I am grateful to the Minister. As I suggested, the Government have the authority to put these things in guidance, but not in the Bill. I do not
understand that, but there you go, Madam Deputy Speaker—that is the vagaries of the establishment and the Executive for you.
The point that I want the hon. Member for Croydon North to note, given that this is his Bill, is that if we have 11 things in statute, putting two others in guidance does not really cut the mustard, because they will not be statute but guidance. Institutions will focus on what is in the law and what they can be taken to court for if they do not act properly. We cannot have a pick-and-mix effort, with some of these things in law and some in guidance because, by definition, the things that are in guidance are clearly not as important as those in law. My contention is that the matters specified in amendments 11 and 12, with which the hon. Gentleman said he agreed, are so important that they should be part of the list that goes into law. Guidance just is not good enough; it is not acceptable.
Amendment 11 would include in the Bill training for mental health staff on who is responsible, and on roles and procedures when the police are called to assist. The amendment would ensure that we have a structured approach regarding the involvement of the police when restraining a patient, and it goes to the heart of one of the purposes behind the Bill. This is one of the reasons why the hon. Member for Croydon North brought forward the Bill in the first place, in my opinion, so it would be extraordinary if the Bill did not include training on the thing that is central to it. The amendment stems from that inspiration.
The hon. Gentleman has detailed on several occasions in the Chamber the case of his constituent, Olaseni Lewis, and the treatment he received in the lead-up to his death. On reading through the inquest into Mr Lewis’s death, alongside the coroner’s report, a number of things stood out to me, but predominantly the fact—I believe it can be agreed—that the entire scenario that took place on the evening of his death was a mess. It was a shambles, and it should not have happened. There seemed to be a sudden shedding of responsibility from the medical staff to the police, which I believe caused the quality of medical care that Mr Lewis received to be compromised.
What I find most disturbing is that the police seem to be blamed for Mr Lewis’s death, yet his cause of death was identified by the coroner as medical negligence. I therefore ask what responsibility medical staff have in such events and what responsibility the police have. That is fundamental to this particular case behind the Bill. Common sense suggests that if a patient is in a medical unit and experiencing an episode of mental illness, the priority is for medical staff to control the situation, due to the cause of the situation being medical, and the police are purely there to assist in giving someone appropriate medical care and treatment.
An interesting case is that of the former premier league footballer, Dalian Atkinson, who died in the early hours of Monday 15 August 2016. Police were called to attend a report of concern for safety. Neighbours had reported that Mr Atkinson was banging on and kicking his father’s front door after
“flying into a booze-fuelled rage”.
They had also reported that Mr Atkinson was trying to enter his father’s property because he claimed that he was homeless. Mr Atkinson’s father, who was not the person who called the police, stated of his son:
“I don’t know if he was drunk or on drugs but he was very agitated and his mind was upset…He was threatening and very upset.”
At the time of the incident, Mr Atkinson was reported to have been suffering for some time from a series of illnesses that left him in a fragile state, with a weakened heart. Alongside pneumonia and liver problems, Mr Atkinson was also said to have undergone dialysis for kidney failure and to be battling depression. Mr Atkinson’s brother Kenroy stated that, on the night of his death, Mr Atkinson
“had a tube in his shoulder for the dialysis”,
which he had removed himself, leaving him “covered in blood”. He also said that his brother had attacked their father, who was 85, and held him by the throat, telling him that he was going to kill him. He told their father that he had already killed his sister and another of his brothers, which was not true.
What makes Mr Atkinson’s case different from Mr Lewis’s is that, instead of force from person-to-person contact, Mr Atkinson was subject to the use of a Taser gun. With a combination of multiple health issues and a weak heart, this caused him to suffer cardiac arrest, which subsequently caused his death. In the days following his death, Mr Atkinson’s nephew, Fabian Atkinson, said of his uncle:
“He had some health issues that he was trying to get through and that’s why his heart was weak. When a Taser is deployed, as soon as a Taser is deployed, they need to automatically call an ambulance. How do they know the health of the guy or the girl that they are affecting?”
That is exactly my point.
