Mental Health review highlights failings

Wednesday, 23rd March 2016

AN INDEPENDENT review commissioned by Staffordshire’s Police and Crime Commissioner Matthew Ellis into why a seriously ill man spent 64 hours in police custody has highlighted disjointed services and a lack of accountability and responsibility.

The Ethics, Transparency and Audit Panel (ETAP) examined the case which saw the man, who was in mental health crisis, kept in custody despite not committing a crime because a suitable NHS services weren’t available.

The Commissioner previously made public the shocking three-day timeline of last March’s incident, which highlighted a series of phone calls, texts and conversations with mental health professionals that failed to help find a suitable place of safety for the 48-year-old man, who absconded from a mental health unit in London and ended up in Stoke-on-Trent.

The county-wide ETAP was established by the PCC in 2013 under his ‘New Dawn of Transparency’ agenda. It is made up of members of the public who have become expert citizens and has received national recognition for its scrutiny of the police use of Taser, stop and search and crime recording in Staffordshire.

ETAP’s 31-page review included the following findings:

  • There were two missed opportunities for police to detain the man earlier
  • It was not clear which clinician had overall responsibility for the man’s medical treatment while in custody
  • A lack of staff at the man’s ‘home’ hospital in London meant information about him was not quickly available. The hospital was unable to provide a bed
  • The NHS Mental Health Team contacted 11 different places to try and find a suitable Psychiatric Intensive Care Unit (PICU) bed
  • A PICU bed was eventually found in Manchester but withdrawn
  • A PICU bed was then offered in Bradford. Suitable patient transport was delayed for several hours. The bed was withdrawn while the man was in transit, forcing a return to Stoke-on-Trent
  • A whole police custody wing had to be cordoned off because of the man’s condition
  • At least 22 police officers were involved in the incident over the long weekend
  • Despite the best efforts of police, the man’s condition deteriorated while in custody
  • At one point, the man was kept in a vehicle for over two hours in the car park outside police custody facilities due to the deadlock before he was finally taken to Harplands Hospital in Stoke-on-Trent.

Mr Ellis said the report comes at a time when progress has been made across agencies in Staffordshire and Stoke-on-Trent to make sure people in mental health crisis get the right support. This has seen NHS and police staff work closely together and led to the number of people detained in police custody under the Mental Health Act fall by 80 per cent. Funding has been secured for an expansion of Harplands Hospital in 2017 which will include PICU beds.

The Commissioner said: “Senior NHS Trust managers across the country failed to get a grip of the seriousness of this situation meaning an individual in distress was left in a criminal justice environment for so long. It also meant that police officers were left to deal with mental health complexities on a scale which was way outside their expertise.

“This isn’t about criticising front end mental health professionals, this is about a failure of senior NHS managers to be accountable.

“The ETAP report reinforces a lack of join up and responsibility across services, in particular NHS Mental Health Trusts across the country.

“The last two years in Staffordshire have seen an 80% reduction in the number of people suffering mental ill health being put in cells but this sad incident reinforces the importance of senior people being accountable in providing decent services in difficult situations.

“There are senior managers across NHS Trusts countrywide who must take some responsibility for this situation where a man was incarcerated for 64 hours despite not committing a crime and two dozen police officers were tested to their absolute limit.”

Assistant Chief Constable Bernie O’Reilly, from Staffordshire Police, said: “I welcome the review and learning that has come from it. Our custody facilities are rarely the right place for prolonged periods for people with mental health issues. Our officers do their best in difficult circumstances – but are reliant on qualified experts to provide appropriate alternative accommodation that better suits the needs of people in distress.”

We reported on this incident back in September last year, that article can be found here.

The tragic and avoidable timeline of the incident.

Thursday 5th March 2015
09:12 – Reports from Brewers Fayre, Etruria, about a male whom they are having problems with (harassing other guests/pulling trousers down). Police attend, decide there is no offence. Male refuses to give any details, only states he is not from this area and will be buying a car and heading back to London, Police leave.

13:59 – Call from member of public at Munchies Café, Hanley, regarding suspicious male who is banging and shouting. Concerns he may harm someone, description given, no sightings, so incident closed at 16:36.

18:00 – Male acting suspiciously outside shopping centre. Enters centre/shops throwing stuff, trousers around ankles, talking to himself, urinating everywhere. Details checked: wanted /missing report (abscond from hospital London).

