Saturday 16 June 2012

No seriously, leave it with us!

"34 year old female, under section, delusional, ready now"

It doesn't take long for mental health to rear its ugly head again. It didn't take long into the shift either too, 07:03 to be precise before we were off to a sectioning. In a change from the norm we were transporting from the A & E at one hospital to a specialist psychiatric hospital. There were no immediate safeguarding issues as she was in a place of safety so, in theory, it should be a simple load and go. Who am I kidding?! It's mental health! 'Simple' is never a word that is used around the transferring, admitting and sectioning of mental health patients. There is always far too much red tape, hoops to be jumped through, dragging of heels and differences of opinion, to make the simplest of things simple. Besides, where is the fun in having a fully accessed, ready to transport patient, complete with escort and a willing receiving unit?! Boring! We arrived at the hospital to a full welcoming party; lots of smiles, waves and enquiries after our health and wellbeing... OK, that's a lie; a miserable looking matron pointed at bed 1 and said 'she's in there'. That's more like it! 

Our patient had been in hospital for 32 hours. There were points where she had been on the verge of discharge but due to relapses in her psychosis she had 'flipped' and become volatile and violent again. To calm her down they loaded her with diazepam in the hope she would be lucid for transport. It appeared to have worked! She was lying on the bed, asleep, husband by her side, and the AMHP who had been with her for 14 hours and on duty for 23! THIS was encouraging. We put the beds together to make the transition across an easy one. Her husband woke her, she looked at him, she looked at the nurse, she looked at us, she looked at the bed next to her, she looked at us again... then the shouting began. Not so lucid after all. After 20 minutes or so we had made no progress. No hospital staff had attempted to help us, the exhausted AMHP from the hospital we were taking her to was trying her best but failing. The patient's husband was shouting, the patient was shouting (in another language now) and then she got up and made a dash for the exit. We initially tried to stop her but the husband said she was going to the ambulance and the AMHP seemed keen to get her on board. We went with it and that is exactly what she did. 

We now had a patient, under section, in the ambulance complete with belongings, notes and the husband. Where is the AMHP?! In her car. This concludes her involvement! It appeared we had the parcel, the music had most definitely stopped! NO NO NO NO NO NO NO! I went back into the hospital to remind them we were supposed to have an escort. I was told she wasn't their patient and there were no staff or security to send. Brilliant. I went back to the ambulance where our 'calm' patient was now trying to escape from the ambulance. She was not safe to transport in this way; we had no means to restrain her, nor the man power. We requested the police. This is the message we got back:

"Sorry, this is not in our remit; the hospital will need to provide an escort / security for the transfer"

I get it. Yes, that is what they are supposed to do but they haven't. This is not the hospital asking the police to be the escort, this is me, the ambulance, the police service's best mate if you will, asking for assistance. I went back into the hospital to say they had to provide security for us as it wasn't the police's remit. This was the response I got:

"We only have passive security here, if you need an escort the other hospital will have to provide it, not us"

I'd already been told by the AMHP before she foxtrot oscar'd that this was wrong and her hospital (15 miles away) had no one to send, nor was it in their remit. Back in the ambulance, my crew mate was assisting the husband to restrain the patient manually as she was lashing out, punching the windows and threatening suicide. This was starting to feel like a wholly inappropriate, possibly illegal situation. Do we actually have the power to restrain? I'm going with 'yes', as I was restraining her for my own safety, but it does beg another question: is the AMHP legally allowed to leave, abandoning a duty of care, especially to a vulnerable patient who's needs clearly reach beyond two girls in green?! Hmmmm! I made another request for police, as yet again they are the only people I can realistically turn to. This was the response I got:

"We will not be attending this CAD, it's a hospital issue"

Seriously, what are we supposed to do? The patient is now in our care, although the 'being in our care' was a contentious issue. The patient was under section and as such is in the care of the AMHP, but this care was apparently delegated to us (whether we wanted it or not) right before she scuttled off to her car. Unfortunately, had we not wanted to convey, her legal obligation to stay could not be argued with as she was now screeching away in first gear, grinning into the rear view mirror! Back to the matter in hand. The hospital wouldn't assist us, the police wouldn't assist us and our control had told us not to convey if we don't deem it safe. That is easy enough to say, but we can't walk away now; we can't leave her in the back of the ambulance, and letting her run off would make her a danger to herself and others. Why on earth were we in the back of an ambulance trying our best to calm down and restrain a patient in the first place?! This is not what we signed up to when we accepted the job! Remember me saying 'simple transfer'?! Why were the words 'violent' and 'aggressive' not mentioned when requesting an ambulance? Where was the risk assessment? Basically, there wasn't one, or if there was it was written on a tissue in the AMHPs pocket. I imagine it read something like this:

"Call ambulance, say hello, run away."