When the police are called an incident, they are not aware—they cannot possibly be aware—of a person’s medical history. There is no briefing beforehand, because that is simply not possible when they are put into an urgent situation. Training is designed to help them attend incidents and de-escalate them quickly and efficiently. The question is: how is it possible for this to be done and for them also to be able to take on the additional task of medical assessment?
It might be assumed, from the medical setting, that there is the reassurance of a medical professional being present to monitor the person’s health. In the Royal College of Emergency Medicine’s best practice guidance, the advice is that when a patient is restrained in the emergency department, even if the police are providing that intervention, the ultimate responsibility for the patient’s safety and wellbeing rests with the doctors and nurses of the emergency department. I think that that is absolutely crucial.
I appreciate that those guidelines are for a patient who is taken to an accident and emergency department, while Mr Lewis was in a specialist mental health unit where there were medically trained staff who should have been well versed in such situations. From reading the reports, it seems to me—other people may have a different interpretation—that the staff felt it appropriate to pass responsibility for Mr Lewis’s medical wellbeing to police officers, who are not of course medical professionals. I believe that that was the most detrimental aspect of the last moments of Mr Lewis’s life. That is why this matter should be one of the key focuses of the Bill.
In its memorandum of understanding, “The Police Use of Restraint in Mental Health & Learning Disability Settings”, the College of Policing states:
“People who talked to us wanted mental health staff to be proactive and use their therapeutic skills to de-escalate situations and only call on the police when absolutely necessary…Each situation where the police are called for emergency assistance should be properly assessed on its merits…The police role is the prevention of crime and protection of persons and property from criminal acts.”
This provides a very clear distinction between the responsibilities of the services. In case it was not already apparent, the police are responsible for crime, and the medical staff are responsible for health.
I do not want the police to have to be given a full medical briefing before assisting with the restraint of a patient—in most cases, there simply will not be time—so there needs to be understanding about the co-operation of the medical services and the police, with the medical staff giving direction to the police. I ask that amendment 11 be made to ensure that staff are given clear training to alleviate the possibility of a similar chaotic scenario arising when the police are involved in restraining a patient, and so that they are fully aware that the police are there to assist, not to take over additional responsibilities that the medical staff would otherwise have.
It seems to me that amendment 11 goes to the heart of what the Bill is trying to achieve: to prevent anyone from suffering in the same way as Mr Lewis suffered on that particular occasion. I do not understand how the Bill can be fit for purpose unless it specifically puts that aspect of the training into statute. If it does not cover that, I do not think we are being diligent in making sure that what happened to Mr Lewis is prevented. The hon. Member for Croydon North is quite right to bring that terrible situation to the attention of the House and to try to prevent such a scenario, but the provision in my amendment is what would most help to achieve that, and it is not right that it is not in the Bill. I hope that hon. Members will overcome the bureaucratic nature of the Government and insist that the amendment goes into the Bill. I would like to see that, and the promoter has said that he would also like to see that. It is our job to make the Bill fit for purpose.
Amendment 12 to clause 5—“Training in appropriate use of force”—relates to the same area. It would insert another new paragraph—paragraph (m)—with regard to training on acute behavioural disturbance, which is another really important thing that has been missed out of the list of areas that must be covered in training. The amendment would ensure that there was staff awareness training on acute behaviour disturbance, which can be life threatening when paired with restraint techniques on a patient.
I will again refer to the case of Olaseni Lewis, whose cause of death was detailed by the coroner as hypoxic brain injury caused by restraint in association with acute behavioural disturbance, or ABD. It states in the circumstances of death that Mr Lewis became agitated and fearful, resisting efforts to leave him alone in the seclusion room. Officers restrained him but were unable to regain control. Eventually, Mr Lewis became unconscious and suffered cardiac arrest.
Hypoxic brain injury, or hypoxia, is caused by an interruption to the constant flow of oxygen that the brain requires. The brain uses 20% of the body’s oxygen
intake to survive, and that is needed to make use of glucose, which is its main energy source. Interruption of the oxygen supply causes a disturbance in the brain function and will therefore cause immediate and irreversible damage. A person can take as little as 15 seconds to fall unconscious due to a lack of oxygen, and damage begins to take place after four minutes.
