An investigation into care of people detained under Section 136 of the Mental Health Act who are brought to Emergency Departments in England and Wales. October 2014 1
Executive Summary The care of people suffering a mental health crisis has received welcome political attention recently. Attention on its own, however, is not sufficient to improve care. We investigated the care of people brought to emergency departments who had been detained under Section 136 of the Mental Health Act, as we have received many reports of concerns of care for these vulnerable people. The care of these people is simply not good enough. We found that Fellows reported significant concerns about the provision of services for people detained under Section 136. Even where services were provided, the compliance with local procedures and protocols was often sub-optimal. We have made four recommendations to improve care. Recommendation 1: access to services Commissioners should ensure that all people have access to a dedicated section 136 suite at all hours, and that a suite has sufficient capacity and staffing such that the person is not diverted to the emergency department and that the police can be returned to duties promptly. This needs to include both children and older people who are suffering a mental health crisis. Recommendation 2: good governance Police officers should complete section papers on all patients detained under Section 136 of the Mental Health Act. Detentions need to be applied consistently and this requires the police to engage in on-going training. A detention should be applied because of the person s need, not the current local availability of services. Emergency department staff should support the police by storing Section 136 papers at the emergency department. Recommendation 3: right person to the right place Pathways are developed, commissioned and audited that help a person suffering a mental health crisis and who appears not to have a physical health problem, to bypass the emergency department. These pathways need to consider people of all ages, care of children and older people detained under Section 136 is frequently worse than for working age adults. Recommendation 4: timely response Mental health trusts are commissioned and managed to provide a response for emergency calls within 60 minutes and that this service is available 24 hours a day for all age groups. 2
Background There has been recent, welcome, political interest in improving the care of people with a mental health crisis in England, through the Concordat. The College of Emergency Medicine is a key participant in the work of the Concordat. The Concordat has proposed an expectation to see the use of police cells as places of safety falling rapidly, dropping to below 50% of the 2011/12 figure by 2014/15. The College of Emergency Medicine supports this aspiration, but only if adequate alternatives are available. The College has received many reports of sub-optimal care in the way people with mental health crisis are cared for, through the Quality Emergency Care committee and its Safer Care sub-committee. Care for these vulnerable people requires good working relationships and coordinated services between the Police, Mental Health Services and the Emergency Department clinicians. The Quality Emergency Care Committee looked to find examples of excellent care and highlight areas that require improvement in the care of patients suffering an acute mental health crisis. We focused the investigation on patients detained under Section 136 of the Mental Health Act, as this well-defined patient group test the system better than any other mental health patient group. (Section 136 is a part of the Mental Health Act that allows the Police to remove a person from a public place to a designated Place of Safety ) Methods We surveyed all of the emergency departments in England and Wales between July and August 2014 with a ten item online questionnaire. Each department was invited to submit a single response. We removed any duplicate answers. We sought narrative descriptions of examples of excellent and poor care. We excluded Northern Ireland, Eire, and Scotland as the law governing mental health care differs. We included Wales as the law is the same, though the Concordat does not apply to Wales. The College has received a number of concerns about mental health care in Wales. 3
Results 104 Emergency Departments submitted full returns, representing 52% of all Emergency Departments in England and Wales. Where are patients under a Section 136 taken to? 28% of respondents identified their department as a designated of place of safety. 51% of respondents reported that they routinely received patients in the Emergency Department detained under section 136, without any physical health problem. This is at odds with accepted policy. 14.4% of the Fellows indicated that there was no dedicated Section 136 suite in their area. 22% indicated that the section 136 suite was adjacent to the emergency department. How often do police comply with local agreements? Compliance with local agreements was reported as usually or always by 52%. I.e. 48% of the time police do not follow local agreements. Examples of this were given such as bringing a patient without paperwork or choosing to come to ED rather than to a designated 136 suite. What is the opinion of emergency physicians regarding optimal care for patients in crisis? Only 36% of respondents thought that their local agreements provide high quality care. There was widespread acceptance that people with mental health crises and no physical problems should not be assessed in a police custody suite, with only 2% of respondents stating that this was optimal care. There was an equally strong response that emergency departments are not the optimal place for caring for patients without physical health problems detained under section 136 of the Mental Health Act, with no responses endorsing this option. 56% of Fellows felt that the emergency department was the appropriate place to assess a detained patient with apparent physical health problems. This signifies a clear opinion that mental health trusts should provide some assessment of physical health. The two figures on the next page show the difference between optimal care and what is currently happening. 4
What are your local arrangements for patients detained under section 136? Section 136 suite run by the mental health trust adjacent to the Emergency Department Section 136 suite run by the mental health trust remote from the acute hospital There is no section 136 suite and patients are taken to Police custody suite There is no section 136 suite and patients are taken to another type of mental health trust facility There is no section 136 suite and these patients are brought to the Emergency Department What do you think is the optimal arrangement for people detained under section 136? Section 136 suite run by the mental health trust adjacent to the Emergency Department Section 136 suite run by the mental health trust remote from the acute hospital Assessment in Police custody suite Assessment in another type of mental health trust facility Assessment in the Emergency Department 5
