The management of individuals with enduring moderate to severe mental health needs: a participatory evaluation of client journeys and the interface of mental health services with the criminal justice system in Cornwall

Neighbourhood Harm Reduction Register

The 12 NHRRs for Cornwall were used to identify potential audit cases. Entries on the registers are based around addresses to which the police have been called at least three times in 3 months. Data entered for each address varies both within and between registers. Figure 4 provides an overview of the identification process.

• Where a principal person (PP; the main person at the address that calls relate to) was identified on the register, the individual was automatically entered onto the case list (see Figure 4, box 1).

• The PP was then located on the Operational Information System (OIS) and all associated persons’ (APs; individuals associated with the PP) entries examined. Where an AP of the PP was (1) involved in an incident within the time frame or (2) associated with the address in the NHRR, they were included in the case list (see Figure 4, box 2).

• The address of all PPs was entered into a View Street Index (VSI) search on OIS. All APs of the address who were (1) involved in an incident in the time frame and (2) associated with the address subjected to the VSI search were included in the case list.

• Where only an address was identified on the register (see Figure 4, box 3), the address was entered into a VSI search on OIS. All APs of the address who were (1) involved in an incident in the time frame and (2) associated with the address subjected to the VSI search were included in the case list (see Figure 4, box 4).

FIGURE 4.

Case identification methodology using the NHRR and Operational Information System.

National Strategy for Police Information Systems Custody System

The procedure used to identify individuals from the Custody System and each of the custody centres in Cornwall to be case-linked was as follows:

• ‘Custody Record’ was selected as the chosen data source to be searched.

• Each custody centre in Cornwall was searched for records that related to custody entries in weeks 16–30 of 2011 inclusive.

• Each search provided a list of custody records. Data of individuals aged > 18 years (i.e. date of birth prior to 18 April 1993) within the period of the audit were collected.

The name and date of birth of each identified individual were recorded and stored on a secure spreadsheet on a DCP secure server.

Criminal justice system-derived cases

Figure 5 illustrates the process by which linked cases were identified. A total of 2717 individuals were recorded on police custody records and the police NHRR as having interacted with the police in the second quarter of 2011. Of these, 529 had a record on the RiO system. There were nine deaths and one imprisonment between initial recorded police contact and case-linkage, resulting in 519 (19.1%) linked cases (i.e. individuals who also had a record on RiO). Of these, 321 (61.8%) were identified solely through custody records, 120 (23.1%) were identified through the NHRR and 78 (15.0%) were identified through both custody records and the NHRR (Table 1).

FIGURE 5.

Flow chart of case identification process (CJS-derived cases).

NHS-derived cases

Thirty-four individuals were recorded as being detained under Section 136 at the place of safety. Of these, 30 had a corresponding record on DCP CJS databases and were aged > 18 years. Seven of the cases had been identified previously through the CJS-derived sample selection, two of which were recorded on OIS as attending the custody centre first, and were therefore removed from the sample. There were three deaths in the group before the audit commenced and one incident was recorded as an inappropriate use of Section 136. Of the remaining 24 cases, 15 (62.5%) had records for Section 136 place of safety detentions only; one (4.2%) had a custody record; five (20.8%) had additional NHRR or OIS logs; and three (12.5%) had records across all systems.

Theme 1: risk to self

In order to assess contemporaneous decision-making by the police it was necessary to ensure that the researcher used information that was both available to police and recorded as a result of the incident (indicating information available directly from the presenting situation being witnessed and dealt with by police officers). As such, data were restricted to OIS logs with information supplemented by information provided by police to MHTs and recorded in the mental health progress notes. All 32 contacts were perceived as being a risk to themselves by the attending police officers. Figure 8 presents the categorised factors that precipitate a decision to detain under Section 136 due to risk to self.

FIGURE 8.

Categorisation of risk to self for Section 136 detentions (n = 32).

Two cases were witnessed as attempting suicide at the scene: one individual had thrown themselves from a window and one individual had attempted hanging. Three individuals were witnessed to be engaging in deliberate self-harm (DSH) at the time of detention: two by cutting (one with razor blades) and one by hitting herself in the face. Eight individuals were classed as missing persons during the initial logs relating to their detentions. It was only for these latter missing person cases that officers were able to collect historical information that facilitated a more detailed assessment of risk, including history of self-harm or mental health conditions (e.g. depression, anxiety) and recent overdose.

Information with regard to risk to self was categorised into the following:

• immediate threat/danger to self

• threat of suicide

• DSH

• behaviour perceived as indicative of mental illness.

Theme 2: risk to others

Thirteen Section 136 detentions involved individuals who were perceived by attending police officers as being a risk to others at the time of apprehension. This was characterised either by threat or actual violence to specific single and multiple individuals including professionals such as:

• The attending ambulance crew (n = 3, one individual also threat to mother, see below).

  1. OIS log

     OIS: f/AMB [call from ambulance crew] – called to a 20 yrs old male self harming – threatening further violence – autistic patient who also has ADHD [attention deficit and hyperactivity disorder]

  2. OIS log

     girl tried to hang herself – now being violent (call made by crew)

• Police (n = 2).

  1. OIS log

     the DP [detained person] was completely uncooperative and had been violent towards officers so was taken to cell and searched by PC [police constable]

• Health workers (n = 1, one individual also threat to partner, see below).

  1. OIS log

     could hear disorder in background CPN [community psychiatric nurse] is female and male driver, patient in back of car. they are transporting him to [mental health hospital 3] taking him to [custody suite] att because of behaviour – 2 CPNs with him are arranging MHT to attend [custody suite] within next 1–2 hours to do assessment

Non-professionals deemed at risk were:

• The individual’s partner due to violence (n = 2, one individual also threat to health worker, see above).

  1. OIS log

     RP [reporting person] states his friend and him are at the sig being threatened with violence by this female as she has had too much to drink and they want her removed, RP [reporting person] also sounded in drink.

• The individual’s mother (n = 1, one individual also threat to ambulance worker, see above).

  1. OIS log

     further call from AMB [ambulance] to say male getting aggressive now he has just assaulted his mother

• The individual’s child due to the child being present during the incident (n = 1, also threat to public, see below).

  1. OIS log

     caller on matched log is happy to keep an eye on her as she appears very distressed – caller more concerns for the child.

Public safety was perceived as being an issue due to the individual wandering in traffic (n = 1); threatening behaviour to the public (n = 1, also threat to child, see above); intimidating behaviour in a shop (n = 1); attempting to break into surrounding properties (n = 1); and threatening to stab others (n = 1). Finally, one individual was perceived as a risk to others due to his fear that he would harm his family following self-presentation at a police station. A further detention involved an individual who was deemed a risk to others once in custody by the police.

Tasers were authorised to potentially manage three incidents, although they were not used. Rationales for authorisation included aggression by the individual, violence by the individual toward their partner and the individual threatening to stab others.

Theme 3: known to services

Whether or not the individual was known to the police was information used in making the decision to detain under Section 136. The 32 OIS logs associated with each incident, were examined to determine if this was the case. One incident did not have an associated police record (the contact and detention was recorded only in mental health records).

Eighteen individuals were recorded as known to the police through PNC warnings. Of these, eight individuals had a PNC warning for mental health and of the seven who had a PNC marker other than for mental health, five had a warning for behaviour associated with mental health issues (i.e. suicide or self-harm).

Examination was made of OIS logs to determine the knowledge of the individual by the responding officers and/or call operators, and showed this was the case in eight incidents. Seven of the incidents in which police officers and/or call handlers had previous knowledge of the individual were related to two service users with multiple Section 136 detentions in the research window: one with four recorded detentions and one with three recorded detentions. For the individual who had four Section 136 detentions, call handlers provided the response officers with information on his mental health and forensic history. For the individual with three Section 136 detentions, examination of OIS logs indicate an escalation in knowledge, from the call handler being aware of the individual being left at home by an ambulance crew immediately prior to the incident (first detention) to the call handler being aware of the individual’s behaviour (second detention), to both the call handler and response officers recording previous knowledge of the individual’s behaviour (third detention):

local officers well aware of female

OIS log

Additionally, and also presented above, individuals were currently on the caseload of, and therefore known to, mental health services in the case of 20 Section 136 detentions. Contact was made between police and mental health services prior to 11 of the detentions examined here in relation to the decision to detain under Section 136. The following examples show how knowledge of the individual by mental health services coupled with this communication between services can both support the decision to detain under Section 136 and provide information to help the police with their enquiry when an individual is missing:

I spoke to the police officer who said he was reluctant to take [service user] back to [residence] as he would leave immediately they left and they did not have the resources to keep returning him to [residence]. in view of his vulnerability i suggested that they consider a Section 136 to maintain his safety and dignity.

OIS log

[Officer] spoken to [service user]s CPN [community psychiatric nurse], a [CPN], she has not heard anything from [service user] over last couple of days, she says she has a support worker in [support worker], she starts work at 1600 and shall also try to contact [service user] then . . . log numbers passed to both, however they can only suggest we look at cemetery which has already been checked. please advise btp [British Transport Police], in case travels into Devon, no destinations known ATT [at the time].

OIS log

Theme 4: outcome considerations – attempted diversion from Section 136

Although the factors discussed above impacted on the initial decision to detain under Section 136 for the majority of detentions, in some cases, services suggested potential alternatives to Section 136. In one case, the police attempted to involve the home treatment team (HTT) in order to avoid the individual being detained, but due to the unavailability of the HTT until the following day, and on assessing the potential risk to that individual, they were detained under Section 136. However, diversionary measures that offer the support required to keep individuals (and in some cases, others) safe cannot always be identified. For example, in the case of one individual’s detention, he was not perceived as being a risk to himself or others, and the police attempted to find an alternative to his management. However, social services advised that he be detained at a place of safety because, despite the individual’s residential home being happy to reaccept him, they would not be able to maintain his safety as they were unable to lock the doors.

contacted by staff member at [residence] as SU [service user] was causing a disturbance in [home town] the police were with him. SU was confused and disoriented and had been incontinent of urine. I spoke to the police officer who said he was reluctant to take SU back to [residence] as he would leave immediately they left and they did not have the resources to keep returning him to [residence]. In view of his vulnerability I suggested that they consider a Section 136 to maintain his safety and dignity.

Progress notes

Records also showed examples of further attempts at diversion prior to police involvement. In one case, the individual recognised the service user had mental health issues and had called the out of hours MHT. However, on not receiving a reply and having continuing concern for the individual, it was deemed necessary to call the police. Furthermore, in the case of a Section 136 detention that occurred out of the force area, the individual themselves attempted to divert the Section 136 by communicating with the relative who called local police to report them missing. Initially, Section 136 was thought to not be applicable as the individual was found in their hotel room. However, once the individual was taken informally to an out of county police station, they were then detained under Section 136:

contacted [other Force] and they have the female at [out of county] police station and the have been updated on the last and the female is currently in the process of section 136.

OIS log

Theme 1: alcohol and drug consumption

Alcohol consumption was a precipitating factor in the decision to locate 11 detentions in custody. The police officers’ decisions to locate 12 detentions in custody due to alcohol consumption and violence show adherence to the local Section 136 protocol. For the three detentions that were initially located in custody but were later transferred to either general hospital or the place of safety, the police made the initial location decision due to alcohol and did not involve the place of safety as they were clearly following protocol. In the case of one of the two detentions that were initially taken to the place of safety but not admitted, alcohol consumption was given as the rationale for non-admittance. However, the officers’ records show that although officers were following protocol in that they did not assess these individuals as intoxicated, the place of safety staff took a different interpretation of the protocol, which prevented location of the service user at the place of safety. This illustrates the importance of interpretation of protocol with regard to alcohol consumption.

Theme 2: risk of violence

Theme 3: resource

Table 8 shows that six individuals were unable to be detained at the place of safety due to issues regarding resource in terms of capacity (n = 3) or technical issues including, broken alarms, locking systems and lighting (n = 3). Officers were informed of these issues during calls made to the Section 136 suite to check availability. None were recorded as being either under the influence of alcohol or violent/aggressive and so met the protocol requirements for entry to the place of safety. Although the suite itself has the capacity to detain two individuals unless one detainee is aged <16 years, capacity is also determined by perceived risk from detainees, available staffing levels and the individual needs of the detainees (Mr Andrew Fox, Head of Social Work, CFT, 2013, personal communication). The following example illustrates capacity issues at the place of safety:

call from [custody suite] to advise that [service user] had been picked up by the police in the town and had been taken on a section 136 to the station. [service user] states she is hearing voices and wants to commit suicide.advised police that we were struggling to find beds as this was the 3rd section 136 at [place name] tonight. tel[ephone] call to [professional],on call manager for the west.advised her of the current situation and the lack of bed space.

Progress notes

Lack of capacity is an acceptable exception to locate a detention in the place of safety noted in the Section 136 protocol. 52 Technical issues are not specifically highlighted in the protocol as a legitimate exception. However, as the safety of service users and staff is fundamental to the protocol, this was regarded as an unavoidable exception. An example of such a technical issue is illustrated below:

female detained Section 136 – [Place of safety] unable to take her…why won’t [Place of safety] take her? . . . no panic alarms working so can’t accept anyone

OIS log

The location of detention itself can impact on resources available in custody to manage the individual once detained. The following examples, although not impacting on the decision as to the location of detention itself, illustrate issues of resource that are affected by the decision to locate a detention in custody. The failure of the place of safety to accept an individual has implications for the police in terms of their resources. Specifically, if the service user is female, a female detention officer must be available to appropriately manage the individual, as shown in the following extracts.

now at [MHL1] – cannot take anyone due to fault with their alarm unit now on the way to you – do you have female do [detention officer] working pse [please]

OIS log

Cust Sgt [custody sergeant] asking for another 1 poss [possible] another female to assist will need to be strip searched

OIS log

The following OIS log details the impact on not only the custody centre but the level of police response available for the geographic area. This followed the decision by the place of safety not to admit the service user due to their consumption of a glass of wine, thereby raising a debate in the interpretation of the protocol as shown in the following log extract:

for inspector [name] to review please the consequence of this on a busy night was that [custody suite] went migrate red due to the needs of this individual which had severe impact on local response cover due to the volume of logs and prisoners pending review by Insp [inspector] [name] – thanks

i will e-mail ins [inspector] [name] about this and ask him to review acquaint himself with this state of affairs and raise it yet again with [Place of safety]. log can be closed.

OIS log

female coming back initially to prevent bop [breach of the peace] . . . will need 2 female officers to search her

OIS log

Theme 1: the impact of alcohol

While someone is detained in police custody, the initial decision to request a MHAA lies with the FME who then requests this from the MHT. In some cases, particularly where the individual was not under the influence of alcohol, the detention under Section 136 was sufficient to prompt the FME to request a MHAA. In these instances, the request was viewed as a routine continuation of the management of the individual through the Section 136 detention process:

will benefit from a MHAA . . . Medical advice DP [detained person] will require a MHAA, assessment requested. Spoken to HTT WEST [NAME] which will pass the information to AMHP and will arrange a MHAA to take place, will call back with an eta [expected time of arrival]

Custody medical form

Intoxication at the time of detention, however, often prevented the decision to request a MHAA as a straightforward follow-on from detention. Twelve individuals were recorded as being under the influence of alcohol when they were detained under Section 136. It was not always clear if their behaviour at the incident that precipitated detention was due to the effects of alcohol or a potential mental health need. In these cases, the FMEs were recorded as conducting an informal mental health assessment when the individual was no longer intoxicated in order to determine the need for a formal MHAA without the potentially confounding effects of alcohol:

Will require MH [mental health] assessment by FME in morning when sober. Medical advice. Referred for formal MHAA.

Custody medical form

Once she had sobered she was assessed by the FME and at that time continued to have suicidal ideation, therefore a MHAA was requested.