Hypoxia is not easily identified at the beginning of an examination since the primary cause is often unrelated to the brain. Common causes can be low blood pressure, heavy blood loss such as a haemorrhage, suffocation, choking, strangulation, asthma attack, drowning, exposure to high altitudes, smoke inhalation, carbon monoxide inhalation, poisoning, drug overdose, electric shock, and predominantly—as was the case with Mr Lewis—cardiac arrest and heart failure. It is the acute behavioural disturbance element, which was referred to by the coroner in Mr Lewis’s case, that I feel would be most beneficial to add to the training, and I want to explore it further.
According to guidelines written by the Faculty of Forensic & Legal Medicine, acute behavioural disturbance may occur secondary to substance misuse, such as intoxication and withdrawal; physical illness, such as following head injury or hypoglycaemia; and psychiatric conditions, including psychotic and personality disorders. Of all the forms of acute behavioural disturbance, excited delirium is the most extreme and potentially life threatening. Similar to abnormal brain function, it can cause a loss of consciousness, confusion, stupor and agitation, which is the contributing factor to causing the characteristic outburst of violence.
The agitation element of the symptoms can stem from several causes, as stated in module 4 of the College of Policing’s personal safety manual. The causes are acute brain inflammation such as meningitis; limited oxygen supply to the brain, such as through acute pneumonia or heart attack; metabolic problems, as diabetes can cause high or low blood sugar levels, both of which can cause severe changes in personality and behaviour—from sleeping to agitation—and can be lethal if untreated; and general illness, in that severe sepsis can cause confusion.
It then goes on to list the symptoms associated with more severe agitation, which are as follows:
“Psychiatric illness…
Acute intoxication with a broad range of drugs or withdrawal from them”
or an
“Acute brain injury (such as a ‘stroke’”
Aside from violent behaviour, other clinical symptoms may include impaired thinking, disorientation, hallucinations, acute onset of paranoia and panic, shouting, unexpected physical strength, sudden tranquillity after frenzied activity or vice versa, high mental and psychological arousal, aggression and hostility, and insensitivity to pain and incapacity.
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Reading through the transcripts of the coroner’s court inquest, it is apparent that those symptoms were present in Mr Lewis at the time. He appeared to be demonstrating signs of hyperpyrexia—an extreme fever, usually more than 106°, which one of the police officers on the scene, PC Michael Aldridge, commented on in the inquest. He said:
“I came onto the ward and saw Mr Lewis sweating profusely. His clothing was soaked.”
Mr Lewis would have been terrified. He had experienced psychosis; he was being held in a hospital and he wanted to leave. He was surrounded by several uniformed officers and medical staff, so sweating would have been understandable. But if he were sweating to the point that his clothes were soaked through as though he had just stepped out of a shower, I am sure that would have been noticeable to anyone, particularly medical staff who, I believe, should have been looking out for such symptoms. Mr Lewis was already established as having been violent and aggressive, which were symptoms of his psychosis. He had kicked and broken a door, and was said to have been aggressive towards staff who claimed to have been in fear for their own safety. To reiterate that, the hospital night site manager, Hilda Abban, stated at the time:
“I told staff to give him intramuscular medication because he was apparently refusing oral medication, and because of his level of violent aggression it was decided during the staff handover that he would be sectioned, and that was so that the intramuscular medication could be given against this wishes.”
The nursing assistant stated that Mr Lewis
“was physically violent and would put me and my colleagues in danger.”
PC Michael Aldridge said:
“On sighting us he moved at speed to our position, crouched forward, shouting he wanted to get out, it was nearly all over, repeating it again and again. Mr Lewis presented a possible risk to others on the corridor and he damaged the door. He was really strong.”
Mr Lewis was showing at least four of the 14 previously mentioned symptoms for ABD: violence, aggression, agitation and hostility. Along with the previously mentioned hyperpyrexia, his apparent state of panic, shouting, paranoia and heightened physical strength makes that nine out of the 14 symptoms, prompting the question why medical staff did not pick up on the fact that Mr Lewis was experiencing ABD. Further glaring signs of ABD being present in Mr Lewis were revealed by another police officer, PC Adam Mitchell, who stated:
“He was growling with every breath he exhaled. The sound and tone didn’t suggest he had difficulty breathing, more something on the inside of him, an aggression and a ferociousness that couldn’t be controlled.”