I'm hoping you now sense the sarcasm in the title! Sensing the delay and confusion over her 'imminent' transport she became violent; she scratched us, bit us and spat in our faces. The three of us, including her husband, were holding her, tears running down her husband's face. I requested police again, this time citing a crew emergency off the hospital premises. This was the response:

"Unit on way, ETA 2 minutes"

At last! Is that how it works?! We have to actually wait until we are bleeding for it to become a police issue? OK, I know that isn't the case but being stuck in a grey area, the police, hospital and ambulance all work within their own policy frameworks. Why, where mental health is concerned, is there not clear procedures in place for the transporting of mental health patients? In terms of restraint, who is best placed to do it? Us? The hospital? The police? I know there are vehement oppositions to restraint, and I only see it as a last resort, but in this case it was a necessity. Does a hospital A & E have the means to restrain for a journey to another hospital? Apparently not! Are the police the most appropriate body to restrain a patient during transport? Apparently not! That's the issue yet again, when it comes to mental health, no one really knows who is supposed to do what! By definition, mental health is a health issue; one that in my opinion should be treated and dealt with solely by the NHS. In reality, it is also a huge part of policing but surely an inter-hospital transfer is not part of policing? Maybe it is; maybe prevention of an assault is prevention of crime! I know for a fact the police will say that the mental health teams are more than equipped to deal with it, and theoretically they are (see this post by Mental Health Cop explaining his stance on what the police should be doing). The problem is they don't play ball, and when they don't play ball, something has to give. Personally, if an ambulance crew requests police to their location then that is what they should get! Thoughts?


I'd love comments / thoughts from police, ambulance staff, hospital staff, AMHPs and anyone who has an opinion on these issues! Get talking!!

40 comments:

  1. What county are you in - direct message on twitter if not willing to reveal @mizog366 - a lot of our problems stem from the comms rooms both ambo and police not understanding the issues and quoting 'guidelines' and 'policy' - arse!
    Your predicament is not new to me, deal with this kind of thing quite often. No bugger will listen tho as long as they hit their target times whether through use of Specials - Police or CFR's - ambo.

    Regards

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  2. I have sent you a DM. Totally agree with you and to that end I have added a sentence at the end of the post! Thanks for the comment!

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  3. Tough one.. In my jurisdiction we would have attended cause it's paramedics calling. To be honest when I got there the patient would most likely end up in cuffs if she was still violent. And I would be pissed at wasting my time on a call that should have been sorted out prior to moving the patient anywhere without a suitable action plan that covered these issues as soon as she was going nuts in the hospital. Scotcop

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  4. Yep yep yep yep yep! But how many times have we said that!! If they planned as well as they palm off there would be no problems at all! Thanks for the comment!

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    1. Had another suicidal male kicked back to us my last shift. Apparently expressing positive thoughts and future plans which when we spoke again consisted of 'I'm killing myself as soon as you let me go'. Docs knew we would have to arrest... Wtf do you have to do to get sectioned?!! Scotcop

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    2. God knows! Even then the lord almighty would probably need a second signature from someone on their lunch break!

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  5. If ambo require police assistance for their safety, there should be no issue in 'de babylon' attending, as quickly as possible. if you are in fear of violence - get my drift?

    @mizog366

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    1. I knew cops would agree! You are right, it's an issue of our controls understanding that if we are asking for police we are doing so for a reason!

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    2. And police did respond when this occurred. The issue is with the hospital who failed in their duty to provide an escort trained to assist. Cops spend too much time dealing with these matters when NHS doesn't meet obligations. Ties up masses of police time

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    3. Everyone is to busy worrying about their own arse and that is when there is such a reliance on the last resort! Police and Ambulance. We have no one to pass the buck on to and everyone knows it!