Progress notes

Theme 2: mental health history

Mental health history was used by the FMEs to provide support for their rationale to request a MHAA. This information was often provided by the service user in the initial risk assessment and/or the assessment conducted by the FME. Self-report of mental health conditions, diagnoses and previous contact with mental health services aided the FME in building up a picture of the extent of need and previous mental health service input. The persistence of this need also provided impetus for the MHAA request. In the following example, the individual reported both the duration of mental health needs and specific diagnoses which, together with the presenting situation and detention, provided support for the need for a formal assessment under the MHA:

Long h/o [history of] mental health problems. Reports PTSD [post-traumatic stress disorder], depression and OCD [obsessive compulsive disorder]

Custody medical form

Communication between the FME and the MHT facilitated knowledge exchange with regard to mental health history and the presenting situation. In the following case, the FME’s contact with the individual’s MHT provided historical information about the individual’s behaviour in relation to her presentation in custody (non-compliance with medication). Due to the potential for increased risk associated with this behaviour, this provided the main driver for requesting a MHAA in custody:

MHAA requested with AMHP [NAME], she said the morning team which starts @0900hrs will call custody with an ETA [expected time of arrival] for the assessment. DP [detained person] will benefit from further assessment as has become noncompliant with her medication for 1 week and does not need her medication anymore. Discussed with AMHP, DP’s has become non-complaint with medication in the past and then DP becomes unwell. DP has High Risk Behaviour tendencies when upset, which is a possibility due to her recent situation at home and with her personal life. This warrants a MHA assessment at custody and not in the community.

Detention log

In a further example, discussion of the individual’s current behaviour in the context of their mental health history revealed a pattern of potentially escalating behaviour that warranted further attention by services through a MHAA:

P/c [phone call] from Dr[FME], FME at 2.20am. He was asking for advice about [service user]. He had redressed her arms. She had many cuts on both arms and had ‘written’ ‘help me’ on one. She had been picking at her wounds. [FME] reported that she was sober, alert and wanting to go home. He asked if he should release her. I explained a little about her background and that her behaviour recently was becoming increasingly risky. I was not prepared to advise alone. I suggested I would seek views of the duty consultant and call him back.

Progress notes

P/C [phone call] to Dr[name], duty consultant. After hearing of [service user]’s history and recent events he and I concluded that [service user] should be assessed fully.

Progress notes

Theme 3: presenting situation

On receiving a request from the HCP for an initial assessment of mental health needs, the FME conducted an assessment of those individuals detained in custody. In general, records showed that an assessment of the presenting situation included evaluation of both mental state and personal care as well as any change in presentation during detention.

Mental state was assessed through self-report during discussion with the individual, direct observation during assessment and detention logs, and reports of officers who had been conducting regular checks on the individual throughout the detention. Records showed that assessment focused on what was perceived to be paranoid or delusional behaviour. The following extracts from the custody medical form of individuals being assessed by the FME show examples of paranoid and delusional beliefs that were seen to precipitate the need for a MHAA:

Today seems paranoid – believed police were trying to kill her and her child.

Custody medical form

DP [detained person] stated she does want to be alone, she stated she hears voices and would like kill herself.

Custody log

Other detention related issues? – ‘Yes. states she hears voices all the time’

Medical form

Assessment of personal care included the individual’s ability both to self-care and engage with services, including the potential to engage with services in the community should the individual be discharged without being formally assessed, as well as compliance with medication. The following extract from a custody medical form shows how an individual’s overt non-compliance with medication can have a direct impact on the FME’s perception of the need for a MHAA:

DP [detained person] is noncompliant with her medication and is refusing to start taking them again. DP stated she is on various medication but feels better now and does not want them. DP called the police tonight and stated she does not want to live anymore. DP has changed her statement and stated to me that she does not remember. MHAA requested for the morning (DP is well known to the CMHT) due to 1. DP Noncompliant with medication. 2. High risk behaviour when upset. 3. DP calling police and going missing tonight and stated she is afraid she will harm herself. 4. DP stated she does not remember saying or doing anything tonight and that everyone is lying that she called the police.

Custody medical form

Perceptions of individuals’ ability to self-care involved an assessment of risk of self-neglect. An individual’s inability to engage in appropriate self-care was evidenced by historical knowledge (either from self-report or discussion with the MHT), circumstances of the detention and/or direct observation of current presentation. The following example from a custody medical form relates to an individual for whom a MHAA was requested due to both mental state and concerns for self-neglect due to the circumstances in which they presented at the time of detention and continued to present in custody:

Seen re Section 136 assessment. Brought in very confused & self neglected after call from concerned MOP [member of public] – out on road, shuffling, very self neglected, covered in own faeces, confused ++, refused to return to own address, brought in on Section 136 as concerns for personal safety . . . Unable to assess MH [mental health] fully but no SI [suicidal ideation] expressed, denies ideas DSH. D/W [detainee with] AMHP [NAME] who is here for another DP [detained person], agrees.

Custody medical form

The above discussion showed that change in presentation when an individual has been under the influence of alcohol can determine the decision to request a MHAA. In the same way, change in presenting situation with regard to mental state and behaviour can also impact on this decision. In the following example, the change in the individual’s behaviour, coupled with the assertion by the FME that he would not engage with services in the community if released, drove the decision to contact the AMHP to request formal assessment:

advised DP [detained person] that I will go to speak with the MH [mental health] team and get back to him in regards to if he will be assessed in custody or not. I spoke with OOH [out of hours] MH team AMHP [NAME], I advised her that he appears well to be sent to home address with no MHAA in the custody, she agreed. I went to talk to DP that he will be going home and he became upset and stated that he wants to be released now and became aggressive and punched and kick the cell door. He stated he will make his own way back to [home town] from [police station]. DP became unpredictable and irrational and refused to give his address. The Custody srgt [sergeant] assisted me when I went to see DP and concluded that he will not release DP with this presentation of unpredictability and irrationality. I have spoken with AMHP [NAME] and requested her for full assessment on the new presentation and that he will not keep his appointments in the community and that he will require further assessment (which he missed) which can be arranged at the custody under the MHA and that he will benefit from a period of further assessment at the hospital due to his unpredictability, vulnerability and non compliance with medication and him not attending his assessment set out in the community.

Medical form

Theme 4: resource

The availability of resource emerged as relevant to the decision to request a MHAA, in terms of staffing and in timing of the MHAA. First, both the required levels of staffing (including Section 12 doctors and an AMHP) and the co-ordination recommended by the MHA (which recommends that all practitioners conduct the assessment simultaneously) carry resource implications. It could be argued that this is further exacerbated in a large rural site due to geography and associated logistics. The following extracts from a police detention log and mental health progress notes, respectively, highlight these resource issues in making the decision to request a MHAA:

have called home treatment team and spoken to AMHP [name] she stated they can not get any Dr’s at this time as there are two more 136 at [place name]. she stated it will probably be some time this afternoon before anyone will be available. she will contact when arranged.

Detention log

It was now almost 3am and I was unlikely to find a s12 [Section 12 of the Mental Health Act 1983;18200719] doctor who would respond as they would be working in the morning.

Progress notes

Resource as a precipitating factor in the decision to not request a MHAA can have a negative outcome for the individual, particularly in terms of timing of the MHAA. As shown, individuals can be detained under Section 136 for up to 72 hours. However, this duration of detention, particularly in custody, is not considered to be in the best interests of the individual. Where timing of either the FME assessment or the MHAA could potentially prolong detention, efforts were made by police to provide solutions to expedite the process of requesting and securing a formal MHAA for detained individuals. The following entry in a detention log illustrates one officer’s attempt to reduce the time required to wait for an assessment of need for MHAA by the FME:

Considered transferring DP [detained person] to [place name] to assist in speeding up the FME assessment, but it is likely DP will need to be dealt with by her own team and this will not happen until the morning, therefore no benefit to a transfer.

Detention log

Theme 1: imminent risk

The imminent risk associated with managing the care of an individual in the community was a major consideration in the decision to detain under the Mental Heath Act following formal assessment. As was the case when considering risk in the initial decision to detain under Section 136, risk was assessed according to risk to self (the individual) and risk to others, both of which are presented below.

As previously discussed, all detentions under Section 136 in this sample were perceived as being a risk to self by the attending officers. Further assessment of risk to self was undertaken within the MHAA to determine if the individual remained at risk. For example, it was noted above that risk to self at detention could be due to the location of the individual on apprehension (e.g. on a railway bridge). Although location was not a factor during assessment, the MHT would need to assess if the individual was likely to return to the risk location on discharge. Furthermore, for those individuals threatening suicide, the potential and imminency of this risk was reassessed. The following example is an extract from the mental health progress notes of an individual whose continued elevated potential risk to self was a factor in the decision of the MHT to detain under Section 2:

At the moment she is in a low period and has constant thoughts of wanting to end her life. Decision made to detain given significant risks to self (recent significant paracetamol overdose and being found on train tracks last night).

Progress notes

As presented above in relation to the FME’s decision to request a MHAA, intoxication was a factor that changed the perception of risk to self. In the following examples, individuals who were considered a suicide risk at detention did not express the intent to commit suicide when no longer under the influence of alcohol and therefore were no longer considered a risk. They were therefore able to receive appropriate care in the community without the need for detention:

acute suicidality under the influence of alcohol and social adversity, with underlying depression. suicidality now resolved in sobriety and ready to return home with appropriate support.

Progress notes

[service user] had recovered from her drinking yesterday and denied any further thoughts of suicide.

Progress notes

Consideration of risk to others contributed to almost half of police decisions to detain under Section 136. As with risk to self, risk to others was reassessed in the MHAA to assess the potential for continued risk and to determine the imminence of this risk and thereby the need for detention:

Discussed case with Dr. [name] Duty Con Psyh. [consultant psychiatrist] and Dr. [name] S.12 agreed she had a degree of capacity, but she may pose a risk to her child without back up care and support for her and [daughter], also with no medication to manage her mental health overnight would place her and child at risk. [service user] was placed under Section 2 of the M.H. act 83-07.

Progress notes

Furthermore, analysis showed that in some cases, a combination of risk to self and risk to others was explicitly stated as supporting the rationale for formal admission. In the example below, imminent risk to self and others coupled with lack of appropriate informal support to manage the individual’s behaviour was a factor in the decision to detain.

[service user] was admitted under the M.H. Act due to risk she pose to herself and other (son). She would be managed at home overnight if medication was available with the support of her ex-partner, but given that they are no safeguard her risk was too high to remain at home.

Progress notes

Conversely, the decision not to detain in the example below was based in part on the lack of risk posed by the individual either to himself or others:

no evidence of risk to self or others due to mental illness

Progress notes

Theme 2: formal management

Although all but one of the individuals detained following MHAA were on caseload at the time of detention, effective management due to being both known to services and under current care was not guaranteed following detention. Therefore, the MHAA included assessment of level of engagement with services and compliance with medication from historical records, the report of third parties and self-reports. Engagement and compliance were varied across cases and recorded as factors in the decision for formal admission. The following example is of an individual who was not detained, partly due to his expressed commitment to engage with short-term intensive support from the HTT:

He said he was happy to accept support from HTT in the short term and agreed to daily visits, he also agreed to use the telephone service if he was feeling suicidal, saying that he had found talking with us useful today. He said he did not want to go to hospital, but rather get on with his life. Given the guarantees we did not feel he was detainable; he also was very distressed about been locked in a cell, therefore forcing him to be in hospital would have proved counter theraputic.

Progress notes

In contrast, the following extract is from the notes of an individual who was detained under Section 2 following both multiple Section 136 detentions in the research window and observation of lack of engagement with services:

She has been supported by the HTT over the past couple of days but today has refused to engage.

Progress notes

Lack of engagement with services in the following example was coupled with lack of compliance in taking medication. In this case, both factors contributed to the decision to detain the individual under the MHA as it could not be guaranteed that community services could deliver the care and management required.

Had earlier refused to see the CMHT as he was convinced that he was going to die complained of chest pain. Has been refusing to take his meds consistently in the community.

Progress notes

Similarly, decision to detain in the example below was precipitated by both lack of service engagement and non-compliance with medication. The individual was offered informal admission to ensure compliance with medication that had affected his sleeping pattern. However, on indicating he would not engage with the voluntary service offered, detention under Section 2 of the MHA was viewed as the only course of action available to ensure he received the care and management required.

He has not been compliant with meds recently and has had very little sleep. Was offered an informal admission which he initially appeared to accept. However when I returned to the cell to go over this again with him and ascertain whether he had understood this he refused and given the concerns of assessors was detained under s2 [Section 2 of the Mental Health Act 1983;18 200719] MHA

Progress notes

Theme 3: informal management

The availability of informal support and management from family, friends and other carers was a further important factor in the decision to detain following MHAA. Every MHAA includes consultation with family or carers where applicable and appropriate, and evaluation of whether or not family and/or carers are willing to and capable of providing the required support. The availability of this type of support, or lack thereof, can impact on the decision to detain, as illustrated in the following two examples:

Has good supportive relationship with grandparents, a poor one with his mother, and says he has never seen his father

Progress notes

little support from family: [service user]’s nearest relative is her son [son]. He is currently away on holiday in [overseas] with his friend. [service user] have since spoke to him via his friend phone letting him know what her current situation is. In view of this and [service user] not able to remember contact details of her son’s friend I was unable to have a discussion with her NR [nearest relative].

Progress notes

It was also important to review regularly the ability of family member/carers to maintain support for their relatives suffering from mental health conditions. This ability may change as a result of the individual becoming more challenging or the personal circumstances of the family member/carer. The following example involves an individual who was detained under Section 136 twice in the research window; the extract relates to his first detention. An entry in the mental health progress notes shows how the individual’s mother, who cares for him, is finding managing his condition increasingly challenging and describes the support that she herself requires in order to effectively care for her son. On the second detention, due in part to the potential risk to his mother which prevented her from being able to manage him at home, the individual was detained under Section 2 of the MHA.

Mum agreed that [service user] could go there this evening but is finding it increasingly difficult to know how to manage [service user]. Mum has done lots of research on BPD [bipolar disorder] but is unclear how best to respond when [service user] in crises. She has not had a carers assessment and she agreed that she would find this useful. Mum has had her own counselling at the GP [general practitioner] and is due to cease this shortly, she would be interested in any support groups for carers. Mum said that part of the problem has been [service user]’s refusal for information to be disclosed to mum, agreed I would discuss this with her and ask that a carers assessment and support be officered to [service user]’s mum.

Mental health progress notes

Theme 4: behaviour

Behaviour that precipitated the decision to detain following MHAA, similar to that which drove the decision to request a MHAA by the FME, often centred around behaviour considered to indicate underlying delusional beliefs. In term of the MHAA, this behaviour was either directly observed by the professionals undertaking the assessment or was described by the individual themselves. For example:

Assessed by Dr[medical 1] and Dr[name] S12s [Section 12 of the Mental Health Act 1983;18 200719] and [name] AMHP. Presented as confused, thoughts being blocked and felt the cell was being bugged. Felt that his flat would have been ransacked whilst in custody and believed that this had been transmitted to him. He also felt that his computer will be being used and his phone but could not explain by who or why. Paused for long periods between answering questions and often appeared to lose concentration.

Progress notes

Additionally, consideration of mental state contributed to the decision-making process when individuals were unable to look beyond the present, with a bleak or limited outlook toward the future. The following extract from the formal recording of the MHAA in the mental health notes of an individual detained under Section 2 of the MHA showed that this feeling of hopelessness toward the future contributed to the assessment of risk and, therefore, to the need for detention:

[service user] very emotional at times, concerns that she had no sense of hope and could see no way forward. Given level of risk and recent high risk behaviour decision to detain for assessment.

Progress notes

Certain types of behaviour in the custody centre and during assessment also elevated the potential risk to self to such an extent as to warrant detention. The following extract from the formal record of the MHAA presents the rationale for the need to detain for further assessment under the MHA as in part attributable to this. Furthermore, in this case, health professionals took into account that the level of informal management in place was unable to meet the needs of the individual given the presenting behaviour:

Patient presented as mono-syllabic and totally uncooperative. Following interview whilst professionals were discussing options patient locked herself in the toilet and stuffed toilet paper in her mouth. Presented in a teenage tantrum manner. It was felt that admission was perhaps not clinically the right way to go but given her behaviours whilst in the suite and the fact that her father was unable to cope and unable to maintain her safety and she would consequently have nowhere to go there was no other option than to admit to hospital. As she would not go as an informal patient she was detained under S2 [Section 2 of the Mental Health Act, 1983;18 200719].

