One Size Fits All

“A nation’s greatness is measured by how it treats its weakest members.” ~ Mahatma Ghandi

 

Her Majesty’s Inspectorate of Constabulary (HMIC) have just published their report on “The Welfare of Vulnerable People in Police Custody.” For those who have been championing the apparent recent progress in this area it makes for sober reading. That is not to suggest for a moment that there hasn’t been progress but the report lays bare the scale of the journey still required. It is a long one with many obstacles.

Before writing this blog I have looked back at many of the previous ones I have written over the last three years. I am a relative newcomer to the field of policing and mental health. Others, such as @MentalHealthCop have been leading the charge for a decade but as I read the report from HMIC I couldn’t stop myself from thinking “said that” “been saying that” “I raised that three years ago.”

The good news is that there is now an Inspectorate report which says some of it as well. The bad news is that they will probably still be saying it in another three years.  Negative though this sounds, I say that sadly but with every confidence. HMIC and others have been saying that police cell suites are not suitable as a “Place of Safety” for over ten years but only recently has any government come close to doing something about it. Even then they seem destined to ensure that the most vulnerable of the vulnerable (those whose condition makes them ‘unmanageable’ anywhere else) will STILL find themselves in a police cell. 

Reading the entire report is a bit of a roller coaster. For every reference to good practice there is more detailed mention of instances where things have not gone so well. Before you get to the Conclusions chapter you would be forgiven for thinking (as I did) that it is very narrow and heavily focussed on the negative. Then you read the Conclusions chapter and the tone seems to change. 

The report concentrates on a number of key issues and was commissioned to answer the following question:

How effective are police forces at identifying and responding to vulnerabilities and associated risks to the welfare of those detained in police custody?

This is actually a very tight remit as the question does not set out to explore the role of any other agency in how someone came to be in police custody in the first place or whether those agencies are fulfilling their responsibilities once someone is taken into police custody.

When you come back to the question it is just looking at what police do with the people in their care. I was initially annoyed about this but, on reflection, the report does answer that question whilst having a reasonable poke at a variety of other organisations. 

I wish there had been an examination of the reasons why vulnerable people end up in a police custody unit but the question is actually once they are there – how are they being treated? 

I have blogged before about the reasons why vulnerable people find themselves in police custody. The long and short of it is that the police have become the default option for other agencies when things get tricky. 

The report talks about unnecessary criminalisation of children and vulnerable adults but it is a sad truth that the police are positively encouraged to take the criminal justice path. This encouragement comes from within the service and from outside.

 

  • The NHS has a zero tolerance policy against violence towards its staff. Absolutely right if the assailant is a drunk or angry patient in A&E but things start to get a bit muddy when the patient is disturbed or mentally ill. Having said that, I am yet to meet a patient whose consultant has not declared them to have capacity and know the difference between right and wrong. Indeed I have often heard “they need to understand that their actions have consequences.” Those consequences? Call the police.
  • Crisis Teams are actively telling people to call the police. There is more than enough evidence that this is happening. “My husband is suicidal and self-harming. I called the Crisis Team and they said to call the police.” I have had heated discussions with Crisis Teams over such incidents. I have been asked many many times by mental health practitioners “can’t you just arrest them?” 
  • Care homes for children seem to have a universal policy of calling the police. If a child fails to return or even storms out following an argument with carers they call the police because the child is now absent or missing. One such caller told one of my team that they had “no intention whatsoever” of doing anything other than reporting it to the police. 
  • Care homes frequently call the police when one of the children in their care “kicks off.” This is sometimes justified. I have been to a number of very violent and dangerous incidents in care homes but on other occasions it has been because the child has thrown a tea cup in temper.
  • The report itself highlights how the “positive action” policy with regards domestic abuse is interpreted as “arrest.” It even talks about how a target culture makes this worse. The definition of what constitutes a domestic incident is quite wide. Words within that definition are then sub-defined. Critical to this context is “Family members”. There is a list of what defines a family member and it includes children of, siblings and even in-laws. Historically and even culturally, most people would perceive domestic abuse to be between partners. It isn’t – it goes much further than that.

There is a theme with each of these. The response from the caller and the police is blunt. One size fits all. 

The same can be said of the definition of child. A child is any person under the age of 18. 

In the United Kingdom, the government have determined that the age at which a child can be held criminally responsible is 10. I make no comment on that other than to say it is one of the lowest in the world. 

What this means is, that from the age of 10 years old, a child can be taken through the Criminal Justice system. Liable to arrest, subject to the same laws and procedures (with amendments) and potentially imprisonable. 

There is, in reality, a world of difference between a 16 or 17 year old and a 10 year old. But not in the eyes of the law. 

Nearly all political parties are saying that they want 16 year olds to have the vote. They deem them adult enough to determine the future of this country. The age of consent is 16 which means you can lawfully have children of your own at that age. You can marry at 16.

But you are still a child and should therefore be treated as a child if you should enter into the criminal justice system. Outside of that system – and even in the world of working with children – you are likely to see the term “young adult”.

