“Refused to Help”

A number of mental health professionals have expressed concern something like this would happen and I mentioned recently that some were seeing signs of what I called “over-push”: an Approved Mental Health Professional (AMHP) in Wales has been punched whilst attending a premises to conduct a Mental Health Act assessment, having asked for police support because of a client’s previous assaultative behaviour.  Police support was apparently declined.  The British Association of Social Workers (Cymru) stated they were fearful something like this could happen after it was announced the police were looking to reduce the number of mental health calls they attend – it described the initiative as placing staff in “grave danger”.  The AMHP Leads Network has also issued a statement.

First things first: there is very little detail here and I would argue it’s impossible to draw any conclusions about what limited detail has been made public in the news article.  It obviously is concerning and discussion about it by those who have the detail seems like a really good idea, but there are a number of ways in which someone could legitimately be described as assaultative whilst leaving open the question about whether the police should be involved —

• Did they, for example, assault an AMHP during their last one or two mental health assessments, conducted within the last few months?
• Or did they, for example, assault a healthcare professional during a much more historic assessment, several years ago? – are we are saying, for example, the police must accompany all AMHPs, paramedics and healthcare professionals to all locations where there has ever been any kind of assault no matter how long ago?
• How serious were the assaults? – to say that gravity affects risk assessment is not to condone any degree of assault for even a moment, but it might help us understand certain aspects, especially if assaultative behaviour was more historic.  There is a difference between someone pushing past an AMHP conducting an assessment to leave a property they wish to leave and assaults at the more serious end of the scale involving GBH or weapons, etc..
• If it were historic behaviour, it certainly doesn’t mean it’s irrelevant and can be dismissed – but it may be worth knowing as well, whether other contact since that assault had been problematic and / or whether it involved the police? —
• If there had been subsequent assessments without a police presence and no further repeat of the incident, it might be wondered whether it was something of a one-off – was it considered out of character to those who knew the person?
• If there had been subsequent incidents or near-misses, it changes the perspective.
• And finally, crucially – what is the patient’s family saying about risk and any assaults towards them?

This is a non-exhaustive list that would be necessary to understand what sits behind any request for the police.  I repeat my point for the avoidance of doubt: we don’t know the answers to any of these questions from the coverage and it could well be that if we did, we would wonder why the police might refuse to attend.  It’s just not possible to say either way but we do know, for example, requests are sometimes made for support “just in case”, where any risk is minor and historic and not something necessarily thought likely to repeat.  We also know the opposite is true and it is in this context that we might worry about any refusal to support.

I’d also add, in case anyone is wondering whether the above is just words to obfuscate a simple issue: these kinds of considerations happen as well with regard to the safety of police officers.  For example, officers investigating crimes may need to attend premises to make an arrest of someone for an assault, let’s say; and whilst doing background checks they learn the suspect has “a firearms marker”.  Does this mean that all such suspects are arrested by armed officers? – no, it doesn’t.  A process of risk assessment, not dissimilar the questions I’ve outlined above, is undertaken by a police firearms commander to determine whether the response should be armed or unarmed.  Having performed that very role for several years, I have undertaken quite literally thousands of assessments for ‘armed / unarmed’ and it gets in to the weeds of people’s backgrounds, historicity and gravity of the supposed risk as well as the context and reason for the intended contact.

So what’s going on?

MENTAL HEALTH ACT ASSESSMENTS

AMHPs coordinate MHA assessments, including those which occur in people’s homes.  The question of police support to assessments in those locations has been the stuff of inquests, more than once and it remains resistant to clarity, for reasons I admit I can’t really fathom.  For me it’s not hard:

• If there is a warrant under s135(1) MHA for the MHA assessment – the police must attend
• If there is an immediate risk to life or immediate risk of serious injury – the police must attend
• If there has already been a crime or it is anticipated there will be a Breach of the Peace (properly defined) – the police must attend.
• If none of these three things apply, discretion can be exercised.
• A joint protocol in the relevant area should determine and clarify all of this — so it’s not unclear too anyone or left to improvisation.

It might be worth summarising the issues which often arise when it’s not properly laid out —

• No warrant / no police – this is the idea that unless an AMHP has a warrant under s135(1) for the MHA assessment in someone’s house, that the police are unnecessary and can refuse to attend.
• I’ve written before about how dangerous an idea this is and nothing has shifted my thinking on this point.  The issue is not about legalities like whether there is or isn’t a warrant, but what the actually risk appears to be – ie, the risk of self-injury, absconding or assault to anyone, whether the AMHP or anyone else who attends the premises, lives there or happens to be be there at the time of attending.
• Just as I finished drafting this post, I came across a comment from an anonymous twitter account which I will assume is a police officer and just had to come back and add these two bullet point.  They help make the point about the last two bullet points! “Why would police attend an assessment of a violent person without a warrant? It just leaves everyone at risk and police have to ‘force fit’ legislation to keep people safe. This reads more like poor planning by the trust than a failure of the police.”
• There is, quite simply, no way to tell whether this is poor planning by anyone and the answer to the question about why the police might attend should be obvious: any risk which exists is extant whether there is a warrant or not and if there is an article 2 or article 3 risk or an anticipated breach of the peace, there are legal obligations regardless of warrants.  It’s also true there may not be time to secure a warrant and for all we know, the poor AMHP may have tried to get one and failed.  In all those scenarios, the risk still exists regardless.

