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Police need better training in mental ill health, writes trainer Jim O’Dwyer, pictured, of AEGIS Protective Services.
In about August 2013, the Metropolitan Police began ordering officers not to respond to calls from mental health units and hospital emergency departments for help to control and restrain patients unless there was a “significant threat to life or limb”.
The new protocol stated:
• Transportation to a place of safety should be in the form of an ambulance and responsibility for transfers between psychiatric hospitals and to emergency departments rests with the hospital not the police.
• Police will not attend a health trust to assist in restraining patients receiving treatment or assessment.
• Police will not attend trust premises merely to restrain a patient located therein or to stand by and prevent a breach of the peace.
• Police will attend all premises in the event of a significant threat to life or limb that requires force necessary to regain control.
At the time, the Met was acting against a backdrop of growing concerns in the police nationally about the impossible burden that responding to incidents involving mental health issues was placing on forces. The Met was also conscious and concerned that while staff in mental health facilities are specially trained to control and restrain psychiatric patients, the police are not.
Note: at the time, several Met officers were being investigated in relation to the death in 2010 of Seni Lewis, a 23-year-old graduate who had mental health problems. Mr Lewis had died following restraint by police who had been called by staff to the Maudsley Hospital, in south London. In 2015, the Crown Prosecution Service (CPS) decided that no criminal action would be taken against police involved in Mr Lewis’ death as there was insufficient evidence for a realistic prospect of conviction. The CPS said it had carefully considered evidence provided by the Independent Police Complaints Commission (IPCC) and an external review by a Queen’s Counsel which was concluded in early 2013. It said there was insufficient evidence strikes with a police baton and the handcuffing of Mr Lewis were unreasonable or unlawful in the circumstances and the actions could not be considered as an offence of assault occasioning actual bodily harm, as defined by law. “It is important to remember the law entitles officers to restrain an individual until they achieve control. The evidence of the hospital staff does not, on the whole, criticise the methods as excessive and there is considerable evidence as to Mr Lewis’ strength and violence.”
Chief Supt Chris Bourlet, of the Met’s mental health team, said: “This is about making sure everyone knows where we stand. This is not about withdrawing service where it is appropriate, it is about defining who is responsible for what and where the line is.” Bourlet said the Met policy was consistent with the protocols issued nationally by the National Policing Improvement Agency (now superseded by the College of Policing).
Police re-affirm in 2015
In November 2015, the College of Policing consulted on their Authorised Professional Practice (APP) – for Mental Health. The consultation documentation outlined police expectations of NHS Trusts, including that, ordinarily, the police should not need to be called to assist healthcare staff in responding to a patient who is presenting management problems. The consultation documentation also emphasised that NHS trusts, local health boards and other health service providers have legal obligations under the Health and Safety at Work Act 1974 to ensure that sufficient numbers of trained staff are available to restrain patients for medical intervention or to place them in isolation for their own, or another’s safety where this is necessary; and that performing this ‘duty’ should ensure they are capable of dealing with most problems themselves and only need to call for police assistance in exceptional circumstances, such as:
• There are insufficient numbers of trained staff available to cope with the situation (for example, in emergency cases of sickness absence)
• The situation is clearly beyond the capability of the staff to manage the patient safely (for example, because the person is armed, or a hostage situation has arisen)
• A breach of the peace or other offence has occurred or is anticipated
• It is an emergency, and the person needs to be detained in a place of safety that is not the current facility.
Good reasons to minimise
In their Police Use of Force study published in March 2016, the Independent Police Complaints Commission (IPCC) recommends that police forces review existing arrangements relating to police attendance and their role at hospitals, mental health units or other medical settings, to minimise the involvement of the police. (Recommendation 15).
The data in the report supports this. The IPCC cites that of ten people who experienced use of force by police while in a hospital (for example, in accident and emergency or a specialist mental health unit) five of them died during or following the incident. That’s one in two of them!
Before you fall off your seat – please bear in mind that the police are called to assist NHS staff to manage patients on thousands of occasions every year and generally do so very well. The figures quoted in the IPCC report only considers the few incidents referred to them for investigation. Even so, the figures are still pretty alarming!
Of the ten people who experienced use of force by police while in a hospital:
• Five died during or following the incident.
• Nine were men and one was a woman. Eight were White, one was of Asian ethnicity, and the ethnicity of one was unknown. The most common age group involved was from 31 to 40 (six people).
