A curious thing appeared on the internet recently: a preventing future deaths report from the Warwickshire Coroner, which has been sent to the Chief Executive of Birmingham and Solihullâ€™s Mental Health Trust (BSMHfT). It follows the death of a man by suicide, thirteen days after the BSMHfT street triage (ST) scheme had contacted with a man who ended his own life in a hotel. No details were given about why the contact with ST occured in the first place, but we know from the PFD report that it was contact by telephone. Amongst other concerns the Coroner had about record keeping by ST (there was none), point 5 on the PFD leapt off the page at me when I first read this.
And if it wasnâ€™t a mental health assessment, what does it mean, if anything, for police officers who have ST schemes across the country where they become involved in police incidents because they believe the person needs MH assessment, often as an alternative to the use of s136 MHA? If I believe someone may be unsafe because of mental health problems and requires a level of assessment beyond my capability, are we saying that no telephone discussion can ever be a mental health assessment or that this telephone exchange wasnâ€™t? â€¦ itâ€™s not clear, is it?!
This fits in to the narrative unfolded by Her Majestyâ€™s Inspectorate of Constabulary earlier in the year: that â€˜street triageâ€™ schemes needed clearer strategic objectives; as well as evidence of evaluations being â€˜poorâ€™ or â€˜very poorâ€™, according to the NICE Guidelines on the Mental Health of Adults in the Criminal Justice System (2017). We still donâ€™t understand these things as well as we need to â€“ I remain of the view they were set up too casually and some of the problems weâ€™re seeing emerge were predictable and forewarned by some of us!
Over many years, Iâ€™ve heard a number of clinical mental health professionals say that the first thing you do when you undertake a mental health (Act) assessment is a physical health check, if for no other reason than to ensure there arenâ€™t obvious concerns about other medical issues or alcohol or drug intoxication. Iâ€™ve seen the importance of this myself: how many times have paramedics turned up at s136 detentions made in good faith by officers, only for the good people in green to say, â€œErr â€¦ A&E: this is not a mental health matter.â€ Diabetes, brain tumours, encephalitis, meningitis, etc., etc., â€“ all because a decent physical of basic observations was done by an experienced healthcare professional.
There was also that job when I was shadowing a street triage team â€¦ we walked in to a manâ€™s house one evening after a GP, who had not attended his patientâ€™s house to examine him prior to ringing 999 for the ambulance to serve to â€˜send triage and section himâ€™; and it was obvious to me and all my clinical qualifications (expired first-aid certificate) that the only thing needed was for this bloke was for him to be taken as soon as possible to A&E by ambulance. His head, stomach and foot were heavily swollen and largely purple: something the GP and his medical degree would have noticed himself if heâ€™d bothered to turn up and examine the man before reaching for the 999 bat-phoneÂ In fairness to him, though, it was end of office hours on the Friday before Christmas and he probably had a family or a party to get to.
So as weâ€™ve seen the expansion telephone based approaches to mental health, itâ€™s important to understand what these phone calls are, starting as they do at a massive disadvantage that the clinician canâ€™t see the patient. Is it really possible to fully,and properly assess someoneâ€™s mental health? There seem to be varying views on this; but itâ€™s importance because of one simple fact: in most areas where ST operates, the nurses do not actually see the majority of patients face to face. There are some exceptions and ironically enough: West Midlands Policeâ€™s triage scheme with Birmingham and Solihull Mental Health Trust claims to see a small majority of all the people at the centre of calls, but they are the exception. In some areas, ST actually sees 15%-25% of people and the rest are supported by the provision of telephone discussion and information sharing. So itâ€™s unfortunate that this PFD from the Warwickshire Coroner ironically relates to a job in the area who perhaps see most. And of course, in other areas, all of the â€˜triage schemeâ€™ is telephone based, with the nurse in the police control, acting in remote support and sometimes speaking to patients by phone.
So this question of whether telephone discussion is or can ever be mental health assessment is actually important to the vast majority of ST schemes and I would urge those involved in them, whether police or NHS, to have the discussion for the record: is telephone discussion never, ever or always or a mental health assessment? â€¦ and if not never or always, when is it ever?! Whatever actually was going on in the phone discussion to which the Coroner refers it was definitely thought to relate to someone thought by the police (or ambulance service) to be at risk because of mental health problems. But all we really know at this stage is that when after hearing the evidence in the inquest, it has caused the Coroner to be concerned enough to raise the question about what the purpose of it was, if it was â€˜not a mental health assessmentâ€™ and the trust definitely stated it wasnâ€™t.
Did the police or paramedics know this? â€¦ or did they think it was and therefore feel able to walk away reassured on the basis that an assessment had occurred?! Communication was and is always vital to joint agency working and police officers need to be careful to understand what has actually happened in an incident. There have been a few other Coronerâ€™s incidents recently where officers have made assumptions about the nature and quality of healthcare assessments and then felt reassured to walk away, only to learn the very hard way (gross misconduct investigation) that healthcare professional hadnâ€™t clearly communicated and in some instances, including this one, hadnâ€™t made any professional notes about what happened.
The original point of ST, as outlined by the Prime Minister when she was Home Secretary and by various senior officers since, is to ensure more appropriate assessment of vulnerable people and this should lead, it was hoped, to a reduction in the use of s136 MHA and in the use of police cells as a Place of Safety under the MHA. It was further hoped this would, in turn safe police time and resources and Iâ€™ve written elsewhere about why I think in some cases, the opposite has occurred â€“ I wonâ€™t repeat that hear, but Chiefs should think about it more!
Where my brain is completely seizing up is this â€“ so all comments from mental health nurses welcome: is non-face-to-face discussion of someone ever a MH assessment? â€“ or not?!
One-word, closed question.
Whilst Iâ€™m at it, Iâ€™m going to outline a related concern raised to my attention recently by an AMHP. In that AMHPâ€™s area where he regular conducted a number of s136 assessments each month before the invention of triage, he would personally expect â€˜at least a handfulâ€™ of people detained under s136 whilst so intoxicated by drugs or alcohol that they would be allowed 4-6hrs by him to sober up before his assessment â€“ his colleagues would see other people each month and allow sobriety periods, also. He wasnâ€™t complaining about the use of s136 on intoxicated people, except in the odd case here and there because the individuals were often found at risk on bridges, on high buildings or in positions where suicide was imminently accessible, if the choice were made. He also accepted a large proportion were found to be known to mental health services currently, or previously. His point was this, after discussion with his colleagues: they, as AMHPs, were *never* seeing people in such circumstances any more, or maybe 1 or 2 per month across the whole AMHP rota. Street triage were seeing them instead and his question was this â€“
Are mental health nurses in his local triage scheme assessing drunk / drugged on their own, whilst still intoxicated, in positions where they were previously being detained under s136 in order to allow them to sober up and be assessed? A section 136 is always at least two-professionals undertaking assessment in controlled conditions â€“ sometimes three professional. Street triage is one MH nurse, usually operating alone (clinically speaking).
We still havenâ€™t fully discussed all that we need to, in order to understand the new dynamics of these processes and on the day that publication is made of the IOPC deaths in and after police custody and contact report where, yet again, no specific mention is made of street triage despite the fact that s136 related deaths in or after custody have risen as have deaths after contact without custody, I think we need to start talking just to make sure we understand whatâ€™s going on here.
Winner of the Presidentâ€™s Medal from
the Royal College of Psychiatrists.
Winner of the Mind Digital Media Award.