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    4. I don't get it? Seriously, if you've spent FOURTEEN HOURS with someone, even if you've been on duty for 23 what difference is another hour or so going to make to see the whole thing through to a satisfactory conclusion? Satisfactory is the wrong word but you know what I mean. Quite frankly if it were me I couldn't live with myself if I'd walked away only to find that something bad had happened either to the patient or those I'd lumbered with the responsibility.

      The complete lack of agreement on inter-agency procedure can't be good for the patient's welfare either. Surely it can't that hard for someone with some sense to sit down and work out who should do what should any of say scenarios A - Z arise, get all agencies who could possibly end up involved in said scenarios to agree the procedures and implement them? But of course, silly me, I'm forgetting that horrible little word 'politics', flocks up many a great idea does politics.

      & FWIW I think would should certainly be able to use whatever restraint you deem necessary to prevent and / or minimise injury to you and your charge.

      @NuggyLlas

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    5. Thanks for the comment. Totally agree. Ive said it many times before, so much depends on who you get! Sadly patient care often comes second to shift times, clock off times, times since break, time to finish time and time to bed. I will the mangers of all the departments, agencies, ambulance and police could see that all their staff on the front line are willing to work together and listen to each other! Why oh why wont they!!

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  6. As a AMHP i have been here one of the issues we have although based at a psychiatric hospital were employed by the local authority and when in the AMHP role are classed as a independent public body we have no authority to instruct NHS staff and the ward the patient was going too would claim that until she was on the ward and pinks accepted she was not their responsibility. Their is no one we can call in jobs like this other than the police or ambulance service and like yourselves have no protective equipment no training in restraint and are normally on our own once Docs have got fee forms and buggered off.

    Unless the AMHP gave you the pinks she cant of delegated authority and the conveyance would be illegal in this case i would of called for police explaining the patient was violent our policy is that whoever is conveying signs a carbon copy form and we supply a risk assessment for the trip. Only times i have not followed the ambulance or sat in is when the unit was on rare occasion hundreds of miles away.

    Agree that most frontline staff are brilliant and more than willing to help out but bad systems and boards faced with no penalties for failing to commission adequate resources will carry on failing

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    1. Thank you very much for your comment. Great to have your perspective. I agree with your points, you have re-affirmed that this was not a totally legal transfer. We had no pink slip for starters, but an ambulance we are sent a job, turn up, are told who our patient is and where we are going. Handovers are usually minimal and we have to work out what is wrong from patients and relatives.

      One question though. You say you have no powers of restraint....What happens in a hospital if a patient needs restraining? In an ideal situation how should this patient have been transported? Surely the police & a pair of handcuffs should not be the first port of call. There has to be procedures in place for transporting volutile, violent patients.

      Thanks for reading and thanks again for the comment. Lets continue to TRY and work together!!!

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  7. As a AMHP i have been here one of the issues we have although based at a psychiatric hospital were employed by the local authority and when in the AMHP role are classed as a independent public body we have no authority to instruct NHS staff and the ward the patient was going too would claim that until she was on the ward and pinks accepted she was not their responsibility. Their is no one we can call in jobs like this other than the police or ambulance service and like yourselves have no protective equipment no training in restraint and are normally on our own once Docs have got fee forms and buggered off.

    Unless the AMHP gave you the pinks she cant of delegated authority and the conveyance would be illegal in this case i would of called for police explaining the patient was violent our policy is that whoever is conveying signs a carbon copy form and we supply a risk assessment for the trip. Only times i have not followed the ambulance or sat in is when the unit was on rare occasion hundreds of miles away.

    Agree that most frontline staff are brilliant and more than willing to help out but bad systems and boards faced with no penalties for failing to commission adequate resources will carry on failing

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    1. I think your computer is playing tricks on you! Got the comment first time!

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    2. sorry for the double post. We have powers of restraint just no practical means of using them ourselves we can only ask other staff to use restraint on our behalf. When in a psychiatric hospital trained staff can and will restrain but outside of that nothing. In the case of a violent patient at least in our area yes the police would be first port of call, sadly we have no alternative no staff or transport of our own to call on.

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    3. So your hands are tied like ours! I think there should be much more information readily available to allow transparency in job roles, powers and abilities! I didn't know what you just told me! Thanks for the reply!