MH1

Lack of insight on the part of the individual was also taken into consideration in the decision to detain following assessment. Perceived lack of insight included denial of mental health condition or diagnosis and irrationality:

GP [general practitioner] diagnosed bipolar disorder but patient refuses to belief this is the case

Progress notes

[service user] was not clear about exactly why she had gone to the railways station. She said she was in the station toilets when the police detained her. She said she was not planning to throw herself in front of a train and pointed out that, at the railway station, the train would be travelling at low speeds or even stopped and then it would be difficult to throw oneself in front of the train there.

Progress notes

In comparison, the behaviour of individuals who were not detained was perceived quite differently by the MHT. As might be anticipated, these individuals displayed an absence of the behaviours that were viewed as being indicative of a mental health condition requiring assessment and potential treatment. Furthermore, they displayed insight:

No evidence of thought disorder, no delusions, no abnormal perceptions. Has insight and has accepted support.

Mental health core assessment

Evidence of good personal interaction, appropriate engagement with the questions in the assessment and the individual’s positive demeanour were associated with decisions not to detain following assessment:

[service user] presented as bright and friendly. He had good eye contact and did not present as depressed or anxious.

MH1

[service user] had stopped taking her prescribed medication. This may have contributed to her presentation of underlining irritability and elevation in mood. There were no obvious signs of [service user] being troubled by intrusive thoughts. She maintained good eye contact and although some of her answers were a little evasive in the main she did answer coherently. Reasonable eye contact and rapport.

Progress notes

As was the case with the FME decision to request a MHAA, the MHT also assessed any changes in behaviour during the assessment, including those that could be indicative of alcohol withdrawal rather than mental illness requiring detention under the MHA. Other changes in behaviour were also noted that enabled the team to differentiate between behaviour that indicated a condition requiring detention or that which could be treated in the community. In the following example, elevated mood of the individual on seeing her family indicated that the flattened affect with which she initially presented was not pervasive:

Appeared tearful at times, initially flat but becoming more spontaneous and smiled when her mother and boyfriend arrived.

Progress notes

Follow-up in the community following Mental Health Act assessment

Nineteen of the 25 individuals formally assessed under the MHA were not detained. Progress notes and the formal recording of the MHAA were examined to determine if there was any follow-up care or management of these individuals; this ranged from no plan by mental health services to enhancement of care plans. Five individuals were not provided with any follow-up, with three of these advised to contact their general practitioner (GP) (one was provided with a letter to support this). Four individuals were advised to continue with the support of their current care teams (including HTT and CMHT). For one of these individuals the MHT liaised with the current care team to ensure that the existing package of care was continuing. One further individual who was not on the caseload of mental health services, but was being supported by domestic violence (DV) services run by the police, was advised to remain engaged with these services following detention. Eight individuals were offered enhanced care following MHAA. Of those, five were not on the caseload of a MHT at the time of detention: of which three were referred to either a CMHT or HTT, one was referred to an alcohol specialist nurse and one was put in touch with CPN support. Of the three that were on the caseload of general secondary mental health services, two were to be followed up by their current care teams and one was to be provided with support with her current housing needs.

Post-detention actions by the police

Actions taken by the police to follow-up an individual at the point of disposal and afterwards were explored by looking at the final outcomes on detention logs and whether information about an incident had been entered into new or existing non-crime vulnerable adult records. In some cases, the police provided referrals and support in addition to that provided by the MHT listed above. This included transport home and between hospitals (n = 5), advice and directions as to how to return home (n = 1), advice regarding housing (n = 2), and making direct contact with services on behalf of the individual (n = 1). Finally, two individuals were offered referrals to external service, these being drug and alcohol services and a women’s rape and sexual abuse centre.

Recording of non-crime vulnerable MHA records by police would have been required for nine of the incidents as they occurred in October 2011 or later, from when a record of a Section 136 incident was required, including the outcome from the mental health services. However, in three cases, a record was not created.

In the four cases predating October 2011, entries were made in the pre-existing non-crime vulnerable adult records (n = 3) and information was recorded retrospectively in a record linked to a later event (n = 1).

Theme 1: decision to instigate information exchange

As discussed, although police may have knowledge of mental health issues of individuals, this knowledge is often limited to PNC warnings, their own past experience of the individual and information conveyed by operators. It is useful to examine the rationales for information exchange between services in order to understand the nature and degree of success of communication and the impact that this has on the care/management of the individual and their disposal. Contact was made with MHTs associated with individuals prior to five arrests. For example, the following notes were recorded on OIS logs pertaining to contact made with the individual’s CPN:

just taken the call from [CPN: manager of CMHT] she has been speaking to SU [service user] and can clearly hear the sound of hissing gas in the background of the call.

OIS log

Although the information exchange in this case did not directly aid the decision to detain, it did open up the lines of communication between services and supported the joint management of the individual through his detention and subsequently.

Furthermore, in one case, contact from the housing provider of the individual to the police and to mental health services provided information that both alerted the police to the offence and provided information required by mental health services to aid their decision to conduct a MHAA:

[service user] did not attend clinic today. Informed by [housing professional] at 4.30pm that they have had to alert the police because he is armed with a machete as well as a firearm (air rifle/pistol). Endorsed their decision to call the police. Informed that I would alert HTT and duty consultant but that the police needed to be informed that a psychiatric assessment needed to be conducted under safe circumstances. HTT alerted. Discussed with duty consultant and background details given.

Progress notes

Information exchange also provided police with reassurance as to the management of the individual. For example, in the case below, direct contact with the support worker provided information as to the mental state of the individual to be detained and the level of need in terms of mental health input required on detention:

[NAME] who is support worker says she isn’t coming round, she is quite happy that [service user] and [service user friend] remain there are on their own and capable to look after themselves. She considered it attention seeking as [service user] is new to the house and has taken the attention away from [service user friend]. Support worker’s number has been given to [service user] who says she is happy to speak to them at any point during the night but won’t be attending

OIS log

The decision to instigate information exchange between services at the point of despatch of officers to the scene was guided by prior knowledge of mental health issues associated with the person concerned. This knowledge stemmed from either the experience of the police officers themselves and/or the operators relaying information to officers from their own direct experience of co-ordinating previous incidents and/or from their examination of associated police records. Examination of the records in relation to these precipitating factors is provided below.

Theme 2: decision to use restraints in the conduct of arrest

The Independent Commission on Mental Health and Policing’s recent (2013)42 report highlighted the disproportionate use of restraint with regard to the cases examined. Due to the secondary data on which the case-linkage study relies, factors covered in the report such as length of time in restraints could not be examined in this research. However, recorded rationales for restraint were identified and coded through examination of the OIS logs. Restraints in the form of handcuffs were used in 46% of arrests (n = 58). Thirty seven (63.8%) of these involved an individual recorded as being under the influence of alcohol/drugs, which could be a contributory factor in the decision to use restraints due to the potential for unpredictable behaviour. There is no regulation for officers to record a rationale for their decision to use restraints during detention. However, specific rationales were available for 11 of the 58 (19%) detentions in which restraints were used and fell within three themes. Each theme is noted below with example quotations from OIS logs:

i. Use of restraints for the individual’s own safety (n = 5).

lady in cuffs for her own safety

female did try to out a ligature around neck – string from clothing (in van)

No injuries or threats made to officers at scene. Captor deployed to stop subject injuring herself.

male is banging his head on the van and thrashing around.

male is banging his head against the cage

ii. Use of restraints to maintain the safety of others (n = 4).

male says if I take the handcuffs off him he is going to smash my face in and everyone around him.

DP [detained person] asked to wait outside for officers but refused myself and PS [police sergeant] attempted to escort DP outside he became violently aggressive and was take to the floor where he proceeded to spit in my face – arrested placed in cuffs and escorted to cell.

would advise Taser. Units to effect arrest as male can be unpredictable and known to use drugs. [incident where restraint was used and Taser also authorised]

Female wasn’t pleased to see us now under arrest for breach of the peace and was quite violent on arrest.

The rationale provided for the use of restraints for one individual was due to both safety of the individual herself and others: ‘has tried to strangle herself in the back of a van with a sock’; ‘DP [detained person] in handcuffs as attacked police at the scene of arrest’.

iii. Use of restraints to aid the conduct of the detention (n = 1).

Finally, one rationale was based on the need to conduct the arrest, as the service user was uncooperative:

[service user] is in the house refusing to come out so have to put the door in.

Although the records examined show that restraints were used in almost half of the arrests examined here, due to the lack of rationales for the majority of these cases and the lack of measure of effectiveness in meeting the identified rationales, it is not possible to conclude as to whether or not the use of restraints in this sample was disproportionate.

Theme 3: decision to authorise tasers

The Metropolitan Police Service survey ‘Mental Health and the Police’, cited in the Independent commission on Mental Health and Policing’s report,42 reported that 34% of taser deployments were linked to individuals or incidents related to mental health. The Commission further reported that in the cases that they examined, officers were unable to comment on the efficacy of taser deployment in the management of detention. In the current research, tasers were authorised but not deployed during the conduct of five arrests and armed response officers were deployed to a single further incident. In order to understand the precipitating factors for the decision to deploy, OIS was examined to determine the rationale for authorisation. For all incidents, including that to which firearms officers were deployed, the rationale was based on the potential or actual possession of a weapon by the individual. With regard to the taser authorised incidents, potential or actual possession of knives were the basis of the rationale in the case of three incidents:

knife mentioned

threatened mother with knife

knife – male had a knife in his back pocket and showed them the knife but did not take it out of his pocket they only saw the handle – black, about a 3 inch blade – poss. a veg knife.

In addition, a general threat of possession/use of weapons was the rationale for the remaining two incidents:

male is stood on the top of his car and has dented his roof. RP told him to get off and he said no! he’s possibly in possession of a weapon also but caller can’t see what it is.

male armed himself with an iron bar, mother will not let us in.

The clear rationale for deployment of firearms officers to the scene of the final incident was potential possession of a crossbow:

**note PNC marker – possible possession Crossbow** asks if [housing organisation name] have any restrictions of holding these items in his room . . . having these items in his room is not an offence as such . . . to clarify last their policy is that ‘he cannot have weapons on the property’

As noted, although tasers and armed response were authorised for the above incidents, none were deployed and the decisions not to deploy was not available for scrutiny in the secondary data analysed for this research, as these were not recorded.

Theme 1: decision to instigate information exchange between services

Records were examined to determine both the level of mental health service involvement and communication with MHTs during detention. As highlighted above, examination of current caseload at the time of arrest was made in order to identify if current access to mental health services was a precipitating factor in the decision to instigate information exchange. Fifty-five related to an individual on caseload at the time of detention (Figure 15). For 25 (45%) of these detentions, there was communication between police and MHTs during detention (Table 12). Regarding the 71 detentions related to an individual not on caseload at the time of detention, there were only eight (11%) records of communication between police and MHTs. Therefore, there was a higher proportion of information exchange between services for those cases on caseload at the time of arrest than for those not on caseload, suggesting caseload status as a precipitating factor underpinning this decision. Although not clear from the records available, such communication may be facilitated by the service user or family/friends present at the incident, informing the police of the caseload status of the individual. Mental health progress notes, custody medical forms, and detention logs were examined to determine the origin of initial contact, the rationale for contact, and any information exchange due to the call.

FIGURE 15.

Degree of communication between police and MHT depending on caseload status of individual.

Ten of the 25 (40%) recorded communications for those contacts on caseload were directly between police officers and the MHT. Four of these contacts involved provision of information regarding the arrest of the individual. Five included requests for an AA, including highlighting the need for an AA for court and two included a request for MHAA. In one instance, the detained individual requested that his CPN be made aware of the detention. In terms of the care and management of the individual, one contact involved a request for a CPN to provide support for the individual, one consisted of a request for information as to the nature of the current support received by the individual and one requested information as to the possible support that could be provided by the individual’s supported housing on their release. In two cases, information exchange between police and mental health services culminated in a recorded joint decision. In one of these cases, a joint decision regarding support in custody was made between services because of this communication due to the individual having a general anaesthetic for electroconvulsive therapy in the last 24 hours. In the second case, the information was to inform the FME’s assessment which would be fed back to the MHT with a plan of management for the individual.

Six (24%) of the 25 contacts on caseload where there was communication with mental health services during detention were directly between the FME and mental health services. Two of these were recorded solely as direct requests to conduct a MHAA. In the third case, a joint decision was made between the FME and MHT not to conduct a MHAA and in a fourth, an assessment other than a formal MHAA was requested by the FME, which resulted in the individual being referred to a CMHT. The final two examples were requests by the FME, first for information regarding if the individual was fit to release and second, to request that the individual’s care co-ordinator contact the custody centre following the individual’s return from accident and emergency (A&E).

Four of the 25 contacts on caseload where there was communication between services during detention were between the HCP and MHTs. In all four of these cases, records showed provision of information concerning the details of arrest with one individual explicitly requesting that the MHT were made aware of the detention through the HCP. These communications also involved requests for information to facilitate management of the individual in custody. This included requesting (and questioning) the level of support currently being received by the individual, requesting additional support for the individual while in custody, requesting general information about the individual and asking for corroboration of information provided by the individual with regard to previous section and future mental health service appointments.

In two cases both the police and FME contacted mental health services, both of which involved requests for MHAAs, provision of information regarding the detention and in one case, the raising of police concerns about releasing the detained individual due to threats made to harm others.

In one case, the MHT had called the police prior to detention to report the service user as a missing person, which had facilitated continued communication through to ensuring support in court from a court liaison nurse. Finally, in two cases there was recorded communication between the AA and the mental health services. In one instance, this communication also involved the HCP and related to an enquiry regarding the individual’s medication following release from custody. Communication facilitated arrangements to be made to ensure that the prescription required contained the correct information to meet the needs of the service user. In the other example of AA–MHT communication, the AA’s communication with a social worker led to a referral for the individual to social care services.

Six of the eight communications relating to contacts that were not on caseload at the time of arrest were directly between police officers and mental health services (Table 13). Of these, five were solely to request an AA. The remaining two examples were communications between the MHT and HCP and the FME and police respectively. Rationales for communication included the provision of information regarding the arrest, information requested as to the mental health condition of the individual and alerting the MHTs that requests for MHAAs may be required.

Theme 2: decision to request an appropriate adult

The decision to request an AA for an individual in custody lies with the custody sergeant. According to PACE, ‘When the custody officer has any doubt about the mental state or capacity of a detainee, that detainee should be treated as mentally vulnerable and an AA called’. Forty-two requests for an AA were recorded in the detention log and/or the custody medical form, of which 30 had an explicit rationale recorded for the request. Table 14 shows the proportion of rationales provided under each category. Mental health was either the sole or a contributory precipitating factor in the rationale for requesting an AA in 19 cases, with a specific diagnosis of a mental health condition being a factor forming the next largest group (n = 11, with three cases also explicitly recording a statement of concern regarding mental health). Diagnoses included schizophrenia, bipolar disorder, borderline personality disorder and psychosis. Rationales identified as implicit within the records by the researchers concerning mental health were recorded due to one detention involving a MHAA where attending mental health practitioners acted as AAs and the other detention involving an FME assessment for a MHAA during the course of the detention.

Detention logs, custody medical forms and mental health progress notes were examined to determine the rationale for requesting an AA. Eighty-six (68.9%) cases did not have AA support during detention. Thirty-one (24.6%) detentions had a record of attendance of an AA, and the remaining 11 (7.1%) had no record of AA attendance although attendance had been requested. This did not necessarily highlight that an AA had not attended, but may have reflected lack of explicit recording of attendance. Of the 31 requests that culminated in AA attendance, 19 were made by the HCP and the remaining 12 were made by the detention officers alone.