According to law – you are a child until your 17th year and 364th day passes. 

The point the report makes on this is that a custody unit is a pretty bleak place for a child despite the best efforts of the staff within it. This is true. A secure facility for convicted children is a very different environment from an adult prison. Police custody is police custody. Blunt. One size fits all. 

Use of force and restraint is examined in the report. Concerns are raised over the fact that too many officers didn’t recognise a mental health crisis as a medical emergency. I can’t speak for the individual cases seen by the HMIC inspectors but it must be hard to remember that something is a medical emergency when much of the medical world is declining to help. When a hospital refuses to accept a medical emergency because the patient is “too violent, too drunk, too drugged” then where do you go from there?

Remember that, despite just about everyone pleading for police stations to be taken off the list of Places of Safety the government had recently chosen not to do this. It is even stipulated that police stations are where you can take someone whose behaviour cannot be managed elsewhere. Arguably the highest risk and most “medically medical emergency” cases you are likely to find. 

The report makes the point that many of us have been making for a while. That the restraint techniques taught to police officers are intended to deal with violence from ill-will and not violence caused by mental health crisis. They are two very different things. Police are expected to deal with them both and have had no training in the alternative.

It still amazes me that this is not higher up forces’ strategic risk registers (if it is even on there.) there are more than enough tragic cases to demonstrate that restraint, when used in mental health crisis, kills people. I would put money on the fact that more people have died through contact with the police this way than have ever been shot. 

Casual reminders about positional asphyxia and excited delirium once a year at refresher training are not enough. Officers need to be taught to recognise it and deal with it a different way. Until then, they have the training they have. Blunt. One size fits all. 

The report goes on to look at the elderly in custody. There really isn’t too much to say on this except that it is not uncommon for the police to be called to an elderly persons residential home to deal with an “aggressive” octogenarian dementia sufferer armed with a walking stick. Don’t get me wrong – you would be surprised at how  powerful and strong someone like this can be. It is a risky and dangerous situation. I just don’t think that the police have any business whatsoever in dealing with it.. Yet we get called to it. 

The police have become, by expectation and demand, the coercive arm of mental health, childrens and elderly persons services. This has to change.

The police service has custody units which are built for dealing with suspected criminals. They are not nice places – they are functional – but they do not always suit the functions for which they are used. Functions for which their design was never intended. 

I asked once whether we could consider a secure room for detainees under the Mental Health Act. Something which wasn’t like the other cells but where someone could be left without risk of being able to harm themselves. A room officers wouldn’t need to enter and enforceably restrain someone. I was told we didn’t want to do that because it would mean – as we had such a facility – other agencies wouldn’t have to provide one. The fact is that such a room remains necessary. Police stations will still be a Place of Safety and will potentially house those most seriously at risk. 

If nothing else I would urge you to read the Conclusions chapter of the report. It is here that HMIC venture into criticism of other agencies and say that, on the whole, the police are often left isolated and dealing with things they simply do not have the expertise, training, equipment or facilities to deal with. This is the cause of the problem. Overuse and over-reliance on the police.

The symptom is that police then end up getting it wrong in custody as they try to make what they know, what they have been taught and what they have fit the circumstances. Blunt. One size fits all. 

The reports recommendations are primarily about data gathering to inform future strategic work and allow greater accountability. This will be helpful and should arm the police with a very convincing amount of evidence to present to joint commissioning bodies. Evidence which will show exactly where the gaps are. Evidence which is currently lacking to the point that no-one actually understands the true width or depth of the problem.

The problem with this is that meaningful data will take time to gather. Comparative data will take years. We cannot wait that long. 

Whether the police like it or not they will still be expected to deal with these kinds of calls. There is no room for complacency. The report even shows that use of Section 136 detention has gone UP in the last two years. 

There is work which could be undertaken immediately which could help how the police treat the most vulnerable. It starts with empowering call-takers to assess threat and risk – deferring or referring callers away at the point of source. It involves difficult strategic level conversations internally and with other agencies about what police will and won’t do. It involves changes in working practices and the removal of sledgehammer policies and targets. 

It involves training staff in alternative methods of dealing with violent MH crisis. It involves considering whether police might need to invest in bespoke areas of a custody suite which are situation and detainee appropriate. 

It is about teaching people to think differently. 

It is about giving people sharper tools to use rather than the blunt, one size fits all ones they have now. 

