About a decade ago, I was pottering about as the duty inspector in south Birmingham when a full-scale police mobilisation of public order units was ordered. This involves having to get together a sergeant and seven constables on to van, all of them ‘level two trained’ in public order tactics – riot police, to you and me. For every three vans you put together, you need an inspector in overall charge and that group of twenty-five officers (x1 inspector, x3 sergeants, x21 constables) deploy as a ‘police support unit’, or PSU. Large scale events or disorder frequently have a number of PSUs under the leadership of one or more Bronze commanders; and the overall command of a Silver. This thing was ordered around 1pm on a weekday afternoon and the requirement was for us to be at a rendezvous point at Birmingham airport within 60 minutes of that mobilisation being ordered. My area had been obliged to send a sergeant and seven but also to supply the PSU Commander for a group of three vans from other south Birmingham policing areas and off we went to the airport.
On arrival, there were a number of other PSU Inspectors turning up, each of them with three vans under their direction and rumour was bouncing around as to what was going on – was there some dramatic event about to unfold at the airport; or were we just being bounced on a mobilisation exercise to test readiness?! … that was one of the possibilities we considered as we chatted en route to BHX because we were asking control and making phone calls to find out but nothing was coming back. But you never truly know and when we got there, we were all ordered off the vans with our public order bags for a kit inspection and somebody with clipboards emerged – just a mobilisation exercise! It was a much larger than any I’ve ever known before and I’m ashamed to say that I personally failed the kit inspection!! It being a hot summer day in an era where we all wore formal white shirts under our protective vests, I wasn’t wearing a tie (summer rules permit this) and I didn’t have one in my bag either!
EPIC FAIL – we all understand intuitively as children how badly one needs adequate neckwear if Air Force One is due to crash-land at the local airport, etc.!
Why am I boring you with this? – well recently, we were discussing section 140 at a Care Quality Commission event and the discussion came up about planning and preparedness for predictable events. Whether Air Force One was due unexpectedly at Birmingham Airport or whether a riot had broken out in another city and we were being RVd and prepped to provide support – the point is, this test-exercise ensured that we were all assessed and given feedback on what needs to improve to ensure we’re at a state of readiness for whatever level 2 public order officers are potentially sent to. So the question arose, where urgent admissions to hospital are required, do we have the systems in place to ensure that what needs to happen even can happen within timescales?
WORKING TO DEADLINE
Police forces tend to work to timescales by which they have to be able to do things – each force will know what its basic, ‘primary mobilisation’ requirement will be: how many PSU’s have to be ready, dressed in riot gear to hit the streets within an hour or an hour and a half of being told to form up. How many PSUs must they be able to provide within a further period of 60 or 90 minutes, etc., and this is what you saw happening in 2011 when riots broke out in London and spread to Birmingham and Manchester – large numbers of officers in riot gear, deploying in groups of 25. We know it will occasionally be necessary, so we have to be prepared. We know that police officers might have to point a gun at someone and decide whether or not to end their life: so we spend a lot of time and money training firearms officers, buying expensive equipment of various sorts; ensuring they have advance first-aid training, etc.. Planning and preparedness for what we heavily predict we’re going to have to deal with.
In the context of urgent hospital admissions, then – I got to wondering whether the NHS start from the perspective of thinking about what we know they may need to do, even if only rarely, and planning for how we ensure it will happen within the law. So here’s a scenario for you –
A child is assessed in an Emergency Department after having been detained by the police under s136 and removed there because of serious self-inflicted injuries. They are assessed as requiring admission to a Tier 4 CAMHS beds and this conclusion is reached at 6pm on a Saturday evening. Consideration is given to how support could be provided at home over the weekend but it is ruled out as viable on the basis that the risks involved to the child are unconscionable.
Let’s be generous and assume it took just 6hrs to provide initial care for injuries and convene a Mental Health Act assessment on a Saturday: if this situation occurred a hundred times, in how many of them would we identify a CAMHS bed and fully conclude an application for admission to hospital by midday on the Sunday?
My point would be, that inability to do this by that deadline means we start to drift in to difficult legal territory, many versions on which would involve violating fundamental human rights, even if it doesn’t further endanger the patient from a medical point of view. Repeat the scenario, if you will – but this time, change ED to police station for an adult man who was arrested for GBH on a relative who steadfastly refuses to make any complaint of assault because they are more concerned about their relatives mental health. Assessment by 6pm in police custody is that the patient requires a PICU or even an MSU bed by midday on Sunday: how many times in a hundred would this occur by the deadline?
