Elephants in the room
I predict that in a decade or more, we will still know Nicola’s Edgington’s name. I really fear, as with many of these cases, that the public will have forgotten Sally Hodkin’s name and that it will be her family who keep her memory alive, forever consumed with regret that it was their wife, their mother and their grandmother who had to be the one who was attacked – forever wondering whether two massive organs of the state, the police and mental health services, could have prevented it? I also predict no-one will remember Kerry Clark, who was fortunate not to die during that incident and who will forever live with the impact that event has had upon her and who has had to watch the trial unfold the background of the woman who attacked her. The hopeless tragedy of this case is beyond measure. We will be hearing about it for years to come because there will yet be a criminal appeal against conviction and sentence, there may well be an Inquest, there will – eventually – be reports from within the NHS about the treatment and care of Nicola Edgington and Sally Hodkin’s family have stated through their solicitor, that there could be civil action against the NHS and/or the police. I want to provoke a thought in you to consider as you read this blog about the Metropolitan police response on 10th October 2011: Do we think that the judgement of the court today reflects a message from the criminal justice system to the mental health system that attempts to say, “You’ve had your chance to handle this case: now we’re ensuring beyond doubt, the public’s ongoing protection.” Discuss. Background I am not going to rehearse all of the ins and outs of the events leading up to and including the 10th October. If you are not entirely familiar with the case, you should read the report from the IPCC into the matter or the BBC News website. (It is paragraph 47 on page 12 of the report that is concerned with the substantive events of 10th October). Alternatively, pick up a more respectable newspaper but I will tell you upfront that none of them – none – have summarised this case correctly and I’ve spent the afternoon and evening reading them all having read the IPCC report cover to cover – twice. Finally, by way of introduction(!) – there are two things here that I am not commenting about: – The validity of the original decision in 2009 to release Nicola Edgington from secure mental health care; OR, – The judgement reached by the Crown Court, in terms of whether I think it was right or wrong. There is now an appeal pending. On the first issue, we don’t have published reports about how that decision was reached; on the second, there is a criminal appeal pending where the debate about liability for murder versus manslaughter on the grounds of diminished responsibility will be aired, along with an appeal against the sentence imposed which a life sentence with a minimum tariff of 37 years. I am interested in the policing-related decisions. The tenth of October The police were called at around 4am to a taxi rank in Greenwich to a report of a female who was asking for help to get “sectioned”. When officers arrived, they found Nicola in the private area of the taxi firm’s offices. She was asking for help and willing to receive it, albeit that she did not want to be conveyed by the London Ambulance Service. She was removed to A&E by the two officers in police car. – They arrived there just before 4:30am and having booked her in and her being in a queue for triage, made to leave A&E at 04:31am. – Nicola followed them out, indicating she didn’t want to wait on her own. – At 04:34am, the officers returned her into the waiting area – she is shown on CCTV to be agitated. – At 04:37am, the officers left the department and Nicola followed them again, claiming she just wanted a cigarette and she then re-entered the hospital. – Keep reading the IPCC report from paragraph 72 on page 16 if you want more detail after that point – for my purposes on this blog, that is all I want you to focus upon. The Independent Police Complaints Commission report highlights two particular points of contention for the police. – Firstly – that officers did not undertake a PNC check at any stage prior to leaving at 04:37am – it is suggested that had they done so, it would have confirmed Nicola Edgington to have been previously convicted of a homicide offence which may have influenced police decisions (around the second criticism) or medical decisions, in terms of the priority afforded to her as a patient. – Secondly – officer missed an opportunity to detain Nicola under s136 MHA at the point where she first attempted to follow them out of the hospital at 04:31am – it is held that if they had detained her, the assessment of her, especially one informed of the homicide conviction from the PNC check that never happened – may have reached a different decision about her risk and therefore may have taken different decisions. The PNC Check – I’ve worried about this observation whilst acknowledging that PNC checks take just a couple of minutes and can be done by an officer in any location over their radio. I’ve worried about it not because I would have questioned a check being done – certainly not. I worry about it because we’re seeing this through the prism of a murder trial, knowing Nicola’s previous history. The two officers on 10th October went to a taxi rank and met someone who, at that stage, wasn’t committing an offence, or resisting the care pathway the officers were offering her. She was described in the report as “agitated” but essential capacitous and willing to engage. So I ask this: are we now expecting a PNC check on every person we meet in a non-arrest situation where we are any part of offering a pathway to care in connection with mental health issue? And if we’re doing this for people with a mental health presentation are we also doing this for other, potentially risk-related presentations where we are not detaining or arresting people – like drugs and alcohol? Section 136 – It is beyond doubt that the officers could have detained Nicola at 04:34am under s136. I have hinted before that for me, this decision rests on how you interpret the word “necessary” in the definition of s136(1) MHA. Officers may detain “if it is necessary” … if by that you mean, “making sure she is enters a process she is not willing to enter” then you may take the view it was not “necessary”. If you mean “making sure she remains detained in a process that she is currently engaging with but from which we worry she may withdraw”, then that is a different approach. We just need to be clear about which approach we’re telling people to take. Of relevance to the decision is a whole background of principles to the application of mental health law on vulnerable people which talks of “the least restrictive principle” and the “necessity test” for arresting people under any legal provision. Whatever position you take on the issues in this case, one thing is beyond doubt: Nicola Edgington remained at that hospital until after she was assessed by mental health services who offered her admission to hospital and walked her over to the mental health ward with a security guard. By this time, because of access those mental