The Doctor/FME will medically examine the individual for physical and mental health issues. Prior to the examination the Doctor must explain their role in terms of independence and the purpose of their presence. Once this has been done the Doctor needs to then ensure that the individual has the capacity to understand and retain information as such for the examination to take place (Fitzpatrick et al, 1993).
However, historically there have been many arguments with regards to Doctor’s not being Section 12 approved and only GP trained therefore, having limited knowledge of mental health issues i.e. drug induced psychosis. When dealing with an individual with a possible mental illness the Doctor/FME needs to have a substantial understanding of polysubstance misuse when conducting a physical examination, the FME should assess for signs of intoxication, dependence or withdrawal through the assessment of disorders in speech, mood, perception, thought, cognition, insight and risk of self- harm (Norfolk, 1997). As a result forensic physicians are increasingly being asked by the police to assess for substance misuse with respect to their fitness for detention, the need for treatment and fitness for interview. The individual will be tested for drugs when the FME requests a urine test. A study carried out showed that 61% of detainees had taken illicit drugs and one in three tested positive for multiple drugs including alcohol (Norfolk, 1998).
This would indicate a potential risk of violence or aggressive behaviour; many Mental Health teams will not assess individuals under the influence of Alcohol leaving the FME in a difficult situation. Effective liaison with the police custody officer can be relevant in terms of the individuals presentation when and where arrested which highlights the need for collaboration when compiling a comprehensive risk assessment. Approved Social Worker (ASW)
The role of the ASW is that of interviewing the individual (client) contacting any relatives/ friends and ascertaining whether there is any mental health history. Once the person is assessed the ASW will make any arrangements that are necessary. ASW’s are separate from the medical profession in terms of discipline and use the social model, however they have also been targets of “bad press” in terms of how the public view them. The public image of social workers is a major problem as it distorts the discussion away from what social workers actually achieve in both preventive and rehabilitative work with individuals, groups and communities onto a small number of high profile scandals and disasters. In these circumstances, there is a danger that the social model and the social care disciplines will not be highly valued in the new mental health services (Duggan, 2005).
The promotion of the social model requires the continued existence of social work as a discipline, however changes to the proposed to the statutory roles of Approved Social Workers in terms of making approved Mental Health Workers, also disquiet about the civil liberties implications of the new proposals, particularly in relation to the proposals for the detention and treatment of those with presumed ‘dangerous personality disorder’, need clarity about the value and effectiveness of social interventions to support individuals and groups with mental health problems to temper and modify this process (James,2000).
Nurses For nursing staff whether in the community or in-patient setting a detailed assessment is required with all risks assessed. In the acute patient setting nurses have to check all MHA documentation is in order and handed in to the MH administrator. The idea of Crisis Resolution Teams (CRHT) is that of treating individuals in their own home environment due to the lack of hospital beds and 9-5 community mental health teams, the CRHT are mainly nurse led, and run on the basis of 24hrs 7 days a week. They are the 1st point of contact for MHA due to ASW involvement in this Multi-Disciplinary-Team setting.
Statistical Evidence The evidence, scale and nature of the problem for which people who come into contact with the criminal justice system is approx at least 200-300 incidents a year in Coventry whilst mentally distressed. Some evidence for this estimate is as follows (provided by Coventry Police and AWS’s in Coventry): Police Stations across Coventry, during the period of August to November 2004, Custody records, charge sheets and, where appropriate, reports of medical examinations by the Forensic Medical Examiner (FME). Forty-Nine cases were identified in which there was a mental health issue recorded.
Extrapolating this proportion to the total annual caseload (3,160) approximately 200 cases a year. The police response to these cases can be summarized as: Bailed 10% Place of Safety 56% Hospital 11% Court 8% No further action 15% In terms of gender and race: White – 19, Black – 13 & Asian – 8 (Males) White – 3, Black – 4 & Asian – 2 (Females). The total: White 22, Black 17, & Asian 10. a) The difference in the number of cases estimated from Police records to go forward to Magistrates Court (20) and the number of cases in which mental health problems are identified at the Court (80) suggests that in a significant number of cases mental distress symptoms do not appear to be identified at the Police Stations.
b) Section 136 appears to be being widely used to remove people from the Police station to hospital (rather than direct from the public place to hospital), but many of these cases are not being recorded – thus informally diverting them from the criminal justice system, aarrangements in this area seem pragmatic. c) It is difficult to determine the proportion of cases where clients had housing problems or were homeless, although there were indications that this is an important issue.
Over the last year, a large proportion was not properly recorded and often the completion of relevant forms misplaced. Some of the problems were due to the police and the FME suggesting there is no need for a MHA or assessment. However, when assessed by the psychiatric team and admission is needed the client is often brought in on an s4, s2, or s3 on the monitoring sheet. (This information contrasts strikingly with data from Police Records) Management of Aggressive Behaviour and Risk Assessment. Follow up responsibilities
There have been a number of cases where deaths have been linked to management of aggressive behaviour involving restraint or medication. According to MIND, (2003) “several of these incidents have taken place when a person has been detained in a police station prior to being transferred to another setting.” Carson (1993) has highlighted that the assessment of risk involves consideration of three different components.
These are consideration of, initially, the outcome; secondly, the likelihood of the outcome; and finally, an expected timeframe. This has particular relevance to the decision to continue or terminate behaviours we do not want the patient to display; namely violent or seriously disturbed behaviours. Consideration of what we know about the patient, their previous behaviours, the nature of their illness and the environment in which they will be returning to; the time frame in which this process is occurring; and the need to remain aware of the time scales are required before termination can be achieved.
However, this process is not as simple as it first appears. McNeil & Binder (1996) highlighted how “evaluation of potential violence is inherently problematic, i.e.: some people evaluated as low risk will become violent and some people assessed as high risk will not become violent.” Grounds (1995, p46) also highlighted the difficulties associated with risk assessment; stating that “it has to be recognised at the outset, first that there are limits to our knowledge about risk, secondly that there are limits to our ability to assess it, and thirdly that there are limits imposed upon us due to the structure and ethos of our services.” Indeed, Grounds (1995) proffers that we worry too much about some patients and not enough about others.