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    4. Because there was no delegated athority to detain and convey the conveyance would have been illegal; so you'd have called the police?! ... presuambly so they could have illegally detained and conveyed instead of the ambulance service?

      OK! ...

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    5. Ahhh but I could argue I called the police because an assault had happened! We also didn't request they convey. Only ensure our safety ;-)

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    6. What we really need is more training, and to be told exactly what we can and can't do, and have a reference copy in writing. I know it's supposedly the grey areas that we get paid for but it would be good to avoid breaking the law.

      What would be brilliant is to be trained together (i.e. police, ambulance, hospital and social services all in one room) so we can hear and understand how the other sides work. But that's probably a big ask...

      This is where blogs like this are so useful, as we get to see other sides of the arguments.

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    7. YES! That is exactly what is needed! Like an 'accessing mental health' seminar open to ALL service users, giving transparency in everyones roles and limitations! Thanks for the comment!

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    8. "We have powers of restraint just no practical means of using them ourselves we can only ask other staff to use restraint on our behalf. When in a psychiatric hospital trained staff can and will restrain but outside of that nothing. In the case of a violent patient at least in our area yes the police would be first port of call,"

      I may be a PC in a very uninfluential position but I am the sort of officer that would be turning up at this type of job.

      Not every officer we employ is 6 feet 8 and built like the proverbial, I am and many other on my team are completely the opposite. The only forms of restraint other than wrist/hand holds (not ideal) are a pair of rigid handcuffs and some velcro limb restraints. Two handcufing techniques are taught, one to the front (which really is for the more compliant of people, with both arms on top of each other) and one to the back with both palms facing outwards (for the more non compliant). Limb restraints are used for the legs to stop people kicking out. The training we have is not exactly exhaustive.

      I have never had any training or guidance in the restraint of persons for transport between mental health hospitals/A&E. Let alone the legal issues (the fact any use of force has to be lawful) I have the fear that one day the use of the police in these scenarious will lead to a police contact death. The statistics of police contact deaths and persons with mental health issues is already alarming.

      We have Complaints & Discipline departments and the IPCC, both of which will be looking at me extremely closely should I restrain someone in any circumstances and they die. I am likely to be suspended or removed from operational duty for many months, face long tape recorded interviews with C&D/IPCC implying that I caused the death, then have to face coroners court if there are no criminal cases to answer. All the time worrying if I am going to be able to pay the mortgage.

      I appreciate this sounds like a dramatic view but the fact are uses of force are probably the biggest cause of complaints against police officers, I do not want to be in the above position if it can be avoided. I am likely to be unimpressed if I am in this position purely for the fact that another agency (be it the MH trust), arguably better suited to the job at hand does not want to put measures in place, for whatever reason.

      I fully appreciate that when someone poses an exceptional risk of course the police need to be involved, when the threat is such that they could not be managed with a couple of restraint trained nurses/staff but these are probably going to involve officers with taser/public order gear or firearms. These to my knowledge are the exception.

      Sorry if this sounds a bit like a rant but I hope you can see why some officers may be reluctant to go wading in.

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    9. Thanks for your comment. You make some excellent point and I understand the frustrations you talk of! I will though play devils advocate when it comes to the ambulance service requesting police and having no units to sent! The police do the same trick day in day out. We are requested by the police time and time again for RTCs etc where we are used to triage and see if police are needed. The message 'no unit to send' or 'no unit assigned' are very common. Your lot are just as bad as our lot on that!

      I agree about the deaths in custody or restraint. There needs to be more clarification on what is acceptable and who should do it. I don't think you should go wading in but neither should we. I refuse to believe that MH services to not have the ability to transport their own violent patients without the use of police.

      As always, thanks for the comment.

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    10. Are you guys saying that paramedics can not restrain patients? Where I am from, police go with us on every psych (wether it is behavioral, attempted suicide, or sometimes even heavily intoxicated patients) and I can't tell you how many patients I've helped restrain in the last 6 months alone. It's usually one on one in the back of an ambulance and we don't play when it comes to our safety. The minute we deem a patient as violent, out comes the spine board and four point restraints. If this call wasn't flagged as one PD needed to respond to, then we still have fire on scene to help us out. Once the patient is restrained, it is then up to the lead medic to decide whether or not they need to be chemically sedated.

