Tuesday, 28 July 2009

Section 136

I get called to a lot of section 136 assessments, out of hours. In fact, it's pretty much all that out of hours work typically involves. Section 136 of the Mental Health Act 1983 allows a police constable to stop and manage, ". . . a person who appears to him to be suffering from mental disorder and to be in immediate need of care or control . . ." to, ". . . remove that person to a place of safety . . ."

Locally, that's a 136 suite in our hospital.

Police find someone acting "a bit odd" and have a choice. They can arrest them, with all the attendant paper work, take them to the cells, wrangle with the custody sergeant why the person needs locking up, do that paperwork . . . or they can fill out a paragraph on one of our forms and drop them at our doors.

No surprise, use of section 136 is increasing massively in my corner.

In fairness, much of the time the police get it right. It's just that sometimes it's clear that the alcohol and social situtation has generated the volatile presentation, so taking them to my door for a psychiatric assessment isn't going to generate hospital in-patient or acute psychiatric care since we've simply not been asked to (and therefore aren't resourced to) deal with this. If you're drunk and feisty, it's not a psychiatric problem.

I concede that having mental illness at the same time can ramp up risks of problems, but if the presentation at that point in time, in that place, in that situation, is because of getting roaringly drunk, I don't have an instant cure for that.

Section 136 is an interesting section of the MHA 1983. You can be picked up anywhere the public have access to. You are thought to need care. You're picked up by police. You have no choice. You're taken to a place of safety. You have no choice. You're held in this locked environment. You have no choice. You're detained there for assessment for as long as it takes, up to 72 hours (that's right, 3 whole days). You have no choice.

What rights do you have, how do you appeal, who do you appeal to? Can you get a First Tier Tribunal to discharge your section 136? No. You can't appeal. You're there for the duration. You have no choice.

Quite scary, really. Anyone acting "a bit odd" can be locked up for 3 days with no rights of appeal or redress.

In fairness, section 136 assessments usually are undertaken pretty sharpish. I always do them straight away, attending immediately. It only seems fair. I need to do the assessment anyway, so why wait? Also it's just a stress to me, knowing I've work to do but not doing it. So when a section 136 is 'phoned through, I'm skipping off to see the patient as soon as an Approved Mental Health Professional (AMHP) can get there (which in my corner still means a band 7 social worker).

The last assessment was relatively brief. A gentleman was brought, by police, after saying over many hours in a pub that he was feeling suicidal. He wasn't. It took just an hour to go through history, mental state and formulation. Discharge options were then discussed and off he was, on his merry way. He's been seen subsequently when both he and staff felt he was in fine form, consistently cheerful, with no mental illness evident.

Another gentleman. Another assertion of suicidality. Another assessment over the course of an hour, with no evidence of mental health problems (meaning neither psychological problems nor psychiatric illness) but social upsets (rows with two girlfriends, thrown out by one of them, feeling skint yet owed friends cash, hated his poorly paid sporadic monotonous work). He was told the good news by the AMHP that he wasn't that ill, he didn't need hospital in-patient care and was no longer detained. A free man. He became angry, smashing his fists on walls and kicking doors and screaming like a banshee. He wanted to be in hospital, but wanted to be detained, to show his girlfriend what she had done, what she caused. Police don't like patients being angry and violent aronud NHS staff. Thankfully they take it seriously, here. They arrested him and he had a night in the cells.

A recent section 136 assessment was different.

The gentleman was brought in mid week. He had a curious account of overdose and suicidal thoughts and actions which was inconsistent. Police didn't find his presentation was in keeping with having taken the materials he said he'd taken. When he presented it was clear he was pretty well, physically, when if he'd taken all he said he had, he'd be flat. Odd. Assessing lethality of overdose and ongoing suicidality perplexed the AMHP who sought more information. The section 136 continued after we saw him, so more information could be gleaned, to inform the assessment (and need for discharge or detention). Blood tests were undertaken and showed he'd not taken what he'd asserted. The next day the AMHP tracked down the clinical team in another county that had been looking after him, prior to his drive to my corner and subsequent overdose here. They gave details of two other counties he'd had contact in. More information was gleaned from them. It was on day 3 that he was discharged from his section 136. Only then did the AMHP feel she had sufficient information of psychosocial history, support available, past behaviour, risk, how he'd managed problems historically (with what escalated risks and what reduced risks) and what sensible discharge planning could helpfully and realistically effect support and change. Months on, he's back in his own locality but I heard that he's coping well and is much, much improved. The assessment and care planning and initial local support was of merit, did effect change and this has been sustained back in his own corner.

Maybe then sometimes, just sometimes, detaining someone for 3 days is in their best interests after all.

I still favour getting it all done and dusted in an hour, though . . .


Jess said...

Ah the postcode lottery...here the police hate using 136 because it means at least two of them will end up sat in the sideroom of A&E with the patient for the forseeable future, 12 hours plus is not unheard of.

What's your view regarding the public place provision? It's not unusual for us (ambulance) to go to someone who in a public place would be detained under section 136 yet as they are in a private place cannot be removed. I understand the reasons for not wanting police to be able to come and "kidnap" anyone, but with the OOH provision so poor it leaves us between a rock and a hard place.

The Girl said...

This is an area of psychiatry that I find fascinating and a bit scary at the same time. I can't think of anything in another specialty that even comes close - recalling patients for more tests or keeping them in for longer because you think they are declining physically is just not the same!

How was it the first time you were the one responsible for deciding whether or not the patient was suicidal, or did you have good support and advice from those with more experience?

I'm really looking forward to doing psych again, but acute assessment is one area that would be quite challenging the first time you do it.