Theme 3: decision to authorise Police and Criminal Evidence Act 1984 clock extensions

The ‘PACE clock’ refers to the 24 hours in which police are able to detain and charge individuals following arrest. The PACE43 requires that a detained person (DP) has the validity for detention regularly reviewed. An individual can be released or charged at any time while detained. On arrest, a person should be taken directly to a police station and custody of that individual should be handed over to an officer of at least the rank of sergeant (constable only in exceptional circumstances). The role of the receiving officer, referred to as the custody officer is to determine that the arrest was lawful and that there is sufficient evidence to charge that person for the offence for which they have been arrested. If there is insufficient evidence to charge, the custody officer may authorise the detention of that person in order to secure and obtain evidence or to obtain evidence by questioning. As soon as there is sufficient evidence to charge, the person must be charged and released either with or without bail.

Reviews are made at regular interviews throughout the detention process. The role of the reviewing officer is to ensure there are sufficient grounds for further detention and that the investigation into the offence is taking place expeditiously. The time of the first detention is known as the ‘relevant time’. Approximately 6 hours after the relevant time, an officer of at least the rank of inspector must review the reasons for detention and, if appropriate, authorise further detention for the same reasons as above. Following this, 9 hours after the first review (or 15 hours after the relevant time, whichever is the sooner), a further review must be conducted by an inspector or above and, if required, further detention can be authorised.

After 24 hours following the arrest, the DP must either be charged and released with or without bail or released from custody unless a superintendent authorises detention for up to a further 12 hours. This authorisation can only take place following the second inspector’s review. A superintendent’s extension is rare and usually only considered for a serious offence. Following this, and only in extreme cases, a further extension of detention can be obtained from a magistrate’s court for up to a total of 72 hours.

Examining detentions within this sample, the mean time spent in custody was 9.2 hours (range = 0.25–27.00 hours). According to PACE, detentions in custody should not exceed 24 hours without charge. Therefore, the rationales to extend the time in custody over the 24 hours, and the total time held, in the case of four detentions were examined here (Table 15). One of these detentions (27 hours in custody) was a failure to answer police bail, which is not subject to PACE and, therefore, is not included in the findings below (see Table 15). Mental health needs and the provision and arrangement of assessment supported the rationales associated with two of the remaining three PACE clock extensions. Although it is ultimately a police decision to review and extend the clock in accordance with PACE, this can be due to delays that are not under the control of the police, as was the situation in the final case examined. The following extract records the rationale for an extension due to a delay in the arrival of the team to conduct a MHAA:

the grounds are DP has been in custody on sus [suspected] criminal damage and has been awaiting mental Health assessment before he can be spoken to with regard to allegations. This is just commencing and as such, he will not have had the allegation put to him within the 24 hour period. Requests made for review of his detentions and a further 4 hours to allow for interview and any further enquiries to take place I authorise further detention of SU [service user] without charge until 20:00

Detention log

Theme 1: detention circumstance

Analysis of the circumstance of the detention showed that assessment of risk to self and others was an important factor in the decision to conduct a MHAA and mirrors the precipitating factors that underpinned the decision to detain the individual. Risk to others was a factor in the rationales for all seven MHAAs. In one case, the need for a MHAA due to threatening behaviour constituted the main rationale for the initial detention.

Informed by [housing professional] at 4:30 pm that they have had to alert the police because he is armed with a machete as well as a firearm (air rifle/pistol) Endorsed their decision to call the police.Informed that I would alert HTT and duty consultant but that the police needed to be informed that a psychiatric assessment needed to be conducted under safe circumstances. If patient not admitted or not taken into custody I will attempt an urgent assessment next week to evaluate risk to others in light of today’s information

Progress notes

P/c [phone call] from [service user]s mum prior to midnight, she had called the police earlier today and they had agreed to take her to a women’s refuge for her safety . . . she was then made aware that they had attended her home and removed [service user] for common assault, he had pushed her across the landing earlier . . .

Progress notes

Risk to self was evident in the rationales for four of the seven requests for MHAAs. All of these cases involved DSH at the time or immediately prior to detention. In the examples below, the need for a MHAA again links back to the original rationale for the detention:

PC [police constable] from police to [professional]. they have detained her on a SCT 136 [section 136; there was a misunderstanding about the detention which was for a Breach of the Peace] after been called by her mother, she absconded when they arrived and was found cutting herself; taken back to mother’s where she resumed cutting herself and had to be handcuffed, paramedics attended to the cuts. [Professional] liaised with the ward who felt she was not appropriate to be supported in 136 suite, so will be taken to custody.

Progress notes

DP has attended hospital in early hours for attention to cut to left wrist/arm (not assessed as DP refused) also for MHA. DP became too aggressive & was bought to custody.

Custody medical form

Theme 2: presenting situation

The presenting situation in custody also supported the rationale to request a MHAA. Regular checks are made on detained individuals, which include monitoring of behaviour to ensure that assessments by the HCP and FME are made as appropriate. Behaviour recorded by the attending officer, detention officer, reviewing officer or HCP influenced the decision to conduct a MHAA and the outcome of that assessment. A range of behaviour recorded in the detention logs, custody medical forms and mental health progress notes emerged as underpinning the rationale to request a MHAA.

Lack of co-operation with officers or medical staff was noted in two of the seven cases in which a MHAA was requested. In the following example, information conveyed by the HCP to the MHT detailed the difficulty in appropriately assessing the individual due to uncooperative behaviour:

[name] said that he was now settled and been sleeping since 23.00, he said [service user] had been uncooperative, refusing to speak to custody nurse, [name] had yet to see him being currently at [place name].

Progress notes

Perceptions of behaviour apparently indicative of mental health issues also contributed to the rationale for MHAA requests. Assessment of this behaviour following direct observation was evident in the rationales for five of the seven MHAAs and included behaviours perceived as reflecting paranoia and auditory hallucinations:

Some paranoid ideas and bizarre statements expressed in patient known to drugs team who has been described by them as psychotic and who has been referred to CMHT

Progress notes

P/C [phone call] from dr. [name] at [custody]. [service user] presenting much the same as 2 weeks ago but with superficial cuts to arms. States she is hearing voices.

Progress notes

He is presenting as paranoid, suspicious

Progress notes

DP is presenting with paranoia, odd behaviour, agitation, pressure of speech.

Custody medical form

Monitoring of detained individuals enabled any change or continuation in behaviour to be assessed and recorded. Three of the individuals for whom a MHAA was requested and conducted presented with suicidal ideation on detention. The persistence of this ideation was an influential precipitating factor in the request for a MHAA, particularly where this persisted when the individual was no longer under the influence of alcohol:

FME continued to request MHAA due to suicidal ideas.

Custody medical form

He is now not under the influence of alcohol. [service user] is now stating that he intends to swim out to sea and drown himself once released.

Custody medical form

Further persistent behaviour that contributed to the rationale to conduct a MHAA included that which indicated a risk to others. In the following example, the continuation of threatening behaviour toward others was recorded in the custody medical form:

DP seen in cell as volatile & making threats to harm others. DP is visibly agitated & angry, no evidence to suggest alcohol intake & drug use denied. Vital signs normal.

Custody medical form

Finally, the individual’s presenting situation could have a direct impact on the resource allocation and timing of the MHAA. The data show that the delay in despatching the MHT to conduct a MHAA could be due to acting in the individual’s best interests and the conduct of an appropriate and accurate formal assessment of the individual’s mental health under the Act. For example, if the individual had consumed alcohol, a MHAA could not be conducted until they were no longer under the influence and were able to be appropriately assessed:

Discussed with AMHP [NAME]. Advises I speak to duty consultant Dr [NAME] who is here to see another DP currently. Is FTD [fit to detain] in interim. They will arrange review tomorrow by own team when sober.

Custody medical form

Theme 3: resource/availability

Resourcing issues represented another factor that influenced the decision to request a MHAA. For five of the seven MHAA requests, resource issues were recorded as causing a delay in the conduct of the MHAA. As presented above for two cases, this resulted in their detention being extended beyond the 24-hour PACE clock. Generally, resource issues were related to staffing. In the example below, the mental health staff had already conducted a MHAA assessment and there was no capacity to conduct another MHAA until the following morning:

Informed Custody Sgt [sergeant] that MHA assessment will be arranged for morning of 11/7/11 as AMHP has just returned from MHA assessment (5 am) and it will not be able to set up MHA assessment until day shift comes on duty at 8 am. Custody Sgt ok with this but said that [service user]’s Mother had been informed that MHA assessment would take place at 10 pm last night by the mental health team and would be upset that this did not happen. I said [service user]’s Mother will be informed when MHA assessment takes place.

Progress notes

In a further case, resource issues drove a request by the MHT for a review of the current situation by the FME to ascertain whether or not a MHAA was still required. The request was refused by the police, however, as not conducting a MHAA following the original request by the FME would go against policy (PACE code of practice C: Fit to detain, fit to interview).

T/C [telephone call] from [L33] asking expected time for the MHAA. Informed them that no time had yet been set but once a time had been arranged they would be informed. Also asked if their FME had seen [service user] again but was told this would not happen now because the request for a MHAA has been requested and accepted

Progress notes

The availability of specialist staff members able to best assess and manage the individual was also seen to guide the dispatch of MHTs to conduct formal assessments under the MHA. In the following example, a team could have been sent out to assess the individual and not doing so would have an inevitable impact on police resource in the custody suite due to the consequent retention of the individual in custody. However, as the individual was resting, it was considered in his best interests to delay the assessment until his care team were available the next day, as they would be best placed to assess and deliver care:

PNs [name] was concerned that duty consultant be contacted re: any instructions Dr [Medical 1] may have left but felt that the assessment could take place in the morning as [service user] now settled. I agreed to call duty consultant (Dr [name]) who on hearing information agreed that as [service user] was settled and sleeping that the assessment would be preferable for the morning by his own team.

Progress notes

Theme 1: imminent risk

Mental health professionals conducting the MHAA evaluated the potential imminent risk of the individual both to themselves and to others in making the decision to detain under the MHA. Each of these forms of risk is presented below with reference to how they informed the decision to detain.

Perception of risk to self by the assessing MHT was recorded in all cases that were formally assessed under the MHA. In the two cases that involved detention under the MHA, the first was regarded as a risk to self through self-neglect and the second due to not being able to leave the house because of his mental state. However, as detailed below, both of these cases were further concurrently assessed as an imminent risk to others, which combined with risk to self, drove the decision to detain. In the cases of those individuals who were assessed but not detained, risk to self-behaviours recorded in the mental health notes included both historical and current, observable DSH or suicide, for example:

[service user] was at her mother’s home and was self-harming superficially to her arms. She ran off so mother informed the police. She was returned by the police but continued to self-harm. She became very difficult and was detained for breach of the peace and taken to [custody centre]. They did not pursue the B of P [breach of the peace] but requested a MHA assessment

MH1

Solely historical risk, however, was not considered sufficient for risk to self to be a precipitating factor in the decision to detain. For example, although one individual had a historical recording of suicide and DSH risk, this was not considered relevant to the current presenting situation. Therefore, in this case, the lack of current risk to self was directly attributable to the decision not to detain:

There appeared, to all those involved in this assessment this afternoon, to be no evidence at this time of [service user] having overt plans of either suicide or deliberate self-harm, and no evidence of him requiring hospital admission at this stage.

MH1

As noted above, perception of risk to others was recorded in the mental health notes of both cases in which individuals were detained under Section 2 following MHAA. Both individuals had presented with behaviour that put others at risk and further, was likely to pose a risk in the immediate future, in comparison with those who were not detained as an outcome of MHAA whose risk to others was not assessed as requiring immediate detention to mitigate risk.

Detained case one: According to [professional] manager at [service provider] fellow residents have complained about [service user] stealing from the kitchen and harassing a female resident by hiding her things. It has also come to light that [service user] has weapons in his room including a homemade crossbow, a machete, an air gun, and an axe. He is also stockpiling bits of bicycle in his flat. He is said to be firing his air gun out of the window. [service user] had locked himself in his room and police had to break in.

MH1

Detained case two: MHA undertaken at [custody centre] [service user] assaulted his mother the previous evening she thought he was going to push her down the stairs she grabbed onto a door frame a friend who was in the property heard the commotion and came to help. [service user mother] sought [housing agency] apparently the police were going to transport her but she missed them at pickup point police went to house and [service user] was arrested. [service user mother] has been spending much of her time out of the property through fear [service user mother] reports that he had been responding to the internet part of his beliefs is that the lady who lives next door is part of the stalking, she is expecting a baby so there were concerns for her safety

MH1

The individual related to the second case was formally assessed under the MHA in custody following arrest on a previous occasion in the research window to that in which he was detained. On that occasion, risk to self was recorded predominantly as threats but without the level of seriousness or imminence necessitating further detention:

T/C [telephone call] from Dr. [name] at [custody centre] raising concerns about [service user]. he was arrested last night under the influence of alcohol for common assault, after going to a bar, and when asked to leave hitting the doorman

Progress notes

However, at the second arrest related MHAA in the research window, risk to others had become both imminent and serious, thereby raising the need for intervention by the MHT under the Act.

She also said he believed his stalker’s sister lived next door to her. He shouts about her sometimes, and has said he is going round, but has never got up from his seat when saying this; she has told him she will phone 999 if he goes to, which she says she would.

Progress notes

Theme 2: existing formal management arrangements

Assessment was made of individuals’ current access to and engagement with services during the MHAA. The two cases that culminated in detention under Section 2 of the Act, although known to services, either did not have formal management in place at the time of detention or were not engaging with services in a way that facilitated the support that they required. Detention was therefore in part determined by the current or historical level of engagement with community services, which could necessitate admission to ensure engagement and therefore effective assessment and treatment. For example, detained case one:

[service user]’s family, professionals, his housemates and managers of [supported housing] have all expressed concern over the past few weeks. He has not been seen by CMHT over this period though attempts have been made.

MH1

Detained case two:

His mother Mrs. [service user mother] informed Dr. [name] that AMHP [name] contacted her on the 11th April with regards to an MHA planned for the 13th April. Mrs. did not hear any more and the MHA did not happen. He was discharged from EIT in January 2011. He moved back to his mother’s from [place name] and has not left the house for about four months because of his paranoid beliefs . . . He said he would be happy to try a different anti-psychotic and engage with HTT. We stressed that we could not guarantee no side effects with anything, but pointed out the risks of becoming increasingly psychotic, and stressed if he was concerned about medication to discuss it with workers so changes could be made without risking relapse

MH1

In the case of the five contacts who were not detained following formal assessment and who were not currently on the caseload of a care team, as presented above, enhanced care/management was offered in the form of referrals to CMHTs following release from custody. However, in these cases, as in the following example, the MHT assessed the individual’s potential for successful engagement:

[service user] is a 35 year old man, whom had recently been discharged from CMHT, and has had various previous contacts with psychiatric services. [service user]’s diagnosis has been unclear, but he has reportedly suffers from a psychotic or paranoid illness, and has suffered from anxiety and severe depression for some years. However, over the preceding few months [service user] had reportedly been improving in his mental health and, although remaining low in mood, appearing to reach a relatively stable point and not wishing to have further active contact with the CMHT at this time. He was therefore discharged on 12/4/11 . . . However, their remained the need for [service user] to be re-referred to Psychiatric Services, primarily for a review of psychiatric medications, as well as a review of the need for him to receive at least short-term support from the CMHT whilst his social situation remains a current active stressor within his life. Dr to complete a referral to CMHT services for immediate review. [service user] is happy with this plan, and reports he would be willing to see a consultant further. [service user] reports that he has plans to go into detox and rehab at ‘[rehab]’, has reportedly been referred and is awaiting placement. This will need confirmation by the CMHT when contact is re-instigated. A call was made by myself to ‘[rehab]’ at approx. 6pm to investigate [service user]’s referral, and a message left for day-time

MH1

Theme 3: existing informal care/management arrangements

Assessment was made of the degree of informal care and management available to the individual on release from custody. Providers of support could include family and friends able to support the individual with, for example, social care needs, their behaviour because of their condition and engagement with services. Existence of informal support/management reduced the need for consideration of formal admission. For example, in the case of the second detained case above, who had a previous custody MHAA in the research window, his mother’s willingness to support her son with enhanced HTT input prevented a formal admission at this point. However, with increased risk to others (including his mother) 2 months later at the second custody MHAA, this informal management was not possible and in part drove the decision to detain under Section 2 of the MHA. First MHAA:

She felt that home treatment was the best way forward, and was happy to have him home with support. She said she felt he wanted support, but people have not come out to help him, and he has not been able to leave the house to go to see others. She would like for him to look at supportive living in the future, but is concerned he wishes to leave Cornwall and he will not cope. HTT number given, she has agreed to phone 999 if she feels threatened.

