Health in Justice and other Vulnerable Adults Strategic Clinical Network (SCN)
Vulnerable Groups - The S136 Population
1. Background
1.1 This short paper looks at the people who are detained by the police under Section 136 of the Mental Health Act 1983, as a vulnerable group.
1.2 Every year significant numbers of people are detained by the police in places to which the public have access, using powers under S136 of the Mental Health Act.
1.3 In most cases these people will not be offenders, but will be suffering some sort of mental health crisis that requires police action to establish care and control and to mitigate risk to that individual or others. These people are inherently vulnerable and impact significantly on the Justice System (police) and Health services in London. We also know from our Street Triage and Joint Health and Policing team, that a large number of those detained under S136 are already known to mental health services (see 2.2 below).
1.3 Amongst this group there are many that have unmet needs and who repeatedly present to different agencies, however in the absence of a cohesive response that addresses these needs, they continue to present as ‘frequent flyers’.
1.4 Previous London based research on S136, indicates that its use is associated with social disadvantage, a diagnosis of schizophrenia, male gender, and Black British, African or Caribbean ethnicity. Threatened or actual violence is the most common presenting problem leading to S136 detention, followed by threats or acts of deliberate self-harm[1]. From a British Transport Police (BTP) perspective there is a high representation of people suffering from depression, bipolar disorder, schizophrenia, stress related conditions and personality disorders (many linked to drug and alcohol misuse) amongst the people they detain under the act. Many of these issues seem not to be well catered for in terms of treatment options in primary care.
2. Data
2.1 Statistics in this area are confusing, as we have different numbers provided by the MHMDS (Mental Health Minimum Data Set) and KP90 data which is provided by health, and different numbers provided by the police. However the number of detentions in London would appear to be at least 4,335 for 2013/2014, which equates to nearly 12 a day.
2.2 In the year 2014/15 British Transport Police Officers made 634 s136 detentions in the London area, of these 32 individuals were aged 17 and under. Additionally 189 of these detentions were classed as potential “Life Saving Interventions” where suicidal people were physically prevented from taking their own lives on the railway. 12 of these involved young people aged 17 and under. Additionally of these 634 detentions, 438 subjects are shown to have a mental health history and in 307 of these cases there is an indication of previous suicide and/or self harm behaviour[2].
3. The User experience
3.1 The experience for people suffering a mental health crisis and being detained under the act in London is generally not a good one. It will involve actions and more often than not, transportation by the police to Health Based Places of Safety (HBPoS), the provision of which is limited on a national scale.
3.2 A number of recent publications and Inquiries have produced substantial evidence of the need for wholesale improvements in this area. These include;-
· 2013 HMIC/CQC/HMIP report “A criminal use of police cells”
· 2014 CQC report “A safer place to be”
· 2013 Independent Commission into Mental Health and Policing by Lord Adebowale
· 2015 Home Affairs Select Committee report on policing and mental health
· 2014 Government review of the operation of S135 and S136
3.3 All of these publications make recommendations for change and improvement with a number aimed at health and social care commissioners. The Government has also led the creation and implementation of the Mental Health Crisis Care Concordat as a vehicle for driving improvements.
3.4 Through the proactive work of the Mental Health Partnership Board in London, the use of police cells as a place of safety in the Capital has all but been eradicated (87 in 2013, 22 in 2014 and 3 so far in 2015[3]), but significant problems still exist in transportation, accessing HBPoS and facilitating assessments under the Act.
3.5 Difficulties are also often encountered when the detainee has a physical injury. It would appear that HBPoS are not equipped to deal with even a minor injury, whilst Accident & Emergency Departments are reluctant or not equipped to carry out mental health assessments. This can lead to a lot of further delay in transfers between Mental Health and Acute Trust facilities that doesn’t see to put the welfare of the patient first.
3.6 Mental Health bed availability has been a consistent challenge in London for sometime, which can and does have a direct impact on those who have been assessed under the Mental Health Act but then have to wait for lengthy periods of time for a bed to be found. This can effectively put a Place of Safety out of action, which in turn causes further delays in police officers accessing much needed care for other persons detained under S136.
Case Study 1January 2015.
A Police Officer was called to a male threatening suicide at a railway footbridge in London. As a train passed underneath the male tried to jump but was grabbed by a police officer and dragged backwards. The officer undoubtedly saved the man’s life. The man was detained by the officer under S136 at around 8pm. An Ambulance was requested for transportation, but LAS reported that there were no ambulances available.
The local and surrounding HBPoS all reported that they were full and could provide no alternative provision. 90 minutes later the local HBPoS advised the officers to transport the male to their hospital, but the officers would have to wait for a room to become available, which was estimated to be a couple of hours away.
At 2am the following morning officers who were still waiting with the male outside the HBPoS were advised that the hospital was no longer able to receive the patient and refused access. Officers tried to find alternative provision and travelled to the opposite side of London to access an available HBPoS. The male was detained under S2 MHA after waiting in a police vehicle for over 7 hours.
3.7 Significant problems also exist in relation to the lack of follow up plans and effective care pathways for those released after assessment. The MHMDS data shows that only some 20% of detainees under S136 nationally, are further detained in hospital following assessment, and it is believed that a similar number will be subject to voluntary admissions. Recent research by Sussex University suggests that some 50% of S136 detainees are released with no follow up plan[4].
