You may not have heard about “swing beds” in mental health care – this is a term used in some of the annual reports by the Care Quality Commission in to the operation of the Mental Health Act 1983 (MHA). A little explanation about this term before we look at the sad case of Mr Martyn Stringer from Sussex, where the coroner has suggested this may have been of relevance (albeit the coroner doesn’t use the particular term).
A health-based Place of Safety (PoS) is ostensibly there to accommodate those detained by the police under s135 or s136 MHA – it is not a ‘normal’ inpatient bed, if it’s a bed at all. In fact, the facilities in some PoS services do not include an actual piece of furniture on which a human could lie down and go to sleep. Some do, others have what I might call a ‘crash mat’, of similar kind to those you will have seen in school (or police) gymnasia for safety reasons during activities. But some PoS facilities are just empty rooms save for one or two chairs or sofas and where there is cold floor to lie on if you really do want to lie down.
So first things first: a PoS is not a “proper” inpatient bed where humans could properly remain with dignity and comfort during the first hours or days of their inpatient mental health care. You may remember a point I’ve emphasised on this blog many times: when you are detained under the MHA, you are legally not admitted to a bed, strictly speaking, but to a hospital. The word “bed” does not appear in the MHA at all – not once.
URGENT ADMISSION
We know the admission of some patients is urgent – it is literally life or death where some vulnerable people are suicidal and will take their lives if not protected from doing so. That’s why it’s important NHS trusts have capacity and contingency to ensure admissions where they are necessary. (Anyone heard of s140 MHA yet? – it’s sixty-five years old this year.) Ideally, of course, an urgent admission would be to a ‘proper’ psychiatric inpatient bed on a ward with all the facilities and support that entails to ensure safety and dignity of those of us affected by our mental health.
However, as the United Kingdom has decided to deliberately cut its inpatient provision during a period where its population were always going to require more specialist mental health services, pressures on beds has become incredible. We frequently hear professionals on social media lamenting a lack of available beds anywhere in the country and we can now see such a declaration in a Preventing Future Deaths report for Martyn Stringer who we’ll think about and remember very shortly after these background points.
You might wonder, if someone urgently requires admission to hospital to safeguard them from suicide, why can’t they be “admitted” to the hospital where the health-based PoS is situated and protected there in that place, assuming it’s available at the time? Well, there’s no legal reason whatsoever why this can’t happen – and this is what the CQC term a “swing bed”. It’s the use of a PoS as an interim ‘bed’, to allow someone’s safe and timely admission when there is no ‘proper’ bed and somewhere from which they’ll be moved on just as soon as a ‘proper’ bed becomes available on a ward.
SUSSEX SADNESS
Mr Stringer was found by Sussex Police one Friday evening in March 2023 in circumstances where officers obviously feared he may take his own life and they detained him under s136 Mental Health Act to keep him safe. I’m assuming the PoS was not immediately available because he was transported first of all to an Emergency Department in Eastbourne which provides us with a good guess as to where he may have been found and he assessed there by an Approved Mental Health Professional and two Doctors who decided he required admission to hospital under s2 MHA.
This is where the bed problem began:
There were no psychiatric beds available nationally, according to the remarks of the Coroner in the PFD notice. Mr Stringer remained in the ED until Sunday when he was collected by his family and taken home – it’s worth remembering, the initial police detention under s136 MHA only lasts for 24hrs so that would have expired at some point on the Saturday, having been started on the Friday. By Sunday, he was legally free to leave because the AMHP had been unable to ‘section’ him because of the lack of an NHS bed.
At some point during his time in ED, perhaps on the Saturday whilst the s136 was running or perhaps after it expired – the PFD is not clear on that – it must have become known the PoS had become available. His Majesty’s Coroner noted –
“It is the case that a Health Based Place of Safety bed did become available but a decision was taken that due to anticipated demand for potential patients not to offer this to Martyn.”
PRIORITY AND DEMAND
I will admit: I don’t even begin to understand why services would not do this and I’ve known this kind of decision a lot and I’ve given evidence in court on this point, whilst wondering why such things are not always considered as options to safeguard people at risk? I write “not always” because we know it does happen – I’ve seen it and known it happen, but it’s rare.
Why would you leave someone un-admitted and at risk, when the option to protect them was actually available in the real world?
The word ‘offer’ in the Coroner’s PFD wording is a little disingenuous as well, because Martyn was due to be ‘sectioned’, which means he’s either not being given a choice about his admission or that he lacks capacity to take the decision for himself. Either way, the point remains a PoS was now empty and someone decided deliberately not to make the application to that hospital and admit him for safeguarding and protection.
I do understand that a person being “admitted” under s2 MHA to the PoS is far from ideal and that it means the facility is then out of commission to others who may be subsequently detained by the police under s135 or s136 MHA. But here’s an obvious point to make in response, one which is overlooked: others detained under police powers who require a PoS can be accommodated in other places, and not just Emergency Departments as Mr Stringer originally was.
I repeat the point – I’m very well aware that none of this is ideal and I made that precise point when giving evidence in an inquest after someone died in a homicide by a mental health patient. Of course it’s not ideal to have a s2 patient in a PoS and to close that service to others but it’s not ideal either having a suicidal or, much less often, homicidal mental health patient at liberty for the want of a ‘proper’ bed. Yes, it’s the wrong thing to do in objective terms, but it may be ‘righter’ than doing other wrong things, because it puts reality ahead of hypotheticals.
DOING THE WRONG THING RIGHTER
Nobody working in public services is working in ideal circumstances:
Everybody is improvising to some degree and trying to do the best they can with limited resources and the ultimate arbiter of staff actions is whether what they’re doing is legal and whether it does, in fact, mitigate known risks we are obliged to manage to protect human rights. We shouldn’t be declining to safeguard people we could actually help protect and who we know are at risk, to protect hypothetical people who might – or might not – need safeguarding later.
I was left wondering whether, whilst poor Mr Stringer was at liberty and ended up ending his own life, whether the PoS in question did end up used for someone else detained under s136 MHA? – and how upsetting would it be to learn that it wasn’t and notwithstanding all other things, I would wonder why my relative had not been safeguarded just so someone else’s could be, when we didn’t even know it was necessary and when we knew would would be able to improvise a solution for that other person, if they did come to the attention of the police.
I admit it: I don’t even begin to understand.
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 am not a police officer.
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 