MH1

Second MHAA:

He has had limited food and water. It was decided to detain for a further period of assessment and because of the uncertainty of his behaviour was transferred to [Acute Psychiatric Ward]

MH1

Theme 4: behaviour

Assessment necessarily included the individual’s presenting behaviour at the time of assessment. In terms of the two cases who were detained under the MHA, both presented with behaviour perceived to be delusional, with corroborating information from both third-party report and direct observation. Detained case one:

He has been described as ‘floridly psychotic’ and seems to have delusional ideas about seeing scorpions. This has come from his family and was the case a few days ago. Present at the interview were Drs [name] and [name]. Both S12 [Section 12] and [professional] AMHP. [service user] was prepared to say very little other than the female resident had been bothering him for 25 years. This was clearly odd, as he had only known this person for a short time. He refused to say anything else went to the toilet and then returned to his cell. He was brittle resentful and there were also signs of self-neglect.

MH1

Detained case two:

When we interviewed him he admitted to us he was hearing voices and that he was being watched plotted against on the internet and Facebook [Facebook Inc., MenloPark, CA, USA] he couldn’t explain why or how anyone would want to do this

MH1

Furthermore, following assessment of mental capacity, in the case of detained case one, there were also concerns with regard to capacity that contributed to the decision to detain. Detained case one:

There is some doubt about his insight and capacity to make rational decisions.

MH1

Although it was recorded for detained case one that there was ‘no reason to doubt capacity’, the record also showed that there was some difficulty in adequately assessing the individual that could impact on capacity assessment, and therefore on the potential for risk to the individual that could influence the decision to detain.

The outcome of the assessment of behaviour was markedly different with regard to the five cases not detained under the Act following formal assessment. In some cases, the assessing clinicians/practitioners did not agree with the individual’s self-report of presenting symptoms:

[service user] suggesting she has psychotic symptoms but professionals do not feel this was the case. PD [personality disorder] diagnosis accurate . . . Has capacity for actions

MH1

In other cases, the presenting mental state did not influence capacity or require immediate acute care as would be provided by formal admission. Example one:

Concern emerged upon his return to the Police station and his presenting low mood and suicidal ideation. Dr [name] [service user] presented as slightly withdrawn initially, but was soon able and willing to engage in lengthy conversation regarding his arrest, his past and his current situation. Throughout the interview [service user] appeared to be somewhat anxious, and regretful of the incidents that had led to his arrest and consequent assessment, although not distressed or overtly depressed in mood. He maintained good insight into his previous suicidal ideation and suicide attempts and was able to identify his apparent progress in terms of his long-term recovery, and the progress he had made over the previous year. Having said this, he appeared to be realistic about his continuing struggle with his mental health, his alcohol addiction, and his housing situation. Equally, no evidence today of psychosis, although overt reports of struggling with his paranoid thoughts when in particularly stressful situations or when drinking heavily. No medical recommendations were made.

MH1

Example two:

No evidence of mental disorder warranting admission formal or informal. No evidence of hopelessness or plans. No evidence of significant mood disorder or psychosis. Had full capacity to understand the assessment and the outcome, as well as being fully able to engage in conversation about his future and make active plans in an attempt to resolve his difficult social situation.

MH1

Post detention actions taken by the police

For those cases who were not detained, any actions taken by the police post MHAA were also explored to determine if support/management by the police affected outcome for the individual. In two cases, the custody officers were concerned about access to accommodation once the individual was released from custody. Subsequently, police provided support via communication with family or housing to ensure that accommodation was available:

spoke with [service user]s mother who stated will arrange for her keys and other belongings to be dropped at station within 30 mins or so

Detention log

DP cannot return to accommodation in [AREA] due to 2 breaches re leaving accommodation overnight and Social services are not assisting for accommodation at this stage. AMHP has stated that he will have to arrange his own accommodation and that he has told her that he will stay with a friend and is aware he must remove property by 21.00 tonight. DP has money and is able to get train back to [AREA].

Detention log

In a further two cases that were not detained following MHAA, transport was arranged for the individual, with one individual taken home by patrol officers and one prepared for transportation to court by the officers managing his detention.

Action taken. Full details of the d/p’s [detain person’s] self-harm issues given to Reliance officers [NAME] and [NAME] – d/p was clothed in track suit bottoms, paper knickers, t shirt and flip flops – d/p handed to reliance for court with fully completed PER and medication

Detention log

In another two cases not detained following MHAA, the police provided individuals with additional support in the form of information regarding other agencies and services additional to that provided by the MHT:

she did not wish to be referred to any support agencies – provided with a Samaritans leaflet and also MH [mental health] literature.

Detention log

MHA team carried out assessment and decided to release him. They have contacted New Connexions for him to stay there tonight. Given Partnership Agency information and Samaritans card.

Detention log

In the final case regarding an individual who was formally assessed but not subsequently detained under the Act, the detention officers took extra steps to try to support the individual by attempting to influence the MHT’s decision to detain under the MHA following their persistent assessment of risk with regard to the presenting situation. The example below provides the rationale as to why the decision was taken not to detain under the MHA following assessment:

Discussions with Sergeant [name] ([custody centre]), [professional] and [psychology 1]. Sergeant [name] concerned about releasing [service user] in the face of the threats she has made to harm others and herself. He asked if I would reconsider admission. I informed sergeant [name] that I appreciated and shared his concern but did not believe that admission was appropriate and I would organise a meeting between the police and ourselves as soon as practical to work out strategies for jointly addressing the risks she presented [professional] shares my view that Hospitalization would have been inappropriate given that she was fundamentally threatening criminal behaviour.

Progress notes

Custody disposal outcomes

Police recorded disposals for all cases arrested in the sample were examined. Figure 16 presents the disposal categories for all custody detentions. The largest disposal category concerned there being no further action (NFA) by the police (n = 38, 30.2%) following detention. Therefore, although individuals would have a custody record and a record on CIS, the case regarding the original offence would not be taken any further by the CJS, often due to lack of evidence and therefore the potential strength of the case at court.

FIGURE 16.

Disposal categories for all custody detentions (n = 126). Numbers represent the number of detentions in each disposal category.

The data were examined to explore the disposal category for each offence type (Table 17). It can be seen that the majority of offences categorised under public order received NFA and, furthermore, NFAs following public order offences were the highest group within this disposal category. Additionally, a high proportion of cases in which individuals were arrested for offences against people were also NFA. MHA diversion was recorded for three contacts: one public order offence (detained Section 2 MHA); one contact due to an offence against people (detained Section 2 MHA) and one breach of bail or an order (individual not detained under the MHA). The highest number of police detentions following arrest was for arrests related to breaches of bail and orders.

Types of police contact in the research window

None of the 15 individuals were detained by the police during the research window. For 10 of the individuals, their contact with the police had triggered the individual’s address to be recorded on the NHRR (if there were three calls to the police regarding the address in a 3-month period), eight of which were named as a PP (i.e. their name was recorded on the NHRR alongside the address). The five individuals not recorded on the NHRR did not meet the criteria, as four had fewer than two incidents each over the year and one had five incidents but none in the same NHRR quarter.

In the eight cases involving a PP at the address on the NHRR, data were available for warning markers entered by officers to highlight issues relating to that person. These markers are summarised in Figure 18, which indicates that five of the eight individuals recorded on the NHRR had a mental health marker. Therefore, only 33% of the 15 individuals were highlighted on the NHRR as having mental health issues, despite those individuals being case-linked on RiO.

FIGURE 18.

Non-detention contact group individuals with NHRR warning markers (n = 8).

Ten individuals had a non-crime vulnerable adult record linked to their CIS records. These are generally created when a referral to the police is received from another organisation, for example adult social care, and will relate to an incident or concerns raised, usually about the care and management of the individual. It is then allocated to an ‘officer in charge’ who takes responsibility to collate action. The non-crime vulnerable adult records explored in this research contained long-term plans for an individual as well as interagency information exchange. The records seemed to be used in place of problem solving plans (PSPs), which are normally created as part of the solution to a long-term problem, often including individuals whose behaviour is affecting service delivery or the local community (definitions of non-crime vulnerable adult records and PSPs – Chief Inspector Mark Bolt, personal communication).

Table 18 compares NHRR entry with the number of OIS logs associated with that individual, whether or not they had a non-crime record and/or corresponding warning markers and flags. All individuals with more than 10 OIS logs (n = 5) had non-crime vulnerable adult records. Of the 10 individuals who had fewer than 10 OIS logs, only two had a non-crime vulnerable adult record indicating that records were being created for those individuals who were repeatedly in contact with the police.

To determine the uniformity of recording of warnings across police systems, the warning markers on the NHRR were noted against available PNC warnings on CIS. Two of the 15 individuals examined here had PNC warning flags (see Table 18). Seven of the 15 individuals included in the sample had a local warning flag on their CIS record. It can be seen from Table 18 that recording of markers on the NHRR and warning flags on the PNC did not always match; for example, a vulnerable adult marker is noted on the NHRR entry for case 11 but there is no similar warning flag on the PNC system. Control operators and response officers do not have access to NHRR, and therefore would not see those warnings when responding to an incident.

Theme 1: perception of immediacy of need

The grading and classification of an incident by the operator and their decision to dispatch a response officer or not depended on the origin of the call, what the context of the call was (type), and the operator’s perception of risk to the individual and others. As part of the operator’s assessment of a call, they provide a grading of the level of necessary attendance and a classification of the type of call. To provide context for the operators’ decisions to dispatch, the grading and classification of the 418 contacts are discussed first.

Perception of risk

The type of risk posed by the individual to themselves or others as recorded in the OIS logs was categorised by the researchers (Figure 19) in order to identify any patterns in relation to the operators’ perceptions of risk and subsequent dispatch of officers. It can be seen from Figure 20 that the vast majority of non-attended incidents had no discussion of risk in the logs. Where there was an indication of risk either due to the individual’s behaviour, risk from others or third-hand reports of risk, the incident was at least twice as likely to be attended by police officers than not.

FIGURE 19.

Categorisation of level of risk derived from OIS logs for attended contacts (n = 140).

FIGURE 20.

Categorisation of level of risk derived from OIS logs for non-attended contacts (n = 278).

Theme 2: individual’s history

Operators’ decisions to grade and dispatch response officers were also based on historical information about the individual. This could be from recorded experience in logs or personal experience as described under the headings below. Previous knowledge of the individual was mentioned in 365 contacts (87%).

Theme 1: awareness of mental health

To understand whether or not officers dealt with the incidents with any knowledge that the individual had mental health issues, the OIS logs were explored to search for any mention of mental health. Awareness of mental health issues was noted in 359 of the 418 logs (86%). Only one individual in the non-detention group had a PNC mental health flag, meaning that little information was gained about mental health from the PNC warning flags. Although the NHRR included mental health and vulnerable adult markers, as described in Table 18, this information would not have been available to the response officers unless they were in contact with NBTs. Therefore, awareness of mental health issues was largely dependent upon the knowledge of the operators (experience and searches) and the officers.

The relationship between being on the caseload of the care team at time of contact and police awareness of mental health in the logs was explored to determine if this had any impact on police awareness of mental health at the time of an incident. Findings indicated that police awareness was recorded in more logs when the person was on the caseload of a MHT. For contacts on caseload at the time of contact (n = 350), awareness of mental health issues was mentioned in 333 (95%) logs. Where the individual was not on caseload (n = 68), awareness of mental health issues was mentioned in 26 (38%) logs.

In some cases, the individual’s history was not the source of raising awareness of mental health, but how the person presented during the call or once officers interacted with the individual. In three cases, the caller’s description of the individual highlighted that they had mental health issues, assisting the attending officer in understanding what they might encounter:

rambling call from male with mental health problems

OIS log

In three further cases, it was the individual’s presentation at the scene of the incident that led to officers’ awareness of mental health issues:

AIO [all in order] here. Female has MH [mental health] issues. Spoken to other residents on same floor but nothing heard by them

OIS log

with lady now – 2 care workers here ATT [attendance/attended] – female has severe MH [mental health] issues and carers state she probably disposed of Tel no.s herself

OIS log

Theme 2: information exchange

Police communication with a MHT was noted in 50 of the 418 logs and nine logs noted communication with social services. For six of the 50 contacts, the MHT initiated the phone call to the police and for three of the nine social service calls, social services initiated the call; therefore, these nine cases do not relate to a decision to instigate information exchange by the police. However, as they pertained to communication and joint working between the services, they were still explored. For two of the nine partner organisation initiated contacts, the call was made to ask for police to escort an individual to a MHAA. The other calls initiated by the partner organisations included three calls to report a missing person and four calls to update police intelligence, including:

• corroborating that an individual was having a problem with a prowler

• reporting the recent return of a family member from hospital

• providing contact details for social services for a repeat caller

• informing the police that a safeguarding process had been put in place.

The following text relates to one (from the MHT) of the two calls for assistance to escort an individual to a MHAA. Corresponding texts from the RiO progress notes and OIS log relating to the call show how responsibility for dealing with the individual moves between the services during the incident.

Found to be missing from the ward during hourly checks at 11 am. Ward searched, grounds searched and 2 x staff searched [L19] town including Asda. Mobile phone tried, going straight to answer phone. Reported missing to the police and at 12:35. Attempts made to contact [individual mother], next of kin with no success, staff to continue attempts to make contact. Log number. This morning reports of [individual] being a little quieter in mood but no obvious sign of distress. Reported as moderate risk to self, low risk of harm to others.

Progress notes

called [name] ward they are sending someone down with a car – they have no other means of transport -they’ll try and get her in the car and take it from there . . . [service user] handed over to staff will update compact at the station

OIS log

The following texts illustrate the calls made by the MHT or social services to update police intelligence:

R/p [reporting person] wanted to warn us in case we receive any calls from the female who is known for making spurious calls to the police, female may genuinely be reporting sus circs [suspicious circumstances].

OIS log

R/p [reporting person] wishing to inform us that [wife] is likely to be going on leave from hospital tomorrow and returning to address with husband

OIS log

For the remaining 41 of the 50 logs where communication with the MHT was noted, the calls were made by the police during the logged incident. In 19 cases, this related to the aforementioned individual with dementia, where part of the vulnerable adult plan for dealing with the individual required the police to inform the individual’s MHT and social services that contact had been made with the police. For the remaining 12 logs where communication occurred (and was not initiated by the MHT), the reasons were as follows. Most communication related to requests for intervention from the MHT during an incident (two contacts where the individual was the focus of the call and four contacts where the individual’s partner needed care). In the example below, the police called a MHT to obtain care for an individual; however, the MHT required a definitive request from the police. The police officer at the scene discussed how to progress with the attending ambulance crew:

I have spoken to females mental health worker – they will not come out unless we actually [operator] 2022 [time] 22/02 [date] request them ourselves . . . paramedic is going to speak to [mental health hospital] to find out what the best course of action is re this

OIS log

For three of the 12 contacts, communication was simply to inform the MHT of an incident for their records. This exemplifies good practice concerning information sharing and up-to-date record keeping.

no stated incident or reason for the call for intel [intelligence] submission re the male & notification to local MH [mental health] team.