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  8. Been here sooooooo many times! I landed in a similar grey area arguing with a GP in a patients house over why I wasn't going to kidnap the patient because she said so. We disagreed over whether the patient had capacity, as did the advocates for the patient. I explained that the police wouldn't help without section papers either, as the patient was an old man with dementia who was unwell. The GP acted extremely unprofessionally in my opinion, and thankfully the patient agreed to come (with a little diplomacy from us obviously, not the GP) otherwise I'd probably be facing a complaint from a GP for acting within the law and in the best interests of my patient...

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    1. Same old story!! So frustrating! Thanks for for comment!

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  9. My favourite bit of getting someone to hospital, either under section or informally is the transport. Often we get referrals from a&e and people go from there to psych hospital. Our management says we (crisis team) can transport and if it's safe (but then that can take a long time, means other crises aren't responded to as quickly and people get frustrated with us...), but if we can't a&e says it's the psych hospital's duty to transport, psych hospital say it's a&e, upper/senior management reluctant to "ok" the private ambulance/transport unless we can argue it's REALLY necessary...all a bloody nightmare...

    ...and I have to say I do feel sorry for the AMHP in your story, waiting for 14 hours on duty for 23...? Poor woman. Am pretty sure I'd be liable to make a mistake or two (or bugger off when it felt remotely possible!) after that...

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    1. Transport is always interesting to say the least! As Mental Health Cop called it, a conveyance conundrum. I did feel sorry the the length of time she had been on duty but personally I feel she neglected her responsibility for the patient leading to an illegal removal. Thanks for the comment.

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  10. The ambulance service should not be subjected to assaults either physical or verbal of any kind.

    That said the NHS's unwillingness to deal with the issues surrounding mental health has to stop. This includes the ambulance service.

    As a serving bobby I often feel that our motto should be 'the emergency service that doesn't say no.' We getting bummed by all our. 'partner' agencies, ambulance included and everytime I get a call from the paramedics I get a look of dread.

    A recent (and very common) call from ambulance control is female taken overdose. AND???? Anyway we attend to find female has actually taken overdose. I find out where the ambulance is as they have apparently called us for help only to be told they haven't allocated yet. 1 hour later they finally rock up. The woman refuses to go to hospital and the usual conversation happens whereby the paramedics tell me she lacks capacity and I should section. Pissing competition ensues where we end up compromising and putting a bobby in the back of the ambo to assist the transport of THEIR patient.
    Once at hospital we then have the usual conversation with staff there that if we leave so will the patient. We know we're going to end up staying but remind them they can detain and restrain only to be told they don't employ that sort of staff.

    I'm not having a pop at the paramedics here, as the author of this blog points out we generally work and respect each other very well. I have issues with policies in place. The automatic policy to call police in all mental health incidents and then not allocate an ambulance. The cynic in me might suggest that is because they hope we'lll cancel the ambulance and deal themselves. I also take issue with pretty much every policy the hospital has for dealing with mental health and then social services for allowing these people to live in the community without any support network except the default position of calling 999.

    I just can't see it changing either! I like what mentalhealth cop presaches but he'd find himself quickly silenced in my force!

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    1. I don't the the ambulance says no either, we just often need police to. We don't have options of restraint and man power like you.

      I agree with what you say though, the NHS as a whole needs to buck its idea up! Thanks for the comment!

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    2. No, I wouldn't ... and my blog is testimony to the fact that I want a certain message going out loud and clear. Whilst the blog is supported by my force, that wasn't case originally because they didn't know I'd started it and I've long since stopped worrying about dripping like a leaky tap.

      Cops who ignore the messages I keep shoving out keep finding themselves complainted about, sued, prosecuted or heaven forbid, seriously injured or dead. More than happy to tell those who would have you do the wrong thing in the wrong way at the risk of your safety / career that they cannot order you to act illegally. Just tell me who you want me to ring.

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    3. I want to see MHC go in all guns blazing! I'll be on standby for medical support and a few 'yeahs' and 'here here' s!

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  11. I would say , put her back into the hospital until someone makes up their mind . And don't go without an escort .

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    1. We have no power to force her into a hospital once she was on our ambulance and with no AMHP the hospital would not let her in! Stuck between a rock and a hard place!

