On the latest episode of Ambulance, the police were called by North West Ambulance Service to a patient who had recently walked out of Salford Emergency Department. The lady had been in there after self-injuring and claiming to have taken an overdose and there was some suggestion she had ‘absconded’ from the ED. She was now injured and bleeding, admitting she still had suicidal ideas and having spoken to the patient to get what they could, there was still confusion about her legal status and about what had happened the previous day. I found it immediately interesting, they rang the police to untangle all of this uncertainty, not the ED. This pre-supposes the patient or their circumstances would have been reported to the police and it looked like this was not the case when the call went in.
On a cold, wet night the paramedics persuaded the lady on to the ambulance so they could speak Norte easily and work out what best to do. She was obviously reluctant to return to hospital but as the paramedics explored her circumstances, it seemed obvious there was little other choice and in the absence of her agreeing to return, they’d have to consider contacting the police. The lady agreed eventually and still reluctantly but not long afterwards she walks off down the road and the paramedics are following her on foot, attempting again to be persuasive and then eventually, asking for Greater Manchester Police to attend to consider application of section 136 of the Mental Health Act 1983.
In fairness to the paramedics, they had little choice and had explained they didn’t want to do that to her, but would have to if she insisted on putting herself at risk.
IMMEDIATE RISK TO LIFE?
Was this an “immediate risk” situation? – definitely.
The lady had made various references to suicide, including threats to jump from a bridge, she claimed to have taken an overdose the day before (exact details of which couldn’t be ascertained at the scene) and she had, in fact, self-injured that day. It would be a bold paramedic or police officer who felt able to say there and then, “this doesn’t require anything further because she’s choosing not to receive care.” And by ‘bold’, I mean ‘negligent’, of course – you could easily imagine such a decision ripped apart in any investigation or inquest which resulted from it. But it did occur to me to wonder whether everyone would agree — whatever the risk was, you might argue it was not an ‘imminent’ risk. Today’s self-injury seemed relatively minor and one might imagine if the hospital had been dealing with someone who had taken a life-threatening or life-altering overdose, they would have reported her missing to the police as soon as she’d walked out and there’s no evidence they had.
We do know some NHS organisations have argued in the court that for a situation to amount to an “immediate risk” scenario, death or serious injury must be imminent – this is not correct(!) and the Supreme Court made that very clear. You should ask not whether a risk is ‘imminent’, but whether it is ‘present and continuing’. So the police were called and she did return to hospital, albeit the programme is not clear whether s136 MHA was invoked by the officers in order to facilitate that. After the ambulance service had disengaged, we see a conversation amongst a group of paramedics about this lady’s case and I suggest it’s typical of many discussions across #Team999 on a daily basis.
“It’s a really difficult one isn’t it because obviously we’ve got a duty of care. But she’s got capacity to make her own choices – just plays in to that revolving door where they want to support them in the community but the support isn’t good enough in the community so we just go ‘round in that circle of they phone 999 we go out to them they don’t want to go to hospital we get the police they end up on a 136 they go to the hospital get referred to the home treatment team and out they go and then it’s that all over again. That viscous cycle.”
Chats like this go on all over the UK in paramedic and police crew rooms, I’m willing to bet. They have in places I’ve worked.
MENTAL CAPACITY ACT
One aspect of the above incident I want to emphasise and contrast with a non-mental health incident in the same programme, is the discussion about capacity and the Mental Capacity Act 2005. In the above quotation, the paramedics are emphasising the lady has “got capacity”. This needs careful handling when it comes to mental health, though and it’s worth professionals in many organisations remembering this point because I often hear it misunderstood —
The Mental Health Act 1983 is not predicated on concepts of ‘capacity’.
In other words, the MHA can be applied to people who do have capacity to take their own decisions – and this is the legal regime for making decisions about people’s treatment for mental disorder. The questions for application of the MHA are to do with whether someone has a mental disorder which necessitates their admission to hospital. The big lessons out of this for police / paramedics (as well as others who’ve been known to confuse the point), is that dealing with someone who “has capacity” (as assessed in accordance with the MCA) to decline medical treatment, for example, doesn’t mean they should be allowed to do so because the MHA may be relevant to their situation as well. The MCA is the regime for making decisions about whether someone can consent to treatment for physical illness or injury, as well as some cognitive or neurological conditions like dementia.
So contrast this with the physical injury to a homeless man in Manchester City centre which is featured towards the end of the programme, a very sad incident. Paramedics attended a report of an assault and a man was found with injury where there was concern about infection and the potential for sepsis, which can be fatal. There is a considerable effort by the paramedic to persuade the man to hospital, outlining all the potential consequences, reassuring him against his instinct that he’s not wasting NHS time or anything similar and in the end, the man declines care. This was not a mental health / mental disorder related incident, so the MCA is the sole judge of whether the paramedics must reluctantly accept his right to make what they believe to be an unwise decision.
And there’s the lesson from the programme — how it’s the MHA which should be applied to the lady with mental health problems and the MCA which should be applied (or not) to the man with a physical injury where he’s declining treatment.
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, 2024
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 – www.legislation.gov.uk
Mental Health Cop 