OIS log

The three remaining contacts relate to calls by the police to gain information about an individual’s current care. In one, the police needed to find out when a MHAA was going to be conducted, in the second, they needed information about the care of an individual’s partner, and the third related to confirming that a care package was in place with a long-term care team. An example of the police contacting the MHT for information about current care is provided below:

I have also spoken to [name] of adult social care who has passed Mr through to the long term care team. They are aware of [service user] as they were informed of his wife’s departure some two days ago. Awaiting call back from [name] of the long term care team to see what actions have been put in place.

OIS log

Being on the caseload of a care team did not seem to influence if the MHT or social services were called. For those contacts where the individual was on caseload (n = 350), police contacted the MHT in 43 cases (12%) (social services in eight logs). For those not on caseload at time of contact (n = 68), police contacted the MHT in seven logs (10%) (social services in one log).

Theme 3: authorisation of tasers

Tasers were authorised for two of the incidents but not deployed. Alcohol or drugs were not mentioned in either of those incidents. Violence was highlighted in one of the taser-related OIS logs. In one of the incidents, the individual was deemed to be a risk to themselves and others and, in the other, the service user was perceived to be at risk from others. As with the Section 136 and detention incidents, tasers were deployed when weapons were indicated. For the one contact where tasers were authorised for an individual in the sample, the incident relates to a call from the MHT asking for assistance in taking someone sectioned under Section 3 of the MHA to hospital:

from FIM [force incident manager], I understand social workers have no way of dealing with a male who could potentially cause harm with a knife. He has been asked to give the knife up but refused. The social workers have requested police assistance and raise concerns if not done sooner rather than later as he may go missing potentially with the knife. I will authorise Taser for the protection of officers and staff as this male has a knife and states it is for his protection.

OIS log

Theme 4: diversion from detention

For nine contacts, there was a discussion of potential response options relating to detaining the individual under Section 136 or arresting them for an offence. Discussions about Section 136 detentions were instigated by the MHT as an option for returning an informal patient into their care or to ensure that the individual was dealt with safely if their behaviour deteriorated:

. . . as mentioned previously they believe she is safe with a friend but asks if she is seen out and about during the night in a distressed state pls [please] could officers consider Section 136 – there are no immediate concerns and medical staff plan to do an assessment later today . . .

Progress notes

have phoned RP [reporting person] again to find out what they want us to do with the male when he is located. They initially stated for police to return him as he is a vulnerable adult but explained to him that we have now powers as such as he is an informal patient. they have asked if police could try to encourage him to come back to the ward – police can give [Place of safety] a call to see if they can come and collect him – they have also said that he is posing a risk to others/himself, he can be detained Section 136 and brought back that way

OIS log

During the latter incident, the police indicated that it was their responsibility to make the decision as to whether or not to detain under Section 136 and that a detention could not be directed by the MHT:

. . . units will decide if he is displaying sect 136 or not . . . they will not bring him in on it just because sig [street index gazetteer] suggest it.

OIS log

Similar to the log entry above, the following example involved consideration of how to deal with someone who is not engaging with the MHT and how police involvement can be used to achieve treatment for the individual:

AIO [all in order] here. female has MH [mental health] issues. Spoken to other residents on same floor but nothing heard by them. Night staff due in shortly but female is calm now and ok going back to her room . . . – call from Dr [name] to say they have attended her h/a [home address] (sig) [street index gazetteer] to do assessment on the female but she is not there – as mentioned previously they believe she is safe with a friend but asks if she is seen out and about during the night in a distressed state pls [please] could officers consider s.136 – there are no immediate concerns and medical staff plan to do an assessment later today

OIS log

In six logs, the possibility of arresting the individual for a substantive offence was mooted. In two cases, this was in an attempt to halt the individuals from making nuisance calls to the services.

this will need to be crimed and further updates ref [mental health] MH and capacity of female placed on crime. E-mail sent to officer requested this is crimed in line . . . I am speaking to local PCSO [police community support officer] – female will not have capacity and we will confirm this SS [social services]

OIS log

The following quote relates to the same log and provides a short rationale as to why the incident did not result in criminalisation; the individual was thought not to have the mental capacity to take responsibility for her actions:

this lady is ill, not a criminal

OIS log

In the second contact, related to nuisance calls, threat of arrest was used as a measure to reduce the volume of calls:

. . . nothing wrong with her. She claims swollen AMB [ambulance] needed x-ray. She does not. She said she will continue phoning for police and AMB. She has been told she will be arrested if she does, but she didn’t seem to care so may get more calls from her.

OIS log

For the other four contacts that made reference to the use of arrest, the use of police power was used as a way of encouraging engagement with mental health services or as an alternative if intervention by the MHT was not successful. The following extract reflects a discussion with the service user about the need to use police powers if they continued with non-engagement:

spoke with [MH (mental health) team] who has had no joy re MH assessment. She stated that the only option potential is to deal with [service user] with the crime. And possible assessment then. However she will be writing a letter to [service user] today stating that if there is no cooperation then it will be handed over to police.

Progress notes

This communication is potentially an example of local services meeting the recommendation from the Steven Hoskin serious case review, as ‘where a threshold for risk is crossed, non-engagement and non-attendance should not be a barrier to internal multi-disciplinary discussion and wider multi-agency liaison and consultation’. 55

One log gives an example of where intervention by the MHT and returning an individual to hospital would prevent a BoP, thereby removing the need to detain that person using police powers for the protection of others:

spoken to staff at [name] ward [mental health hospital] they are happy for [wife] to be returned to there as a place of safety-concerned if she remains at the location there will be a BoP

OIS log

Theme 1: referral to Neighbourhood Beat Teams

In 103 incidents, the contact was logged with the NBT for further action. Operators ‘actioned’ NBT intervention, which would then result in a follow-up telephone call, visit to the individual or an update of information in the log or non-crime vulnerable adult plan for the individual.

I have spoken with the r/p [reporting person], who states that she has had [service user] calling out to her from a vehicle. The r/p has stated that she does not wish to get [service user] in to trouble and does not want her arrested. The r/p has finally agreed to a mediation between the two parties with local NBT officers present to resolve the situation. I will email the NBM [neighbourhood beat manager] for the area to arrange a suitable time for this to happen.

OIS log

Referrals for NBT contact were mostly for welfare issues (n = 82). The remaining cases involved neighbourhood disputes (n = 8) and reports of alleged ASB and harassment (n = 13).

Theme 2: joint management of individual

The data for the 15 individuals in the non-detention group revealed joint management between the police and NHS as part of the resolution of an incident. As mentioned previously under Theme 2: information exchange, some joint management involved information sharing only, ensuring each agency was kept up to date with the individual’s latest care needs and their interactions with services.

For five contacts there were recorded interactions between the services to jointly manage the individual at the end of or after police contact. In the following example, a DV officer liaised with social services and created a log about an upcoming multiagency meeting. The officer details how their interaction with social services will inform the meeting and may aid joint management of the individual and their partner.

f/DVO [from domestic violence officer] – I have spoken to [name] who is the lead for adults safeguarding – he has arranged a meeting with [service user] doctors and CPN, etc. at [name] surgery at 2.00 pm Monday 16th may, it is hoped that at this meeting the GP’s will be forced into acting on ‘best interest’ with regard to [service user] and [husband] unfortunately as things are at the moment, [husband] makes a complaint, [service user] has no capacity, so is not arrestable, and then [husband] will do work with SS [social services] or doctors to protect himself. DVO will supply a detailed history to try to show the impact that this ongoing problem is causing all agencies.

OIS log

In another case, an officer liaised with a CPN before making a decision to issue a harassment warning. The CPN was able to give officers their opinion of the situation; officers issued the warning, but were aware that the harassment may have been two sided between the individual and a neighbour:

[service user] does have m/h [mental health] issues and is under CPN [name] of [mental health hospital] . . . I have spoken to [CPN] and she is aware of the ongoing issues between [service user] and [AP1; associated person 1]. CPN was under the impression the harassment was the other way round and it was in fact [service user] being harassed by [AP1] . . . harassment warning to be issued to [service user] and then [AP1] updated and intel [intelligence] to be input. But officers to be aware [service user] may make a counter allegation.

OIS log

The issue of intervention, whether by the police or MHT, was discussed in relation to lack of engagement by another individual. This led to a discussion of responsibility for the individual if they continued non-engagement with services:

I have spoken with [service user] who was at home with his mother. He is having delusional thoughts and seeing things. He is safe and well but flatly refuses to engage with the MHT. Unfortunately, mother is not strong willed enough to persuade him to see the MHT and has in the past been obstructive towards their intervention. No offences and no concern for [service user]’s welfare he is just a poorly man who will not seek help. – there is nothing we can do- the MH [mental health] team are the only people that can help him – but he is still refusing their help all resources leave scene/dispatch cancelled etc. Advise MH team no in log – and close plse [please] – OOH [out of hours] MHT have been advised and will pass this onto [EIT contact]

OIS log

The following example illustrates joint discussions about pursuing a criminal matter associated with another individual:

I have spoken with pc [police constable] [name] who was dealing with previous vulnerable adult matters concerning [service user] and [service user 2]. Message from switchboard stating that social worker phoned. I have attempted to contact him but he was not available, message left for him to call back. This matter is a historic report and as a result is not time critical. I suspect that it will be best dealt with by raising a non-crime vulnerable adult and progress matters in conjunction with social services. Have read log and agree that domestic side to be closed and none va [non-crime vulnerable adult] will address the issues alleged with multi agency input this matter is a historic report and as a result is not time critical. I suspect that it will be best dealt with by raising a non-crime vulnerable adult and progress matters in conjunction with social services.

Progress notes

In the final case where joint management was noted, the potential impact of police involvement in the management of an individual was discussed, and how this would impact on their health. This led to discussions with the police about suitable times and methods for approaching the individual to continue their investigation:

Tel call from [individual] this evening. Very tearful and initially it was very difficult to engage in conversation with him he is feeling very confused, scared and frightened and states he is struggling to cope with day to day living. He feels unable to leave his home for fear of his safety. He is also very worried about having to go to [custody suite] police station at 11 am in the morning. He isn’t sure why he is having to go but is convinced he will be going to prison for 5 years. Tried to reassure him but it was very difficult due to his distress. I am sending this to the CMHT as I am unsure what current support, if any, is being offered to [individual]

Theme 3: police aftercare

Examples of pastoral care provided by the police were recorded in some logs, reflecting actions beyond their normal duty of care, highlighting a compassionate and caring response on the part of some officers. Due to the vulnerability of the individual and the lack of available family or care support, in the following example, officers ensured the individual’s basic needs were met:

on leaving [service user] I ensured he was fed and watered by making him a cup of tea and a pot noodle snack.

OIS log

In another example of police aftercare, police took steps to ensure that an individual would be able to get to a police station for questioning and that an AA would be in place:

having read the updates Mr [service user] will need to be seen at a police station for the first response book completion. I have spoken to him and arranged to have him collected at 1000 in the morning as previously arranged the only difference being we will need to go and get him from around the corner. PS [police sergeant; name] has the matter in hand, [AP2; associated person 2] the friend will also be attending and can act as app. adult for the purposes of the booklet completion.

OIS log

Further to the above log, the police raised concerns about the care in place for this individual and highlighted that he may have been overlooked by services, despite potentially suffering domestic abuse. This case reflects good practice in relation to the recommendations of Bradley6 and the Steven Hoskin serious case review55 whereby support should be in place for individuals who may be missed because they are not detained and not associated with crime:

[name] has concerns for [service user]’s welfare, care & support whilst she is being dealt with by other agencies. It appears that [service user] maybe ‘going under the radar’ for care and support by all agencies. [service user] is unaware that [names from housing co.] are reporting this to the police. due to the difficulties this causes any approach the pol [police] make on the back of this call from [name], I have located this log and explained that I will ask units dealing, if they could use this log/call from the AP as a means to get [service user] to reveal the current circs [circumstances] he is living under in being a male victim of dv [domestic violence]?. I have also explained the need to continue their liaison with him and to use this as a means to encourage him to report to the pol and other supported agencies in Cornwall that deal with male d/v. am aware retired Insp. [inspector] [name] dealt with this very issue.

OIS log

Resolving a neighbour dispute constituted a follow up measure for another individual and involved linking with the housing officers to manage the situation:

both of [neighbours] complaints are in the process of being dealt with by pc [police constable] [name] and [name] – housing . . . [service user] is due in for an interview next Tuesday. [service user] discussed her and her sons concerns and increasing anxiety linked to allegations from [address]

OIS log

Perspective

Total costs were calculated from a service provider perspective, including the mental health, social and criminal justice services. The total costs of mental health and social care services were computed for each participant by combining the following costs: inpatient services, client contact (including contacts at community clinics, the client’s home, at hospitals, GP surgeries, public places, custody centres, supported/residential/nursing housing, and contacts by phone), meetings in the absence of client and patient assessments.

Criminal justice services were defined in this study as contacts with the police (i.e. telephone calls to the police, police attendance at incidents, arrest and removal to a place of safety under Section 136). Police attendance was defined as at least one police officer attending an incident. Court proceedings and prison were not able to be included in this study. The total costs of contacts with criminal justice services were computed for each participant by combining the following costs: initial contact costs (cost of contacting the police, police attendance, ambulance attendance at incident), custody costs (length of stay in custody suite, MHAAs, HCP triage, FME, AMHP, hospital attendance) and other costs (transport, follow-up calls by police and escorting). Total costs per participant were computed by combining total mental health, social care costs and criminal justice services costs. Contact with the police was defined as any incident which was logged by OIS.

Due to the novel and complex nature of the study and the population, only major cost drivers were included, therefore providing an estimate of the general order of magnitude of cost impacts linked to criminal justice pathways. Thus, for CJS costs, costs such as police attendance, ambulance attendance, or custody time (see Appendix 5 for full list) were included, but minor contributors to total costs that required more detail than was available in files, such as communication within the CJS or liaison with other agencies, were excluded.

Health care

Of the 55 clients, all had at least one contact with mental health and social care services over the 1-year period. Thirteen (23.6%) had at least one inpatient stay. For these clients, the mean number of days as an inpatient over 1 year was 89.85 (SD 91.50) days. The range was 5–310 days.

Of the 55 clients, 49 (89.1%) clients had at least one client assessment during the 1 year, 52 (94.5%) clients had at least one meeting with a professional and 37 (67.3%) clients had at least one meeting between professionals in the absence of the client.

Criminal justice services

Of the 55 clients, all 55 had at least one contact with criminal justice services over the 1-year period. The number of contacts (separate incidents) with criminal justice services ranged from 1 to 293. The median number of contacts was seven (IQR 3–14). One client was recorded as having 293 contacts (incidents recorded on OIS that did not result in a detention), which was unusually high compared with the other clients included in the sample. The next most frequent number of contacts was 35. For the outlier client, almost 90% of these contacts (261 contacts out of 293) had minimal CJS resource use. This was either a call to police which required NFA, or a call to police that required a follow-up call from the police.

The combined number of contacts with police for the whole sample was 783. Of these, 461 (58.9%) required at least one police officer attendance. One client required a total of 47 police officers in attendance for one incident. This was a fairly unusual client since the next most frequent number of police officers in attendance was 21. Of those incidents that had a police officer in attendance, the median was three officers (IQR 2–5).

Of the 783 contacts, 98 (12.5%) involved some time in custody. Of those, the median time was 8 hours 38 minutes (IQR 4 hours–15 hours 30 minutes). The range was from 15 minutes to 41 hours 30 minutes. Twelve clients (12.2%) had a MHAA.

Health care

Total mental health and social care costs were non-normally distributed and positively skewed (Figure 21). The mean cost per person over the 1-year period was £10,812.08 (SD £23,714.39; IQR £386.33–6335.31; 95% bootstrapped CI £6054.86 to £19,726.27). The range was £41.70–108,434.80.

FIGURE 21.

