Policing Mental Health – a UK perspective for #poltwt

Imagine you are walking down the street. You fall and break an arm. The chances are that you will be picked up by an ambulance and taken to hospital for treatment. The police have no role to play in this scenario.

Now imagine you are walking down the street and circumstances and events cause your mind to break. Rather than being picked up in an ambulance and taken to hospital, there is up to a 50% chance that you will end up in a police cell.

Both are medical emergencies and both require clinical intervention, yet in the latter case there are no systems in place to ensure rapid treatment in an appropriate environment.

Of course, this is not universally true. In some parts of the UK, the 50% chance has been reduced to just 3%, with 97% of cases going to an appropriate place of safety in a hospital. This reduction has largely been achieved by the sustained commitment of individuals who have driven and insisted on change. Elsewhere, however, the picture is far less positive and the necessary change is phenomenally slow in coming.

For the benefit of non-specialists and for readers outside the UK I will explain further:

In England and Wales police have the power to “detain” someone in a public location who appears to be in need of immediate care and control because of a possible mental illness. “Detain” is different from “arrest” because the person is not subject to a criminal investigation.

This power is provided by Section 136 of the Mental Health Act 1983 and no warrant is required to use it. The power can only be exercised when the person is FOUND in a public place. It cannot be used in a private place (for example, inside someone’s home).

In contrast, Section 135 of the Mental Health Act provides the power to enter a private place in order to assess whether a person requires compulsory admittance to a mental institution for further assessment or for treatment.

The assessment process is carried out by Approved Mental Health Practitioners (AMHP) and doctors – often accompanied by the police.

Before the powers provided under S135 can be used, a warrant which allows the use of force to gain entry must be obtained from a Magistrate. Because you are entering someone’s property, the powers are seen as more invasive and intrusive and so an additional level of prior scrutiny is judged to be necessary.

Both Sections 135 and 136 are temporary or initial powers, used as a method of initiating (and, possibly, completing) a process of assessment.

If a person detained under either S135 or S136 is deemed to require compulsory admittance to a mental hospital for further assessment or treatment, the assessment team will then invoke Section 2 or 3 of the Mental Health Act which enables them to detain the person for a much longer period of time. This process has come to be known as “Sectioning”.

Not every S135 or S136 results in a detainee being “sectioned”.

If police detain anyone using their powers under S136, the law says that person must be taken to a “place of safety.”

It is here that we encounter the first problem with the use of S136.

Guidance from the Royal College of Psychiatrists and from the Association of Chief Police Officers (ACPO) makes it quite clear that a police cell is NOT a “place of safety.”

The “place of safety” should be an appropriate environment in which to conduct a mental health assessment, ideally in a mental health hospital.

However, a police cell CAN be used in extremis, but only if the patient is so wholly unmanageable that they would present a risk in any other location.

There are several problems in respect of “places of safety”. They are frequently understaffed and some have unofficial “exclusion criteria” so that staff will refuse to accept a patient because s/he is drunk or violent. However the main problem is that there are simply not enough of them.

There is general agreement that the correct ratio for available places of safety should be 1 bed for roughly 200,000 head of population.

In some areas of England and Wales that ratio is 1 bed for 2.2 million people.

Theoretically, there should be 11 available places of safety. In reality there is just one.

This means that if that place of safety is already in use or is otherwise unavailable, the options as to where else a detainee can be taken are severely limited.

Rather than taking the detainees to a cell, those responsible for setting the guidance would prefer officers to improvise an alternative place of safety – for example, at home or with family or friends. However, there are very few occasions where you can simply whisk someone away and wait with them until they can be assessed. Moreover, in many cases, home is often not a suitable location.

Because of this chronic lack of provision, people are located in police cells for the “crime” of being ill. The practice is almost medieval.

The second problem with use of S136 is what happens if the detained person becomes violent.

If someone with a mental illness needs to be physically restrained, this is classified as a medical emergency. Doctors must be available and a defibrillator must be to hand.

Police cells will have defibs but no doctors. Police officers are not allowed to administer the drugs which could medically subdue a patient. The only way for police to restrain a violent mental health detainee is by use of physical force. This can be prolonged, requires many officers to be present and can result in both the detainee and the officers suffering injury. It can lead to the detainee suffering a cardiac arrest.

