There was a particularly interesting and unusual trial in London which finished today, into a very disturbing and tragic incident for all of those involved.  It concerned the prosecution of Nicholas SALVADOR from north London.  You will probably remember the incident, if not the name: he is the man who went on what some people have called ‘a rampage‘ in the Tottenham area of north London and who, after killing two cats, attacked and beheaded 82yr old Palmira SILVA in her own garden. It is, in many respects, just too awful to contemplate and I’m sure this period is difficult for those who knew and loved her. It is a credit to her that she is known to have tried to calm and reassure the man who killed her after she found him in her garden, when he was in obvious distress.

The facts in this case were not in dispute: it is accepted by the prosecution and by the defence that on 4th September 2014, Mr SALVADOR killed Mrs SILVA.  It therefore raises the question for some of why was there a trial occurring if he admitted the attack? It was to do with his plea of insanity, comparatively rare in the English justice system and where it occurs, it is often accepted by the prosecution and there is no need for a trial. I have written about insanity in the past and in particular about the verdict not guilty by reason of insanity, so you can refresh your memory if it helps.

Mr SALVADOR was charged with murder and committed for trial at the Old Bailey.  His options in this particular context were to plead guilty, not guilty or not guilty by reason of insanity. It is obviously accepted by everyone involved that he is currently fit to stand trial, which is sometimes an issue where defendants are suffering from a serious mental disorder and Mr SALVADOR has been described by one forensic psychiatrist already as being ‘as mentally ill as you can possibly be’. In essence, the prosecution declined to just straight-forwardly accept his plea of not guilty by reason of insanity, insisting that he runs the insanity defence in court and that it is a matter for a jury to determine. I’m yet to work out from the media coverage why precisely the prosecution think this cannot just be accepted but there’s also the point that insanity being a legal concept, not a medical one, it is just ultimately for a court to decide.


He was obviously very unwell – everyone agreed he was experiencing a serious psychotic episode at the time of the offence, so why did any of this matter? Well, there are various things that will differ, depending on whether the jury returned a verdict of guilty to murder and actual bodily harm (for an assault on a police officer during his arrest, which hospitalised the constable) or whether they accepted his plea, on the balance of probabilities, of insanity. Anyone convicted of murder gets life imprisonment as a mandatory sentence; someone found not guilty of any offence by reason of insanity will be sentenced to a hospital order, which can be a restricted hospital order if it is thought that the defendant poses ‘a serious risk of harm’ to the public as a whole.

If he was convicted of murder, he would first go to prison and then spend the rest of his life subject to restrictions by the criminal justice system – contrary to popular assertion, life does mean life because you remain on licence for life and subject to recall even if you are released from prison. Prison still allows for a period in hospital because the Mental Health Act affords for convicted prisoners (s47) or remanded prisoners (s48) to be transferred to hospital, if necessary. If found not guilty by reason of insanity, he will go straight to hospital to remain there indefinitely. A restricted hospital order can remain in force indefinitely and some patients will end their days as a detained inpatient; others may be released if they are assessed as being suitable for discharge. To ensure that discharge decisions are based upon proper risk assessment and multiple opinions, the Secretary of State for Justice has a role to play in overseeing and then authorising the recommendations by doctors. It is the Doctors who are restricted by a restricted hospital order, not the patients.

Finally, what is the difference between not guilty by reason of insanity and guilty of manslaughter on the grounds of diminished responsibility? Essentially, the former is a successful argument that someone was so mentally unwell that they are entirely beyond criminal liability for the act done. In the latter case, they are not quite so profoundly beyond liability that they still end up convicted of a homicide offence, albeit one which recognises the role that their mental ill-health player in the act.

It took the jury forty-one minutes to determine that Nicholas SALVADOR was not guilty by reason of insanity which means he will be hospitalised indefinitely under a restricted hospital order.

The video below does not contain footage of the offence, but of the pursuit to arrest SALVADOR by the Metropolitan Police officers who already knew the nature of the incident.  The judge has recognised their bravery in court, quite rightly.  More importantly, is the permanent impact that this incident has had on Mrs SILVA’s family.

The Mental Health Cop blog

Badgewon the ConnectedCOPS ‘Top Cop’ Award for leveraging social media in policing.
won the Digital Media Award from the UK’s leading mental health charity, Mind
– won a World of Mentalists #TWIMAward for the best in mental health blogs

ccawards2013 was highlighted by the Independent Commission on Policing & Mental Health
– was referenced in the UK Parliamentary debate on Policing & Mental Health
was commended by the Home Affairs Select Committee of the UK Parliament.