Distribution of total mental health and social care costs.

Figure 22 shows the mean proportions of mental health-care costs. It shows that the major cost contributor was inpatient services, which accounted for 76% of the total.

FIGURE 22.

Mean proportions of mental health-care costs.

Criminal justice system

Total costs associated with criminal justice service contacts were also non-normally distributed and positively skewed (Figure 23). The mean cost per person over the 1-year period was £4551.88 (SD £4460.90; IQR £1359.99–7019.72; 95% bootstrapped CI £3551.48 to £6058.47). The range was £42.48–23,840.88.

FIGURE 23.

Distribution of total costs associated with criminal justice services.

Figure 24 shows the mean proportions of criminal justice service costs, examined by incident rather than by client. It shows that the major cost contributor was police attendance at incidents, accounting for 59% of total costs. This was followed by custody costs.

FIGURE 24.

Mean proportions of CJS costs.

Findings

The finding that the mean cost per client per year was large (£15,364) was unsurprising, as was the finding that costs varied widely between clients. However, the finding that short-term referral clients had higher costs compared with long-term referrals could be useful. As discussed earlier, short-term referral clients were those who were on the caseload of a care team on a short-term referral at the time of the index police contact in the 3-month audit period. This was compared with long-term referral clients who were on the caseload of a MHT for at least 2 months at the time of the index police contact in the 3-month audit period. The association between higher costs and having less contact with mental health services offers an insight into costs and resource use, suggesting this could be a potential area to target in order to reduce overall costs, including those impacting on the CJS. A more detailed future evaluation of factors driving costs (beyond the scope of this analysis) would add further insight.

The cost analysis also suggested that the major cost contributor to mental health service costs was inpatient services, and the major cost contributor to criminal justice service costs was police attendance at incidents. Again, this new evidence on the major cost drivers gives some insight into the potential benefits to police and the health-care system if enhanced pathways can be devised that effectively manage and improve behavioural outcomes in this client group.

Strengths and limitations

The cost analysis had some limitations. The main limitation revolves around which costs have been included. The health and social care costs that have been estimated only included mental health-care costs and ignored physical health-care costs. Recent literature indicates that there is an association between physical health problems and mental health problems,67 thus the cost of physical health services in this sample could be substantial, assuming that services are responsive to these sorts of needs for people with mental health problems. Physical health-care costs were not examined within this study but are an important area of potential future research. Similarly, the costs of specialised accommodation were not considered. This is a costly resource and could have the potential to dramatically influence the scale of overall costs estimated. Thus, future research should aim to include this within the analyses. Due to available resources, the cost analyses were also only based on 55 cases. Future research in this area using a larger sample would lead to a more precise estimate of costs.

The cost analysis based on the case-linkage data also had some important strengths. This was a novel study, which is just the first step in studying the complex interface between health and social care and criminal justice services. As well as providing information on an under-researched area, it is also useful in informing future directions of research.

Findings

Each model suggests minimal effects on individual level costs of each enhancement compared with current practice, even when substantial changes are made to key assumptions used to estimate costs. However, when considering the total volume of clients who could potentially be affected by new service enhancements, the overall resource investment in services required could be significant. For example, with link workers, a whole new team of people may need to be employed if every person who is arrested is to be assessed on arrival at a police station and the extension of this service to cover ‘out of hours’ arrests, arguably when many clients require link worker input, would increase resource requirements further. However, the potential impact of this initial resource investment, given the aim of such custody liaison services to reduce recidivism and enhance diversion to appropriate mental health services, should ultimately reduce as service is implemented and embedded.

It must also be borne in mind that costings and subsequent pathway modelling are specific to the CJS (excluding courts and post-sentencing costs) and local mental health and social care services in Cornwall, and do not necessarily represent what might happen elsewhere, as there is likely to be considerable national variation in how people are managed in the interaction between CJS and wider services.

Strengths and limitations of the decision-analytic models

General limitations of decision-analytic models apply to the models in this study. For example, most of the probabilities in the enhanced models are based on informed assumptions as there was no data or literature to further inform the modelling of enhanced pathways. Although this limits the validity of the models, the models were externally assessed by relevant stakeholders, thereby testing the general credibility and validity. The modelling also does not attempt to make any assessment regarding the longer-term impacts of service enhancements and, therefore, whether or not the costs of service enhancement estimated here are justified in terms of any longer-term benefits that may be delivered through better client outcomes.

Each of the pathway models also had some specific limitations. Model 2 has the limitation of not having taken into account the potential effects of street triage on police attendances that result in arrest or NFA. This is likely to have the effect of increasing the mean cost per incident further as a much larger number of clients would receive this service, but the scale of this increase is unknown. This has not been modelled as it is unclear whether or not the service would even be viable for this group of clients. Model 3 has the limitation that it has not accounted for the knock-on effect of increased time in custody due to increased waiting time for MHAAs, which stakeholders have informed the researchers are likely due to the increased number of clients who require an assessment of this type. It would be expected that this would increase costs, perhaps dramatically, but again the scale of this increase in unknown.

There are a number of strengths of the decision-analytic models. First, the standard pathway model was built on observed activity (albeit for a limited number of individual cases) linked to existing pathways. This formed the basis for the development of the models used to estimate the cost of the enhanced pathways, thus increasing their validity in terms of providing a reasonable baseline against which to assess cost impacts in each case. Second, the researchers avoided an overly complex, and therefore, non-transparent, model and have focused on identifying and estimating key cost drivers linked to the identified service enhancements. Third, much of the probability data in the standard model was based on data collected in the attached case-linkage study. 68 However, this is an observational study and as such is susceptible to bias;69 this could have led to inaccurate probabilities in the standard model and thus inaccurate probabilities in the enhanced models.

Theme 1: interpretation of protocol

The first theme concerned the interpretation of protocol and the impact that this has on practice and joint working activity. Necessarily, this focused on detentions under Section 136 of the MHA as this (as presented in the policy review above) has a local protocol, which interprets national policy within the local context. In terms of Section 136, the police focus groups centred predominantly on the decisions that police need to take in their practice of managing individuals to be detained under Section 136; within the context of the research findings, these being decision one (decision to detain under Section 136) and decision two (location of detention). Police officers frequently discussed the location of an individual’s detention in respect of Section 136 detention. Location decisions were seen to have the greatest impact on police management of individuals with mental health issues and involved greater communication with MHTs. The following subthemes focus on police discussion of the barriers and facilitators to practice surrounding the decision, in terms of the interpretation of the local Section 136 protocol52 regarding alcohol intake and violence. The discussion is centred on police perceptions of this interpretation of the protocol due to the low participation rate from mental health services and there being no participation from place of safety staff in the consultation.

Theme 2: resource availability

Theme one was predominantly based on police focus group data. However, all participants spoke about varying resource issues that impacted on their ability to effectively manage individuals with EMHN and further access to appropriate treatment for these individuals. The following section focuses on these resource issues in terms of (1) impact of resource and, in particular, staffing issues at the place of safety; (2) resource-based treatment options that impact on MHAA outcomes; and (3) logistical challenges and associated impact on both management and outcomes for the individuals concerned. Throughout the data related to resource, professionals described a tension between the need to work within and understand resource restrictions (within their own and other agencies) and provision of management/care in the best interests of the service user.

Theme 3: information sharing

Timely, accurate and proportionate information sharing within and between services was viewed across all professional groups as key to effective interagency management of individuals with EMHN. Issues that were discussed in relation to facilitators and barriers to information sharing included the past experience of staff (both in terms of sharing information and of the individual) and knowledge to facilitate appropriate information sharing.

Theme 4: risk assessment and responsibility

Discussion across all participant groups focused on the responsibility that professionals from each agency assume at different periods of the service user journey within and between services. This discussion centred on the assessment of and responsibility for risk for the individual concerned and, additionally, the issues involved in the transfer of risk as the individual moves from being the responsibility of one service to another. In the main, this theme emerged in relation to the police assessment of risk and the response to both this assessment and subsequent transfer of responsibility to mental health services. The following sections present the issues raised by police and mental health professionals in both the assessment of and responsibility for risk of individuals who move between services.

Summary

In general, professional participants were aware of the barriers that affect their own agency’s management of individuals with EMHN. However, professionals described a lack of understanding of the pressures and limitations by other agencies and the scarce allocation of resources in the provision of care for individuals with mental health needs who present to both services. Furthermore, although there are processes in place to support information sharing, these are not widely known across services, placing a barrier in the way of effective interagency management.

Overall, there are differing interpretations of protocol and policy impact across a range of key areas, including assessment of alcohol consumption and risk of violence in order to access the place of safety, assessment of risk to self and others in relation to precipitating the decision to detain under Section 136, and what constitutes proportionate and lawful information sharing to maintain the safety of service users, staff and the public. A tension emerged from these discussions between what is in the best interests of the service user and the options available to the service with responsibility of the service user at that time. This leads to strain between services as they make efforts to meet the aims of their respective organisations and manage their corporate responsibility to service users within the context of often absent or ill-defined and understood protocols and compounded by resource shortages.

Theme 1: police understanding of mental health

The majority of service user discussion focused on police management of individuals with mental health issues. One of the main barriers perceived by service users to police achieving effective management was their inability first to recognise behaviour as precipitated by mental ill health and second, to understand presenting behaviour as indicative of crisis point. With respect to the latter, one service user described an example of an attempted suicide where they were in contact with the police but no follow-up contact was provided, either by the police or mental health services. Lack of police understanding was perceived as a barrier to the police providing appropriate and effective management of individuals suffering from acute mental health issues. In the following quote, lack of understanding of how someone with bipolar disorder might react to the police was provided by a service user as an example of this barrier:

In the experiences I’ve had, and I’ve seen people who’ve got things like bipolar, or depression, and they get arrested, right, in my experience if someone put their hand on me, Police officer or doesn’t matter who it is, I’d go off on one – because I just react to it, it’s instinct to react, yeah, so they give you a bit of a hard time and all the rest of it, you know, what have you – and then when they realise you’ve got this bipolar, you’ve got this manic depression, after they’ve beaten you up and thrown you around or whatever, I think they need to stop and find out if you have got mental health issues. They need to look at that first before they start all the rough stuff and judging who you are.

Additionally, service users saw a barrier in terms of the perceived lack of understanding by the police of comorbidity of mental health and drug/alcohol issues. This was viewed as a pervasive attitude where service users perceived that the police did not believe that individuals who had issues with drugs did not have mental health issues that required referral/treatment, but, rather they should be managed primarily as under the influence of drugs. Lack of understanding of these issues was viewed as the mismanagement of incidents, potentially resulting in negative impacts on service users and inappropriate application of resource, to the point where it could escalate a situation:

In my experience, I had a paranoid psychosis in the public toilets, and the way the Police dealt with it was – to me, I wasn’t a raving lunatic. I was coming off a long induced drug binge but the way they did it was it was all sealed off and there were negotiators, and there was nobody whatsoever to meet any mental health needs, you know what I’m saying? To me if the GP would have come along and given me an injection and put me to sleep for a day, it would have solved everybody’s problems. Because that’s all I needed to do, basically. You know, I needed rest. But the way they handled it was totally off the wall. Because to me, it would have been more sensible to approach . . . with a steady approach, you know what I’m saying? One on one, or two – if they fear for one’s safety, send two. Because that softly softly approach, to anybody in that frame of mind, is a lot more easier than . . . They’re surrounding you by a lot of people and then they’re all like – Yeah, because I came out of the toilets and they trussed me up like a chicken. Do you know what I’m saying? And to me that was senseless.

Where service users had good experiences of police management when they were experiencing crisis, this was generally due to the individual officer’s knowledge of mental health and mental health services. As such, service user participants suggested training in mental health for police officers and, further, the designation of police officers with a specialism in mental health. By having enhanced training and specialist officers, service users expressed the belief that this would improve understanding of mental health conditions and the individuals concerned:

Yeah, but the Police don’t understand mental health. But I think that in that, there should be Police officers that specialise in mental health, because at least that way they’re doing their Police role and their mental health role. Because at least then – And then there’s that little bit of empathy then. Because then if need be, if they need to be a Police officer they can go and do that, if they really need someone for mental health and there’s someone working, they know then – they understand.

Theme 2: information sharing

One of the major perceived facilitators in the management of individuals with EMHN experienced by service user participants was information sharing between the police and mental health services. Although it was recognised that this should be proportionate and appropriate, service users agreed it was necessary in order to effectively manage joint agency service users and expressed surprise that information was not more frequently and formally shared. Service users perceived that a lack of appropriate information sharing could provide a barrier to effective management.

So would you prefer it if the police could actually see your information?

Absolutely, yeah! They should have easier – easy access to your medical records.

It should just come up on the main part of your . . . what’s wrong with you, you know.

Service users provided examples of instances when joint management was enhanced through information sharing conducted in their best interests. Service users appreciated the police providing the MHT with information in order that they could start to deal with the presenting situation and seek to meet the needs of the service user from the point of police contact:

I mean, what I found is at least they can do a proper handover. Then the mental health people know what they’re walking into, they know what the problem is, they know what the mood is. They’ve got a better idea of what your immediate need is going to be.

The following example is of a service user who felt directly supported by police to access mental health services. This showed how provision of information about the incident by the police to mental health services can enhance the experience of the individual concerned and expedite the service user’s journey to appropriate treatment. For this individual, this prevented retraumatisation by preventing him from having to relive the experience by having to recount the incident.

The other thing I did which helped me a lot was they spoke to them first and explained the more traumatic part of what I’d explained to them, so I wouldn’t have to go through it for a third time that day. Because they had it all written down in their notes . . . Because then by the time the mental health team spoke to me, they knew –everything . . . the worst part of it, what had been going on . . . I suffer from PTSD [post-traumatic stress disorder], so the problem is it’s recurring over and over and over. And I don’t want to go through it again and again, I mean I was killing myself because it was the only way I could make the replays stop.

Although there was agreement within the group that services should share information in order to improve service user care, service users felt that at each step in their management they should be consulted about intended information sharing in order that they are fully informed of the process:

But I think they should tell us as well – I think the Police should say, I’m putting you in touch with this person, don’t just do it because then you’re going to think well hang on, why . . . they’ve done it without telling you.

Service users were clear in their support for and understanding of the need for enhanced information sharing between services in order to improve outcomes for individuals with mental health needs. Participants felt that agencies had restricted access to records from other agencies, and that this created a barrier to appropriate management. In order to change this situation and enhance interagency management and understanding of the mental health needs of individuals, service users felt that accessibility of records to appropriate agencies should be improved. Specifically, services users highlighted the efficacy of strategic information sharing at a point when it would be most useful for the police when making a decision. Early access to information when en route to an incident was perceived by participants as a way to enhance the management of individuals with mental health illness:

If they’ve got something like that and they actually get the name of the person before they go out to the scene, then there is absolutely no reason why they shouldn’t then be saying, right – oh it’s so-and-so, wait a minute, there’s a mental health disorder, we need to send one of these officers.

Furthermore, there was recognition of the need for enhancement to current record keeping techniques in order to ensure that the police have access to records with accurate and up-to-date information to improve the provision for repeat service users. In the following example, service users posited a method of ensuring that records are updated to benefit the police and with the consent of the service user:

This is probably a stupid idea, but you know when you go in a doctor’s office, surgery, and you get a little clipboard, and they give you – put your name and address, and all your bits and your health – I’m thinking, maybe, you could do something like that if you get arrested or whatever, or . . . then they can take it off and look, maybe they could put that on their computer for next time. Or whatever. They’ve got the information they need, but they haven’t got the information they really really need.

Theme 3: professional roles and responsibilities

Service user participants discussed their understanding that mental health and police services had defined roles and remits in order to fulfil the work of their respective organisations. They recognised that in dealing with mental health service users who come to the notice of the police, these roles were sometimes blurred, particularly for police who often found themselves on the front line of dealing with such individuals. This situation whereby professionals were attempting to balance the expectations of their respective service, whilst having to simultaneously fulfil the role of the other service, created a significant perceived barrier in the management of service users:

The police are law and order, they’re not a local charity – you know what I mean. And that 50–50 doesn’t work. The police are law and order, to keep the peace. The mental health team are there for care and attention. So they’ve got a job to do . . .