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  12. I am always an advocate of working closely with other emergency services.As a Sergeant I have to balance the needs of responding to calls from members of the public(Ambo included),to that of helping every Tom Dick n Harry,with their own internal problems like Social Services NHS Local Authority etc.The issue for me is prior planning.Piss poor planning leads to piss poor performance.If the AMHP had engaged all the possible agencies to get this woman safely from hospital to hospital,this could have been avoided.Clearly if AMBO is asking for assistance I'm sending the troops to make an assessment as soon as we can.It's a lot quickerto assist AMBO and get the matter sorted.They are also an emergency service and we just might need em.Sometimes common sense must prevail rather than policies.The values of our organisation,the first one is do the right thing.So I ask what is the right thing to do.If we do go we'd probably still get critisised if the patient were to come to harm and classed as a Police Contact death.If we don't we'll still get critisised if something goes wrong and the NHS raises a SUI(Serious untoward incident) hence common sense must prevail on a case by case basis.My staff hate dealing with mental health cases,however I encourage them to look at the bigger picture.We cannot always walk away because a policy say so.As a supervisor my task is to manage threat risk and harm and if a call comes in and there is a threat or risk if harm I will manage it.I'm not the best liked supervisor at the minute however if I have to step outside that Police Powers box ,I will always justify my decision making on issues around mental health.Saying that however,I will not be a roll over for some other agencies who do not try to look for an alternative to an issue and just leave it to the police.Sharing the frustrations of everyone.

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    1. Totally agree! Piss poor planning leads to piss for performance was too long for a title but thats what it all comes down to. At the time I was livid with the AMHP and I still dont agree with her actions but the comments on this post have raised some valid points. After 23 hours on duty perhaps the hospitals refusal to help her, our inability to restrain and the polices previous refusal to help had made her say 'sod it'. I know that is a neglect of her duty but I suppose she is human.

      Most cops as I say would come to our call and then assess when should be done. It's just a shame the dispatcher didnt see it that way. I waited over an hour, most of which was spend manually restraining a patient trying to attack me!

      I think the police are seriously abused by the NHS and end up taking over the mantle of what in essence is the NHSs job. Can't see it changing anytime soon. Glad you have the 'big picture' view point. Wish it was a view in more people! Thanks for the comment!

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  13. The answer to the "Conveyance Conundrum" as @MentalHealthCop accurately calls it is in the hands of those that commission services, currently PCT's and soon to be GP Consortia. Your blog and the comments above have identified what the main issue is: a need for effective inter agency working within agreed protocols, with a knowledge of the responsibilities and constraints (legal and practical) on our colleagues in partner agencies. Finger pointing won't help, and in my opinion neither will continually "making do" without flagging the issues loudly and clearly to supervisors on duty and managers asap. There is an issue as @MentalHealthCop as identified on his blog with NHS Community MH Teams and AMHP's not having training, support & resources to undertake restraint and conveyance with the result they end up relying on Ambo & Police for support BUT the Ambulance service may be commissioned to transport patients between NHS facilities if that is the case then the Ambulance Service may need appropriate vehicles & staff to achieve that if it is a commisioned service.
    Just some Healthcare Security bloke
    @NAHS_UK

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  14. EMS can't restrain a patient? Where I am from, police responds with us to every psych patient (whether it's behavioral, attempted suicide, etc) and i can't tell you how many patients I've helped to restrain. We don't play when it comes to our safety and the minute we decide a patient is violent and dangerous to us or others, out comes the spine board and four point soft restraints. If this call wasn't flagged as one that PD needed to respond to, then we still have fire on scene to help us restrain them. Once they are restrained, a chemical sedative may be given.

    I can't believe the vulnerable position you guys are put in. It's dangerous enough being in the back alone with a patient, but to have no help or way to safely restrain them.... Unbelievable.

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  15. i think it totally unacceptable that you was handed this patient and then ignored by all that was involved on the pychiatric ward i work if we have had a patient that has been to volatile for our ward or even our picu and we had to transfer them we made sure we had extra staff to cover ie agency or off other wards or even in my case been asked to come in on my day off to help do it because your we need to think of the safety of all those involved in the transfer and we been trained in control and restraint of the mentally ill. it really has annoyed that you was left with such a vulnerable unstable person with no help from anyone else.

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