The Legal and Operational Issues we face dealing with Mental Health
Mental Health presentations at Accident and Emergency departments (ED) have increased for a varying number of reasons, however, it should be noted that this article clearly cannot address or cover each and every item or area and only scratches the surface.
In 2017, the MHA was changed to reduce the time a person detained under S136 could be held for assessment; the changes reduced this time from 72 hours to 24 hours and 'opened' up the ED as a place for S136 assessments to take place. This clearly poses a challenge to the assessing team and the ED staff who may have to accept a S136 patient from Police into a very busy, noisy and chaotic department. It is worth mentioning the case of Webley vs St George's Hospital NHS Trust and the Metropolitan Police as this identified safety failings on the part of the Trust and in particular the Security team tasked with monitoring the patient whilst in the ED. A specific blog on the subject can be found on our website and guidance originally issued by NHS England in October 2017 can be accessed here.
Another issue that has arisen and which many colleagues report experiencing is the Voluntary presentation at the ED of a person in mental health crisis. This in itself is not the problem, it is those 'Voluntary' patients who are brought to the ED in handcuffs, legstraps and accompanied by anywhere between 6 and 12 Police officers that pose the issues for staff. Our members have reported challenging Police Officers on this, especially when the person in crisis is handed over to the ED to manage and Police leave as the person is now calm. This creates a number of issues which we cannot fully address in this newsletter but we would suggest that the conversation continue in our mental health group discussion on the NAHS website. The first and most important issue, is the undeniable fact that a person brought to an ED in handcuffs, leg straps and in Police restraint is not in any sense of the word a voluntary attender. If the person posed a physical risk to Police, themselves or others and there were clear indicators to suggest a mental health issue, the person should have been detained under S136 and taken to an appropriate place of safety as per local and mental health protocols. The second issue that must be considered is that of the Trust's responsibility for their staff and patient safety and the ability of the security team to support this. Accepting responsibility for a person who has been in handcuffs, leg straps and restrained or even just accompanied by 6 Police officers is an indicator of a previous safety and risk concern on the part of the Police. Whatever the course of action, a detailed risk handover must always be completed with Police and a judgement made by the receiving staff / Nurse in Charge regarding the suitability of the location and safety of staff and patients and the individual themselves.
The next topic for discussion is the use of force and the use of restraint by Healthcare Security staff. As mentioned earlier, our website has a specific blog on this very issue which you may find of interest.
The use of appropriate and proportionate force to effect a restraint are basics that all Security Officers are taught, however, as we all know, unless it is practiced and evaluated regularly, bad and sometimes unsafe practices can creep in. There are a number of Control and Restraint approaches and practices available such as PMVA, PAMOVA, C&R and MAYBO techniques with many being tailored and made bespoke for the particular sector or service. A good example is the difference between methods and techniques used in Forensic Mental Health services and those taught and utilised in Acute (non Mental Health) Hospitals. In short, Security Officers are permitted and expected to appropriately restrain patients detained under the MHA as the Trust is legally responsible for their care. This includes those under a Deprivation of Liberty Safeguards (DoLS), however, the most common grounds for implementing a restraint outside a mental health unit is under Common Law or the MCA.
Mental Capacity Act - Many patients in general hospitals may lack capacity to make decisions about investigations such as blood tests or scans, treatments, and whether to remain in hospital due to their physical or mental illness (or both). Where a person lacks capacity, it may be necessary for the Healthcare provider to step in and prevent the patient from coming to any harm or harming others. this therefore, may result in the use of an appropriate and proportionate use of force. Further guidance on the MCA is available here.
On a final note, physical restraint is a Healthcare Security professional's last option and where possible should be avoided. NAHS are committed to raising awareness and reducing the need and frequency of restraint and fully support the least restrictive intervention.
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