I want to wade in to a debate which recently unfolded before Parliament about nursing training – and specifically about the training of mental health nurses and their experience or competence in physical healthcare. You might reasonably wonder why I’m interested in some recent events on this topic and what this has to do with me or with policing but I can assure you: I will bring it back to my own area of interest towards the end because the issues around and within this discussion affects policing daily, trust me.
The Health and Social Care Committee of the UK’s House of Commons recently held their second evidence session for their inquiry into community mental health services for adults with severe mental health needs. As part of this, Dr Lade Smith, President of the Royal College of Psychiatrists, gave evidence alongside various healthcare colleagues and made some claims about nurse training which have been questioned. I must admit, I thought what she said was correct but then I’m not a healthcare professional and I’m certainly not a mental health nurse. I was always under the impression, many years ago, you first of all trained as a general adult nurse (and became an ‘RGN‘ – a registered general nurse) before then further qualifying in mental health, becoming an ‘RMN‘ – a registered mental health nurse. I thought this because several nurses, including family members had told me that’s how it worked and so I laboured under that impression until the 1990s when I became aware of a shift towards nurses qualifying via university degree courses where all nursing students covered a common nursing curriculum for 12 or 18-months before then specialising as a general, children’s, mental health or learning disabilities nurse in the remainder of a 3 or 4yr course.
Dr Smith asserted something along these lines in the evidence sessions and the Nursing Times was straight on it, to suggest it’s wrong. The point of the debate was about the importance of care for the physical healthcare of mental health patients who have significantly reduced life expectancy, in part because of far poorer physical health than the general population. There is a whole discussion in mental health care about “diagnostic overshadowing”, which is the idea that someone with an established psychiatric diagnosis receives poorer care because too much is attributed to their mental health condition and because not enough is done to monitor their physical health. (Incidentally, diagnostic overshadowing is an issue in criminal justice issues as well – too much is attributed to the cost of criminal investigations.)
17th CENTURY FRENCH PHILOSOPHY
When I was first wading in to meetings and discussions about mental health in Birmingham, I attended several with a somewhat legendary psychiatrist who, on this topic of physical healthcare, said something as amusing as it was outrageous.
“I’ve got mental health nurses working on my wards who know a lot about seventeenth century French philosophy and f*ck all about blood pressure.”
WOW! – it did make me laugh, but it’s pretty insulting at the same time. That said, it harks towards something Dr Smith is getting at in far less bombastic terms. I’ve been told many times by both doctors and senior mental health nurses, the first thing to be done in any mental health assessment should be a reasonable physical check and if, for whatever reason that’s not possible, a visual examination with focus on physical presentation.
Why? – because many behavioural presentations which might make a police officer think about mental health, could be something else, like diabetes or head injury. I’m aware of s136 of the Mental Health Act 1983 being used in Dudley many years ago, where officers called an ambulance to a guy they’d detained and the paramedics just said, “Nope – probably diabetes, we’re off to ED. The ED doctor there told the officers if they hadn’t detained him and called an ambulance, he’d have suffered serious medical consequences and there are a whole host of other physical health care conditions which have, after use of s136 MHA, led to the discovery of things like Addison’s Disease (I had to look that one up – it’s a kidney / adrenal condition), meningitis or encephalitis.
MEDICALLY CLEARED
I’ve written before about the nonsense of “medically cleared” – the practice of NHS Places of Safety refusing to receive anyone detained under s136 or s135 MHA unless they have been seen and checked by either a paramedic or an Emergency Department. It’s more widespread than you might think and I always feel frustrated when I hear of it. Surely, and especially in light of the reaction taken to comments by Dr Smith in the recent evidence session (or of the offence taken to the Birmingham psychiatrist I knew a few decades back!) it can be expected a mental health nurse at a Place of Safety can do a basic physical assessment of someone presenting without obvious sign of physical injury? If not, then we might reasonably wonder how confident or competent the nurse is the basics of initially triaging patients.
Perhaps some might be offended at that idea, but I wouldn’t be writing this down in a blog from my particular position of ignorance if the many good friends I now have who are senior, experienced mental health nurses weren’t saying the same thing because we are just talking about being able to recognise whether there is any obvious indicator the person needs ED care before they can be seen by an Approved Mental Health Professional and a doctor, for 136 assessment.
And one of my favourite stories helps confuse this debate further:
A good friend has been a MH nurse for almost 35yr: He told me once of a 136 detention where the “street triage” car in Birmingham had responded to help the frontline officers who had used s136 on someone who had been running about in the road, amongst traffic. The officers obviously thought s136 and the MHA were relevant, the paramedic and the MH nurse on the triage car thought it was too and they offered to take over responsibility for the person, let the frontline police clear off to the next job and transport the person to the Place of Safety where my friend worked and was on duty.
MEDICALLY CLEARED
As far as the “medically cleared” people are concerned, this person is OK for the PoS – they have been seen, checked and OK’d by a paramedic and the MH with them had no concerns either. So the person was accepted in the PoS and they started the process to get the AMHP and DR on the way to see them, but half an hour after arrival, “Something’s not quite right here – you’re going to need to go to ED.” Paramedic and nurse stunned, but after some discussion, off they went an a junior doctor gave the patient the once over and said “crack on”, as if “medically cleared”. After another hour in the PoS “Sorry – you’re going to hate me for this: something’s not right, back to ED”, causing more consternation and disgruntlement. This time, the ED Consultant was asked to sign-off on the “medically cleared” idea and after an examination declined to do so, ordering some tests. Long story short: meningitis which would have been missed were it not for a mental health nurse having a keen eye during initial observations in a PoS – and meningitis can be fatal, of course.
What has any of this got to do with the police?
Well, you’ve seen above some stories about police use of s136 leading to “physical” health outcomes and interventions and plenty of doctors will tell you there are very serious conditions which can cause confusion or behavioural change which could very easily convince not only police but also healthcare professionals that someone was “just” mentally ill. And in Section 136 training which I’ve delivered countless times over the years, it has always been stressed the first thing you do after deciding to use the power is call an ambulance and think about so-called “RED FLAGS” – a list of things put together by an ED doctor for police to use to form the basis of taking someone to ED as the first PoS after detention. No RED FLAGS? – then go to the PoS where the nurse on duty will be able to give consideration to those issues as well. But nurses (or mental health trusts) who just say “no admission unless medically cleared” are falling foul of the folly which is the “medically cleared” argument – see my other post for more on that – and they are building in hours and hours of extra time spent, seriously impacting the resources of both the police and Emergency Departments who, it must be remembered, are the first port of call for 42% of 136 detentions and many of those are people who don’t require ED care at all.
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, 2025
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 