 

 

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6 responses to “One Size Fits All”

  1. Jo says :

    Agree with lots of that though the example of the violent MH patient concerns me. MH staff are not there as punchbags and the presumption should be to involve the police if violence has occurred. I have seen numerous incidents where floridly psychotic ppl have attacked a staff member and the police weren’t called as the presumption was that the person was very ill and lacked capacity. However most ppl on MH units are not acutely psychotic and should be accountable for their actions. Some in this debate risk infantilising ppl – the basis of mental health care for those with personality problems and/or substance misuse problems is to get the person to take back responsibility for their own lives. Allowing them to kick and punch ppl along the way is incredibly unhelpful and counterproductive to their well being never mind the morale and health of staff on these units (already experiencing far higher levels of violence than almost any other job)

    • nathanconstable says :

      Hi Jo, there will always be times when it is appropriate to call police if a patient assaults a member of staff. However, it if often expected that the police will arrest the patient and take them away. This is rarely a suitable course of action. I don’t believe that staff should be punchbags either but in some of the cases I have encountered I have more questions about the safety protocols of staff than I had about the actions of the patient. In many cases this was a resourcing issue where staff would be handling a potentially volatile patient alone or in insufficient numbers. I worked in an area with an MH hospital in it and there was a period where would would get a couple of calls a day about patient on patient or patient on staff assaults. Whilst police had to look into these the bigger question was why on earth is this happening on such a regular basis in a place which is supposed to be safe. Nothing seemed to be happening to address the atmosphere or culture or whatever was going on down there which made it such a hostile place. Instead – the simple solution was to call the police after the event in the hope that we could punish people into behaving. If it had been the same patient over and over again that would be one thing but it wasn’t. It was different patients all the time. At one point I hate to think how many patients would have been criminalised had we prosecuted every single one. I have also seen examples where medical staff have tried to report assaults caused by patients they are trying to involuntarily sedate. You can’t have it both ways – either the patient is acting criminally and the police are called or their behaviour is caused by their condition and they require chemical sedation. In one instance the doctors said the person had full capacity and knew what they were doing – in which case – why were staff trying to forcibly medicate them? You cannot treat a criminal action by chemical sedation – even in a hospital.

      • Judy says :

        All great points. Lock ill people up in an aggressive environment with very little to do, some will harm themselves and some may lash out. Look at the environment first. In fact a cell in a custody block on constant watch with a sympathetic officer, can be a far less distressing environment than an acute ward in a mental health unit……….It’s all about people……..

  2. Doc M says :

    I completely sympathise with your frustrations and they are shared by many health and associated professionals in MH services. White papers, inquiries, commissions and reports that endlessly repeat the same issues. I started my NHS clinical career (1998) working with adults with a diagnosis of learning disability when the drive was to move people with a history of challenging behaviour out of large institutions into community based homes and there was also a programme of closing large psychiatric hospitals and developing more local inpatient facilities. The idea being more local services that reduced separation from communities and families and were planned for shorter patient stays during acute crises. Community MH teams were meant to support people longer term to reduce the need for inpatient care. Then the dominant message was to head off “revolving” admissions and first time admissions with Assertive Outreach and Early Intervention teams, then to avoid S/T admissions with Crisis Resolution & Home Treatment teams. Community forensic MH teams used to be some mediating resource between prison / acute psychiatric hospitals, etc. Uhm, what happened to those apparently imperative concerns?
    I have no problem with any of these and think there was, sometimes great, value in them especially for the service users and carers. BUT many of these services were always under-resourced and recently very many disbanded or had their remits changed significantly. We all know who picked up the shortfall, the police.
    I am sick of hearing how various forces/ officers have failed to be the perfect answer to crises caused by the failure of other properly responsible services/ personnel. Just because many officers and forces are decent and have a genuine belief in their role of public service (and apparently do better than statutory services) they should not be made the scapegoats when things go wrong. I do not excuse individual failings when police services/officers are responsible, but my personal opinion is that largely this is due to them being inappropriately placed in a role they should never have had to be in.
    The answer is not more training for police officers in MH issues, but more training for NHS, LA and Social care staff about the LAW – which lets face it they should know too. And of course, for commissioners, NHS senior managers, LA executives to appropriately resource services generally and acutely to manage the situations and risks when they arise.
    This is not a new problem and not likely to go away any time soon, but I think we should all keep nagging away and refuse to allow those that DO have the power to change it to keep passing the buck.
    These last years the police seem to have been taking the lead in addressing this tragedy and have been dedicated in pursuing a better outcome. I hope all relevant parties; service users, carers, MH and LA professionals, commissioners, members of the public, politicians, who knows even journalists, may step up and support them to achieve the necessary changes.
    Apologies for the lengthy post.
    Thank you for all your good work, it is really appreciated.

    • nathanconstable says :

      This is a wonderful response. Thanks, Doc. It does seem as though the actual delivery of community based services has left massive gaps and a whole population group of people who don’t seem to “qualify” for anything other than constant visits from the police when they call for help. Those diagnosed with “behaviour disorders” are particularly highly represented. When you call a Crisis Team about one of these poor people you frequently get told that they are not mentally ill and that will be the end of the conversation. This really needs addressing and is, to my mind, one of the reasons why 136 detentions are so high. Because “something” has to be done and it is the only “something” available. Crisis Teams have a very narrow remit it seems. Anything outside of that they simply won’t come to. Leaving the police to deal with an individual who needs some form of help – which just doesn’t exist. It is a scandal.

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