Reforming the Narrative

Yesterday, the Reform think tank published a (very modestly titled) report on policing “How To Run A Country: Crime and Policing”. It is one of various briefings they will be publishing ahead of the comprehensive spending review in autumn 2015 relating to various areas of public service.

This blog relates to just one brief section of the document on policing and mental health. To save you opening the file and finding the particular paragraphs, I have copied and pasted them here, from pages 9 and 10 —


“4.2.2 – Particular attention needs to be given to addressing the current inadequacies in dealing with people with mental health issues. As discussed above, the police service is increasingly responding to mental health related incidents as the service of last resort. This is placing unacceptable strain on police resources, but more importantly is damaging for those individuals suffering from mental health problems. As HMIC’s report stated, the lack of alternative is leading to “vulnerable adults and children…being criminalised unnecessarily”.

The Department of Health is currently funding pilots using mental health street triage vehicles as a way of tackling this. Whilst it is early days for the scheme, initial evaluations have been promising, with a 40 per cent reduction in the use of Section 136 of the Mental Health Act by some forces.

Encouragingly there are examples of innovation in this area, with many PCCs piloting new ways of working. In Northamptonshire, following the initial success of a triage pilot, PCC Adam Simmonds has just extended the use of triage cars to 4pm – 2am at the weekend. He believes the additional time will enable more vulnerable people to be reached out of hours and reduce the demand on traditional services on Friday and Saturday nights. In Norfolk, PCC Stephen Bett has introduced a Mental Health specialist within the Norfolk Police Command and Control Room. This allows ‘real time’ support to be provided to vulnerable individuals and for the most appropriate services to be engaged reducing unnecessary police involvement.

However at the system level criminal justice services and health remain entirely separate, regardless of the considerable crossover. Despite multiple crime-related indicators in the Public Health Outcomes Framework, neither PCCs nor police chiefs are mandated to sit on Health and Wellbeing Boards, leaving it up to Boards whether to include them. This needs addressing.”

How To Run A Country: Crime and Policing – Reform, London, June 2015.