Furthermore, service users recognised the frustrations of individual professionals who wanted to deliver an optimal service for those with mental health issues created through the limitations placed on services relating to their roles:

They want the right person to help you, rather than them trying to deal with it and they can’t. They just try and put you through to someone else.

Interestingly, service users recognised that although services should be available and responsive to their needs, that there was some onus on them (as service users) to actively engage with services in order that they might be effectively managed and receive the care appropriate to their needs. Therefore, in order to improve interagency management, part of the responsibility was perceived to lie with the service user to recognise that they are in need of help and take steps to accept what is being offered:

Yeah. To me it comes back to the issue of if you want the help that’s there, sometimes you’ve got to make that first step yourself, haven’t you. You’ve got to say, right I’ve hit rock bottom, I don’t want this anymore, right. And anybody that can do that, or try to do it, these people can then work – like [Service User 2] said, there’s a budget they work by, but I’ve never ever known [agency] turn anybody away.

Additionally, in taking responsibility to access care, engaging with services and affecting change in their lives, service users expressed the need for this to be recognised by services, so that attitudes and treatment of the individual by professionals should be adapted as they assumed responsibility for and changed their lives:

Until only about 12 months ago, the only contact I used to get – I used to get hustled in the street all the time by them, but in the last 12 months I’ve got to be honest and say there’s been a complete turnaround, because I suppose they see a change in me. You know, I get the odd one and I’ve had it, who say leopards don’t change their spots as far as I’m concerned, and I said well they do, mate. He said they don’t change their spots, the spots just get bigger until the colour completely changes. But generally I’ve found overall there is a change of attitude towards me, because I suppose they can see a change, you know what I’m saying? Because I’m no longer this, in their eyes, raving lunatic walking around, psychotic or paranoid or whatever, and causing them work as far as they’re concerned, you know.

Rather than more strictly delineating professional roles and responsibilities in order to improve the situation with regard to the barriers presented above, it was clear that service users perceived specialist integrated services as being the optimal method to provide the structure to improve care/management. Service users had some knowledge of and were positive about the recently implemented custody liaison and diversion service in the research site. Furthermore, as the following extract exemplifies, service users could see the value of integrated police and mental health services that were able to facilitate timely access to services and support for service users:

The thing is, how do they define mental health? And we all know it’s a minefield. You know, I think you can get, like I say if you’ve got CPNs or drug workers in the Police station, which is a good thing, but all the multiple agencies need to be working together and to have first-hand experience. And like [service user 1] said, this is the breakdown, it’s law and order against care and attention, and you’re always going to get that . . . you need somebody that can liaise between the two – in the ideal world

Theme 4: understanding the needs of service users

Although the service users felt that some police professionals understood elements of mental health conditions and mental illness, there remained a lack of understanding of service users’ needs and how to ensure those service users were able to access appropriate services. In the first instance, at the very least, there was a call for the police to recognise when individuals were requesting help:

Well, they think you’re psychotic if you ask them for help. They think you’re gone in the head. And I was like, no, I’m not gone in the head, I was like I just need help, and they were like we’re going to section you, and I was like I don’t need sectioning, I just want help.

Not all of the participating service users had received care/management follow-up from the police following contact; however, those that did had found this useful and supportive. Examples included follow-up letters and the offer of support when required and the understanding of when the service user was able to self-manage their needs more and move away from the support of the services:

They sent me letters, to make sure that I was all right . . . Oh yes, and in the end I just like got hold of them to say I’m now living in blah blah blah, I’ve got this help and this support, and if I need your help I’ll contact you, and they were like that’s fine. But they’ve always said that if I need them, they’re there.

Another facilitator linked to management of service user needs was that of ensuring a single point of contact who would be consistent in the provision of support. Support facilitated by the same individual throughout their journey gave service users confidence and facilitated engagement with all services. For example:

Yeah. I mean, he wasn’t in uniform or nothing. But because he just made me feel like he was a normal person. But he come with me once a month whenever I’d see me counsellor, he used to come with me, just to make sure I was ok . . . Because obviously he was the one who’d put me through to the mental health team. And then obviously he followed it all through right until the end.

Furthermore, the following example presents another impact of consistency with respect to changing their attitude to police services and potentially encouraging them to seek help when previously they would not have felt supported to do so:

It’s the same one that’s done, like, from the start to finish, rather than someone else coming in and having to explain to that person, it just gets boring saying the same thing, but it’s the same one that’s stuck throughout the whole . . . It destroys the stereotype for me, you’re left with the feeling that I could approach them if I knew something was going to happen and I was out somewhere, if there was a Policeman around I probably wouldn’t be able to get anywhere near the right response . . . but you feel it wasn’t this horrible thing that if I’m contemplating something to stop the . . . and if there’s one walking down the road you can metaphorically grab them and say that you need their help, look I’m in danger of hurting myself.

An important factor perceived as necessary to improve service user journeys was a diversionary approach to individuals with EMHN so that a contact with the police did not necessarily end in detention, or mental health services could be accessed before an incident escalated to the point where police had to attend. An example of this was to have knowledge of out of hours access to mental health services (for both the service user and police):

It’s better to talk to someone without them going ‘oh yeah we’re going to section you’. I don’t want to be sectioned, I just want to talk to someone. And then it took a few weeks, and then I finally got a phone number that you can call now. You can text them out of – like, quite late at night –

Out of hours.

Yeah, and they’re bloody helpful.

Oh ok. So you could have done with just being given that to begin with.

Yeah, if they’d have given me that in the first place it would have been a completely different story . . .

Summary

Service users, although having experienced a range of barriers in interagency management of incidents in which they were involved with both services, were keen to share potential facilitators and suggest improvements in service that could enhance interagency care. Overall, early joint service intervention and provision of an integrated care package was an important factor in all the themes. An exemplar was provided by one service user who had been in contact with the police at crisis point and from that point on had a quick and supportive journey through the services:

I was arrested by them, they found me in the middle of a suicide attempt, and the way they approached it was only one of them approached me, the other one was about 50 metres away. I later found out that it was one of my friends who’d alerted them to the suicide attempt so they arrived knowing what it was and I was more a danger to myself than anyone else. They sat down, talked to me rather quietly for at least 30 minutes, they weren’t arresting me, but if necessary to protect myself they would, they asked me if I was with a doctor down there, I said no I’m not registered with a doctor. They said, what we’re going to do, we’re going to take you to a GP surgery now, we’re going to get you registered with him, but then before we leave we’re going to make sure that that GP has contacted mental health services, and we’ll wait until someone arrives from there before we leave, but we’ll just be in the surgery, we won’t be in the doctor’s waiting room. I was lucky I got the two most reasonable police officers in Cornwall! . . . I mean it was 4 o’clock in the afternoon of the same morning that I was brought in here [referring to the shelter], sedated by the mental health team, so I could start the process of putting my life back together.

The above example highlights some of the main factors discussed in the group and exemplifies where all aspects came together to create what could be deemed as a gold standard scenario, including joint working, information sharing, diversion from custody, understanding of mental health needs and expedient routes for treatment. Furthermore, the above example highlights intervention by a third-sector organisation, in this case the homeless shelter in which the focus group took place. Third-sector support, particularly in the form of housing, money management, addictions, etc., was viewed as vital by the group.

Well I’ve been here two years and nine months now, and I’m waiting for a, like, to move into a council property. I’ll probably be here for another year. But I can’t slate [the shelter] whatsoever. If it wasn’t for them, I wouldn’t be what I was now. I’d still be an alcoholic, and I’d still be taking drugs.

In summary, the service users wanted to see an improvement in the awareness and knowledge of mental health issues within the police. Although it was viewed that general training of the police force would be beneficial, the service user participants perceived the development of specialist officers as having more far reaching impact. Services could be greatly improved by the sharing of information, with proportionate and necessary sharing of information between the police and mental health teams to expedite and smooth the transition between services.

Fundamentally, having accessed services at a time of crisis, participants could see the challenges service users posed to the two services that attempted to deliver care and manage them effectively – despite the barriers in achieving this. The police were viewed as the service that often needs to deal with the immediacy of situations with potential risks to the individual themselves and/or to others. Although the service users understood that the police needed to deal quickly with incidents, they highlighted the need for officers to consider the needs of service users in managing situations where mental health may be an issue. Although no comment was made in relation to the adherence or otherwise with policy or protocol, recommendations made by service users included integrated liaison services, the need for diversionary services and that of mental health training for police officers reflect the recommendations made in Lord Bradley’s 2009 report. 6

Finally, both professionals and service users focused on two key areas in the management of individuals with EMHN. First, both consultations generated discussion with regard to interagency information sharing. Both groups (i.e. professionals and service users) could see the benefit of accurate and timely information sharing that would benefit interagency working and the professionals involved in delivering service, and have both immediate and long-term benefit to service users as they move between services. Both groups were keen for there to be clear and transparent processes and procedures to support information sharing to be of most benefit to interagency working and service user outcome. Second, both groups raised the tensions and dilemmas with regard to role, remit and responsibility of police and mental health professionals. Both groups recognised that the boundaries in role and remit are often blurred, creating a barrier to the effective interagency management of mental health service users who come into contact with the police. Training, the development of joint protocols with clear delineation of responsibility and a clear shared understanding of roles, and appropriate resourcing of provision or at least awareness of the impact of under-resourcing for service providers and service users, were viewed as potential facilitators to effective interagency management.

1. Creation of a Master Index:

1. Personal identifiers (name and date of birth) of the cases identified by the registered audit will be randomly assigned a PseudoID. These linked data will be held in a single Excel worksheet on a secure drive on the Trust N3 server. 100 cases identified by the stratified sampling frame will be marked within this master index as those required for examination for the case-linkage study.

   1. Access CFT Master Index: LC, John Morgan (JM), SE, Trust Information Governance (IG) Lead

2. A copy of the Master Index will be held in a single Excel worksheet on a secure drive on the DCP server. 100 cases identified by the stratified sampling frame will be marked within this master index as those required for examination for the case-linkage study. Access CJS Master Index: LC, SE, Force Data Protection Officer.

2. Data access:

1. Data will be accessed on the RiO mental health records system for each case. Records will be accessed in the CFT Forensic Mental Health Team Offices. The worksheet containing the personal identifiable data and PseudoID will be accessed from a CFT laptop in a docking station connected to the CFT network allowing access to the dedicated server drive. The RiO record of each case to be examined for the research will be accessed from the same laptop.

   1. Access: LC, JM, SE, Trust IG Lead

2. Data will be accessed from the CJS systems for each case. Records will be accessed from a docked networked laptop or networked PC in Crownhill Police station, Plymouth. The worksheet containing the personal identifiable data and PseudoID will be accessed from a DCP laptop in a docking station/PC connected to the DCP network allowing access to the researcher’s police server drive. The CJS record of each case to be examined for the research will be accessed from the same laptop.

   1. Access: LC, SE, Force Data Protection Officer

3. Data collation and storage:

1. RiO data required to answer the research questions will be collated and stored under PseudoID in Microsoft Excel and Word files on the dedicated server drive.

   1. Access: LC, JM, SE, Trust IG Lead

2. CJS data required to answer the research questions will be collated and stored under PseudoID on Microsoft Excel and Word files on the Police server drive.

   1. Access: LC, SE, Force Data Protection Officer

3. Data depersonalisation and storage:

1. RiO-derived collated data will be depersonalised. Depersonalisation will include removing any identifying features from the data including names, addresses and distinguishing features of cases. All data will be depersonalised including that of service users, all third parties and organisations. All data will be stored on the dedicated server drive as above.

   1. Access: LC, JM, SE, Trust IG Lead

2. CJS-derived collated data will be depersonalised. Depersonalisation will include removing any identifying features from the data including names, addresses and distinguishing features of cases. All data will be depersonalised including that of service users, all third parties and organisations. All data will be stored on the Police server drive as above.

   1. Access: LC, SE, Force Data Protection Officer

4. Pseudonymisation and depersonalisation check:

1. The Trust IG Lead will work with the Research Manager (LC) to ensure that data are appropriately pseudonymised and depersonalised.

2. The Force Data Protection Officer will work with the Research Manager (LC) to ensure that data are appropriately pseudonymised and depersonalised.

5. Data transfer and storage:

1. Pseudonymised and depersonalised RiO-derived data will be stored and transferred on a Trust issue encrypted hard drive.

2. Pseudonymised and depersonalised CJS-derived data will be stored and transferred on a Police issue IronKey.

   1. Access: Whole research team (LC, JM, SE, Susan Lea (SL), Graham Thornicroft (GT), Anita Patel (AP), Barbara Barrett (BB), Diana Rose (DR), Iain Grafton (IG), Mark Bolt (MB), and Margaret Heslin (MH).

6. Data linkage and storage:

1. Pseudonymised, depersonalised RiO and CJS-derived data linked via PseudoID and stored on dedicated server drives and encrypted hard drives at Plymouth University and King’s College for analysis. Hard copies of pseudonymised depersonalised data will be stored in locked filing cabinets on University premises (Plymouth and King’s College). Data will be exported to Statistical Packages for the Social Sciences (quantitative data derived from Excel spreadsheets created above and NVivo (qualitative data derived from Word documents created above) as appropriate.

   1. Access: Whole research team (LC, JM, SE, SL, GT, AP, BB, MH, DR, IG, MB).

7. Securing of Master index:

1. On completion of project, the Master index at both sites will be limited to contain only RiO number (CFT data) and Nominal code (CJS data) and PseudoID. The electronic file and all data contained on the server drives of each organisation will be deleted. A hard copy of the resulting limited Master Index will be created and stored under each organisation’s Records, retention, and Destruction Schedule.

   1. Access CFT Master Index: Trust IG Lead.

   2. Access CJS Master Index: Force Data Protection Officer.

Additional points:

• Only those research team members with substantive or honorary contracts with CFT (LC, JM & SE) and who are Trust Information Governance trained will have access to the personal identifiable data and case records (in RiO and CJS systems) in order to collate and depersonalise data. Only the aforementioned research team members will have access to the Master Index and PseudoID for each case and be able to link to this alias in order to access therefore the personal identifiable data. All those with access to personal identifiable information for the purposes of research (LC, SE and JM) are fully aware of their responsibilities in terms of data processing, the Data Protection Act (1998) and the Caldicott Principles.

• No hard copies of personal identifiable data will be made. Hard copies of depersonalised data under PseudoID 2 will be made for the purpose of analysis and stored in locked filing cabinets in King’s College London and Plymouth University.

• The CFT IG Lead will audit the researchers’ access to records on RiO for the purpose of patient safety and to comply with information governance requirements. The DCP Data Protection Officer will audit researcher access to CJS systems

Analysis: A combination of quantitative and qualitative analyses will be used

1. Quantitative analysis: Core demographic information of all 100 selected cases identified via the audit will be collated. Descriptive analyses will be conducted to gain a picture of the sample. Data would be captured using Microsoft Excel and imported into Statistical Packages for the Social Sciences (SPSS) for analysis. Statistical analyses will be undertaken to compare the core demographics of full and subsamples to assess the representativeness of the final sample obtained.

2. Qualitative analysis: A full pilot will be conducted on two individual cases. Documents will be anonymised and either converted or scanned into electronic text documents and uploaded into NVivo. All records over a defined 12 month period will be accessed. The data corpus will be necessarily complex and rich. Using NVivo to organise and structure the analysis will ensure the centralising of data from the variety of sources presented above and systematic conduct and record of the analysis of this large data corpus. Data will be coded independently by two researchers. Functionalities to check for reliability of coding provided by NVivo such as Coding Comparison Queries will be conducted. Any differences will be resolved through discussion of the key themes and the interpretations placed on them.

Member validation will be sought through service user involvement at relevant stages throughout the analysis.