Thursday 12 April 2012

Pass The Donkey - Part 1

"46 year old female, suicidal"

We pulled up outside a busy pub; our patient was sat in a wheelchair arguing with a member of the public. We knew her very well, she was a very regular caller and was always a difficult patient to deal with. The normally phoned police or ambulance daily for anything from being suicidal or simply being locked out. It transpires she had been discharged from hospital only an hour previous, she had been given transport in a private ambulance home but had kicked off in the vehicle and been kicked out by the private ambulance driver. They had then called us because she said she was going to kill herself; and she had tried several times in the past. This was going to take ages! We approached her which immediately got her back up as she hates the ambulance, police and hospitals (begs the question why does she normally call!). She wheeled off towards the entrance to the pub and in a scene reminiscent of Little Britain she just got up and walked inside. Obviously, we followed. The pub was packed and she was drinking strangers' drinks at every opportunity. After half an hour of coaxing, and the landlord asking her to leave, we got her outside. She refused to come to hospital and said she just wanted to go and kill herself. Knowing all too well we couldn't physically force her onto the ambulance we requested police. 

What happened next I will explain, but I thought this post would be the perfect opportunity to get the views from a number of different perspectives. With only the above information I've invited guest blogs from a police officer and a police inspector to offer feelings on mental health patients and what they would have done in the same situation and to provide where the job stands legally within the mental health act. From a hospital point of view there is a guest post from a charge nurse and finally the thoughts and feelings of patient. Obviously, I'm the voice of the ambulance but this is a kind of experiment to see how all five opinions tally up.

Firstly I'd like to introduce fellow blogger Laptop Cop who is a service police officer on the front line in a busy city. I asked him how he felt about mental health jobs and what he would do in this situation:

"Dealing with people who suffer with mental health conditions can be very challenging; the biggest tool we carry in our kitbags is communication. I would genuinely say a lot of the calls involving mental health can be dealt with by talking. This isn’t always the case though, sometimes force has to be used. 

The police and ambulance are emergency services, so we should only be called when there is an immediate threat to life or someone is in danger. This is often not the case, far too often we are receiving calls where a community team or local MH practitioner could attend and deal but they don’t, I guess it’s a lot easier to pass the buck and shift the ‘problem’ onto someone else rather than take responsibility for something. From our point of view, we can turn up, if someone is in a public place and is posing a danger to themselves or an other we can section them under 136 of the Mental Health Act and take them to hospital. If they’re in no immediate danger, and they don’t want to go to hospital all the police can do is take a report that gets forwarded on to our Mental Health Liaison Officer.

Unfortunately the culture we live in today is something that I’ve referred to as CYA, which means Cover Your Arse and I hate it with a passion. I will do everything in my power to help someone, it’s in my nature and it’s why I joined the service but the problem is that this culture is all about making sure you’re covered incase the brown stuff ever hits the fan. So, in the job that Ella dealt with I am quite sure that even though this patient had the capacity to refuse treatment, the fact that she had made threats to hurt herself I would without doubt had to section her using 136 powers. This is so we can take her to a place of safety and get her help but I make no bones about the fact that this is partly down to covering myself. If I did nothing, even though she is a regular caller and probably won’t carry out the threat; IF she did, it would be me ‘gripping the rails’ at a coroner's inquest with the potential for losing my job." 

I would now like to welcome back Mental Health Cop to Trying My Patients. Although he is more than qualified to offer much more, I simply asked him to tell me the police powers and procedure for dealing with the patient as she presented to us:

"If the police are called to support the ambulance service where they are dealing with a non cooperative mental health patient who is making threats of suicide or self-harm, thoughts should turn to whether there are any criminal offences being committed and / or whether or not the criteria for detention under s136 Mental Health Act are satisfied. Although resolving a situation without resort to legal coercion is far preferable, it may well be thought unlikely to succeed if the Ambulance Service have called for police support, having already tried and failed to persuade.

Threatening or attempting suicide is not a criminal offence, so in the circumstances outlined it appears to be s136 or persuasion. Officers have tried to persuade - actually, sometimes a police uniform is persuasive as it also implies 'or else' - but that having failed, it looks like detention under s136 is the only viable option to consider. In so doing, thought should pass to what the consequences would be of not implementing s136? Amidst known mental health problems and threats of suicide, were these to be realised after such contact with NHS and police professionals, it is reasonable to assume difficult questions would be asked. The patient would have the right to walk away from any healthcare offered, as the paramedics concerned have stated that a decision to decline treatment could not set aside by virtue of the Mental Capacity Act.

So on the circumstances as presented, I'd have been implementing s136 MHA and doing so in knowledge that this may then mean a wait within A&E or at a place of safety, pending assessment."

Sadly it didn't quite work out how a) I wanted and b) how both Laptop Cop and Mental Health Cop would have wanted. The police did come. They implied they were going to section and forcefully assisted the patient onto the ambulance but then left. I assume this was partly due to the fact that they had spent most of the previous night with her and were extremely busy again tonight but I wasn't at all happy with the situation we were left with. As Laptop Cop says, the 'cover your arse' attitude dictates most of what we all do everyday, in this case the police had got the patient off the street and into the safety of our ambulance. It was now no longer a public issue and although, like Mental Health Cop confirms a Section 136 would have been the appropriate action, the fact of the matter was the patient was now being taken to a 'place of safety' without any further strain on police resources.

As much as I disagreed with the methods used as I could see no legal right to take her off the street without arrest or section, I'm not one to look a gift-horse in the mouth, so we took her to hospital. Bear in mind she didn't want to be in the ambulance, she certainly didn't want to go to hospital, but she made no attempt to leave so I didn't push the subject. It was a short journey but long enough for us to be called every name under the sun.

To be continued.............

Part 2 - Click here


  1. I thought patients like these were a waste of time. The woman isn't mentally I'll, she's learnt that her only way to get human contact or affirmation is to behave like this. It's a public order offense. And she needs counselling, not a hospital which will only reinforce her behaviour patterns.

    1. Have a read of Part 2 tomorrow and see it from the patients point of view! And the hospitals!

  2. I'd echo mrswupple's remarks above.
    Why can't we have a volunteer responder team who'll sit and have a natter?
    Oh, they'd probably get fed up with the abuse too.

    I'd suggest removing her to a place of safety where she can't trouble the emergency services for rather a long time. If she can be rehabilitated then good. If not she represents a significant drain on ALL our joint resources.

    I'm just a Special Needs teacher so what do I know? Except some of my students will end up like this unless I can give them some coping strategies.

    1. See Part 2 tomorrow! We do indeed take to a place of safety! See what happens and hear the patients point of view!

  3. Late to the party, but I think I'd have been looking at why she was in hospital, and what the situation was when D/Cd, by phoning the department. I'd have done a SADPERSONS score, and almost certainly have non-conveyed - there's only so much can change in an hour, and the "suicidal thoughts" were said in anger rather than as a result of her change of mood.


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