  • Agency of last resort – I actually think the problem is that the police are the agency of first resort.  I’ve said so for years and I think, if anything, street triage is making this even more true. I remember many years ago reading the website of the world-renowned Institute of Psychiatry in London and looking at the page they used to have for those who may need help and support. First on the list was ‘call the police’ – world experts in psychiatric and mental health research thought that the police, should be or were the first resort. They even went on to incorrectly claim that ‘the police have powers to remove people to a place of safety’. Of course, this is only partly true – they have no powers in private premises which is actually where most police demand connected to mental health actually occurs! We know that mental health services have often deflected demand to policing, purely because it’s more convenient to do so and street triage sees this continuing and extending – examples are available on request, but I did enjoy the story of the GP in Northampton whose patient rang for an out of hours, unscheduled appointment for ongoing mental health problems and was told to ‘ring the police, they’ve got mental health nurses now.’
  • Unnecessarily criminalised – this is an interesting remark, isn’t it? I know that it came from HMIC, but Reform have picked it up and used it. It very much depends on what you mean by unnecessary criminalisation as to whether this proposition stands true. It has been argued by some policing academics (Egon BITTNER, Meslissa MORABITO) that the reverse is true: that the police ‘criminalise’ vulnerable people with mental health problems to a lesser degree than the population as whole. So if we want to argue about whether someone was ‘criminalised’ are we simply asking whether they had contact with the police or justice system and ‘treated like a criminal'; or whether they were treated more or less favourably to someone else in the same situation who did not have a mental health problem. If someone in crisis stole food and was arrested, taken to police custody and then diverted from justice, were they criminalised? Yes, because they were arrested; no because their mental health problem meant a different outcome was achieved in recognition of their vulnerability – it depends on your values!
  • Initial evaluations (of street triage) – I do wonder whether the initial evaluations have been read. Now I’m not an academic, as you know, but I wonder how some of the evaluations I’ve read would do if they were subject to proper academic rigour. We know that street triage mostly occurs in private premises, largely in people’s own homes. Yet most evaluations focus on reduction in the use of s136 of the Mental Health Act 1983, which can only occur in public places and therefore, in a minority of street triage encounters. So initial evaluations, it could be said, are actually an evaluation of between one-third and a half of street triage – the remainder seems untouched by critical examination as if we’re just assuming it must be making things better to a similar extent. The fact is, most areas are not collecting data about the majority of their interventions so who knows what we can say about it? We need far more data and analysis of these (often expensive) initiatives, not least because there are various operating models in play, some more resource intensive for the police than others.
  • 40 percent reduction – this is presented automatically as a good thing; and I wonder why? Of course, if the police encounter someone in a position where s136 could be used, being able to render support to that individual without legally detaining them is, on the face of it, a good thing. But this is only one aspect of an encounter – what about those situations where there is also a crime within the incident: what do we know about how officers make their decisions? Very little, is the answer to that and if someone suggested that officers sometimes use criminal powers of arrest to immediately safeguard someone they suspect to be mentally ill rather than resort to the Mental Health Act, we couldn’t rebut that assertion with real data. We know that officers’ decisions are affected by issues of expedience and given that use of s136 MHA is a decision to take two officers off the street for hours on end, in breach of various agreed national guidelines, we know that officers will avail themselves of other lawful options. The Deputy President of the Supreme Court, Baroness HALE, therefore wondered whether s136 is actually very under-used?
  • Reduced demand on policing – this needs very careful examination and hard data. Tediously detailed data that can be properly analysed. Street triage analysis tends to go like this: “We used to have 600 detentions under s136 each year and each of those involved two officers for four hours on average remaining in a Place of Safety pending assessment. We now have just 350 detentions which means we’ve saved 2000 hours of police time and that equates to a full-time equivalent police officer.” I’ve heard this kind of thing a lot – we need to remember that in order to achieve these savings, some areas have constructed triage teams with between four and seven police officers, who work between 8,000 and 14,000hrs each year, in order to make those kinds of savings. And, we also need to remember that each of those 250 avoided-detentions s till took time to deal with and those hours needed to be deducted from the initial appearance of ‘savings’. Of course, the private premises dimension needs to be factored into time costs and benefits but we don’t have data on that so few areas can do so.
  • Unnecessary police involvement – if we want to reduce unnecessary police involvement, why don’t we just build accessible, flexible health services in both primary and secondary care? I spoke to a mental health nurse recently who told me that the number of nurses available in their trust’s CrisisTeam is currently 25% of the number of nurses available approximately ten years ago. We know that inpatient mental health beds have never been at lower levels in the modern era and that the number of times the Mental Health Act is used to hospitalise someone has never been higher: more admissions, for shorter periods and all against a background of mental health community care failing to keep pace with demand because some Community Mental Health Teams have seen their caseloads rise 100% in the last twelve months alone. No-one is going convince me that this is all entirely unconnected to why we see the police experiencing ever-greater levels of demand connected to mental health. If NHS structures don’t exist or are ineffective, the consequential policing impact is hardly unnecessary where people are perceived to be at risk or very obviously are.


This is all based on a narrative that has been quietly building – the police, untrained as they are, have been drawn further and further into managing mental health demand and arising from that, they have been unwittingly or unavoidably criminalising people, being connected to untoward outcomes, consuming lots of time and effort only to subject vulnerable people to traumatising experiences — therefore what we need to do, is provide expertise from mental health services to help the police get their response right by providing alternative options to those blunt tools they currently have and wrestle the decision-making back to the experts, in nurse-led teams, both the community (street triage) and in custody (liaison and diversion).

You’ll notice how this is still a conversation about improving police responses, not about withdrawing it from the landscape to the maximum possible degree and wondering about how we created the situation we currently have. There will always be a role for police involvement because not all crisis predictable and preventable; but assuming that all demand is just work to be done, rather than failure demand arising from a mental health system that MPs, inspectorates and others have branded inadequate or falling short, is to miss most of the point. Creating better police responses probably has, in some areas, meant that the police are now expending even more resources than they ever were before, in a way that encourages even more demand to be deflected by the health and social care system. There are reasons to think this arising from the data we see in the very evaluations relied upon in the Reform document as evidence of efficacy against the assumptions that underpin this reaction: that s136 is overused, the police unnecessarily criminalise vulnerable people as the agency of last resort.

What if that’s all wrong? – what if s136 is underused, that the police demonstrably criminalise those of us with mental health problems to a lesser degree than those of us without and are often an agency of first resort because increased capacity and focus to handle mental health calls (even without a core police component like a crime or immediate threat to life) is having predictable, if unintended, consequences?

