding alcohol withdrawal, or delirium tremens which is found in all ages), however their role in the cause of ABD should be considered by clinicians.

UNDERLYING PHYSIOLOGY OF ABD

Due to the nature of persons exhibiting ABD, measurement of the underlying physiological changes has proved problematic; advances in medical technology, has led to a greater understanding of the dynamic processes involved. For persons exhibiting ABD the physiology is akin to the “fight or flight” response, albeit elevated beyond the body’s tolerance. As a consequence of grossly elevated circulating catecholamine levels (adrenaline, nor-adrenaline, and dopamine) a state of autonomic disturbance arises; put simply the autonomic system is responsible for regulating processes such as heart rate, blood pressure, and blood flow to organs.

Characteristic of ABD, the individual will constantly be moving as a result of the underlying agitated state; when responders attend and attempt to administer aid, this is met with intense fear and often violence (secondary to delirium and misinterpretation of the offer of assistance). This constant physical activity results in a rise in body temperature (hyperthermia); sustained activity levels, with escalation in resisting efforts of help overwhelm the ability of the body to compensate for this heat generation.

The third aspect of physiological changes resulting from ABD is referred to as metabolic acidosis. The body strives to maintain the blood pH in a constant range – neither too acid, nor too alkaline. Complex systems interplay to achieve this neutrality (far beyond the scope of this article); suffice to say in ABD these adaptive systems are overwhelmed and a state of acidosis exists. One of the compensatory mechanisms to temporarily achieve this is to increase the respiratory rate to ‘blow off’ carbon dioxide, hence why suffers of ABD will hyperventilate, and prior to sudden death often exhibit panting patterns of respiration.

WHY DO PEOPLE DIE OF ABD?

Not everyone who exhibits features of ABD will die; it must be appreciated that survival outcome is related to the duration of the state. When police are asked to respond to a person (usually male) who is behaving aggressively or in a bizarre manner, it is impossible for officers to determine how long such a person has been suffering such a state without direct observation.

Non-fatal cases – this is often as a result of early recognition of agitation, without the extreme physiological response and is the most common conclusion to the milder forms of ABD.

Sudden cardiac arrest – an unexpected cardiac arrest, often after intervention by police officers, is by far the most controversial event associated with ABD. Sadly resuscitation is rarely successful, even if cardiac arrest occurs when the person is being transported in an ambulance to hospital, reflecting the extreme physiological stress and irreversible changes leading to cardiovascular collapse. The effect of metabolic acidosis reduces the strength of contraction of the heart; this acidosis also affects the transmission of the electrical activity within the heart, increasing the susceptibility to abnormal rhythms. When first responders attend such a person, the sudden burst of catecholamines released when struggling may result in ‘stunning’ of the heart and sudden cessation of contractions.

Multi-organ failure – as a consequence of sustained hyperthermia (with body temperatures persistently elevated above 41 degrees), multiorgan failure ensues. The heat stress upon the body activated the blood clotting systems with the generation of microclots, which almost immediately are dissolved, consuming the clotting factors, resulting in spontaneous bleeding in various body systems. This coupled with dehydration, and a reduction in blood pressure will result in low perfusion of vital organ systems, namely the liver, kidneys and brain. Intensive care may support the patient for a period to assist recovery, however death may ensue within 48 hours to 2 weeks due a variety of complications.

POST-MORTEM EVIDENCE

As discussed in part 1, autopsies often prove inconclusive to provide a definitive cause of death. Minor injuries associated with use of force, or toxicological studies positive for drugs may be the only positive findings – given a lack of information and understanding of the physiological processes responsible for death, it is natural to conclude death is related to use of force.

Measurement of blood catecholamines after death is not a viable option as they degrade within minutes; measurement of the metabolic stress the body is under (referred to as ‘blood gas’) is reflective of the state of the person at the time of the test, and again is invalid once a person is deceased.

Ultimately determining the cause of death requires as much information as possible, but a critical understanding of the extreme physiological state underlying ABD which is only measurable during life, rather than at post mortem.

Part 3 of the series will explore treatment options for persons with ABD, and the limited options available to first responders (predominantly the police) in attempting to respond to such events.


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

Winner of the Mind Digital Media Award