How well supported are emergency departments by mental health staff and the Police? 68% of Fellows were usually satisfied or very satisfied with the response from their local mental health teams for a patient with a mental health crisis who arrived in working hours. Out of hours, the picture was less positive, with 75% of fellows indicating that they were somewhat dissatisfied or very dissatisfied with the response from their local mental health teams. There were 44 free text comments. These illustrated a number of overlapping key themes. There was a lot of enthusiasm for liaison psychiatry services and a number of examples where a Consultant led psychiatric liaison service was thought to have been extremely helpful. Police training was consistently identified as a key vulnerability. A number of respondents observed that junior police officers were often ill equipped to apply a section 136 detention appropriately. There were a number of concerning reports that the Police would only apply a section 136 if a section 136 facility was available. Where this happened, people were being brought to the emergency department by the police, often in handcuffs against their will, but not arrested or detained under the Mental Health Act. There were a number of comments indicating that the emergency department was a poor place to provide care for people suffering a mental health crisis. Patient was picked up by police (who knew the story) and rather than put him on a 136, called 999 to bring him to us.he was put on one to one nursing but absconded when back was turned whilst waiting. Police informed but jumped off high scaffolding and ended up in major trauma centre with multiple life threatening and life changing injuries. Police report extremely long waits when they take a patient to the 136 suite. As a result they frequently bring patients to the ED who are not arrested under 136. My belief is they tell these patients to come with them or they will arrest them, hence avoiding the need for a formal 136. There were multiple concerns expressed that the section 136 suites did not have sufficient capacity and that people were brought to the emergency department when these facilities were full or closed. The police have become increasingly reticent about utilising S136 and just bring people to ED under the guise of needing medical assessment and then leave them there. This is because of the lack of facilities and resistance from mental Health services in assessing such people and because the police do not want them in custody suites. So EDs continue to be used by all services as their 'holding pen' which is inappropriate and detrimental to the care of all patients not just those with Mental Health and / or behavioural issues as well as contributing to overcrowding in ED and often exposing ED staff to verbal and physical abuse risks 6
A number of other responses expressed concern about the care of children who had been detained under section 136, and felt that getting timely assessments was extremely difficult. We have instances where the police "dump and run" with patients who ideally should be on a 136. There are also understandable frustrations from the police as there are unacceptable delays in getting people assessed. There is currently no agreement as to where children on a 136 should go. Discussion and recommendations This survey has demonstrated that there are significant problems in the service provision for people suffering a mental health crisis who are detained under the mental health act. There are some important limitations to the survey. The response rate of 52% was low, but sufficient to make useful conclusions. There may be a source of bias in that the fellows who were motivated to respond are more likely to experiencing difficulties in local provision. However, even if the non-responders had reported perfect service, this survey still would have identified important problems in a number of emergency departments. The survey only looks at the care of people from an emergency department and it has to be acknowledged that emergency department clinicians may be unaware of a lot of good work that goes on between the police and the mental health services that does not involve the emergency department staff. However, our findings are consistent with other reported problems in urgent mental health care. This survey has highlighted some important problems for commissioners and stakeholders. The investigators are concerned that there are still a number of emergency departments that do not have access to a section 136 suite. Where there are section 136 suites, it appears that these frequently do not have sufficient capacity and that people are being taken to emergency departments because this is the easiest option. The services provided for people suffering a mental health crisis are much worse out of hours, and it should be remembered that the majority of the week is out of hours. 7
Emergency departments should not become the default option or holding pen for other services. Frequent use of the emergency department or police cells indicates a failing system. Recommendation 1: access to services Commissioners should ensure that all people have access to a dedicated section 136 suite at all hours, and that a suite has sufficient capacity and staffing such that the person is not diverted to the emergency department and that the police can be returned to duties promptly. This needs to include both children and older people who are suffering a mental health crisis. It is not clear from our survey whether a section 136 suite needs to be adjacent to emergency department or not. There are potential advantages to adjacent location, not least that transfer between the two health services is easy if the clinical state of the patient changes. This has to be balanced against the significant costs of maintaining a dedicated suite, which may not be efficiently used. There will also be transport problems when a patient on a section 136 needs admission to the local mental health hospital. 8
It is of great concern that recording of section 136 detentions are inadequate or absent. The College recommends that there is good recording of all patients detained under the Act. Absent recording makes meaningful local governance and service planning impossible. Recommendation 2: good governance Police officers should complete section papers on all patients detained under Section 136 of the Mental Health Act. Detentions need to be applied consistently and this requires the police to engage in on-going training. A detention should be applied because of the person s need, not the current local availability of services. Emergency department staff should support the police by storing section 136 papers at the emergency department. There should be good links between the emergency department, the mental health trust and the local police. Joint governance meetings may be helpful. A Consultant Emergency Physician should provide a single point of contact for the Police and the Mental Health Trust. There should be a local protocol that all three partners agree and sign. This protocol s effectiveness should be periodically audited and reviewed. 9
The Fellows of the College of Emergency Medicine are clear that an emergency department is a poor environment for a person suffering a mental health crisis. Confidentiality is usually compromised, the noise and bustle of a crowded department is an agitating, frightening and disorientating environment for vulnerable people. Stretched staff are unable to provide adequate support to these most vulnerable patients. Recommendation 3: right person to the right place Pathways are developed, commissioned and audited that help a person suffering a mental health crisis and who appears not to have a physical health problem, to bypass the emergency department. These pathways need to consider people of all ages, care of children and older people detained under section 136 is frequently worse than for working age adults. 10
Lengthy delays to assessments, and subsequent admission, of people who are suffering a mental health crisis were frequently reported. A timely response from psychiatric services is better for the patient and allows both the police and emergency department clinicians to return to their duties more promptly. Recommendation 4: timely response Mental health trusts are commissioned and managed to provide a response for emergency calls within 60 minutes and that this service is available 24 hours a day for all age groups. 11