• Execute it yourself – But whilst we’re on the subject of warrants, other AMHPs have reported on social media the police refusing to attend MHA assessments even where there is a warrant under s135(1).
• An AMHP on Twitter stated only last week, “Police declined to execute both warrants. [Fingers crossed emoji] nothing goes wrong.  One call handler asking why the police were needed even after we emailed the warrant and risk assessment.”
• This is ridiculous, to put it bluntly: only the police can execute such a warrant and if a Magistrate has issued it, it’s reasonable of an AMHP to expect the police will make officers available to execute it – and in a timely way, so we don’t end up in Coroners courts wondering why it took days, as happened in Sheffield several years back.

• Failure of risk assessment – there is also the situation where there is a failure to comprehend the potential of what may happen.  Perhaps the basis of a fear of assault has not been properly discussed or explored (for example, using some of the questions I outlined above).
• And finally, in supplement to risk assessment, there is the question of legal responsibilities of the police.  The ‘threshold’ for police involvement in a mental health related incident is about crime occurring or an immediate risk to life or immediate risk of serious injury.  It is in that context, judgements about attendance against the known and predicted risk must be judged.

Amidst all of this BASW Cymru seem very concerned — the BBC news article speaks not only of “grave danger” but also of the risk that a social worker could be killed and it’s not the first time I’ve heard a mental health professional wondering whether that is possible.  BASW(C) make passing reference to an incident where a mother in Wales was tragically killed during a Mental Health Act assessment.  This is not an incident I’d heard of before and again, there is no further detail to help us understand that but it’s concerning to hear of it, obviously.

OVER-PUSH

See we cannot know from the article whether this was an example of over-push, but that’s seems to be how BASW(C) are summarising it, at face value.  When Dr Sarah Hughes, Chief Executive of Mind, gave evidence at the Health Affairs Select Committee last month, she made mention of police officers or forces who are yet to formally roll-out the Right Care, Right Person initiative beginning to decline to attend incidents.  Welsh police forces are yet to commence RCRP, to my knowledge and whether this incident amounts to premature over-push or to something else entirely, we can only speculate so it’s probably best we don’t.  We shouldn’t be too quick to link any refusal which has occurred to RCRP because we know some officers or forces have declined to attend such things in the past – this really isn’t new but some may well be wondering whether frequency is increasing.

In the inquest after the death of Nigel Abbott, considerable discussion was had in evidence between the local authority and the police about what the policy was, regarding police support for MHA assessments.  It was claimed the police operated a ‘no warrant / no police’ policy and demanded 24hrs notice of any requirement to attend.  The Coroner heard evidence the joint protocol in existence did not in fact say either of those things, but the lack of clarity and understanding was such that he issued not one but two Preventing Future Death reports, both of which mentioned the need to revise the joint protocol and ensure it was then disseminated for clarity.  So there is no doubt: some AMHPs in that area really did genuinely believe the police operated a ‘no warrant / no police’ approach, despite what local protocol said.

It is just one example of the kinds of myths which can abound and I’ve written about myths before – there are many of them.  For example, AMHPs have told me during discussion about operational incidents that when police enquire about whether there is a s135(1) warrant for a MHA assessment, that they are unable to secure warrants from Magistrates unless they’ve already attempted to gain access to the premises.  This is a requirement for s135(2) warrants, but not for s135(1) warrants and the Code of Practice sets out that this is true by requiring the AMHP to explain to the Magistrate in the written application why a warrant may be sought if access has not been attempted.  The fact that the explanation is required demonstrates a Justice of the Peace can issue a warrant if satisfied as to the reason the AMHP has not yet tried.

WHERE ARE WE NOW?

Well, I would imagine discussion is going on in whichever area of Wales this occurred – is this because of impending RCRP or for some other reason; was this accepted to be an error of any kind and if so was it an individual error to decline attendance or a policy approach?  There is quite a bit to get in to with that – because policy approaches on MHA issues should be governed by joint protocols, according to the Code of Practice MHA (in both England and Wales) and any changes to those protocols should be agreed and then communicated so staff understand what will happen and what is expected of them.

The BBC article mentions a Home Office response which references a National Partnership Agreement for Wales, like the one brought out already for England.  For those who are unaware, policing in Wales is governed politically by the Home Office in London, but health is governed politically by the Welsh Assembly Government in Cardiff.  The NPA published in June ‘23 is for England only and this Home Office response clearly indicates their preference for that to be introduced in Wales as well, or something similar to it.

What I can say, imagining myself as an AMHP or other mental health professional who may have to attend a premises: keep asking for what you think you need and make the police take their decisions on the record.  Do not be put off asking for what you think is right because you anticipate you will get nowhere – if you fail to ask, you take responsibility for not asking, but if you ask and are declined, the person declining is responsible for their decision.