Losing My Patients

Last night I tweeted about a situation where a patient had absented themselves from A&E.

This person was awaiting the results of tests. The doctors were convinced that they should really be in hospital as they genuinely feared he may have a condition which required urgent treatment.

Having left of their own accord and apparently having made a conscious decision to leave – even against medical advice – A&E reported this fact to the police with the expectation that we would go to the persons address.

This request leads to a few questions.

1. Is this a missing person or a concern for welfare?
2. Why are the police being asked to go and speak to the person?
3. What exactly do you want officers to do when they get there and find him?

The answers are:

1. It depends. Is the person “missing”? Well – we don’t know where they are so technically. There is some serious concern for the person’s welfare, of that there is no doubt but they have managed to get out of hospital and there is no compulsion for them to remain there.

2. I am quite certain that the request to find this patient was made with their best interests at heart but is this a police function? What we are being asked to do is to locate someone with a medical problem who has left a clinical environment. Crucially, we have no powers to return them when we find them.

Police have been told their function is to reduce crime “no more – no less.”

Anyone who works in policing will tell you that this is nonsense and that police work involves a lot more than that. We have a duty of care to the vulnerable but the Home Secretary wants us to “single minded crime fighters.”

Does this situation fit that definition?

3. Is the $64,000 question.

At present there are only two pieces of legislation in existence which allow for someone to receive treatment against their apparent will. They are the Mental Health Act and the Mental Capacity Act. Both of these allow for “treatment by force” if necessary.

As I responded in one tweet last night – you might as well call the RAC for help in the circumstances as I have described above. They have as much power as the police to deal with it i.e. none at all.

Until the person is located it can be argued that the risk they present to themselves currently “makes” it a police matter in the absence of anyone else to deal with it.

Once they are located police are faced with one simple, clinical, decision.

“Does this person have the mental capacity to make an informed decision?”

In what other area of medicine (outside the Mental Health Act – and even then it is only a preliminary assessment aka – “guesswork”) is it acceptable or appropriate for police officers to be making clinical decisions?

The most that any police officer is medically qualified to say is “This person appears to be alive.” The extent of our training on the Mental Capacity Act can be counted in minutes.

(Let it be known that the law does not allow a police officer to claim someone is dead – even if they have been decapitated. This can often mean waiting hours at the scene of a “sudden death” for a doctor to arrive and state the obvious. Ambulance won’t come any more.)

The fact that they might very well be making entirely the wrong decision does not make them incapable.

You could argue by extension that anyone who smokes or drinks heavily is making a poor decision about their well being but this does not mean they lack the capacity to make that decision – no matter how obviously bad it is.

If the person seems rational and simply states that they got fed up of waiting (as happened in this specific case) police can do nothing.

It wouldn’t matter if the person had the most virulent, deadly, contagious disease known to mankind. Police still have no power to detain them preventatively or otherwise.

My response, once we located him at home, was to tell my officers to call an ambulance so that they could go and make a proper and educated clinical decision on his mental capacity.

Which raises the question – why didn’t they send an ambulance or doctor to his house in the first place then call police if he wasn’t there or was deemed to lack capacity and they needed help?

Ultimately, this was a bad decision by a patient which led to police involvement. The accepted response now seems to be – if they walk out of NHS premises – call the police.

The NHS staff involved have reported the facts to the police and then gone about whatever else it is they were doing. They played no part in the locating or recovery of this poorly individual.

I am concerned that the police are being overly relied upon by the NHS in a variety of situations.

Mental health matters have been covered in great detail on previous blogs and I have also opined on how we appear to be plugging gaps in ambulance provision and availability.

It is becoming increasingly common now for police to be asked to find and locate patients in circumstances as I have described them here.

These are all clinical matters and the problem is being passed to an agency whose staff have had little or no training and who have no power to deal with such situations – simply because there is no-one else to do it or no-one else is willing to do it.

Are the police actually being asked to ensure that NHS procedures are complied with (capability assessments / discharge / disclaimers) and is this really the role of the police?

Once again I stress that I am not specifically blaming front line staff (though there is an argument that “call the police” has become a cultural norm.)

The issue is strategic.

When NHS Commissioning Bodies look at what is required over the coming months it is high time that they looked beyond what can be simply achieved on clinical premises and looked at contingencies, using NHS staff, for when things take an unexpected turn. Occasions where, for example, a patient decides to up and walk out.

At present police are being called far too early in the process by both the ambulance service and in cases such as this.

There needs to be a capability for the NHS to be more self-sufficient in these matters – only calling the police when absolutely necessary, once initial enquiries and actions have stalled and when there is a power for them to actually do something.

To put it another way – rarely.

I believe that @DiagnosisLOB may have written a blog with an identical title. I haven’t checked but I think I remember. Apologies for my lack of originality. The title just fits the blog so well.


One response to “Losing My Patients”

  1. Stargazer says :

    NC, hats off to your writing and observations. I am a regular visitor and the vast majority of your posts resonate strongly with me, as I suspect they do to most cops.

    On this particular topic it must be the same the length and breadth of the country and is a total abrogation of responsibility on Health’s behalf. We used to get a lot of ‘patient has walked out with a venous catheter attached and there are concerns that they might bleed out’ calls from our local infirmary. You could virtually guarantee there would be at least one a shift from either A & E or its adjunct wards. You can imagine the cost in police time to track them down and they would invariably be found in their home or with friends/family, perfectly fine. As you state there was nothing we could do anyway when we found them other than convey them back to the hospital, if they consented, or try and get a medic to attend, if not. I always used to moan about cutting out the middlemen, i.e. us, and just let health get on with it.

    Amazingly, someone somewhere has listened to these pleas. A protocol has been agreed that we no longer attend such calls unless there is some other identified vulnerability which would give a genuine and reasonable cause that significant harm may befall the patient. That’s been a few months now and happily there have been no instances of patients bleeding out in the street; not that there were ever any before.

    I suspect/hope this protocol will be extended to situations as described in your post but we’re not quite there yet. Not that long ago we spent about a week looking for an individual that had been brought in by ambo suffering from a diabetic hypo in a public place. He was given glucose by the ambo and seen by a nurse at hospital and appeared to have made a full recovery. However, he got fed up waiting to be seen by a Doctor to sign him off after a few hours and took his own discharge. Key hyperinflation of the panic balloon and compound it with only an unconfirmed name recorded by the medics and you’ve got probably hundreds of police hours wasted in trying to track him down. He was eventually identified by a Facebook user and found safe and well…..unsurprisingly.

    Time is the most precious commodity frontline officers possess but unfortunately it is not theirs to manage, being as they are at the beck and call of every numpty on the end of a phone. Calls such as the above illustrate the hair tearing frustration we face on a daily basis when we know something is OTT but can’t stop the bureaucratic machine rolling for fear of the one-in-a-million chance that it may have an unfortunate outcome.

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