One Step Forward – One Step Back?

Today, Her Majesty’s Inspectorate of Constabulary have published a joint report with the Care Quality Commission, Healthcare Inspectorate Wales and HM Inspectorate of Prisons into the use of police cells for persons detained under the Mental Health Act 1983.

This matter has been subject to increasing scrutiny over recent years as there have been a number of deaths in custody. In 2008, the Independent Police Complaints Commission published a report which recommended that police stations be taken off the list of “Places of Safety” altogether. As recently as May, the Home Secretary publicly stated in her speech to the Police Federation Conference that she did not believe that a police station was a suitable place of safety.

It has therefore come as something of a disappointment to see that the HMIC report has not reached the same conclusion.

The report identifies that there is massive disparity across the country between the number of detainees who go to hospital and who go to cells. There is also massive variance in the levels of multi-agency engagement, internal strategic steering and across the board training.

The report identifies that although the Codes of Practice say that a person should only be put in a cell in “exceptional circumstances” it is clear that police custody use is anything but “exceptional” and in some places it is the norm.

It details a number of reasons for this most of which centre on the lack of provision by the NHS, lack of timeliness and forward planning by the NHS, patchy availability of Crisis Teams and the use of “exclusion criteria” such as a detainee being drunk, violent or even potentially violent.

Problems are also reported in the recording and monitoring of use of Section 136 within police forces.

Her Majesty’s Inspector of Constabulary, Drusilla Sharpling said

“This report finds that too many people are being detained in police custody under Section 136. Their only “crime” is that they have mental disorders, but they are treated in many ways as if they were criminals. This deplorable situation cannot be allowed to continue.”

Given the strength of this last sentence it is a great pity that the contents of the report fail to convince me that the situation will not simply continue well into the future.

Let us start with the good news.

We should welcome the recommendation to reduce detention time in police custody to 24 hours – but I still think that will leave other agencies thinking they have 24 hours before they have to do anything.

We should welcome the independent custody reviews by both police AND health professionals. For too long, once someone is in police custody, their detention has been deemed a police matter. Bringing health pros into the equation creates some accountability.

We should welcome the call that commissioning bodies should ensure that they have examined demand profiles and that they have sufficient resources and capability to manage actual demand.

We should welcome the fact that it is recognised that the provisions for young people are practically non-existent.

I am personally pleased to see that the authors have recognised that areas where there is a strong and dedicated strategic lead, good multi-agency working and dialogue and increased training are the areas which are clearly succeeding.

The report clearly outlines all of the right problems and issues, all of the right obstacles and all of the right stakeholders. Where it fails is in the lack of teeth, the timescales it allows and a “nuclear option” which is nothing more than a soggy firework.

HMIC say that if improvements are not forthcoming by 2016 they will ask for the law regarding places of safety to be brought in line with the Codes of Practice on places of safety – which states that police cells will only be used in “exceptional circumstances.”

HMIC state that they would ask for a legal definition to exist which clarifies “exceptional circumstances.” You would hope that this would remove any ambiguity but the proposed definition contains the term “unmanageably high risk” – this is subjective and open to very wide interpretation. We know this to be true because it already is. Details within the report outline hospitals refusing to accept patients who arrive in handcuffs or even with a history of violence. There are already arguments about what constitutes an “unmanageably high risk” and these will simply continue.

Although the report goes into a little detail on the reasons as to why a person is refused access to a hospital directly it makes no recommendations about how this might be resolved. The issue of “drunkenness” is one of these. Hospitals will refuse to accept a detainee if they are perceived to be drunk meaning that a person with medical need is then taken to custody to sober up. The medical situation is exactly the same – they just won’t take them until they are sober. Is it for the police to sit and wait for a person to sober up when there is a suspected underlying MH cause?

I am particularly dismayed by the concern that saying that a police station is not a place of safety at all will “put pressure on Health Trusts” – hence the modified call for “exceptional circumstances” – in 2016 – if there is no improvement.

Surely this is exactly what we should be doing – putting pressure on Health Trusts to manage a medical problem?!

The unwritten implication being “we know that Health Trusts can’t cope so the police will just have to carry on plugging the gap.” It is almost an admission of defeat.

I am sure I am not alone in admitting that I was hoping that this report would call for an outright ban on the use of police cells for mental health detainees. Instead, it appears that the police will be expected to manage the problem for some considerable length of time.

That being the case, the authors have made one further spectacular omission. They have not commented at all on the PROVISIONS that are required to safely manage a mental health detainee in a police cell.

ACPO guidance quoted later on in the report acknowledges that police cells do not have any of the right equipment or staff to deal with this medical situation properly. It is strange that they quote this but make no suggestions as to what should be done about it.

Even if the recommendations of the report do work then the only time someone will be brought to a police station is when the risk posed is perceived (by someone) to be wholly unmanageable.

Surely these are the highest risk category patients of all!

Surely they, above anyone else, need medical expertise close at hand. Instead we are still talking about bringing them to police stations where there are no suitable rooms, no suitably trained clinical staff and no option to sedate. Leaving the police to deal with it by use of physical and mechanical restraint – a recipe for disaster which has been highlighted by the Adebowale Report.

It is worth pointing out that only yesterday, the mental health charity, MIND called for an outright ban on the use of face-down physical restraint in clinical settings. This is something that the Government are supportive of.

So the best case scenario in 2016 is that the NHS and Mental Health Trusts will be accepting far more admissions for assessment than they currently are – but they will still be able to use exclusion criteria to refuse admission under the guise of “unmanageable risk” and this will leave the police to deal with the highest risk cases in an ill equipped police station.

There are aspects of this report that we should acknowledge and welcome but I, personally, do not feel that it has gone far enough in its recommendations and it doesn’t put the health service under enough pressure to resolve the problem. Having failed to do this, it then fails to address some of the fundamental practical problems of safe detention management.

I know that this report was researched and created with the absolute best of intentions and I would like to thank HMIC and the other agencies involved for writing it. It’s findings are faultless – I just wish it had concurred more with the opinion of the IPCC, pressure groups, the Home Secretary, front line officers and many service users who feel criminalised by existing procedures.

It was an opportunity to call the situation “deplorable” and they have done so.
It was an opportunity to list many or all of the existing problems and blockers and they have done so.
It was an opportunity to empower the police to step back and say “this is a medical matter and we aren’t dealing with it any more” – that opportunity has been missed.

I genuinely do not believe that the recommendations within this report will be achieved by 2016 because the ultimate sanction at the end of this period isn’t really strong enough.

Between now and 2016 how many more custody related incidents will occur? How many deaths? How many IPCC investigations?

Will it take us forward or is it one step forward – one step back?

News coverage of the report can be read here


2 responses to “One Step Forward – One Step Back?”

  1. sally herzog says :

    A missed opportunity to resolve a very important issue.

  2. Mal Lawrenson says :

    Thankyou once again for an excellent analysis and disappointed but unsurprised at the content of the report. There are so many cells now being mothballed due to “cuts” that it is difficult enough if a response bobby. sometimes travelling over half an hour or more out of division. Stressful for all concerned. As someone who has family who are officers and also someone with MH conditions and involvement in MH mutual support, I see and hear both sides of the situation.
    All best wishes to you and grateful thanks for the work you do, without pay but because you care. It is appreciated more than you know.

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