4. Managing Risk and Safeguarding
4.1 The NHS, Local Government and the Police all have duties to protect life, and the decision in the case of UK v Keenan[5] provides that the obligation to protect life, health and bodily integrity equally arises where the risk derives from self-harm or suicide.
4.2 When Police deal with people in crisis often the power of detention under S136 is the only tool available to ensure the individual does not harm themselves or others. However the mental health assessment looks at risk once the need for admission for further assessment or mental health treatment has been considered. This often means that people who still represent considerable risk to themselves or others are released following assessment, sometimes with fatal consequences.
Case Study 2Riddlesdown Railway Station – March 2013
Female 41 years & Male 3 years
December 2012
A woman with Mental Health history travels to the north of England and attempts suicide by way of a drug overdose. She is treated in hospital, assessed under the MHA and released. She subsequently returned to London. The woman had a 3 year old son.
January 2013 – The women’s mother calls 999 as her daughter is threatening suicide. Subject is taken to hospital by ambulance, assessed under the MHA and released.
22/03/13
The women jumped in front of a train whilst holding on to her 3 year old son at Riddlesdown Railway Station (near Croydon) and both are killed. / Case Study 3
South Kenton Railway Station - December 2013
Male 54
05/12/13
14:40 – police called to person on tracks at North Wembley Railway Station – he had intimated to station staff that he was going to take his own life and left a note with his wife’s details on it, and then went down onto the tracks
15:05 - subject taken to hospital where he was later assessed under the MHA and released.
06/12/13
NHS staff working with BTP joint unit (SPMH team) contacts hospital and discovers the subject had been released with no follow up. SPMH team fax letter to subject’s GP and open Suicide Prevention Plan – considered high risk.
07/12/13
14.33 - subject fatally struck by train at South Kenton Railway Station
4.3 The Care Act 2014 requires local authorities to establish a Safeguarding Adults Board (SAB), which aims to help and protect individuals who it believes to have care and support needs and who are at risk of neglect and abuse and are unable to protect themselves, and to promote their wellbeing. The Act also requires local authorities to take steps, including providing and arranging for services (“arranging for” may include commissioning from others), which are intended to prevent, reduce or delay needs for care and support for all local people including adults and carers.
4.4 Many of the S136 population will fall within the scope of the Care Act and the response to these referrals needs to be managed in a coordinated fashion.
4.5 A more joined up approach to assessing and addressing vulnerability is needed, not only to deal with mental and physical health needs and issues, but also the risks to life. Such an approach would also help to limit the multi service demand that these vulnerable people can place on London’s emergency services.
4.6 A number of models for achieving this exist such as;-
Havering Borough All Age Multi-Agency Safeguarding Hub (MASH) - Representatives from the local authority, police, social services, health and housing services are co-located at Havering council offices and have access to their own organisation’s IT network and databases. The MASH receives referrals, which are prioritised and an appropriate course of action is decided on between the organisations. The actions are tracked. Camden and Enfield boroughs are also developing the same concept as Havering.
BTP Suicide Prevention and Mental Health Units
NHS staff are co-located in BTP premises and have access to data from both organisations, which is a powerful feature. They have a wealth of multi-agency contacts and referral routes. During 2014/15 1186 people were subject to joint risk assessment and deemed to be high risk and placed on suicide Prevention Plans. Of this group 10 people went on to take their own lives, 7 on the railway and 3 elsewhere. This represents a fatality rate of 0.86 percent amongst this high risk group.
Ealing Community Risk Multi Agency Risk Assessment Conference (MARAC)
This forum has been established to deal with many different types of risk, including those posed by people with mental health issues. This again is a multi agency forum where joint solutions are sought
5. What Services may we need?
· Improved primary care services for dealing with depression, anxiety and personality disorders (and connected drug and alcohol issues) as a preventative mechanism.
· Better arrangements for S136 detention and assessment in London (this could even take the form of a central place of safety servicing London, adequately staffed, open 24 hours, with effective security) backed up by better management of Mental Health bed capacity across the capital which can be flexed at times of exceptional need.
· Better access (24/7) to mental health advice and health intelligence for emergency service responders, in order to better manage risk and make more informed decisions
· Better transportation arrangements, so that S136 detainees are routinely transported in appropriate Health service transport rather than Police vehicles.
· Better pathways for care and support following mental health assessment where in patient treatment is not deemed necessary.
· 24/7, 365 days a year Liaison Psychiatry services to be available in all Accident & Emergency departments, which adhere to London Mental Health Crisis Commissioning Standards.
· Effective multi agency safeguarding and risk assessment arrangements for vulnerable people deployed in a consistent way across London.
6. Next Steps
6.1 In order to identify in detail the service improvements needed for London, it is proposed that the SCN;
· Endorses this document as it’s position paper
· Commissions a literature review of S136 research
· Commissions an exploration of the business case for a central facility(s) (linking in with the work that the Health in Justice System team and the MHPB is doing regarding transportation)
· Commissions the tracking of outcomes/pathways for people who are not detained after assessment (BEH have a resource to do this for BTP within their current joint Health and Policing scheme but a similar resource would be needed for Metropolitan Police and City of London Police cases)
· Commissions an exploration of ‘frequent flyers’, by way of a retrospective look at individual contacts with agencies, as a review of lost opportunities to better meet individual needs and to reduce impact and demand on services.