In some areas, the inevitable conversations have begun about what further crisis mental health work could be taken on by triage teams during ‘downtime’. I know this because I have witnessed some of them. Certainly it seems that some CrisisTeams, out of hours GPs and others think there is a now a new, flexible resource on the block and that they should be making creative use of it. It is for this reason that we need to look far wider than policing and police responses: if the resources expended on street triage and liaison and diversion had been spent on the acknowledged inadequacies of mental health and crisis care, I do wonder about the extent to which these initiatives would be necessary at all. And if you were to nail me down and ask what I thought was the crucial, critical success factors of street triage, which it must be acknowledged is achieving positive incident resolution for many, it would be the ability of police services and mental health services to communicate with each other and share information to influence police  options and decision-making. There are a large number of ways of achieving that objective.

This BLOG post is already over average length and I could go on …. I’ll save that for another day and let you enjoy what’s left of yours.

The Mental Health Cop blog

Badgewon the ConnectedCOPS ‘Top Cop’ Award for leveraging social media in policing.
won the Digital Media Award from the UK’s leading mental health charity, Mind
– won a World of Mentalists #TWIMAward for the best in mental health blogs

ccawards2013 was highlighted by the Independent Commission on Policing & Mental Health
– was referenced in the UK Parliamentary debate on Policing & Mental Health
was commended by the Home Affairs Select Committee of the UK Parliament.

Tour of the new Patchway Police Centre. Inside a custody cell.
Photo by Dan Regan
Reporter - Rachel Gardner
Copyright - Local World

Inherent Contradiction

A Coroner’s Inquest in London ruled earlier this week that Darren NEVILLE died from the effects of prolonged restraint after an ‘acute behavioural disturbance’.  This is the second verdict in a month that mentions ABD – you will remember it featured as one aspect of the multi-factorial death of Kingsley BURRELL who died in Birmingham in 2011 amidst a broader ruling of neglect by the police, ambulance and mental health services.  There are other ongoing inquiries and pending inquests into deaths in state care whilst patients were under restraint, including after the use of s136 of the Mental Health Act 1983 where the concepts of ABD or excited delirium (ED) are raised so we are going to hear more about this later in the year and in to the future.

This remains controversial stuff and is at the heart of an inherent contradiction.

There is a pile of printed reports on my shelf at home (I will soon need a new shelf) that includes a range of materials which tell us that ABD (or ED) is a rare, but potentially dangerous medical complexities that we still don’t fully understand.  These materials include –

  1. The Royal College of Psychiatry Standards on s136 of the Mental Health Act 1983 (2011)
  2. The NICE Guidelines on Violence and Aggression (2015)
  3. The Inquiry into the death of Rocky BENNETT (2000).

The BURRELL and NEVILLE coroners were not the first to to return verdicts that mention ABD or ED.  Others have included –

  1. Jacob MICHAEL in Cheshire in 2011.
  2. Jason PEARCE in Shropshire in 2011.
  3. Dale BURNS in Cumbria in 2013

Such is the concern across the police, emergency medical and mental health services that in the South London and Maudsley Mental Health Trust, they have worked with the Metropolitan Police and the London Ambulance Service to produce a training DVD for involved professionals that briefly covers the identification, risk issues and effective responses to situations that could involved ABD (or ED).


No point avoiding that fact: these concepts or conditions are not universally accepted as disease entities or illnesses, notwithstanding what some Coroner’s have ruled.  In the article above about Jacob MICHAEL it is pointed out these terms have been cited in 17 deaths in custody and yet ABD / ED do not appear in the medical textbooks.  Neither the Diagnostic and Statistics Manual (5th edition, 2012) or the International Classification of Disease (10th edition, 2015) list these conditions and it is not recognised by the Department of Health.  In 2012, a File on Four investigation by the Bureau of Investigative journalism looked at this and a documentary was broadcast in which Home Office pathologists were interviewed.  It was interesting to note the Home Office pathologists within that documentary who stopped just a touch short of saying, “This is not a thing!” and did suggest that responses to the kinds of behaviour that was described in various so-called ED / ABD cases is behaviour that should give cause for medical or psychiatric concern.  Police officers and paramedics should be especially careful about applying restraint to such patients because they are likely to resist detention and very unlikely to stop resisting.

