This blog is part of the series which will cover, in detail, the amendments to the Mental Health Act 1983 withinÂ the Policing and Crime Act 2017.
For background to the series, see the introductory post which outlines why Iâ€™m doing this and what other specific issues will be covered concerning laws that will come in to effect in the next few months. Current Home Office estimations of timescales suggest early May â€“ but this is subject to a number of factors and may change.
If you look at the so-called Street Triage schemes, most of them are predicated on the idea of police officers contacting a mental health profession, usually a nurse, and seeking information or advice about a person they have met at an incident. The nurse may opt to turn up to the job and do a face-to-face assessment or the may advise from wherever they are, by telephone. Many areas claim that since the introduction of street triage their use of s136 has reduced, in some cases quite considerably. This idea lies behind the new legal requirement requiring police officers to consult, wherever practicable, with a professional before deciding to instigate s136 MHA â€“ thatâ€™s what weâ€™ll cover in this post.
This pre-136 consultation is a legal requirement, where practicableÂ â€“ you either must do it, or be able to justify why you have not done it. Itâ€™s the one, or the other â€“ you cannot simply use s136 and not explain why you had to crack on. This justification will need to be documented in pocket books for future reference because you can anticipate the legality of s136 usage being questioned if an officer has made no effort to consult and also provided no justification for why they didnâ€™t. In areas of the country where services are also under pressure for their Place of Safety (PoS) capacity, I also anticipate some NHS staff will feel entitled to question the officers about the consultation requirement â€“ especially if they disagree with the necessity of it! â€“ and will become more interested if the police cannot clearly say why they had to act. Â OR â€“ why did they act by detaining if the advice was not to do so?! â€“ thatâ€™s a can of worms explored below.
So you either document â€“
The law says â€“
â€œSection 136(1C) Before deciding to remove a person to, or to keep a person at, a place of safety under subsection (1), the constable must, if it is practicable to do so, consult â€” (a) a registered medical practitioner, (b) a registered nurse, (c) an approved mental health professional, or (d) a person of a description specified in regulations made by the Secretary of State.â€
The section, above, makes no effort to explain the purpose of this consultation. Are we sharing information, seeking that professionalâ€™s opinion about detention; wanting to understand which PoS to go to if detention is the outcome; are we asking for risk information which may be known to the MH trust but not the police; are we asking about clinical issues like whether the person is thought, or not, to be concordant with medication? The last question sounds like something a bit clinical that is nothing to do with the police, doesnâ€™t it? â€“ yet I could tell you the street triage story about the nurse who didnâ€™t ask a patient about medication and then gave officers an under-inflated risk assessment that led to them not detaining the person under s136 when hindsight indicated very clearly that knowledge of medication issues would have led the nurse to give a different view. So how detailed do we want to make this stuff?!
So is this enough? â€“
â€œHi, this is Inspector Brown â€“ Iâ€™m at an incident with young man who seems to have mental health problems and I want to consult, as per s136(1c) because of the potential that I may detain him.â€
I admit if Iâ€™m ringing up, I have more questions and Iâ€™d be asking them!
â€œSo, in addition to you telling me whatever you think I need to know and any opinion you might want to offer about whether detention might be appropriate. Iâ€™d like to know a) any information you have relating to risks to either him or me, including whether or not you have information that he may possess items which could be used to harm himself or me; b) whether he is prescribed psychiatric medication and whether you have any grounds to believe heâ€™s not taking it; and c) what mental health condition you believe he has.â€
And this is interesting moral territory for mental health professionals, isnâ€™t it? â€“ what if they are aware that a person habitually carries a bladed item, either for harming themselves or, as I was once told about patient who carried a knife, â€œItâ€™s his comfort blanket â€“ itâ€™s just something he carries.â€ Â Is a nurse going to tell the police that there is risk information which may then lead to that person being searched and arrested for a criminal offence when the officer finds them in possession of something theyâ€™re not legally allowed to have?