MS V UK, 2012
This latter version of this story was the situation in the MS v UK human rights case, a verdict from 2012 following an incident in Birmingham in 2004. In the case specifics, the patient had been assessed within 9hrs of being detained under s136. The fact that he had assaulted his aunt only became known after his arrival at the police station under s136 and in the absence of any admissible evidence from the victim in the case (his maternal aunt) there was no basis to charge him. By 9hrs in, the basic MHA assessment had concluded that admission to a forensic unit may be required and it was beyond the 24hrs of detention now permitted by law that a second, forensic assessment took place. So immediately in such a case, notwithstanding any questions about whether or not the patient could or should be prosecuted, if the NHS require a second assessment by forensic services for forensic admission, do we have capacity to do that within the 24hrs permitted? Or do we have that capacity for CAMHS Tier 4 admissions, bearing in mind I often hear that in some areas CAMHS don’t work out of hours?
So how do more specialist assessments fit in to the bare and unchangeable legal fact that section 136 permits 24hrs to do everything that is required to facilitate any admission that is needed? Not only might you need the forensic or CAMHS assessments, if required, you’d also need to contact the bed managers and actually physically find a bed. We know this is problematic thousands of times a year – Professor Wessely made reference to this in his Mental Health Act review and the fact of bed management problems and no obvious
So my argument is, we need to better understand the reality of the way in which patients present: I tend to think of it in essentially three ways, because I group the situations by the legal framework in play at the point of the Mental Health Act assessment –
- Detained under s136 – all admission issues must be concluded within 24hrs of that patient’s arrival at a Place of Safety, unless the assessment was delayed for some reason which has led to a doctor authorising a 12hr extension.
- Under arrest at a police station – those who are arrested for an offence may be assessed in custody as long as their detention there is lawful because of ongoing investigations. Where it is not, some patients may be detained under s136 on release and remove to a Place of Safety, where 24hrs may be taken to conclude assessment and admission procedures not yet complete.
- Unrestricted assessment – for those patients in their own homes or who have self-presented at an Emergency Department or been taken there voluntarily by police, ambulance or other services.
STRESS TESTING
So what I’m suggesting is, from any of those situations we may need to admit someone and that may need to occur within a few hours or within less than a day in order to avoid a situation where someone’s fundamental human rights are violated. This could be something around Article 2 if a predictable suicide is not prevented by detention; it could be an Article 3 violation (inhumane and degrading treatment) as we saw in the MS v UK case; or Article 5 where, because of the obvious lack of procedures by which to ensure rapid admission when needed, someone ends up in police custody, or a Place of Safety or even just ‘held’ in an Emergency Department without an obvious authority in domestic law by which to justify that de facto ‘detention’.
Fully accepting that I see a particular slice of the admissions system and most usually only where it has come off the tracks, I do wonder if we ran the two scenarios above 100 times each in the real world or maybe asked every trust to do so as a table top exercise, how many times in 100 would the admission occur within the implicit or explicit legal timescales? This kind of exercise is also something the police service have done to learn from problems. Older readers will no doubt remember the shooting in Hungerford, Berkshire in 1987 where Michael Ryan killed sixteen members of the public and seriously injured fifteen more. The police service’s capacity to quickly deploy authorised and equipped firearms officers was questioned in the aftermath of what was a prolonged delay in responding and police firearms capability found wanting. Part of stress-testing the system afterwards involved Her Majesty’s Inspector of Constabulary requiring forces to examine how many armed, equipped and trained firearms officers were on duty at a certain time of day in the months preceding the attack. The results lead to a massive overhaul of how forces deploy, train and prepare firearms officers incidents of this kind.
This is what I’d love to hear of us doing around complex urgent admissions: table-top exercises or contingency planning based on real cases from which we might reasonably be expected to have learned. If MS v UK happened in Birmingham, what plans do Birmingham and every other trust have to ensure it doesn’t happen again and violate someone else’s Article 3 rights? I’ll help you out: we know that whatever happened afterwards it has happened again, because I’ve had to deal with worse as a duty inspector. And at the risk of this being taken as yet another example of me whinging or complaining about things and failing to take in to consideration “all of the good partnership work” going on around the country, the fact of these issues being problematic is being cited publicly by senior police officers, mentioned in Government reports and independent reviews of mental health services. This is not about policing resources or NHS bureaucracy: it’s about the protection of fundamental human rights, which is something we’re ALL proactively obliged to do, by virtue of s6(1) Human Rights Act 1998. And we’re not allowed to justify violation of such rights by complaining that it was all too difficult, complicated or expensive. That’s why their called fundamental rights.
Winner of the President’s Medal,
the Royal College of Psychiatrists.
Winner of the Mind Digital Media Award
All opinions expressed are my own – they do not represent the views of any organisation.
(c) Michael Brown, 2019
I try to keep this blog up to date, but inevitably over time, amendments to the law as well as court rulings and other findings from inquests and complaints processes mean it is difficult to ensure all the articles and pages remain current. Please ensure you check all legal issues in particular and take appropriate professional advice where necessary.
Government legislation website – http://www.legislation.gov.uk
Mental Health Cop 