health staff would have had to their own medical records, her previous history would have been established and the IPCC note that mental health staff did not legally detain her either. If the police had detained her under s136 MHA and even if they had then remained involved in the assessment process to ensure she continued to be detained, the officers would have disengaged as soon as Nicola was safely escorted onto the ward. This is standard procedure across the UK for the police because from that point, hosptial staff are responsible and have their own legal powers to detain, if the need arises. She was taken from A&E at 06:25am on the 10 minute walk. She left the mental health ward at 07:19am. The police would almost certainly have been gone by then anyway. Holding powers In my experience, mental health staff don’t take patients into the wards unless they are being admitted – so whilst the IPCC report doesn’t specify that she was formally admitted as an inpatient, I will infer this was the case from the circumstances until I’m told otherwise. So she was a voluntary inpatient from around 06:40am and she left at 07:19am – at a time when doctors or nurses may have applied their holding powers to her under s5(2) MHA or 5(4) MHA, respectively, to keep her detained. << This is the first elephant in the room, for me. When the NHS report into her treatment and care is eventually commissioned and published, I want to know whether my inference about admission is correct and, if so, why holding powers were not applied to stop her leaving or why the physical security of the ward does not prevent this. There is just as much ground to question this as to question the non-use of s136. Of course, the IPCC don’t question this, because their remit is not the health staff decisions – we’re yet to publicly learn those because the NHS investigation isn’t public. Either way, had the police exercised a detention under s136 at around 04:34am, it is my speculation that when she was moved to the ward for admission, there is no way they would have remained there for half an hour or more. They would have left and the “absconding situation” would very probably have been the same as it was in this case – in my view. It is worth bearing in mind – that by the time Nicola Edgington absconded, the Trust would have known her previous history because mental health staff have access to their trusts records on which her status as a s42 conditionally discharged restricted patient would have been recorded. It is also worth noting – that two nurses involved in this case have been sacked. Conditional discharge and MAPPA And why is no-one taking about conditional discharge?! << This is the second elephant in the room for me, along with her status as aMAPPA eligible offender. Nicola was previously a patient detained after the manslaughter conviction under s37/41 of the Mental Health Act. This means that if discharge from hospital is considered appropriate, it’s not a wholesale relaxation of all laws governing her treatment or care. Nicola was “conditionally discharged” under s42 of the Mental Health Act and this ensures that whilst she is in receipt of community care, in Greenwich, there is a named psychiatrist in a multi-agency team including social workers and psychiatric nurses who are responsible for ensuring her care. We know that Nicola had conditions to her release: drug / alcohol testing, residence, exclusion from a defined geographical area and compliance with certain outpatient health regimes. If those professionals develop concerns on any level that a conditionally discharged patient is relapsing and beginning to pose a risk to themselves or others – or merely if they are not abiding by the imposed conditions – then they may ask the Ministry of Justice to issue a warrant for her recall to hospital. The MoJ can be contacted 24hrs a day to do this, if need be. We know from the trial that Nicola had stopped taking medication and was making crisis calls to the police – albeit a police service who did not know she was MAPPA eligible because, in breach of legal requirements on others, they hadn’t been told. I want to read something in an NHS document in the next few years that talks about the 72hrs prior to 10th October and which gives a general impression of how conditionally discharged community care was working – or not. And what we know about MAPPA offenders, is that where the police are told of them being in their area, the local MAPPA meeting may well have devised a “trigger-plan” – a list of what to do, in the event of a relapse situation involving the patient. This may well have involved contacting the psychiatrist on-call and / or the MoJ and / or any number of other things depending on the nature of the event that triggered. Not done of course, because Greenwich MAPPA were not told of Nicola’s release, thus breaching various laws. Blame game We saw the media launch into the blame game, both feet first earlier today. I was utterly amazed by the media reaction to police failures: many of them reporting the issues incorrectly. The truth of this case is you could point to about seven or eight different things done or not done by the professionals involved and put an argument that this alone caused the outcome. The reality is, that it was a mixture of all of those things and more besides that conspired to create the conditions in which it occurred The prevention of that conspiracy is precisely why we have complex offender management arrangements in the form of MAPPA. This is the vehicle through which all risks and intelligence should have been brigaded, shared and understood in order to prevent all of the professional groups involved in this case from attempting to distance themselves from the events. It is human nature to point to the other features of “failure”. It is perfectly valid for mental health services to point out how comparatively rare mental health related homicide is, especially stranger attacks like this one; they also tend to emphasise “you can’t keep all people detained forever” and that discharge, conditional or otherwise, is a normal part of rehabilitation and recovery that has to be attempted at some stage for most patients in these legal cirumstances. << This is not the same as saying that this particular decision was appropriate. Sally Hodkin died and Kerry Clark was extremely lucky not to. We owe it to both of them to reflect as individuals on our professional practice and our multi-agency procedures but we also owe it to the professionals involved not to get our analysis wrong. Everything is connected to everything else and we do confuse cause with effect and vice versa on occasions. Whatever you think of the content of this post, it is only PART of the debate because we don’t know enough about the role of the mental health trust and that’s why we need to know the outcome of an NHS inquiry into the health service decision-making: arguably we need this all brought together with the IPCC report and I personally would like to see this all explored at the Inquest. Media For what they are worth – media coverage from the main broadsheets. Should be read in conjunction with the IPCC report and the Metropolitan Police press release.
Courtesy of the Mental Health Cop