Of course, whether or not these conditions are in the DSM-5 or ICD-10, they are conditions mentioned in various other kinds of medical literature: an academic paper was written in the 1990s following the death from excited delirium in an Edinburgh mental health unit.  I just want to be extra clear here, that this death did not involve the police in any way, at any stage.  There are other academic papers from the mental health nursing profession that make mention of these kinds of conditions – and again: not in connection with policing or police-led restraint.  It is clear from any attempt to survey these issues of ABD or ED that this is not and cannot just be a discussion about police restraint.  That said, there are various reasons I’ve written about elsewhere as to why the police are more and more seen by mental health professionals as the agents of physical coercion and various reasons to think the number of individual encounters by the police with people who are acutely mentally ill has gone up over the last decade or two.


So is it just a question of police officers making sure that where they think they are dealing with a situation involving ABD or ED that they ‘contain rather than restrain’? This is something I’ve argued about for some while and something which I’ve successfully put into practice when working operationally. I’ve often told the story of the young woman in residential care for patients with learning disabilities who had started smashing up the kitchen and the police were called. Seeing that there wasn’t much more damage she could cause by the time we arrived, we left her to chuck the broken furniture around a bit more until she came out of her own volition. At all times, she was kept under observation of a female police officer – because she was naked whilst doing this – but a while later she came out.  I don’t think she was suffering ABD but I do know that avoiding restraint was desirable because her body weight would have increased risks of positional asphyxia – something else to worry about in these situations.

Not all police activity takes place in situations where containment can be applied.  In the case of Darren NEVILLE, it was reported by various witnesses at the inquest that he was ‘covered in blood’.  I realise that can mean a number of things and clearly, I wasn’t there.  But I’m wondering about how practicable it is to contain someone, potentially for a long while, if they are also bleeding to such an extent.  There is the other problem that whilst police interventions in the cases of Olaseni LEWIS and Kingsley BURRELL have involved inpatient mental health units, more police interventions occur in public places where officers would also have to consider other members of the public, traffic and who knows what other situational factors in deciding whether they can contain someone, rather than restraint them.

And what happens next?!

Imagine that officers, perhaps with riot shields, could create a sterile area within which a person in acute distress is not restrained or even touched, but is effectively held within a safe area.  For how long does that position get maintained before something else has to happen?  I always recall a case from London of so-called excited delirium involving Paul COKER.  From (admittedly limited) information online, I was caused to have the impression that Mr COKER was restrained at the point of arrest and taken to a police station, but that once in the cell, he was not actively restrained in the two hours that followed.  It was then he was found to have died in the cell.  So it’s also not just about the active application of restraint, but the observation of people who should have been identified as exhibiting indicators of ABD where restraint has ceased.  Again, in the inquest which followed, the Coroner was dissatisfied with the application of training and concerned that further deaths could occur.  He was right, in fairness to him.


So here is the problem:  we want police officers responding to incidents to recognise those cases where resistant, aggressive or violent individuals are potentially suffering from excited delirium and at risk of sudden death should officers apply and restraint and / or fail to summon emergency medical intervention or remove someone to an Accident & Emergency department.  At the same time, we have a Government recommendation in the review into operation of ss135/6 of the Mental Health Act which wants to codify that individuals whose behaviour is so extreme that it cannot be safely managed elsewhere, are those exceptional circumstances where police custody should be used.

This is a contradiction in the strategic context in which officers and paramedics have to make fast tactical decisions –

  • This behaviour XYZ = a medical emergency, so call an ambulance if possible, and go to A&E.
  • This behaviour XYZ = so extreme it cannot be safely managed, so go to custody.

Can do one of these things, but not both.  We must choose and make it clear to operational officers what the direction is, because some of my colleagues who have been criminally investigated and indeed, prosecuted, arising from this contradiction deserve clarity.  Even more importantly, vulnerable people and their families deserve to know that there is clarity in the policies and directions that are given, because there can’t be anything more traumatising than knowing that when a police officer did something that led – whether directly or indirectly – to the death of your most precious loved one, that they were ignoring some of the advice and opinion that exists.  If that officer then defends their actions with reference to other direction and advice that exists, it can’t help but sound like a fudge and a cover up.

We need to square this circle.

The Mental Health Cop blog

Badgewon the ConnectedCOPS ‘Top Cop’ Award for leveraging social media in policing.
won the Digital Media Award from the UK’s leading mental health charity, Mind
– won a World of Mentalists #TWIMAward for the best in mental health blogs

ccawards2013 was highlighted by the Independent Commission on Policing & Mental Health
– was referenced in the UK Parliamentary debate on Policing & Mental Health
was commended by the Home Affairs Select Committee of the UK Parliament.