To put that into context, by this point Mr Lewis was being restrained on the floor by several police officers. He had on two sets of handcuffs and two sets of leg restraints. He had been struck with a baton during a compliance procedure, yet he appeared not to be in pain. I believe that he was therefore demonstrating the insensitivity to pain that is one of the clear symptoms of ABD.
The terms ABD or excited delirium were reportedly never mentioned during the events leading up to the death of Mr Lewis, yet it was plain that he was experiencing that. Had ABD been identified at the time, the outcome certainly could—and probably would—have been very different. For example, referring back to the ABD guidelines from the Faculty of Forensic & Legal Medicine, the suggested steps to take when dealing when ABD are as follows:
“Ideally, individuals with acute behavioural disturbance should not be taken to a custody suite but directly to an emergency department. However, on occasions, individuals will be detained by the police and taken to the police station, when the forensic physician will be called for advice. In these circumstances, the forensic physician may consider that immediate hospitalisation is
required and advise the police to telephone 999 for an ambulance. Otherwise, the HCP should attend and assess the detainee… The forensic physician should endeavour to establish the underlying diagnosis behind the acute behavioural disturbance before making any treatment decision.”
The doctor should then consider allowing a period of de-escalation where the detainee may calm down away from arresting officers. The forensic physician should avoid responding to aggression and adopt a reassuring and non-judgemental attitude, and
“Only when de-escalation has failed to curb the disturbed behaviour should the forensic physician consider giving medication.”
Looking through the coroner’s court inquest into police and custody-related deaths, I found another case that mentioned acute behavioural disturbance as the cause of death—that of Michael James Sweeney in April 2011. Unlike Mr Lewis, Mr Sweeney was a sporadic user of cocaine on a recreational basis. The coroner’s report into Mr Sweeney’s death stated:
“Following the cocaine ingestion, Mr Sweeney entered a public house with a knife. He was extremely agitated. The Metropolitan Police Service was called and officers attended shortly thereafter. Police officers almost immediately identified Michael as being unwell, suspecting that he was suffering from what had been described in their training as excited delirium. They correctly categorised his condition as a medical emergency and asked police control to arrange for an ambulance to be sent. Police control contacted ambulance control.
London Ambulance Service categorised the call as C1 Amber, rather than Red One or Red Two. At the time, there were no paramedics located in the ambulance control room (who could have recognised the seriousness of the condition and upgraded the call), but that has since changed… Twenty minutes after police first asked for an ambulance, they took the decision to transport Mr Sweeney to the Royal London Hospital in a police van.
Once at hospital, police officers, medical and nursing staff were very challenged by the situation. Mr Sweeney remained violently agitated, and demonstrated extraordinary strength in trying to hurt himself and resisting efforts to help him.
He was restrained prone until sedation was effective and was then turned over. Unfortunately, he arrested within a minute and then died less than two hours later.”
Like Mr Lewis, Mr Sweeney was subjected to a lack of knowledge about his medical situation. Although he was fortunate to have police officers to attend to him who had been given good training in identifying ABD, it was again the medical services that failed him. Ambulance services that were responsible for categorising the severity of medical cases failed to identify Mr Sweeney as an emergency and thereafter left it to the police to transport him to hospital.To reiterate my early point about the roles and responsibilities of the involvement of police assistance,why should it be the responsibility of the police to conduct the work of medical emergency staff?
In response to Mr Sweeney’s death, the coroner detailed his concerns in the report:
“Police officers had clearly been trained in the condition described to them as excited delirium. The training was effective in facilitating their understanding of Mr Sweeney’s condition as a medical emergency. However, this term is not widely used in this country, and neither ambulance, nursing nor even some of the medical staff had heard of it in April 2011. It would be possible to give ambulance and hospital personnel an understanding of the term excited delirium. However, given that this describes a medical condition, it seems more logical for the police to follow health services in this, rather than the other way round.”