• Nine were intoxicated through alcohol or under the influence of drugs.
• Seven had mental health concerns. This included personality disorders, psychotic episode, schizophrenia, and detention under Section 136 of the Mental Health Act (MHA). Three people had other medical conditions, such as alcohol withdrawal symptoms, including seizures and epilepsy.
• Eight were said to be acting in a threatening manner, such as being verbally abusive or physically violent during the incident at the hospital.
• Six were arrested or detained – two for violence-related offences, and four under Section 136 of the MHA, one of whom was also arrested for possession of a weapon.
• Six displayed symptoms of acute behavioural disturbance (*). This included extreme strength or aggression, constant physical activity, and increased breathing, temperature and sweating.
• Nine were physically held by the police including four in the prone (face-down) position; CS spray/PAVA was used on two people (**); one person had Taser used on them (barbs); and restraint equipment was used on four people, two leg restraints, one emergency response belt, and one (improper) use of a contamination hood. Other types of force included taking the person to the ground, pushing/pulling, and use of handcuffs.
• Police primarily had contact with the person either because of a concern for their welfare, or because they were assisting medical staff. While the reason for police attendance was not specifically to assist medical staff with the administering of medication, there were three instances where sedatives were administered while a person was being held by police officers.
• Medical staff and hospital security were involved in four of the ten incidents (i.e. in addition to police).
* Acute behavioural disturbance
The IPCC report doesn’t say how many of the six people who displayed symptoms of acute behavioural disturbance were physically restrained and if so whether or not they were held in the prone position or how many of them died. But, it should have been none.
Below is what the Authorised Professional Practice (APP) developed by the College of Policing (the official source of professional practice on policing) says about acute behavioural disturbance – and restraint:
People who are violent and agitated may have an underlying medical reason for their behaviour. If there is any suspicion that the violence stems from a medical condition the person must be treated as a medical emergency. Whenever possible, the person should be contained rather than restrained until medical assistance can be obtained.
Of all the forms of acute behavioural disorder, Excited Delirium is the most extreme and potentially life threatening. Excited delirium can be caused by heavy use of certain drugs, typically stimulants, of which cocaine is the most common.
The symptoms of excited delirium include:
• a state of high mental and physiological arousal – perceiving others as frightening and dangerous, ‘fight or flight’ reaction
• breathing problems
• high body temperature and/or sweating – so may try to undress
• violence, aggression and hostility
• insensitivity to pain and incapacitant sprays.
People who appear to have this condition should be restrained only in an emergency.
** CS spray/PAVA
In general, where it can be justified in the interests of officer safety, use of CS spray can never be discounted. Even so, I’m very surprised to learn police used CS spray/PAVA in hospitals at all. Besides the fact that some people experiencing mental ill health are insensitive to incapacitant sprays, use of CS spray inside a building can contaminate it for hours if not days, rendering it unsuitable for patient care. In the circumstances I’d recommend that NHS trusts liaise with their local police to formalise a protocol which strictly prohibits the use of CS spray/PAVA in hospital settings, unless the circumstances are truly exceptional and life threatening.
The IPCC has often expressed concern about the relationship between mental illness, restraint and death. One in five of those involved in IPCC investigations into use of force were known to have mental health concerns. They were four times more likely to die after force had been used than those not known to be mentally ill. They were much more likely to be restrained, to experience multiple uses of force, and to be subject to force.
The findings of the IPCC’s report underline that police need training in recognising and communicating with those in mental health crisis.
The College of Policing has taken steps to address the training need. In November 2015, the College of Policing consultation on their Authorised Professional Practice (APP) – for Mental Health, stated that the APP had been developed to support the service (police officers) to recognise behaviours and indicators of concern so that appropriate medical support can be sought.
A finding of the IPCC was that, in general, the public think that police use force more readily now than ten years ago. This perception may not be the same as the reality. For example, the public also thought that the police fired firearms four times more often than they did. Another finding was that people who had direct experience of police using force on them believed that police were more ready to use excessive force and that verbal communication was not attempted first.
Research has indicated that training officers in communication and de-escalation techniques may have a positive impact on police interactions with people with mental ill health. Krameddine et al’s (2013) before/after evaluation found that an interactive training programme may have improved officers’ behaviour (their reported ability to communicate and de-escalate situations, and to show empathy) and reduced the rate at which force was used in mental health incidents.
