Mental Health WorkshopCollege of Policing Annual Conference 30/11/2016

Faculty of Forensic and Legal Medicine

Royal College of Physicians

Margaret M Stark

LLM MSc (Med Ed) MB BS FFFLM (Founding) FACBS FHEA FACLM FRCP FFCFM (RCPA) DGM DMJ DAB

Objectives

• Faculty of Forensic & Legal Medicine

• Identification of vulnerability due to

mental health problems

• Risk assessment

• Interagency working

• Competent practitioners

Faculty of Forensic

& Legal Medicine

of the RCP

(London)

Advancement of

education and

knowledge

Ensuring the highest

professional standards

of competence and

ethical integrity

www.fflm.ac.uk

Importance of recognising

mental vulnerability

Custody – ensure appropriate management,

need for safeguards such as an AA, fitness to be interviewed

Emergency ‘street situations’

Diagnosis doesn’t matter!

Mental vulnerability v capacity(See APP, PACE, MCA)

Of importance for Interviews as may not

understand the meaning or importance of what is said to them (for example, in the form of

questions) or of their replies.

Inability to make a decision because of an

impairment or disturbance in the functioning of

the mind or brain.

FTI - R v Aspinall

Mental vulnerability v capacity

No appropriate adult present

Problem with interviewing the mentally

vulnerable without support is that any

evidence obtained maybe

Unreliable

Misleading

Self-incriminating

Not sure what is in their best interests

Risk assessment

Presentation to you (custody staff or officer in the

street)

Content of the RA in custody – accurate and

informative (takes time)

Information from other sources - arresting officers,

members of the public, family, PNC, etc.

Types – obvious

Mental illness

Intellectual disability

ASD

Substance misuse

ADHD/ADD/Conduct disorder

Types - less obvious

Chronic physical illness

Medication

Pain

Acquired brain injury – traumatic/substance

misuse (alcohol or other drugs)

Can you tell the time?

(ask for demonstration)

Liaison & Diversion

Working in partnership

L&D on site

Summary care records access

NICHE/NSPIS

System One

Quality standards

Multidisciplinary team working – nurses,

paramedics, doctors – ALL need to be appropriately trained (police awareness of

limitations)

Recruitment

Initial Training and Induction Support

Workplace-based Supervision by appropriately

qualified clinical/educational supervisors

Continuing Professional Development

Service Level Standard

Acute

Behavioural

Disturbance

ABD=

UMBRELLA

TERM

Common causes

Stimulant misuse

Psychiatric conditions

Differential diagnosis

Head Injury/Seizures

Hypoglycaemia – low blood glucose

Sepsis – severe infection

Hypoxia – low oxygen level

Thyroid storm – abnormal thyroid gland functioning

Serotonin syndrome – THINK: ecstasy, antidepressants

Neuroleptic malignant syndrome – THINK: antipsychotics

Heat exhaustion

Anticholinergic syndrome – THINK: antidepressants, antihistamines,

Early coordinated

response required

US National Institute of Justice Technology Working Group on Less-Lethal Devices

https://www.justnet.org/pdf/exds-panel-report-final.pdf

Principles of management

Reduce suffering to patient –psychological/physical

Reduce the risk of harm to others

To do no harm

Limit physical restraint/pain

Avoid the prone position

NB European Convention on Human Rights Article 2 (right to life) & Article 3 (prohibits torture, and "inhuman or degrading treatment or punishment“).

Verbal de-escalation–take

time if possible

Single person

Direct clear calm voice

Reduce environmental stimuli

Monitor breathing

Wrestling

• Increases oxygen consumption

• Lactic acidosis = abnormal blood chemistry

ABD - Conclusions

ABD is an umbrella term with excited delirium at

the most extreme end

Medical emergency but not always fatal

Hyperthermia is dangerous - think of treatable

causes

Oral rapid tranquilisation in police custody (unless

advanced paramedic present to assist)

Further Reading

www.fflm.ac.uk

References

Stark MM. Norfolk GA. ‘Care of Detainees’. Chapter 9. In Clinical Forensic Medicine – A Physician’s Guide. Ed. Stark MM. Humana Press, Totowa, New Jersey, 2011. Third edition. Springer, New York

Norfolk G., Stark MM. ‘Fitness to Be Interviewed’. Chapter 11. In Clinical Forensic Medicine – A Physician’s Guide. (as above)

Stark MM. Payne-James JJ. & Scott-Ham M. ‘Symptoms and Signs of Substance Misuse’ (Third edition) CRC Press, Boca Raton, FL, 2015

Vilke GM. Payne-James JJ. ‘Excited Delirium Syndrome: aetiology, identification and treatment.’ In Current Practice in Forensic Medicine. Second edition. Eds Gall J. & Payne-James JJ. John Wiley & Sons, Ltd, Chichester, West Sussex, 2016