That is correct: it would be more logical, but lessons have clearly not been learned. Like Mr Sweeney, Mr Lewis was failed by medical professionals and, even worse, by
those who were supposed to be specialists in mental health, because they did not have knowledge about these key mental health areas and the use of forms of restraint—the core focus of the Bill—for that condition. That area must definitely be brought to the forefront of mental health training, and it is something that other services have already started to address.
In May 2016, changes to standard operating procedures were introduced in police forces across the UK to reflect new mental health procedures and help officers to identify ABD in people. The procedures state:
“The purpose of the procedure is to ensure that officers and staff recognise the heightened risks associated with Acute Behavioural Disturbance/Excited Delirium during and post-restraint, including the immediate emergency actions that need to be taken. Officers and staff are requested to ensure that they familiarise themselves with symptoms and a Summary of Guidelines for restraint and the management of this condition.
Acute Behavioural Disturbance is to be treated as a medical emergency. ABD/ED is a rare form of severe mania sometimes considered as part of the spectrum of manic-depressive psychosis and chronic schizophrenia. Persons suffering from ABD/ED are highly vulnerable to sudden death from cardiac arrest, during or shortly after a strenuous struggle.”
This is a development in training where predominantly ABD or ED, I understand, were not commonly mentioned. I have been told that most police officers have never heard of ABD and were not aware of the symptoms. The police officers who had had joined the force more recently than those who had not heard of ABD and knew very little of the disorder’s consequences. Police officers have often identified the symptoms of ABD as simply that of alcohol or drug misuse and therefore simply characterised these incidents simply as violent and aggressive behaviour.
It is important to know that ABD can stem from several other contributing factors to agitation, aside from psychosis and substance abuse: metabolic problems—diabetes, for example—can cause changes to blood sugar levels, causing severe personality changes; acute brain inflammation; limited oxygen supply to the brain, which can be caused by conditions such as pneumonia; and broader, more general illnesses such as severe sepsis. This means that acute behavioural disturbance could be a far more common issue than people think, particularly when we tot up how many people have those conditions.
Referring back to the revised procedure on this, a concerted effort has been made to ensure that officers are better equipped with the knowledge of how to recognise these symptoms more readily so that they are less likely to be confused with general aggressiveness. It states:
“Many of the signs indicating ABD/ED are common to anyone behaving violently. Therefore, it is important for officers and staff to recognise the difference between Acute Behavioural Disorder and a violent outburst.”
It then goes on to list the symptoms that I have principally mentioned, along with additional ones, such as
“constant physical activity without fatigue”,
and
“excessive strength/continued struggle despite restraint”,
as well as
“acute psychosis with fear of impending doom; hyperthermia …abnormally rapid breathing… abnormally rapid heart rate”.
It states:
“Officers and staff must recognise the heightened risk factors: A person is intoxicated with alcohol or drugs; A person is substantially overweight; A person is suffering respiratory muscle fatigue (exhaustion).”
My point is that if other public services, such as the police, are making an effort to do awareness training on this issue, why is the primary service dealing with these things not making such an effort? I would go so far as to say that I do not know, in many respects, whether it is laziness or ignorance, but it is absolutely unacceptable that training is not given as a matter of routine to people in mental health institutions, given the issues that I have raised. It is deplorable that a potentially life-saving training topic is being left to the police to deal with. Are we really going to end up in a country where we have to rely on the police to aid in these medical ailments? I sincerely hope not.
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Mental health has already been highlighted as an area with a lack of knowledge surrounding it. The amendment is not one that is simply nice to have—it is absolutely crucial in the evolving area of mental health. It is impossible to argue that it should not be in the Bill. I know that the hon. Member for Croydon North agrees about how beneficial it would be. Is there anyone else in this House who could disagree that this should be covered in the list of areas in statute for training among staff? How can the two most important areas of training that the Bill seeks to deal with, in the case of Mr Lewis, not even be covered? The idea that we may put it in guidance at a later date is not good enough. These things must be in the Bill.
I hope that the Government make sure that the amendments are included, and I am grateful that the hon. Gentleman accepts that they should be. Our job in this House is to make sure that the Government put them in the Bill, given that, I suspect, if they had had the time to consider it, they would have agreed to do so. Let us force them to do it. I hope that the Minister, having listened to those cases, will decide that never mind the write-rounds, these things need to go in the Bill today.