The training programme focused on the following skills:
• active listening skills, for example, paraphrasing, emotion labelling, mirroring and uses of silence
• the ability to show empathy and establish rapport
• non-verbal (e.g. body/facial language) and verbal (e.g. word choice, tone of voice) de-escalation skills.
Police need non-aggressive, methods of holding controlling and restraining.
At present, police officers only receive training in techniques that rely on causing pain to gain compliance and such techniques are not appropriate or suitable for use on patients. Supplementing the physical restraint training provided to police officers with non-aggressive, methods of holding controlling and restraining people would be another obvious step to take.
Police restraint methods conflict with DoH guidance.
Department of Health Guidance – Positive and Proactive Care: reducing the need for restrictive interventions (2014) to NHS Trusts states:
• “Staff must not deliberately restrain people in a way that impacts on their airway, breathing or circulation, such as face down (prone position) restraint on any surface, not just on the floor. [Para 70]”
• “If restrictive intervention is used it must not include the deliberate application of pain.” [Paras 58, 69, 75].
Doesn’t it seem paradoxical that, when police are called to assist hospital staff to manage a patient it is OK for them to use prone restraint and pain compliance techniques to control the patient? It’s a problem that needs to be sorted. Knowing the likely police response if they are called, is a barrier that leaves many NHS staff reluctant to make the call.
Police training needs to include ‘attachment’ at a hospital.
Judging from my own police experience and the ignorance I endured about mental health and how badly that affected how I dealt with situations when called to assist hospital staff (at St Mary’s Paddington) to manage patients with mental ill health, I’d recommend that police forces incorporate a period of attachment to the local hospital of not less than six weeks into their officer training.
Such an attachment would be invaluable in helping officers to imbibe the philosophy of ‘patient focus’ and become less inclined to immediately resort to use of physical force. It would also help officers to better integrate with the ‘community’ they police and gain a clearer understanding of how the community wants to be policed.
Controlling use of force
To help support work that community and voluntary sector groups and other organisations are undertaking locally, the IPCC has produced a handy prompt sheet, containing questions you could ask your local police force to find out more about how they are responding to the findings of the IPCC study and the recommendations made.
Question 15 is: How do you ensure that a single officer isn’t able to repeatedly misuse force?
It’s the best question in the prompt sheet and it has a simple answer that has nothing to do with documenting incidents or fact keeping. The only way to prevent abusive use of force is to, through strong leadership, install and nurture a work culture of integrity, non-aggression and respect for others and then, through effective supervision, minimise opportunity for bad things to happen unnoticed and unreported.
NHS Trusts need to increase staffing and capability to manage violent patients. It is clear that NHS trusts are going to have to cope with less support from police and need to be prepared to do so.
Responding to the Met Police ‘policy clarification’ in 2013, a spokesman for NHS England said: “We are working with our provider organisations and their staff to develop new ways of working without relying on police support.” These ‘new ways of working’ were always, inherently, going to require investment in more staff and better training. Unfortunately, I have to say that, to my knowledge, it is unlikely that any NHS Trust has specifically increased staffing levels or training in response to the ‘new need’ – and this will leave staff and patients at risk.
Increased reliance on security
To be able to safely manage aggressive and violent patients without police assistance, healthcare security officers will need more comprehensive training than the standard SIA package.
The need for healthcare security officers to be able to recognise the characteristics of mental ill health (and learning difficulties) and understand ‘Clinically Related Challenging Behaviour’ was identified as a necessary training need by the National Association for Healthcare Security (NAHS) when commissioning the production of a ‘Healthcare Security Officer specific’ training. The AEGIS Protective Services Healthcare Security Officer training course incorporates modules that address this training need; also produced as two short (two hour), certificated, security CPD e-learning courses.”
1. Recognising Mental Ill Health & Learning Difficulties
2. Challenging Behaviour
The NAHS approved healthcare security officers training also includes physical intervention and Restraint Skills. Ideally, patient care should always be managed in such a way as to completely avoid any need for physical restraint and every instance where restraint proves necessary should be regarded as a failure to have intervened earlier. However, in certain circumstances, for example where a patient’s behaviour presents an imminent risk of harm to themselves or others, the only option available to staff will be to physically restrain them. In such situations, it is crucial that the process is carried out professionally, safely and in a manner which minimises any discomfort and loss of dignity to the patient. The training will definitely help to minimise the risks. The emphasis is on keeping calm, utilising conflict management techniques and the use of space to talk patients down and defuse situations. The practical skills are amazingly simple and very effective.