Most importantly, officers in this situation need to focus on the legal situation during consultation. This is a point Iâ€™ve repeatedly raised throughout the progress of this legislation and have discussed with street triage schemes and their managers. Section 136 can only be used if the officer thinks there is an immediate needÂ for care or control, in that personâ€™s interests or the protection of others.
Rights and civil liberties are important here. You only need to watch the BBC news or get involved on social media to see frontline officers creating what Iâ€™m going to call â€˜considerably ambiguityâ€™ about what is occurring legally where they are involved in â€˜triageâ€™ encounters. Â Some service users on social media report having been held, unable to leave for non-negligible periods of time (measured in hours) whilst waiting for triage to get involved. If consultation can happen quickly and easily, we can agree that information sharing within a few minutes which prevents someone needing to be detained is welcome. But I admit that I wouldnâ€™t be prepared to stretch that point beyond a few minutes before I would feel uncomfortable in not letting someone leave who wanted to. Remember, in the ZH v CommissionerÂ (2013) case,Â the Court Appeal ruled someone had been deprived of their liberty by being held, unable to leave, for just 10 minutes. Even if someone is not objecting to remaining with the officers, are officers undertaking a capacity assessment of that decision to remain?
Parliament, having just amended our laws, could have inserted something in to s136 which said, â€œIf following the application of s136 by a police officer, a registered nurse offers information or alternatives to detention which negate the original need for the officerâ€™s use of the power, the person may be released from detentionâ€ or similar. But they didnâ€™t. Parliament do not want nurses on the street ending detention unilaterally, otherwise they would have said so. Any decision to detain remains that of the officer(s) involved in the incident and this remains true after an officer has been told by a nurse that detention isnâ€™t appropriate.
Ask yourself this: in what circumstances, precisely, would you ignore the advice youâ€™re given not to detain someone and proceed to detain them anyway? If you canâ€™t answer that question, youâ€™re effectively going to be doing as youâ€™re told and yet the decision to detain belongs to the police officer â€“ it never belongs to the nurse. I can think of various situations in which Iâ€™d be prepared to detain anyway â€“ I donâ€™t intend to do a disservice to the many excellent mental health nurses who have made great efforts to get their heads around mental health law but I know how little training they get on the legal issues relevant to police detention decisions. As such, examples Iâ€™ve come across over the last few years cause me to think some of the advice weâ€™ll receive will be duff, predicated on misunderstanding relevant legal issues and that I wonâ€™t know in any given situation whether this was the case.
So my own operational approach is likely to be this â€“
Remember, the Code of Practice to the Mental Health Act makes it clear (in para 16.21 (Eng); in para 16.27/8 (Wal) â€“ that s136 should not be used as a route to access mental health services â€“ patients should go via their GP or their community mental health team, where appropriate. So if Iâ€™m prepared to put in a phone call because grounds for immediate detention are not met, s136 canâ€™t be the answer after the phone call if that is just about the convenience of a service to have someone brought to them. But what capacity will they have to follow-up the person at home?
Services should be available to people who need them, not withstanding the legal framework that the police may or may not have applied. So I find this consultation requirement the most interesting of all the new amendments because I think I can see what itâ€™s getting at, but I admit to wondering how that will actually work in practice. And I worry in particular that people may be subject toÂ de factoÂ detention by frontline officers or schemes because somewhere in our recent history somebody unilaterally decided that less s136 is a good thing and that weâ€™ll measure the success of these programmes with reference to their ability to reduce the use of a power which is simply not relevant to most of the referrals they receive.Â (Most street triage doesnâ€™t happen in the street; and most of what they do isnâ€™t triage! â€“ apart from that, itâ€™s well named.)
Areas need to be clear: how are we consulting; why are we consulting; what are we consulting about, precisely â€“ when should officers do as theyâ€™re told and how will incidents be handled if they took a view that is at odds with the advice theyâ€™d received?
The last postÂ in the series will focus on the â€˜exceptional circumstancesâ€™ in which police custody may still be used as a Place of Safety for adults â€“ this will not be written until the statutory Regulations are published by the Government.
Winner of the Presidentâ€™s Medal from
the Royal College of Psychiatrists.
Winner of the Mind Digital Media Award.