It could mean that a detainee who is floridly psychotic might be forcibly restrained by six officers on the floor of a police cell. For being acutely ill. It might lead to the detainee suffering a cardiac arrest. It has led to too many deaths in police custody.

From the perspective of detainees this treatment is unfair: there should be no place for it in modern society. What they need is rapid (possibly chemical) medical intervention but instead they get pinned to the floor.

From a policing perspective, it is both wasteful and dangerous. Numerous officers need to be present if a detainee is to be restrained effectively and with least risk. And whilst they are engaged in the restraint, they cannot be doing anything else.

Even the most placid of mental health detainees requires constant supervision which will necessitate the presence of at least one officer.

Police officers tending to the sick – sometimes forcibly. Nurses in blue.

My good friend @MentalHealthCop has coined the phrase “Paramilitary Nursing” to describe this scenario.

The Independent Police Complaints Commission (IPCC), which investigates allegations of serious wrongdoing by UK Police, has long argued that a police cell should NEVER be used as a place of safety. The IPCC has investigated many instances of deaths in police custody where the person has died after prolonged restraint.

A third problem with S136 is the fact that it can only be used in a public place. If officers are called to a private dwelling and find within it a person who, because of a mental disturbance, is in apparent need of immediate care and control, they are unable to enter and detain them.

The officers can force entry to protect life under Section 17 of the Police and Criminal Evidence Act but having done so they run out of powers.

They are not allowed to persuade the person to step outside into a public place in order to detain them. The law is quite clear that the person must be FOUND in a public place, not taken there.

Those who are suicidal or disturbed frequently call the police. Officers will arrive at the address and will either be allowed to enter or will force entry but once inside they cannot intervene swiftly. There is no power to arrest someone for their own safety.

This means that the police then have to establish whether or not a criminal offence has been committed which will allow them to make an arrest (and often there has not) or they have to call out the health care staff to get a warrant before conducting an assessment.

This can be a very lengthy process and quite simply is often neither practical nor possible.

In Scotland the legislation is far better. The Scots equivalent of Section 17 of PACE allows officers to force entry to protect life and then detain the occupant to protect life (including that person’s own life).

This is eminently sensible. What is the point of being able to force entry to a premises to save life if, once inside, you cannot do anything further because the only threat to life is to the life of the person causing the threat (i.e. a suicidal or severely mentally ill person)?

Work is underway to review these issues but progress seems to be immensely slow, given that a simple change in legislation is all that is required to deal with this issue.

In contrast, dealing with the first problem, the lack of places of safety, will require both massive cultural change and significant financial investment.

Money – as we all know – isn’t exactly growing on trees at the moment and cultural change is just as hard to come by. The need for change has not yet been fully appreciated despite the injuries, deaths, and headlines. Many mental health providers don’t yet recognise the extent of the problem because the full impact is suppressed by the police “coping”.

Except that the police aren’t “coping”. They shouldn’t have to “cope”. Dealing with clinical issues to this extent is distracting from their role in preventing and detecting crime.

The provision of proper places of safety is a clinical issue and is a matter of health commissioning. The problems regarding restraint are clinical issues exacerbated by the paucity of places of safety. Police are not clinicians yet they are being expected to deal with medical emergencies on a daily basis. This is clearly neither reasonable nor safe.

The police obviously have a role to play in dealing with mental health crises and in protecting both patients and the public. However, they are currently playing the part of the protagonist when they should in fact have nothing but a cameo appearance.

If you are interested, you can find the full Mental Health Act 1983 here:

http://www.legislation.gov.uk/ukpga/1983/20/contents

I also heartily recommend the BLOG of @MentalHealthCop – Inspector Michael Brown – which is the best available resource for information on policing mental health.

My thanks to @dorsetrachel for editing this blog.

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One response to “Policing Mental Health – a UK perspective for #poltwt”

  1. Ice Queen (@KarenFoulger) says :

    Nathan I am so pleased you are highlighting these issues in such a manner. This is respectful and supportive of the right’s of those with a mental illness! So many people fail to understand and this approach goes a long way to de-stigmatize mental illness!

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