19:00 – Male detained under Section 136 (“danger to themselves and others”). Possible Section 3 patient. Police confirm it is the same person as on previous two incidents. Decision made that due to agitation and violence individual will go to police cells at Northern Area Custody Facility (NACF), Etruria, Stoke-on-Trent. Ambulance staff at scene declare male physically fit.

19:32 – Individual booked into Custody Level 4.

21:19 – Both the multi-agency Criminal Justice Mental Health Team (CJMHT), North Staffordshire, and Harplands (Psychiatric) Hospital, Stoke-on-Trent spoken to. Reluctance to accept at Harplands as already a sectioned patient. Custody Sergeant insists.

23:00 – Ambulance called to transfer

23:10 – Ambulance arrives.

23:27 – Male taken to Harplands (Ambulance/Sgt & PC) where Officers are asked to remain due to his behaviour.

This phase of incident closed at 02:57


Friday 6th March 2015
06:27 – Individual returned to police cell at Staffordshire Police, Northern Area Custody Facility (NACF) due to behaviour.

09:10 – Detained Person (DP) refused Medical Examination.

12:02 – Health care professional to conduct assessment via hatch.

15:00 – Force Mental Health Lead asks the Health Manager to provide options and believe Psychiatric Intensive Care service (PICU) would be the way forward. (No PICU beds in Stoke so will have to go out of Staffordshire Force area)

05:10 – DP refuses medical assessment.

15:25 – Eden Ward, London will now conduct a further assessment to see if he is suitable for PICU, if so he will then go to bed management to try and find a bed. AMHP/Psych report sent. Trying to recall his Community Treatment Order (CTO) but need a confirmed bed to put on the paperwork to obtain CTO.

17:04 – DP awaiting PICU bed but all are currently full at this time and it is the responsibility of care team in London to source. May be some hours.

17:08 – Text received from L & D:  assessed as suitable by London for PICU so now looking for bed

18:05 – DP spoken to via hatch.

18:54 – Update from Mental Health Team they have made every effort to secure a PICU all over the Country, none available. Concerns DP is not medicated and is not getting any treatment whilst in custody. The DP is currently on a Community Treatment Order in London which can be recalled but only when a bed is available.

20:13 – DP visited by Nurse

21:20 – DP refuses medical assessment.

22:01 – Update from Mental Health Manager: no health staff available to assist. Police ask Triage to cover.

22:56 – Insp. told bed secured in Manchester and DP will be transferred through the night.

23:12 – Confirmation from Triage Nurse bed secured arrangements now being made to transport.

23:16 Medication given to DP by doctor.

Saturday 7th March 2015
00:07 – Text received looking at a bed in Manchester

01:07 – Text received. Bed secured in Manchester Sgt updated.

13:29 – Inspector informed that Manchester had now withdrawn the bed offer due to not thinking they could manage his behaviour. Harplands escalate to Executive level. Discussions regarding providing some provision at Harplands. Matter also raised with London who are responsible for care and transport of DP.

14:10 – Visited by HCP, Doctor and AMHP

16:30 – Medical Examination took place.

17:07 – Custody made aware of risk regarding exhaustion and dehydration.

21:42 – Update from MH Team. Possibility of a bed in Bradford pending them accepting risk assessment which is being carried out now. AMHP and 2 x Doctors to carry out assessment in order to detain.

22:46 – DP seen by MH Team and Doctor.

22:56 – Medication given.

Sunday 8th March 2015
01:14 – Seen by Community Psychiatric Nurse (CPN)

03;39 – Seen by CPN

09:46 – Medical advice to detain under Section 3.

10:57 – Attempts to remove to clean cell. Refused. Risk Assessment to high.

11:00 – Insp. informed DP will be transported at 17:30hrs.

11:30 – DP refuses medical examination.

11:56 – Insp informed transport to will arrive at 14:00hrs

13:00 – DP refuses medication

14:20 – DP refuses medication

18:30 – Decision to use specially trained and equipped shield party to move to clean cell and prepare for entry onto the escorting vehicle. DP to be taken to Cygnat Hospital, Wyke, Bradford.

18:30 – DP refuses medication

18;30 – DP leaves Custody.

18:45 – Section 136 disposed.

The review can be read in full at: